LABUN:
Welcome to Episode 12 in our series of short explainers for the Hunger Vital Sign tool, where we’re discussing the Accountable Health Communities model with our guest, Katherine Verlander.
VERLANDER:
My name is Katherine Verlander and I am the Deputy Division Director for a Division in the CMS Innovation Center that houses the Accountable Health Communities model.
LABUN:
In this episode, we’re getting into early lessons from the AHC Model.
Previous episodes outlined the basic components – all participants had a Bridge Organization using a screening tool to identify social risk across 5 core domains and then providing referral to community services in response to positive screens. Higher risk patients, defined as having both a positive response in a core domain and 2 emergency department visits in the previous 12 months, were offered additional navigation services.
Last episode we also talked about how the tools created for the AHC Model are made available as guides for other communities interested in a similar intervention.
VERLANDER:
We released a screening guide to accompany the screening tool and it's on our website as well as the tool. And it includes strategies for implementing universal health related social needs screening in a wide variety of clinical settings based on the experiences of the AHC model awardees. So there are several promising practices highlighted in the guide and the whole thing is a very long read, but a good read
LABUN:
Within the basic Model parameters, participants had the chance to test many different approaches.
VERLANDER:
The AHC bridge organizations tested a lot of different standard operating procedures at a clinic and an organization level for screening, referral, and navigation. So some of them did face to face screening. Some of them did screening over the phone. Some of them did paper screening or tablet screening in a waiting area while the patient was waiting to be seen. There were a lot of different dynamics there. They also had different staffing setups. Some of them decided to hire staff dedicated to AHC activities specifically. Sometimes they used existing staff to combine multiple activities. So maybe they had somebody already working at the front desk hand out the paper screener to the people that were checking in that day. So they had a combination and sometimes they even had a combination within the organization, right? So I'm one bridge organization. And at these sites we're using dedicated screeners because they're high volume. And at these other sites we're using, the existing front desk staff or the medical assistants because it's a lower volume and it's something they told us they could handle.
LABUN:
The CMS Innovation Center reviews these approaches and posts preliminary results online. We’ve linked those materials in our show notes. Preliminary results can help other regions think through their own approaches. For example, here’s one early finding:
VERLANDER:
Screening in the emergency departments benefited from higher volume of non-repeat patients and longer wait times to work with patients.
LABUN:
We know from the last episode that emergency departments are also a good place to find higher risk, higher cost patients – since those patients are also higher utilizers of the emergency department. And early results also suggest that the time with patients immediately after screening is critical. While 74% of patients eligible for navigation services said they wanted to receive those services, follow through dropped off sharply after a time delay, even a short one:
VERLANDER:
So navigators also reported difficulty in reaching a patient who indicated wanting assistance, even if they reached out within that 48 hour window.
LABUN:
Okay. So, let’s say I’m in charge of building screening, referral, and navigation in my own health system. And let’s say that, looking at these results, I decide to perfect social risk screening in hospitals where there’s a longer time with patients – maybe I’ll combine emergency department waiting rooms and patients admitted for a longer stay. That’s initial enrollment. I might further hypothesize that the primary care system is my best bet for longer term goals like integrating social factors into managing chronic health conditions, or gathering population health data and aligning community resources. For these goals, having a high volume of non-repeating patients like you might see in the emergency department becomes a weakness not a strength.
In that case, I might find some other early lessons relevant.
For example, documentation and follow-up with patients proved extremely challenging in the early months of the Model. Participants reported low success rates in meeting patient needs – partly due to the fact that they struggled to collect the information on what happened with the intervention.
VERLANDER:
Only 14% of those who completed a full year of navigation had any of their health related social needs documented as resolved. Factors contributing to low documentation of resolution rates include difficulties with data reporting loss of contact with beneficiaries, difficulty managing large caseloads, a lack of transportation to needed services, and insufficient community resources.
