How We Help

RVA Community Cares – An Accountable Health Community

RVA Community Cares, an Accountable Health Community (AHC) funded by the Centers for Medicare & Medicaid Services (CMS), is helping beneficiaries overcome these social barriers in the Richmond region. The five-year project connects area residents with the services they need to thrive and improve health outcomes as well as potentially reduce health care costs. RVA Community Cares’ bridge organization, Health Quality Innovators (HQI) coordinates efforts of multiple health care delivery and community service organizations covering Chesterfield County, Hanover County, Henrico County and the City of Richmond.

Clinical Delivery Sites offering screenings to determine eligibility include:

  1. Bon Secours Health System
  2. Bremo Pharmacy
  3. Capital Area Health Network
  4. Daily Planet Health Services
  5. National Counseling Group
  6. Richmond Behavioral Health Authority
  7. Richmond City Health District
  8. VCU Health
Modifiable Factors That Influence Health
Circle graph showing the modifiable factors that influence health, including 10% from physical environment, 20% from clinical care, 30% from health behaviors and 40% from social and economic factors.

“Social and Economic Factors” include education, employment, income, community safety, and family and social support. “Health Behaviors” include tobacco use, diet and exercise, alcohol and substance use, and sexual behaviors. “Clinical Care” includes access to care and quality of care. “Physical Environment” includes environmental quality, housing and transit.

Statistics according to County Health Rankings

Want to be a part of RVA Community Cares?

RVA Community Cares is currently recruiting practices to conduct screenings during clinical visits to identify Medicare and Medicaid beneficiaries in need. These screenings are used to create a customized referral summary that the patient can use to connect with services to assist with their needs. In some cases, patients will be contacted by their own personal navigator. A navigator is a person who will guide the patient to connect with community service providers and follow up with patients to ensure the connection was made.

Click here for additional information to get started.

How We Help Our Community

To encourage alignment between clinical and community services and ensure this vital assistance is available and responsive to the needs of eligible beneficiaries, RVA Community Cares promotes collaboration through three core activities, which include:

  1. A screening tool helps identify certain unmet health-related social needs, which include housing, food, transportation, utilities, and addressing interpersonal safety.
  2. When applicable, screened beneficiaries are offered a tailored community referral summary of local providers that may be able to address each of the needs identified through the screening.
  3. High-risk beneficiaries with unmet health-related social needs are offered navigation services that might assist them in resolving health-related social needs that were identified.

The Role of a Screener

  1. Determine if an individual is a community-dwelling Medicare or Medicaid beneficiary.
  2. Administer the screening tool.
  3. If there are unmet needs, use the resource directory to connect an individual to local community providers.
  4. Offer navigation services to high-risk beneficiaries.

The Role of a Navigator

  1. Conduct personal interviews.
  2. Develop patient-centered action plans.
  3. Perform ongoing follow-up and assistance.
  4. Collect data and document encounters.

Some Qualifications for Participants

  1. A qualified individual must reside in Chesterfield County, Hanover County, Henrico County or the City of Richmond.
  2. A qualified individual must be a community-dwelling beneficiary (i.e., not living in a nursing home, assisted living facility or incarcerated).

RVA Community Cares Goals

  1. Complete at least 75,000 screenings of beneficiaries each year
  2. Reach 51% of the region’s Medicare/Medicaid population in five years
  3. Reduce avoidable emergency department visits
  4. Reduce avoidable admissions/readmissions
  5. Decrease unnecessary use of outpatient services
  6. Reduce total cost of care
  7. Improve the provider and beneficiary experience

CMS Resources

Accountable Health Communities Model Website