Bridging the gap between health care and social services

Poverty rates in Greater Cleveland have been on the rise. According to a community assessment executed by United Way of Greater Cleveland, in partnership with Case Western Reserve and The Center for Community Solutions, “About 78 percent of the county’s residents living at 200 percent or less of the Federal poverty level reside in Cleveland or the inner-ring suburbs.”

These staggering statistics are growing and affecting people in our community in many ways, particularly those who receive Medicare and Medicaid. Cleveland with a poverty rate of 36 percent, East Cleveland at 42 percent and Warrensville Heights at 19 percent have 209,000 residents who are Medicare and Medicaid beneficiaries.

Poverty is not just low-income individuals and families. It is those in need of health care and basic needs support. In many cases, there is a disconnect between health care and social services, making it challenging for folks on Medicare and Medicaid beneficiaries to identify holistic solutions that best work for them, their families and caregivers.

Addressing the need

As a result of this gap in services, United Way applied for a grant through the Centers for Medicare and Medicaid Services (CMS) to establish the CMS Accountable Health Communities (AHC) Model in 2016. With the support of four clinical partners – Cleveland Clinic for primary care and emergency health service, MetroHealth for primary care, emergency health and labor and delivery service, St. Vincent Charity Medical Center for behavioral health service and Care Alliance Health Center for primary care, United Way was able to attain a multi-million dollar grant yesterday to implement the model.

“Creating an AHC in Greater Cleveland will allow our health system to build a bridge and holistically assess a patient’s wellbeing and refer them to proper health care and social service agencies to address basic needs such as housing instability and food insecurity,” said United Way President and CEO August Napoli.

Next steps

Over a five-year period, the grant will be used to embed United Way 2-1-1 community resource navigation specialists into seven Cleveland Clinic, MetroHealth, St. Vincent Charity Medical Center and Care Alliance Health Center sites. The grant will create and support community partnerships for technology, workflow design, evaluation and planning. Additional dollars will be utilized for necessary equipment and supplies.

An AHC is a CMS model to address the health-related social needs of Medicare and Medicaid beneficiaries through assessment, referral and community navigation services, leading to improved care delivery, enhanced quality of care, reduction of the total cost of care and inpatient and outpatient health care utilization.

Patients receiving health care at Cleveland Clinic South Pointe Hospital; MetroHealth’s Main Campus, Broadway Health Center, Old Brooklyn Health Center and Thomas F. McCafferty Health Center; St. Vincent Charity Medical Center and Care Alliance Health Center’s Central Neighborhood Clinic will be screened for health-related social and basic needs such as housing instability and quality, food insecurity, utility needs, violence and transportation barriers. The screening will be followed by a community resource assessment and referral from United Way 2-1-1 community resource navigation specialists.

“United Way 2-1-1 is a free and confidential 24/7 help center with a robust database of more than 4,000 organizations, providing nearly 25,000 services in our area,” said United Way 2-1-1 Director Diane Gatto. “Our specialists will create a customized plan to address patients’ health-related social needs and then follow up to ensure the patient is able to implement the plan.”

The grant also allows for a one-year planning and training period to finalize the intervention, organize and structure the advisory committee as well as hire and train staff, beginning May 2017. Starting in May 2018 through May 2021, the AHC will aim to serve 75,000 or more Medicaid and Medicare beneficiaries per year.

Note: Read our press release for more information on the CMS grant award.

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