This process should be significantly aided and informed by a national model begun in May through the CMS Innovation Center (CMMI), and we are particularly excited that a longtime Philips Wellcentive customer has been selected to participate.
The Accountable Health Communities Model is focusing on housing instability, food insecurity (the topic of a Philips case study in the white paper), utility needs, interpersonal violence and transportation needs as the factors to address, overcome and bridge into the success of clinical care for Medicare and Medicaid beneficiaries.
Participating organizations are diverse, which is the point in understanding and tackling the importance of social determinants of health. They include health systems, governmental health departments, research organizations, ground-level community service organizations, universities and hospitals.
The Communities Model has been established with equal parts science and common sense to build community-based yet far-reaching results. Science? CMMI looked at areas where ER utilization was above the national average, for example, in assessing impactful participants. Common sense? Applicants were asked to explain existing partnerships that could saturate communities. In one example, a participating foundation noted its relationship with a redevelopment committee itself involved with 50 businesses and community organizations in one city.
This is the kind of collaboration a population health management mindset can bring.