Medical Home Network REACH ACO Partners with Community Health Centers in New York and Oklahoma to Improve Care for Medicare Beneficiaries

  • Published On  Apr 25, 2023

Medical Home Network REACH ACO is partnering with community health centers in New York and Oklahoma under CMS’s new ACO REACH model, a value-based payment model with an emphasis on advancing equity, access, and community health. Medical Home Network REACH ACO, which is focused on community health centers, will use the Medical Home Network (MHN) team-based care model to support the efforts of participating ACO providers to improve care delivery and coordination for Medicare beneficiaries in underserved communities.

Patient Care Network of Oklahoma, a clinically integrated network of community health centers, and New York’s The Institute for Family Health and Sun River Health are part of the newly formed Medical Home Network REACH ACO, which is governed and led by its community health center partners.

“The MHN model is closely aligned with the goals of ACO REACH and complements the efforts of community health centers to provide equitable, whole person care,” said MHN President and CEO Cheryl Lulias. “Our approach to team-based care also builds capabilities for value-based arrangements for all populations.”

Care Coordination Builds Patient Trust, Results in Better Care

ACO REACH emphasizes health equity and attention to social determinants of health. Through the MHN model, practice-based care managers help patients navigate the health care system and coordinate care across all venues and settings to help deliver whole person care.

By working closely with a trusted care manager, patients develop a stronger relationship with their primary care medical home. This will ultimately make care less confusing and lead to better overall health.

“We look forward to benefiting from MHN’s model, which is focused on coordinated care for chronic diseases based on a sophisticated risk assessment and interventions for both social determinants of health and clinical needs,” said Dr. Neil Calman, CEO, The Institute for Family Health.

Medical Home Network REACH ACO supports health centers in investing, hiring and developing their care management resources to meet patient needs.

“Sun River Health is committed to evolving our model of care to ensure the best possible resources and results for our patients,” said Anne Kauffman Nolon, MPH, CEO, Sun River Health. “Participation in ACO REACH gives Sun River Health the opportunity to work closely with health centers across the country and share best practices to improve the health of Medicare populations.”

In addition to supporting community health centers in developing care management resources, Medical Home Network REACH ACO also assists health center leadership and clinical staff with training and education as they work to improve care for Medicare beneficiaries.

“With MHN’s care management model and program support we can develop more comprehensive and holistic care for our patients,” said Brian Carter, executive director, Patient Care Network of Oklahoma.

The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.