Accountable Health Communities (AHC) sets foundation for ORPRN’s leadership to address Unmet Social Needs

The ORPRN Accountable Health Communities (AHC) project wrapped up in 2021. Led by Bruce Goldberg, MD and Anne King, MBA, this five-year program would lead to fundamental shifts in ORPRN's focus through development of the Health Policy Program and a strong emphasis on work that addresses the social determinants of health and equity in Oregon and nationally.

The Oregon AHC project was one of 28 nationally funded by the Centers for Medicare and Medicaid Services (CMS) and designed to address a critical gap between clinical care and community services in the current health care delivery system. AHC tested whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services would impact health care costs and reduce health care utilization.

Nancy Goff, ORPRN’s Director of Health Policy notes that the AHC work at ORPRN led directly to ORPRN providing leadership in developing the statewide social determinants of health incentive metric. (Incentive metrics are a measuring tool that the Oregon Health Authority uses to show how well Coordinated Care Organizations are improving care, making quality care accessible, eliminating health disparities, and curbing the rising cost of health care for their Medicare and Medicaid patients.) ORPRN had a hand in convening dozens of partners to collaboratively draft the metric and create guidance documents and webinars to help with implementation.

AHC design also led to ORPRN’s partnership with the Oregon Health Authority to implement several Medicaid spending flexibilities that allow Coordinated Care Organizations to use health care dollars to invest in community health. Goff explains that both Health-Related Services (HRS) and Supporting Health for All through Reinvestment (SHARE) are part of a trend of rolling healthcare dollars back into communities and figuring out based on both evidence and community-defined priorities where that money would make the most impact. 

ORPRN collaborates with OHA to do annual analyses of HRS and SHARE spending and provide support to CCOs on their program. “What’s exciting about the mandate [that created the SHARE program] is that projects need to have a role for community advisory councils that include representatives from local communities, including Medicaid members,” notes Goff.

Goff says that these initiatives speak to how ORPRN is supporting CCOs on an “upstream approach” that pushes the health system to look at root causes as opposed to symptoms. “Taking on these roles is what has grown our health policy unit. We have an opportunity to look at what the connecting themes are across our programs and how we can be intentional about shaping outcomes."

“Five or ten years ago part of the work in health policy was convincing partners of the idea that social determinants of health have a huge impact on overall health. But in 2023, that idea has become a part of our culture. Now the work is operationalizing that concept."