CMS puts $120 million into bridging gaps between clinic and community (Modern Healthcare)

What happens after a patient leaves the doctor's office is just as important, if not more so, as what takes place during the visit itself. But bridging that gap between the clinic and community is a major challenge for healthcare and community providers alike.

In an effort to close the divide, the CMS Innovation Center said Thursday it will give up to $120 million to 32 organizations selected to participate in its Accountable Health Communities model. Over five years, the groups will serve as test hubs helping Medicare and Medicaid beneficiaries with health-related social needs including housing instability, food insecurity, domestic violence and transportation.

The three-track model aims to reduce unnecessary healthcare utilization in order to drive down spending, while also improving outcomes and quality of care for patients. Model participants will work to improve community-clinical collaboration by screening beneficiaries for unmet social needs, referring them to the right services or helping them navigate and access those services. They also work to ensure that community services are available and responsive to beneficiaries.

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