Accountable Health Communities model launches in South Jersey with a new advisory board

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By Amy Yuen

Last year, the Camden Coalition was selected as one of 32 organizations in the country to implement the Accountable Health Communities (AHC) model, which screens Medicare and Medicaid beneficiaries for a range of health-related social needs and provides them with health and social service navigation. Since then, we’ve been partnering with clinical delivery sites and community service providers serving Camden, Burlington, and Gloucester counties to help us launch our AHC model this coming August. To gear up for the kickoff, we’ve convened an advisory board that will oversee this ambitious effort to transform how whole person care is accessed and delivered in our region.

Accountable Health Communities is a five-year national initiative of the Center for Medicare & Medicaid Innovation that aims to bridge the gap between clinical and community service providers. The AHC model is designed to address a range of health-related social needs among Medicare and Medicaid beneficiaries: housing instability, food instability, utility needs, interpersonal violence, and transportation. A growing body of evidence has shown that unmet social needs prevent individuals from living the healthiest life possible. By enhancing community partnerships across these counties through this model, we seek to improve health outcomes, cut healthcare costs, and decrease high rates of hospitalization and emergency room visits among patients with complex needs in South Jersey.

“Our healthcare system is not set up for providers to address the social service needs that can lead to poor health,” said our CEO Kathleen Noonan. “The Accountable Health Communities model bridges the gap for many Medicare and Medicaid beneficiaries in South Jersey by connecting clinical and social service providers, and training providers to screen for social factors that can affect health. As a community of caregivers, we can systematically address interrelated medical and social needs in the region and fulfill our responsibility to treat the whole person.”

As strategic advisers for our implementation of the AHC model, members of the new advisory board will analyze gaps in services annually to assess and prioritize community needs and develop a quality improvement plan. They will serve as ambassadors of our model and will have an opportunity to share best practices, align their organizational goals, and coordinate their resources with other providers to address service gaps in the region. The advisory board, which began its quarterly meetings in late May, is comprised of representatives from the New Jersey Medicaid office, local government, clinical delivery sites, beneficiaries and their caregivers, and at least one community service provider from each of the core health-related social needs categories.

A diverse group of organizations serving South Jersey participate on the advisory board, including CAMcare, Cooper University Health Care, Food Bank of New Jersey, Jefferson Health, Logisticare, New Jersey Medicaid, Oaks Integrated Care, Robin’s Nest, Rowan University/Rutgers-Camden Board of Directors, Virtua Health, and Volunteers of America-Delaware Valley.

Priscilla Davis Martin, Program Support Specialist of the New Jersey Medicaid office, said she’s excited about the Camden Coalition’s AHC model and its potential impact.

“Our goal is to identify and address regional barriers of care across our three counties,” said Priscilla. “We believe if we can connect healthcare with agencies providing housing, transportation, food, utilities, and safety, we can really assess what patients need and connect them to those resources. We’re looking to address both the needs of individuals and communities in this process.”

*The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The project described was supported by Funding Opportunity Number CMS 1P1-17-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.

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