Addressing population health: Integrators in the Accountable Health Communities Model

The Centers for Medicare & Medicaid Services (CMS) Innovation Center tests payment and service delivery models designed to reduce costs and improve quality of care in the Medicare, Medicaid, and Children’s Health Insurance programs. The scope of geographic variation in life expectancy and health outcomes suggests a need to consider how CMS can support innovative care models that address the needs of local populations, many of which are outside the traditional health care delivery system. One promising model to achieve this is the use of a community integrator, a trusted organization that can understand and represent the needs of the community; engage all the relevant service providers within a community (including health care services, public health, and social services); and leverage data-driven, multisector, community-level quality improvement toward shared goals for a defined population. CMS’ Accountable Health Communities (AHC) model is designed to test this approach, by assessing whether (1) identifying and addressing the health-related social needs of Medicare and Medicare beneficiaries improves quality of care and reduces costs at the individual-beneficiary level and (2) use of an integrator can further improve quality and reduce cost by engaging partners in identifying and addressing community-level gaps in 20 communities across the country.