CareJourney | Social Determinants of Health2018-01-28T17:26:45+00:00

Care Model Implementation – CMS Accountable Health Communities

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Time Frame Action
Pre-implementation Build foundation for model implementation:

Track 2 requirements:

  • Inventory local community services responsive to community needs and form a consortium of clinical delivery sites and community services providers responsible for implementing the model
  • Incorporate screening tool into all clinical interactions with Medicare beneficiaries

Track 3 requirements:

  • All Track 2 requirements
  • Put in place an advisory board  that ensures community services are available to address health-related social needs, and data sharing to inform a gap analysis and quality improvement plan
Continuous Screen for health-related social needs

Risk stratify based on ED visit frequency

Assign high-risk patients to “assistance” and “comparison” groups

Trigger event Beneficiary identified as having unmet health-related social needs, including housing instability, food insecurity, transportation difficulties, utility assistance needs, or exposure to violence
Within 30 days of trigger event (flexible) For a beneficiary in the “assistance” group, review and distribute a “community referral summary” that includes contact information and hours of operation for the community-based organization that will address the beneficiary’s needs.
Within 30 days of trigger event (flexible) For a beneficiary in the “assistance” group, provide “community service navigation services” to assist the beneficiary with accessing services. Community service navigation services is an in-depth personal interview, development of a person-centered action plan, follow up, and documentation of each encounter.
Annually For Track 3 only:

  • Perform an annual gap and resource analysis
  • Convene the advisory board to assess and prioritize needs
  • Create and implement a quality improvement plan that improves systems efficiency between clinical care and community organizations

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