AHCCCS adopts integrated approach to healthcare

Leaders from the Arizona Health Care Cost Containment System (AHCCCS) came together at the 2021 Arizona State of Reform Health Policy Conference to discuss the department’s move towards a more integrated Medicaid system.


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Dana Flannery, Senior Policy Advisor & Assistant Director at AHCCCS, discussed the complexity surrounding an individual’s overall health. Data gathered by the Institute for Clinical Systems Improvement demonstrates that 50% of an individual’s overall health can be traced to their zip code.



Addressing individual health needs requires a holistic approach, says George Jacobson, Project Administrator of Targeted Investments Programs. He says any care provided to an individual must include the whole person.

“You really can’t fragment the person. We’re not a series of body parts and you can’t really divorce the emotional wellbeing and mental health wellbeing from the physical wellbeing. Doing well by doing right is really what we’re shooting for.”

AHCCCS launched its Whole Person Care Initiative in 2019 in an effort to integrate the social determinants of health into their services. This initiative expands on existing programming to include services related to employment, criminal justice, transportation, social isolation, and housing.

David Bridge, Director of Housing Programs at AHCCCS, says addressing homelessness not only improves a person’s overall health but is also financially sustainable. Data gathered by AHCCCS revealed that individuals who had been housed for six months or more saw a 45% reduction in the cost of care overall.

“We documented over a $5000 a month savings per client in reduced costs. The vast majority of those savings were a 30% reduction in emergency room visits…and an 89% reduction in behavioral health residential facility admission.”

Housing is a significant factor in improving a person’s health outcomes, says Bridge, but simply having a place to live isn’t enough.

“Not everybody’s a Medicaid patient, right? Not every homeless person lives in a shelter…and so it really is this collaboration and a willingness to look beyond our silos and work with other systems of care.”

Part of breaking down the barriers to improve health outcomes is the development of a closed-loop referral system, says Flannery. These wrap-around systems rely on technology to ensure that needed social support structures can be made available at every point from identifying a need to satisfying that need. Flannery gives the example of access to food.

“I identify that I need some food and whatever provider I’m working with is going to work to send me somewhere where I can access food…the food loop leans on technology to help us do the referrals, but closes that loop. Did I go pick-up my box? Do I have access to food now?”

Bridge says taking an integrated approach to health care ensures everyone has the opportunity to succeed.

“Seemingly insurmountable barriers…can be resolved when you have a coordinated group of people working together for a common outcome focused on the clients needs…and when just about anyone has those support systems…we can all succeed.”