April 7, 2017

United Way of Greater Cleveland receives $4.51 million grant to implement social service assessment with four clinical partners, including St. Vincent Charity Medical Center

United Way of Greater Cleveland received a $4.51 million grant from the Centers for Medicare and Medicaid Services (CMS) to establish the Accountable Health Communities (AHC) Model.

Four clinical partners will adopt the model designed to connect patients with social service 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, 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 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, 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.


Read more in The Plain Dealer:

United Way 2-1-1, four local hospitals to connect patients to social services with CMS grant

By Brie Zeltner, The Plain Dealer on April 12, 2017 at 5:00 AM

CLEVELAND, Ohio--Starting in about a year, United Way of Greater Cleveland will begin deploying its 2-1-1 specialists into seven area hospitals and health clinics to offer low-income patients screening for social service needs such as housing, food and transportation.

With a $4.5 million, five-year grant from the Centers for Medicare and Medicaid Services (CMS), United Way will partner with the Cleveland Clinic, MetroHealth, St. Vincent Charity Medical Center and Care Alliance Health Center to screen 75,000 patients a year and connect them to community resources.

It's part of a federally funded effort called Accountable Health Communities that's testing whether systematically screening for, identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries will reduce health care costs and use of the healthcare system.

"If you have people who have these social service needs -- lack of food or housing, or if you can't keep the lights on -- you can't really focus on healthcare outcomes," said Helen Forbes Fields, United Way vice president of community impact and general counsel. "If we address these things, hopefully we'll see a correlation with reduced healthcare costs."

2-1-1 is a free, confidential helpline and website supported by United Way affiliates nationwide that connects people by referral to health and human services, 24 hours a day, seven days a week. United Way of Greater Cleveland's help center answers more than 200,000 calls a year.

"A significant amount of a person's health is influenced by what happens outside the healthcare setting," said Dr. Brian Donley, Cleveland Clinic chief of staff. "That's why this is so important."

The service will be available to Medicare and Medicaid recipients who are residents of Cleveland, East Cleveland and Warrensville Heights, which have high poverty levels. Partner hospitals and clinics include:

-- 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;

-- Care Alliance Health Center's Central Neighborhood Clinic.

Over the next year, the partners will prepare for a May 2018 launch, said Diane Gatto, United Way's 2-1-1 director. Twelve 2-1-1 help center specialists will be dedicated to the program, with eight deployed to the clinic sites to meet with and screen high-risk patients face to face.

High-risk patients are those who have self-reported two or more emergency department visits in the past year.

CMS provided the screening questions, Gatto said. The same questions will be used by 31 other grantees nationwide, including Ohio's only other recipient, The Health Collaborative in Cincinnati.

The service is similar to a small pilot called Health Leads launched about a year ago in a few pediatric and prenatal care offices at University Hospitals. There, patients are connected to community resources by a staff of 24 student volunteers.

One of the big differences between that pilot program and the current CMS-funded grant is the scale, Gatto said. To receive funding, the hospitals had to collectively commit to screening 75,000 patients a year.

Hyland Software of Westlake will provide technical assistance to the partners to help integrate the social service questionnaire, referrals and follow-ups into a patient's electronic health record. Doctors will be able to see the information and use it in their care, Gatto said.

"Most of the time this type of work happens by referral," she said. "This is systematic screening. It's a tremendous effort and a credit to the clinical partners that they recognize the importance of these things to a person's wellness."

Most healthcare providers have long known these "unmet social needs" have a huge impact on the health of their patients, said Tracy Carter, MetroHealth's senior director of state and federal government relations.

"We know we can do better in supporting these populations," Carter said. MetroHealth had been working with United Way 2-1-1 to create a similar partnership before the CMS grant opportunity was announced.

"Right now, the social service is something we tend to do after the care delivery process," Carter said. "This makes sure that 2-1-1 and our social services are at the table from the start so that there's an increased chance of them getting the support they need."

A patient with asthma, for example, who lives in a home with mold, dust and cockroach allergens, will have fewer asthma attacks and hospitalizations if the home is healthy and safe, Carter said.

"Healthcare has been very focused on disease treatment, and this allows us to work on prevention and keeping people healthy so that they don't even need to come into the hospital," Donley said. "It's been frustrating when it's been difficult to get patients the resources they need. This is exciting for doctors and healthcare providers to have this opportunity."

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