Data-Driven Quality Improvement Strategies Highlighted in Accountable Health Communities Model Case Study

The Centers for Medicare and Medicaid Services (CMS) posted a case study describing how St. Joseph’s Hospital Health System (St. Joseph), a participant in an Accountable Health Communities (AHC) Model, leveraged data to implement quality improvements in their screening strategies.

When St. Joseph’s joined the Accountable Health Communities Model, they found that many sites struggled to effectively engage existing registration staff in taking on additional screening responsibilities for the AHC Model, and as a result St. Joseph’s was having difficulty meeting screening targets.

In response, using data monitoring reports St. Joseph’s began to monitor several key screening indicators. They tracked the number of completed screenings over time; and how many eligible beneficiaries entered a screening site, were offered screening, and completed screenings. St. Joseph’s then used this data to optimize staffing and to identify and address reasons for missed offers to screen.

The St. Joseph’s project management team shared the following strategies for enhancing a data-driven quality improvement process which they learned from this experience:

  • Focus on a few simple metrics
  • Make data collection easy and straightforward
  • Take advantage of low-tech analysis tools
  • Use data comparisons strategically
  • Couple data sharing with face-to-face interactions

The Accountable Health Communities Model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries’ through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. It aims to more fully integrate health-related social needs, such as unstable housing and food insecurity, by providing funding for bridge organizations to strengthen clinical-community relationships. While the model does not provide funding for social programs, the goal is to identify best practices to improve clinical outcomes by focusing on upstream health needs. There are currently 30 bridge organizations participating in the model. The anticipated performance period end date is April 2022.



For more information visit the McDermottPlus Payment Innovation Resource Center or contact Mara McDermott at 202-204-1462 or