On January 5, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the 5-year Accountable Health Communities Model. This model and various other community-based models raise the bar for health care organizations in that they require large amounts of varied data and new types of analytics in order to achieve success.
From CMS' website:
"The Accountable Health Communities Model is based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs. Unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions, reduce an individual’s ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.
This model will promote clinical-community collaboration through:
Screening of community-dwelling beneficiaries to identify certain unmet health-related social needs;
Referral of community-dwelling beneficiaries to increase awareness of community services;
Provision of navigation services to assist high-risk community-dwelling beneficiaries with accessing community services; and
Encouragement of alignment between clinical and community services to ensure that community services are available and responsive to the needs of community-dwelling beneficiaries."