The Centers for Medicare and Medicaid Services (CMS) recently announced an initiative that may help some health systems address patients’ health-related social needs.

Under the Accountable Health Communities (AHC) model, CMS will provide $157 million over five years to evaluate whether identifying and addressing health-related social needs can reduce healthcare costs and inpatient and outpatient utilization among Medicare and Medicaid patients.

Lead author Dawn E. Alley, PhD and her colleagues from CMS published a perspective on the AHC model online in the New England Journal of Medicine on Jan. 5.

CMS plans on awarding 44 renewable, one-year cooperative agreements of between $1 million to $4.5 million. CMS will accept applications from community-based organizations, healthcare provider practices, hospitals and health systems and others until March 31.

“The AHC model is the first Innovation Center model designed specifically to test building community capacity to address the needs of a geographically defined population of beneficiaries,” Alley and her colleagues wrote. “Our test will involve robust evaluation methods (including randomization at the beneficiary level and matched comparisons at the community level, which are exempt from human-subjects review under the Common Rule), is powered to detect cost savings associated with each track, and will have a qualitative-evaluation component.”

Participants in the program are responsible for coordinating care and working with state Medicaid agencies, clinical delivery sites and community service providers. They will screen beneficiaries to identify unmet health-related social needs such as housing instability and quality, food insecurity, utility needs, interpersonal violence and transportation difficulties. They will also help community-dwelling beneficiaries access community services.

The authors cited data that shows 95 percent of healthcare dollars are spent on direct medical services even though 60 percent of preventable deaths are due to modifiable behaviors and exposures in the community. They added that there would be 500,000 fewer hospitalizations each year if the rate of hospitalizations among residents of low-income households was reduced to the same rate as those among residents of high-income households.

Previous clinical-community collaborations have faced challenges, according to the authors. They mentioned a report Institute of Medicine report found there was scant evidence for selecting screening items and collecting data for detecting health-related social needs. In addition, communities vary in terms of their needs and quality of resources, so a national test is complex and challenging. Thus, the AHC model includes three levels of integration of care delivery.

“The AHC model reflects a growing emphasis on population health in CMS payment policy, which aims to support a transition from a health care delivery system to a true health system,” Alley and her colleagues wrote. “The AHC test will improve our understanding of whether savings can materialize when upstream factors are addressed through collaboration among stakeholders who are accountable for the health and health care of their community.”