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5 Key Considerations for Your REACH ACO’s Health Equity Plan

In late December 2022, CMS published the ACO REACH Health Equity Plan Templates, Guide and FAQ, outlining the standards and requirements REACH ACOs must meet in their efforts to address targeted health disparities in underserved communities in their service area. Health Equity is a hallmark ACO REACH initiative and a significant differentiator between the program and its predecessor, GPDC and other CMMI models.

Here are 5 key considerations to include in Health Equity Plans, due to CMS by March 31st, for REACH ACOs looking to successfully establish sustainable programs achieving equitable care.


  1. Health Equity Goal Establishment
    1. Establish Health Equity Goals that are aligned with your REACH ACO’s goals to lower total cost of care and achieve shared savings
      1. Goals that align with shared savings include care & medication accessibility, food security, housing, economic and behavioral health needs
        1. Care and medication accessibility can be impacted by cost of care, transportation, ability to navigate healthcare system, provider, and provider appointment availability
        2. Undiagnosed behavioral health needs may also prevent beneficiaries from accessing the right care at the right place at the right time
  2. Performance Measure Selection
    1. Use HEDIS quality measures to assess your REACH ACO’s progress against Health Equity Goals across calendar years
      1. Leverage Z code utilization metrics to assess progress against Health Equity Goals during the calendar year
      2. Custom metrics may be implemented as needed to reflect the unique needs of a REACH’s community
      3. Leverage CAHPS surveys as confirmation that documented progress against Health Equity Goals are felt by aligned beneficiaries
  3. Evidence-Based Intervention Selection
    1. Choose evidence-based interventions with timeframes that align with your REACH ACO’s goal to achieve shared savings
      1. “Immediate” impacts should generally be seen within 1-2 weeks; these interventions may include removing a beneficiary from an unhealthy or dangerous environment, such as one in which the beneficiary was prone to fall, at-risk of violence or without convenient access to healthy food
      2. “Long term” impacts should be seen in 6+ months, and well before the conclusion of your REACH ACO’s participation in the program; these interventions may include in-home renovations, community outreach programming and increases in home-delivered meals and nutritional preparation webinars
  4. ROI Optimization
    1. Optimize your REACH ACO’s Health Equity ROI by investing in Benefit Enhancements, Beneficiary Engagement Incentives and In-Kind Incentives with the initiatives that address targeted health disparities in underserved communities
      1. For example, if total cost of care for your REACH ACO’s population is heavily influenced by the diabetic population, vouchers for meal programs, a potential in-kind service referenced in the ACO REACH RFA, may align with your REACH ACO’s health equity goals
  5. Outreach to Underserved Communities
    1. Align your marketing activities with the needs of beneficiaries in underserved communities
      1. Conduct community-based activities in underserved communities
      2. Provide culturally competent food at marketing events
      3. Produce materials in multiple languages


To learn about how we can help you with ACO REACH, contact info@copehealthsolutions.com.

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