Hackensack University Medical Center Addresses Health-Related Social Needs Via Accountable Health Communities Program

CMS grant supporting the program to bridge between clinical and community services

The Centers for Medicare and Medicaid Services (CMS) awarded Hackensack University Medical Center a healthy communities CMMI grant, running May 2017 to April 2022, to support Hackensack University Medical Center’s participation in the Accountable Health Communities (AHC) program.

Under the direction of Manisha Parulekar, M.D., this program examines and addresses social determinants of health through clinical-community service partnerships that increase awareness and help 75,000 Medicare and Medicaid beneficiaries per year access services. The design includes screening beneficiaries at clinical delivery sites for health-related social needs in the areas of housing, utilities, food, transportation and interpersonal violence, providing community resource summaries, and facilitating short-term community navigation services for eligible high-risk patients.

In 2020 through October, the program offered screening to 15,687 and has completed screening on 7,466 patients, with food and utilities/financial support ranking as the top needs.

AHC navigators follow up with beneficiaries receiving navigation services until the beneficiary reports their needs are resolved or one or more of their health-related social needs is documented as unresolvable. To address complex needs, beneficiaries are eligible to receive navigation services for one year. All patients who are screened positive for any social determinants receive a tailored resource guide as per patient need and ZIP code. Of high-risk patients, those who have visited the emergency department two or more times, 70% are assigned to our patient navigators who assist them in connecting to necessary community resources, while 30% receive the resource guide alone as a control group.

The AHC model aims to test whether systematically bridging the gap between routine clinical care and community-based resources will help reduce health-related expenditures, improve health outcomes and reduce disparities. It also integrates and applies information captured in EPIC and external data systems to identify eligible participants, customize services and deliver assistance consistently.

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