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CMS to Test Clinical-Community Collaboration to Assist Patients, Align Services

April 06, 2017

In an effort to support local communities in addressing the health-related social needs of Medicare and Medicaid beneficiaries, the Centers for Medicare & Medicaid Services (CMS) will provide support to 32 organizations—including Pennsylvania’s Reading Hospital—working to bridge the gap between clinical and community services.

During a five-year period, these organizations will receive support to test service delivery models that address the health-related social needs of beneficiaries by connecting them with available community resources though:

  • Screening for unmet health-related social needs
  • Referrals to and increased awareness of community services
  • Provision of navigation services to better access community services
  • Better alignment between clinical and community services

The program is part of the CMS Innovation Center Accountable Health Communities (AHC) model which aims to bridge the gap between clinical care and community services in order to reduce avoidable health care utilization, impact the cost of health care, and improve the overall quality of health care services delivered to the Medicare and Medicaid population.

The twelve organizations participating in the AHC Assistance Track will provide person-centered community service navigation services to assist high-risk beneficiaries with accessing needed services. The 20 organizations participating in the AHC Alignment Track also will provide community service navigation services, as well as encourage community-level partner alignment to ensure that needed services and supports are available and responsive to beneficiaries’ needs.

For additional information, contact Kate Slatt, HAP’s senior director, health care finance policy.

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