Food Insecurity Is Most Prevalent Social Need in Accountable Health Communities Model
Food insecurity emerged as the most common health-related social need in preliminary findings from the Centers for Medicare & Medicaid Services’ Accountable Health Communities (AHC) model, which seeks to address through enhanced clinical-community linkages.
The five-year AHC Model, which runs through April 2022, is based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs.
CMS has released a preliminary fact sheet detailing findings from the 29 organizations in 21 states participating in the AHC Model, which seeks to address the gap between clinical care and community services by testing whether systematically identifying and addressing health-related social needs (HRSN) of eligible Medicare and Medicaid beneficiaries through screening for HRSN, referral to community resources, and community navigation services will impact healthcare costs and reduce healthcare utilization.
Over a five-year period, the AHC Model supports community bridge organizations to test promising service delivery approaches to connect beneficiaries who report HRSNs such as housing instability, food insecurity, utility needs, interpersonal violence and transportation with community services that may address the needs. Assistance Track bridge organizations provide navigation services to high-risk beneficiaries. Alignment Track bridge organizations provide navigation services and encourage partner alignment to ensure community services are available and responsive to beneficiaries.
The fact sheet provided details on the first 750,000 screenings conducted in the program. AHC bridge organizations use the AHC Health-Related Social Needs Screening Tool to identify whether beneficiaries have one or more of the following core HRSNs: 1) housing instability or housing quality; 2) utility needs; 3) food insecurity; 4) interpersonal violence (safety); and/or 5) transportation needs beyond medical transportation. All beneficiaries who report one or more needs are offered referrals to community services.
Of the 750,000 people screened, 63 percent were Medicaid beneficiaries, and 37 percent were Medicare beneficiaries. In addition, 67 percent reported no core health-related social need, while 33 percent reported at least one core HRSN.
Of all beneficiaries who completed a screening and reported at least one core HRSN (33 percent of all completed screenings), food was the most common need identified, followed by housing, transportation, utility, and safety needs. For example, 67 percent of beneficiaries who reported at least one core HRSN reported a food need.
Of the first 750,000 completed screenings, an average of 18 percent across all bridge organizations were eligible for community navigation services. Out of all beneficiaries eligible for navigation services across all bridge organizations, an average of 76 percent of beneficiaries accepted the navigation assistance.
Of those beneficiaries who accepted navigation assistance, 76 percent were Medicaid recipients, and 24 percent were Medicare recipients.
Once a beneficiary accepts assistance, the navigator opens a navigation case for the beneficiary. The navigator then works with the beneficiary to address identified HRSNs.
Of the cases referred to navigators, 34 percent were for food issues, 25 pecent for housing, 23 percent for transportation, 15 percent for utilities, and 3 percent for safety.
AHC navigators follow up with beneficiaries receiving navigation services until the beneficiary reports their needs are resolved or one or more of their health-related social needs is documented as unresolvable. In order to fully address the complex needs of beneficiaries, they are eligible to receive navigation services for 365 days.
Denver Regional Council of Governments
One example of an AHC is in Denver, where the Denver Regional Council of Governments (DRCOG) received a five-year award of $4.51 million in May 2017 to implement the AHC model. Over the course of the grant, DRCOG is collecting data and engaging in a quality improvement plan to streamline and improve the process for screening and referring people from clinical settings to community settings, integrate and align clinical and community health providers, and improve understanding of the value and impact of community services on healthcare costs and health outcomes.
This data will also be used to identify areas where gaps exist that create barriers to efficient access to community-based services. The AHC will continue its work beyond the initial grant period to increase funding for community-based services and foster healthy communities in the Denver region.
The Denver Regional Accountable Health Community’s community-level quality improvement plan operates through health-related social need (HRSN) workgroups. DRCOG coordinates each workgroup to prioritize a specific accessibility gap in community-based services to then develop a targeted, timely and scalable project to make services easier to access. Workgroups launched in March 2020 and will sunset a year after that. DRCOG recently released an update of their progress:
Food Security Workgroup: The workgroup is connecting with a local clinic to pilot a co-location service model. People coming to the clinic for medical care who have food security needs can access food resources from a local food bank. This service model reduces transportation barriers for people in need, supporting their nutrition and overall health.
Housing Security and Quality Workgroup: Focused on increasing awareness of tenant rights and resources on housing habitability, this workgroup will develop a guide for navigators explaining Colorado’s 2019 Residential Tenant Health and Safety Act and resources to refer to for help when individuals and families experience health and habitability concerns such as mold.
Safety Workgroup: Comprised of clinical, community-based and advocacy professionals with experience in the state's domestic violence medical reporting options and trauma-informed care, the workgroup will create an enhanced training program educating licensed providers and navigators on medical reporting options for domestic violence survivors and champion trauma-informed care so people are better equipped to address domestic violence and safety-related issues.
Utilities Workgroup: The Utilities Workgroup aims to improve access to the Low-Income Energy and Assistance Program (LEAP) and Energy Outreach Colorado (EOC) utility bill payment assistance program by creating a tool to better outline how to qualify and apply to each of these programs. The tool is meant to lessen confusion, reduce administrative follow-up due to incomplete applications, increase correctly completed applications, and ultimately increase delivery of the much-needed assistance.
