Community Service Navigation Helped Reduced Emergency Department Use

The CMS Accountable Health Communities (AHC) Model reduced emergency department (ED) use for Medicare and Medicaid beneficiaries but did not help resolve health-related social needs (HRSNs) issues as the model intended, an evaluation report found.

CMS Launched the AHC Model in 2017 to determine if connecting Medicare and Medicaid beneficiaries to community resources and addressing HRSNs could improve health outcomes and reduce costs.

The CMS Innovation Center funded bridge organizations that implemented the model in communities through collaboration with clinical delivery sites, community service providers, state Medicaid agencies, and other stakeholders. The model’s five-year period ended in April 2022, but 18 organizations received extensions to continue the model for an additional three to 12 months.

Beneficiaries were eligible for navigation services under the model if they had one or more of the five core HRSNs—housing instability, food insecurity, problems with transportation, difficulties with utilities, and interpersonal violence—and self-reported having two or more ED visits in the 12 months before screening.

Bridge organizations participated in one of two tracks. The Assistance Track tested if navigation assistance connecting beneficiaries with community services led to increased HRSN resolution and lower healthcare spending and use. The Alignment Track tested whether navigation assistance combined with stakeholder engagement in continuous quality improvement helped improve outcomes.

Between 2018 and 2021, bridge organizations screened over one million Medicare and Medicaid beneficiaries. Nearly 40 percent of beneficiaries had at least one HRSN and half of those had two or more ED visits during the year before screening.

Food insecurity (63 percent) and housing instability (47 percent) were the most common needs reported by beneficiaries. Less than 40 percent of beneficiaries reported transportation problems (37 percent), utility difficulties (30 percent), and interpersonal violence (4 percent).

The AHC Model reduced ED use among Medicaid and fee-for-service Medicare beneficiaries in the Assistance Track, the evaluation report found. Compared to beneficiaries in the control group who were not offered navigation, Medicare beneficiaries saw an 8 percent reduction in ED visits and Medicaid beneficiaries saw a 3 percent reduction.

The lower ED use among Medicare beneficiaries was driven by a 9 percent reduction in avoidable ED visits that were considered nonemergent or preventable through better ambulatory care.

The report revealed that total expenditures and other hospital-based utilization decreased among Medicaid and Medicare beneficiaries in the Assistance and Alignment Tracks, but the outcomes were not statistically significant.

While the ACH Model helped reduce ED use, it did not necessarily help beneficiaries access community services or resolve HRSN issues. More than three-quarters of eligible beneficiaries (77 percent) accepted navigation services.

However, more than half of beneficiaries neither connected with a community service provider nor had any HRSNs resolved. A lack of transportation, ineligibility for services, long waitlists, and a lack of resources kept beneficiaries from accessing community services.

Among beneficiaries with more than one HRSN, 38 percent had at least one HRSN resolved, while 20 percent had all of their needs resolved. Meanwhile, 11 percent of beneficiaries were connected with a community service provider but did not have any of their needs resolved.

Although the AHC Model did not increase HRSN resolution, navigation services may influence beneficiaries in ways that change healthcare utilization, CMS said.