Published on April 19, 2017

Reading Health System Receives Federal Grant to Test Care Model that Bridges Gap Between Medical Care and Social Services For Medicare and Medicaid Patients


Reading Health System recently received a $4.5 million federal grant that positions the health system as a "hub" that will help bridge the gap between medical care and social services for local Medicare and Medicaid patients.

Reading Health is one of 32 organizations across the country to receive a Centers for Medicare & Medicaid Services (CMS) grant to help test the federal agency's Accountable Health Communities (AHC) care model. The model is designed to increase Medicare and Medicaid beneficiaries' access to and awareness of available services and to ensure that community partners are aligned to provide patients with necessary services and support.

"We look forward to working with local partners to help bridge this gap in our community," said Desha Dickson, Director, Community Health & Engagement Reading Health System. "The goal is to enhance Medicare and Medicaid patients' health by identifying their unmet social needs and aligning them with agencies that can provide those services."

Reading Health has partnered with the Berks Community Health Center and numerous community social service agencies to create the Berks Accountable Health Communities Consortium.

Under the five-year pilot program, Reading Health and the Berks Community Health Center will offer a quick survey to Medicare and Medicaid patients who receive medical treatment. If a patient's answers indicate they have unmet social needs, a Reading Health team comprised of care navigators and community health workers - who will be specifically dedicated to this initiative - will work to link patients with the appropriate social services.

The pilot program begins on May 1, 2017. Reading Health will formulate its processes and procedures during the first year, and then survey distribution and work with patients will begin in Spring 2018. The care model is divided into three areas of work - Alignment Track, Assistance Track, and Awareness Track. Reading Health is one of 20 organizations named to the Alignment Track. Twelve organizations were chosen for the Assistance Track, and Awareness Track grant recipients will be named this summer.

Studies show that patients' medical outcomes are better when social needs such as housing stability, food availability and transportation are met. The AHC care model is intended to improve Medicare and Medicaid patients' health while reducing costs associated with emergency care or hospitalizations.