The Dallas Accountable Health Community: Its Impact on Health-Related Social Needs, Care, and Costs

Abstract

Summary In May 2017, the U.S. Centers for Medicare & Medicaid Services (CMS) launched the Accountable Health Communities (AHC) Model, a 5-year initiative to address a critical gap between clinical care and community services in the current delivery system. The initiative tested whether systematically identifying and addressing the health-related social needs (HRSNs) of Medicare and Medicaid beneficiaries through screening, referral, and community navigation would reduce utilization and health care expenditures. As one of 32 original awardees, the Parkland Center for Clinical Innovation (PCCI) served as an Alignment Track bridge organization. PCCI partnered with 17 clinical sites, representing five Dallas health care systems and more than 100 local community-based organizations (CBOs), to establish the Dallas Accountable Health Community (DAHC). Using a CMS-developed HRSN screening tool, PCCI and its partners screened 12,548 unique Dallas County beneficiaries meeting the criteria for Model eligibility. PCCI and partner community health workers provided 9,161 unique individuals with active navigation services consisting of referrals to aligned CBOs, accompanied by monthly follow-up calls for up to 12 months or until the documented HRSNs were addressed successfully. Over the initiative’s 5-year course, PCCI identified more than 19,000 distinct needs, with 61% of individuals having two or more concurrent needs. Through the referral process, CBOs provided a multitude of support services, including more than 200,000 pounds of food and $540,000 in utility and rent assistance. Results show that actively navigated individuals experienced a greater decrease in per-person ED visits than those in a comparable control cohort, with the navigation cohort having a statistically significant reduction in average ED utilization, both while actively navigated and in the 12 months after navigation. The navigated cohort also demonstrated a greater likelihood to seek — and keep — outpatient visits compared with the control cohort. Although inpatient admissions were reduced within both cohorts, the between-cohort differences were not statistically significant. Not including the CBO-provided intervention costs and using Model year 4 data (May 2020 to April 2021), the DAHC demonstrated a positive ROI of 1.3 to 1 with a gross savings exceeding $1.25 million. The impact analysis accounted for the dynamic, multidimensional Covid-19 impact via an innovative control group matching algorithm. This study demonstrated the nature and scope of HRSNs among a high-risk vulnerable Dallas County population, a positive impact on health care outcomes, and a more muted impact on expenditures using regularly occurring active navigation of engaged beneficiaries. Importantly, the DAHC showed that combining clinical care with appropriate social services to address HRSNs — at the right time and by the right personnel — resulted in lower utilization and a decrease in health care expenditures. These two factors alone argue for the expansion of the initiative to other at-risk populations while establishing the initiative’s long-term sustainability.