The Health Collaborative (THC) is a non-profit organization based in Cincinnati that strives to positively impact health status, experience, outcomes, and affordability by fostering a connected system of healthcare and community health through innovation, integration, and informatics in the Greater Cincinnati region and beyond. Its HealthBridge service line serves more than 30 hospitals and 7,500 physicians in Southwest Ohio as well as parts of Indiana and Kentucky.

Through its application for the Accountable Health Communities (AHC) model, THC and its local community partners seek to assist the Center for Medicare & Medicaid Innovation (CMMI) to test whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries’ impacts total health care costs, improves health, and enhances the overall quality of care. An integral part of THC’s proposed approach is a comprehensive and integrated technology platform that meets the requirements of Track 3 of the AHC model:

  • Screening of community-dwelling beneficiaries to identify certain unmet health-related social needs;
  • Real-time referral of community-dwelling beneficiaries to community-based service agencies;
  • Closed-loop navigation services to ensure appropriate disposition of referrals made to high-risk beneficiaries; and
  • Performance monitoring (both at the beneficiary and agency level) to inform community quality improvement efforts

The Health Collaborative’s Accountable Health Community application will cover roughly 400,000 Medicare and Medicaid beneficiaries and will include 1 bridge organization and approximately 20-25 sites (a combination of clinical delivery, navigation, and community service providers) with an estimated 100 named system users. THC seeks respondents to this RFI with a proven track record of developing and updating an electronic resource inventory of available community service organizations, managing a patient-centric referral process between clinical and community-based settings, and integrating with resident technology solutions in a variety of care settings (i.e., electronic health records, health information exchange, client relationship management systems, etc.).

To meet the deadline for the initial approval, all responses to this RFI must be received electronically by 1:00 PM (EDT) on February 26, 2016. Completed responses to the RFI should be sent to Keith Hepp, CFO & SVP of Business Development, at Click the block below to download the RFI.

Questions on this RFI should be directed to

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