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Release Date: 04/13/2017

Integra Community Care will serve as local bridge organization linking clinical and community services.

Care New England (CNE) announced it has been selected by the Centers for Medicare & Medicaid Services (CMS) as the recipient of one of only 32 national Accountable Health Communities model grants, awarding an anticipated $3.9 million for the five-year initiative focused on ensuring high-risk Medicare & Medicaid patients have access to high-quality health care services while also achieving cost savings.

The Integra Community Care Network, an accountable care organization comprised of CNE, Rhode Island Primary Care Physicians Corporation and South County Health, will serve as the bridge organization for the Integra Accountable Health Communities (AHC) Partnership in collaboration with a broad, statewide network of clinical providers, community service organizations, academic institutions and governmental partners. Clinical sites will include Memorial Hospital, Women & Infants Hospital, Butler Hospital, South County Health, The Providence Center, CODAC Behavioral Health and CCAP Health Center.

Through the cooperative agreement, qualifying patients will be screened for specific health-related social needs at each clinical site. Participants will be screened for needs in the following core areas: housing, food insecurity, transportation, interpersonal violence, and utility needs. Additionally, participants will be screened for needs in the supplemental areas of substance use/addiction and independent living/caregiver support.

“The Accountable Health Communities model is a patient-centered approach that addresses the gap between clinical care and community support services to improve overall health. By bringing the clinical and non-clinical sides together and making preventive investments, this program can help at-risk patients lead healthier lives and achieve significant cost savings for taxpayers,” said Senator Jack Reed.

“The selection of Care New England to participate in this initiative is another win for Rhode Island. This will enable Integra to connect Rhode Islanders to resources in the community that go beyond their medical needs, helping with things like housing and transportation,” said Senator Sheldon Whitehouse. “Congratulations to Care New England on this award.”

“I applaud Care New England and their community partners for being awarded this $3.9 million cooperative agreement, which will empower providers to take a more holistic and innovative approach to patient care,” Congressman Jim Langevin said. “By addressing both the medical and social needs of patients, this five-year initiative has enormous potential to improve the health of Rhode Islanders while also lowering the overall cost of care.”

"I’m pleased to announce this federal funding that will preserve access to quality health care here in Rhode Island," said Congressman David Cicilline. "This important initiative will help lower costs and improve quality of care. This is a smart investment that will make a real difference in the lives of hardworking Rhode Islanders."

The overarching goal of the initiative is to impact the cost of health care and reduce avoidable health care utilization.

“Rhode Island is an ideal location to undertake this initiative because of our deep commitment to population health and to reaching beyond the traditional medical context to address health-related social needs,” said Dennis Keefe, president and CEO of Care New England. “Care New England, Integra and all of the partners provide a strong platform upon which to build and test the AHC program in cooperation with CMS.”

In addition to screening and navigation, the initiative will seek to increase Rhode Island Medicare and Medicaid beneficiaries’ awareness of community resources available to address unmet health-related social needs and improve statewide capacity to address health-related social needs through quality improvement, data collection and alignment of community-based resources.

“By addressing critical drivers of poor health and high health care costs, the model aims to reduce avoidable health care utilization, impact the cost of health care, and improve health and quality of care for Medicare and Medicaid beneficiaries,” said James Fanale, MD, executive vice president and chief clinical officer for Care New England and chief clinical officer for Integra. “The key to the success of this initiative is that everyone remains focused on ensuring that the necessary services and supports are available and responsive to the beneficiaries’ needs.”

This initiative will be overseen by an Advisory Board with representation from all members of the Integra AHC consortium. Alignment and integration of community resources will be led by a Community Services Council of major statewide organizations representing the core social determinant areas, including Rhode Island Coalition for the Homeless, Childhood Lead Action Project, RI Community Food Bank, Rhode Island Public Transit Authority, RI Coalition Against Domestic Violence, Rhode Island Community Action Coalition, among others.

“We look forward to working with a broad array of community partners to build a robust system for identifying and addressing the social needs of our patients,” said Garry Bliss, program director, Integra Medicaid Accountable Entity. “By integrating health care with critical services available in their community, we will improve the health and quality of life of those we serve.”

Patients participating in this initiative who are deemed “high-risk” will receive community service navigation assistance, to be conducted by specially trained navigators. Training and on-going technical assistance for the navigators will be provided by United Way 2-1-1. HealthLeads will serve as an advisor to the project based on their experience linking patients with social services.

The Accountable Health Communities Model is authorized under Section 1115A of the Social Security Act, which established the Innovation Center to test innovative payment and service delivery models to reduce Medicare, Medicaid, and Children’s Health Insurance Program expenditures while maintaining or enhancing the quality of beneficiaries’ care.

For more information about the Accountable Health Communities Model, visit:

About Care New England

Care New England was founded in 1996, and is the Providence, RI-based parent organization of Butler Hospital, Kent Hospital, Memorial Hospital of Rhode Island, Women & Infants Hospital of Rhode Island, the VNA of Care New England, The Providence Center, CNE Wellness Center and Integra, a certified ACO created in collaboration with the Rhode Island Primary Care Physicians Corporation. Care New England includes 970 licensed beds and 216 infant bassinets. Through Butler, Memorial and Women & Infants, Care New England has a teaching and research affiliation with The Warren Alpert Medical School of Brown University. Kent is a teaching affiliate of the University of New England College of Osteopathic Medicine.

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