LABUN:
A lot of early technical assistance went into how to manage the follow-up. A natural conclusion would be that anyone else planning a screening and navigation system should also anticipate early work on effective follow-up and accommodate that in project planning. Here’s another lesson:
VERLANDER:
So the Accountable Health Communities Model seeks to bridge the divide between the clinical healthcare delivery system and community service providers to address these health related social needs. Screening typically was not integrated in existing clinical processes, but instead it was implemented as an add-on to clinical site workflow managed by new staff. Although adding new staff reduced the burden on existing clinical site staff and it increased their acceptance of AHC model participation -- because I don't have to lend any of my staff time to this to this effort -- it also meant that clinicians were not always aware of screening results either because the results were not integrated to the practices electronic health record, or clinicians did not review the information. Some care management teams did not engage physicians in AHC screening, referral, or navigation, to avoid adding to their workload
LABUN:
In our hypothetical scenario, if we want to use the screening, referral, and navigation in primary care practices as part of supporting patients in managing chronic conditions, this clinical disconnect becomes a problem. In food access it’s a particular problem because food can be both a health-related social need and also a treatment need. I can be food secure one day, and the next day get a diagnosis that requires a specialized diet I can’t accommodate through my normal resources. At that point I become non-compliant with a clinically-indicated dietary treatment due to food access issues. Just like I can walk without any difficulty one day, and the next day break my leg and have a new mobility constraint that needs medical treatment.
We’ll save the clinical integration issue for another time. The point here is that reviewing early results from the Accountable Health Communities model can help organizations think through their own approaches to health related social needs, identifying opportunities and planning ahead for potential challenges.
VERLANDER:
We are still evaluating the AHC model, however, screening and referral and navigating for health related social needs is definitely not new to AHC before we started and even more common in healthcare now, with the recognition that so much of a person's health is driven by factors outside the clinic. And so for that reason, we want to share what the CMS accountable health communities are doing. We also want to share as much of our material that we've shared with them to support their implementation more broadly with the field on our website. So that any information that we've been gaining and learning in the AHC model can be helpful to others.
LABUN:
Some might consider the AHC model a success on this judgment alone – the information gained is useful to others. Attributes of success under this definition would include offering a variety of examples from different settings and program structures, experts reviewing the extensive research base and synthesizing it into practical tools, and detailed documentation that’s easily available and referred to by multiple groups. By these measures – success!
But not so fast. As previewed in the introduction, the CMS Innovation Center has a particular definition of success.
VERLANDER:
If models are deemed successful in that they reduce, or they do not increase federal health expenditures while maintaining or improving quality for beneficiaries, and certain other requirements are met, the Affordable Care Act gave the secretary of the department of health and human services, the authority to expand the duration and scope of the model. Plus the statutory language creating the innovation center stipulated that a model that reduces costs or improves quality can be expanded in duration and scope only if the CMS chief actuary certifies that it would not increase net program spending.
LABUN:
Only a handful of models have reached the standard of success where they are certified by the Chief Actuary.
VERLANDER:
So far six models have generated statistically significant savings to taxpayers and Medicare. Four models have met the requirements to be expanded in duration and scope. These are the home health value-based purchasing model, the pioneer ACO model, the prior authorization of repetitive scheduled non emergent ambulance transport model, and the Medicare diabetes prevention program expanded model.
LABUN:
Describing the job of the CMS Chief Actuary is beyond the scope of this series. It involves macroeconomic modeling. We’ll provide links in the show notes. But here, too, simply providing the analysis is a form of success – even if there isn’t a certification for expansion at the end. It is really, really hard to define social need interventions specifically enough, and with enough data behind them, to extrapolate future impacts if we change our health care framework. The consequences of getting it wrong are immense – measured in both dollars and human health. And that cuts both ways -- consequences of action and of inaction. Which is the greater sin is a topic for moral philosophy. Both behavioral economics and statute err on the side of inaction over actions that risk significant negative outcomes. But that bias shouldn’t prevent progress. New information should lead to next steps.
VERLANDER:
Only a handful of models have met the certification standard. In addition to reducing costs or improving quality model success will also be considered for impacts on health equity person-centered care and health system transformation efforts, which are aligned with CMS wide goals, a more systematic and structured approach to understanding model impacts on these broader factors could help inform not only this CMS innovation center, future models, but also other payers and providers in their move to value based payment and care. As the innovation center identifies practices that work in models, there's commitment to scaling them whether through a certification and expansion, or by incorporating what works into other innovation center models, Medicare and Medicaid.
LABUN:
In summary, the Accountable Health Communities Model has several years and several evaluations left to go before it’s complete. This extended timeline supports conducting complex interventions and allowing them time to mature and show results that are valuable but not immediate.
Being incomplete is not the same as being un-useful.
There’s plenty to learn from the early evaluations, case studies, and data already provided by the AHC Model. These lessons offer insight into the “what next?” question following the Hunger Vital Sign screening – both next steps in screening for more than one social risk, and next steps in connecting patients with community resources.
The show notes provide links for exploring these Accountable Health Communities results in more detail. And we’ll be sure to let you know when the final evaluation is complete.