Accountable Health Communities Track 3 Alignment - Kentucky Consortium for Accountable Health Communities

The AHC model recognizes that social and community-level need factors are key drivers of pervasive health inequalities, contributing to elevated disease burden and healthcare utilization costs among vulnerable populations of Medicaid and Medicare beneficiaries. The CMS Accountable Health Communities track 3 (alignment) model seeks to determine whether providing a combination of tailored community service referrals and patient navigation services assistance, as well as clinical partner alignment at the community level, will yield improvement in patient outcomes, health care utilization and costs. Our proposed 5-year project is designed to reach the most vulnerable populations in the Commonwealth of Kentucky by targeting a diverse range of economically depressed and medically underserved geographic areas across the state and aims to: Address a number of important service gaps, including the absence of a standardized system to universally screen Medicare and Medicaid beneficiaries to identify health-related social needs that can be alleviated through access to targeted services. Develop structural supports to implement evidence-based care at clinical sites to improve health outcomes among our most vulnerable patients and reduce unnecessary utilization. Conduct financial sustainability planning to foster community-wide realignment of resources to more effectively address health-related social needs for those receiving services. Strengthen collaborative partnerships across the state and accelerate the processes of data sharing through technology.