HQI Awarded Grant to Connect Patients with Community Support

April 17, 2017

Health Quality Innovators (HQI) has been awarded a five-year, $4.5 million grant by the federal Centers for Medicare & Medicaid Services to address some of the upstream factors that contribute to poor health. The funds will support the creation of an Accountable Health Community, in which health care providers will annually screen more than 75,000 patients with Medicare or Medicaid for unmet basic needs, and will connect them to local agencies and organizations that can help.

“I am very pleased there will be an Accountable Health Community here in the Richmond region,” said Mayor Levar M. Stoney. “This innovative initiative will help establish the value and benefits of linking clinical care and community services for many of our citizens, supporting a healthier city.”

The Metro Richmond Accountable Health Community will initially focus on food, housing, non-medical transportation, utilities and interpersonal violence. When patients go to a participating hospital, behavioral health clinic or primary care practice to receive care, they will be offered the opportunity to participate in the screening process.

Patients with one or more unmet health-related social needs will be given an individualized referral to such resources as food pantries and utility assistance programs. Those with unmet needs who report visiting an Emergency Department two or more times in the last 12 months also will be given the option of working with a trained navigator who will help them complete their referrals.

“When people do not have healthy food or a stable, safe place to live, they cannot manage their health. It places them at higher risk for chronic disease and increases health care costs,” said Donald A. Glozer, MHA, FACHE, president and chief executive officer of HQI. “We are excited about this opportunity to bring Richmond together to improve the health of our region and the lives of our most vulnerable citizens.”

By connecting patients to community supports for health-related social needs, the Metro Richmond Accountable Health Community expects to reduce avoidable hospital readmissions and Emergency Department utilization. It also hopes to build a sustainable model for clinical-community connections that can be spread to other parts of the region and state.

As the community’s bridge organization, HQI and its partner, the Institute for Public Health Innovation, will coordinate the efforts of multiple health care delivery and community service organizations in the City of Richmond, Chesterfield, Hanover and Henrico. Participating clinical sites include Bon Secours’ four Richmond-area hospitals, the Bon Secours Medical Group, Capital Area Health Network, Richmond Behavioral Health Authority, Richmond City Health District, The Daily Planet, and VCU Medical Center’s Hospital and Clinics. Among the community organizations that have already committed to participation are Better Housing Coalition, FeedMore, Senior Connections, VanGo, Virginia Supportive Housing and YWCA Richmond.

The Metro Richmond Accountable Health Community will be guided by an advisory board that will help identify and fill gaps in community resources. In addition to health care and community service providers, members will include patients, family caregivers, and representatives from local government, the Virginia Department of Medical Assistance Services and the Virginia Department of Aging and Rehabilitative Services.

HQI is one of 32 organizations across the country – and the only awardee based in Virginia – to receive funding from the CMS Center for Medicare and Medicaid Innovation to implement the Accountable Health Communities Model.

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