The Accountable Health Communities model reduced hospital emergency department visits by 9% for Medicare fee-for-service beneficiaries screened for health-related social needs, according to the first report evaluating the Centers for Medicare & Medicaid Services model. The report and at-a-glance summary look at the model’s impact on Medicare beneficiaries through 2019. Future reports will include impacts on Medicaid beneficiaries, who comprise almost three-quarters of model enrollees.

Launched in 2017, the five-year model aims to test whether screening and connecting Medicare and Medicaid beneficiaries with health-related social needs to community resources improves health outcomes and reduces costs. The CMS Innovation Center funded entities known as bridge organizations to implement the model in collaboration with clinical delivery sites, community service providers, state Medicaid agencies and other community stakeholders. Beneficiary screening began in 2018, and hospitals have screened most of those eligible for navigation assistance.

While most eligible beneficiaries accepted navigation assistance, only 14% who completed a full year of navigation had any health-related social needs documented as resolved. Bridge organizations cited challenges contacting navigation-eligible beneficiaries following screening, and navigators described insufficient community resources for referrals, especially to address housing and transportation needs. There was no significant difference in total Medicare expenditures, in part due to relatively few Medicare fee-for-service beneficiaries exposed to the Assistance Track intervention in the first year, the authors said.

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