Mountain States chosen to lead new, innovative program aimed at improving the health of communities in Virginia

$2.5 million, five-year grant from U.S. Department of Health & Human Services will fund the collaborative

JOHNSON CITY, Tenn. – Mountain States Health Alliance is one of only 32 organizations in the country that were chosen recently to be part of the U.S. Centers for Medicare & Medicaid Services’ (CMS) new program aimed at improving the health of Medicare and Medicaid beneficiaries.

The new program – CMS’ Accountable Health Communities (AHC) Model – will seek to improve the overall health of Medicare and Medicaid beneficiaries by helping to address patients’ health-related social needs. The program seeks to bridge the gap between clinical and community service providers to address issues such as housing instability, food insecurity, utility needs, interpersonal violence and transportation.

Mountain States will serve as the bridge organization for the project locally, leading a collaborative with multiple other organizations and care sites to bring the needed services to beneficiaries who live in Southwest Virginia. The collaborative includes:

  • Eight inpatient facilities and 12 physician offices of Mountain States;
  • Five inpatient facilities and 15 physician offices of Wellmont Health System;
  • Frontier Health;
  • Cumberland Mountain Community Services Board;
  • Dickenson Behavioral Health Services;
  • Highlands Community Services Board;
  • Mount Rogers Community Services Board; and
  • Planning District One Behavioral Health Services.

The Virginia Department of Medical Assistance Services (DMAS) – the office that administers the Medicaid program in Virginia – will also partner in the program by providing data that will help CMS measure the program’s effectiveness. Because the data is so important in the overall success of the initiative, bridge organizations had to obtain letters of support from their state Medicaid agency in order to be eligible for the federal grant. DMAS committed to supporting the Mountain States-led project locally.

“We’re excited about the opportunity this program presents for our region, and we believe it has the potential to make a meaningful impact on the health of our community,” said Allison Rogers, vice president of strategic planning for Mountain States and project director for the $2.5 million grant. “We hope that by showing success in this groundbreaking demonstration, we can lay a foundation for future investment by CMS in services designed to address the social determinants of health.”

The U.S. Centers for Disease Control and Prevention estimate that as much as 75 percent of a population’s health is directly impacted by social determinants of health, including education, socioeconomic status, housing and transportation, food, access to care, and community support systems. By addressing critical drivers of poor health and high health care costs, the AHC model aims to reduce avoidable health care utilization, reduce the cost of health care, and improve health and quality of care for Medicare and Medicaid beneficiaries.

The AHC model provides federal funding to Mountain States to hire seven patient navigators, along with additional support staff, who will be located at community services boards throughout Southwest Virginia. The navigators will help coordinate access to the needed services – like housing, food or mental health services – for the beneficiaries.

To be selected for the program, Medicare and Medicaid beneficiaries who live in Virginia will receive a brief screening, which will take place at the participating primary care offices as well as in the emergency rooms, labor and delivery departments and inpatient behavioral health units at participating Mountain States and Wellmont hospitals. Patients who qualify will be randomly selected by CMS to receive navigation services specifically funded by the grant.

CMS, in conjunction with DMAS, will then evaluate data on the patients’ ongoing health status and healthcare service utilization to measure how the beneficiaries’ health improves when social needs are met.

“This type of community collaboration is a good first step toward improving the region’s health by addressing social determinants, but it is by no means the totality of what is needed in our region,” said Tony Keck, senior vice president and chief development officer for Mountain States. “A federal investment of $2.5 million over five years is a good start, but it pales in comparison to the $450 million over 10 years that Mountain States and Wellmont would be able to invest in the region’s health if permitted to merge. Separately, we can combine select resources with the help of federal funding, but together we will be able to do so much more.”

The initiative began on May 1, 2017, with a five-year performance period.

The participating Mountain States facilities are Dickenson Community Hospital, Indian Path Medical Center, Johnson City Medical Center, Johnston Memorial Hospital, Norton Community Hospital, Russell County Medical Center, Smyth County Community Hospital and Woodridge Psychiatric Hospital. The participating Wellmont facilities are Bristol Regional Medical Center, Holston Valley Medical Center, Lonesome Pine Hospital, Mountain View Regional Medical Center and Ridgeview Pavilion. Hospitals and physician clinics were chosen to participate based on the number of Virginia Medicare and Medicaid beneficiaries they serve.

About Mountain States Health Alliance:

Since 1998, Mountain States Health Alliance has been bringing the nation’s best health care close to home to serve the residents of Northeast Tennessee, Southwest Virginia, Southeastern Kentucky and Western North Carolina. This not-for-profit health care organization based in Johnson City, Tenn., operates a family of 13 hospitals serving a 29-county region. Mountain States offers a large tertiary hospital with a level 1 trauma center, a dedicated children’s hospital, several community hospitals, two critical access hospitals, a behavioral health hospital, two long-term care facilities, home care and hospice services, retail pharmacies, outpatient services, and a comprehensive medical management corporation. The team members, physicians and volunteers who make up Mountain States Health Alliance are committed to caring for you and earning your trust. For more information, visit

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