Advisory Council April 2017 Meeting Presentation: Clinical Services Subcommittee Update



Monday, April 17, 2017

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Clinical Services Subcommittee Federal Update

Ellen Blackwell, MSW

Accountable Health Communities (AHC) Model

  • In April CMS announced the Assistance Track and Alignment Track participants ("bridge organizations") for the AHC Model
  • The model tests if identifying and addressing health-related social needs through referral and community navigation services will impact health care costs, reduce inpatient and outpatient health care utilization, and improve health care quality and delivery
  • The foundation of the Model is universal, comprehensive screening for health-related social needs of community-dwelling beneficiaries accessing health care at participating clinical delivery sites
  • The Assistance Track will provide person-centered community service navigation services to assist high-risk beneficiaries with accessing needed services.
  • The Alignment Track will also provide community service navigation services, and encourage community partner alignment to ensure that needed services are available and responsive
  • Bridge organizations will start in the model in Spring, 2017 and end in 2022 Information at:


(Strategy 2.F)

National Partnership to Improve Dementia Care in Nursing Homes

(Strategy 3.D)

Geriatric Competent Care Series

  • The Medicare Medicaid Coordination Office (MMCO) in held two new webinars for its Geriatric-Competent Care series in February and March
  • The Integrated Care Resource Center helps health professionals in all settings and disciplines expand their knowledge and skills in the unique aspects of caring for older adults with Alzheimer's disease and in working with their caregivers
  • The first two Webinars were on 1) Applying Promising Practices To Advance Care Of Medicare-Medicaid Enrollees With Dementia, and 2) Beyond Alzheimer's Disease -- Other Causes Of Progressive Dementia In The Older Adult
  • A third Webinar on Parkinson's Disease diagnosis is upcoming:


(Strategy 3.A)

Comprehensive Primary Care Plus Update

  • CPC+ is a national advanced primary care medical home model through CMS's Innovation Center that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation
  • Starting in January 2017, CPC+ supports 2,891 primary care practices of 13,090 clinicians serving more than 1.76 million Medicare beneficiaries in fourteen diverse regions
  • CPC+ has three payment elements: a care management fee, a performance-based incentive payment, and payment under the Medicare Physician Fee Schedule
  • CPC+ just closed a solicitation of for Round 2, which begins in January 2018


Information at:

(Strategy 2.A)

CPC+ Payment for Dementia

Comprehensive Primary Care Plus document screen shot

Medicare-Medicaid Financial Alignment Initiative Issue Briefs

  • In March CMS announced three issue briefs on the evaluation of the Medicare-Medicaid Financial Alignment Initiative
  • The Financial Alignment Initiative is designed to provide Medicare-Medicaid enrollees with a better care experience and to better align the financial incentives of the Medicare and Medicaid programs

The briefs are on:

(Strategy 2.D)

Connected Care Initiative

  • In March CMS and HRSA introduced Connected Care to raise awareness of the benefits of chronic care management services for Medicare beneficiaries with multiple chronic conditions and provide support to implement CCM
  • Connected Care is a nationwide effort in fee for service Medicare that includes a focus on racial and ethnic minorities as well as rural populations, which have higher rates of chronic disease
  • Some new resources include a toolkit for providers, a partner toolkit with resources/activities, and beneficiary education, including a poster/postcard

Information at:

(Strategy 3.A)


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