Cleveland (April 7, 2017) United Way of Greater Cleveland received a $4.51 million grant from the Centers for Medicare and Medicaid Services (CMS) to establish the CMS Accountable Health Communities (AHC) Model. Four clinical sites will adopt the model designed to connect patients with health-related resources – 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 is one of only two organizations selected in the state of Ohio and one of 32 selected nationally.

“Currently, there’s a disconnect between healthcare and social services,” said United Way President and CEO August Napoli. “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.”

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.

“In this model, we will support community-based innovation to deliver local solutions that address a broader array of health-related needs of people across the country,” said CMS Deputy Administrator for Innovation & Quality Dr. Patrick Conway. “As a practicing pediatrician, I know the power of a model like this to help address the health and social support needs of beneficiaries and their families and caregivers.”

Over a five-year period, the $4.51 million 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.  

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; these cities were selected as the AHC service areas.

Patients receiving health care at Cleveland Clinic South Pointe Hospital; MetroHealth’s Main Campus, Broadway Health Center, 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 with more than 4,000 organizations, providing nearly 25,000 local 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 AHC grant allows for United Way to organize an advisory committee comprised of partners, including clinical sites Cleveland Clinic, MetroHealth, St. Vincent Charity Medical Center and Care Alliance Health Center, along with Better Health Partnership, CareSource, Case Western Reserve University’s Center for Reducing Health Disparities and Center on Urban Poverty, Cuyahoga County Board of Health, Hyland, Creator of OnBase and Ohio Department of Medicaid.

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. Starting in May 2018 through May 2020, the AHC will aim to serve 75,000 or more Medicaid and Medicare beneficiaries per year.

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United Way of Greater Cleveland is committed to addressing the effects of poverty throughout our community. Through the work of our 128 funded programs and the generosity of our community, United Way strives to ensure families and individuals are healthy and financially stable; our children are well educated and on the road to reaching their greatest potential and even those carrying tremendous burdens are safe and provided with resources to become self sufficient. For more information, visit www.UnitedWayCleveland.org.