Subscribe to the Blog

Notifications straight to your inbox

Recent Articles

How ACO REACH Organizations Can Hit Health Equity Benchmarks


ACO Realizing Equity, Access, and Community Health (ACO REACH) organizations have both primary and specialty care providers and serve Medicare patients in historically underserved communities with the goal of advancing health equity. New regulations from the Centers for Medicare and Medicaid Services (CMS) require ACO REACH groups to not only detail how they deliver on health equity goals in 2024 but also to show the efficacy of those endeavors in terms of numbers: improved patient health outcomes. As such, 2024 requires action: ACO REACH organizations need to implement plans, platforms, and tools that advance health equity.

When CMS first rolled out the requirements for 2024 in 2023, risk-bearing organizations had an opportunity – like a trial year of sorts – to implement health equity changes and evaluate what just worked on paper versus what measurably improved patient outcomes. Regardless of if they used the year to fine-tune their offerings, organizations will have to show success in numbers this year.

Each health equity plan has several key components. For example, a needs assessment to note and analyze what social determinants of health (SDoH) impact particular patients. Further, it should identify and flag target communities that have historically been underserved. The plan also includes target intervention strategies to address the unique SDoH impacting patients within ACO REACH’s patient population. Effectively and proactively considering SDoH will make a difference in the path to health equity.

Challenges Ahead for REACH ACOs

On the path to health equity, ACO REACH groups have several common obstacles ahead when implementing their plans. For one, plans require up-to-date data on patient populations, yet many risk-bearing organizations have limited data availability. Even the task of data collection can prove overwhelming, especially amidst a provider shortage. Once that data is collected, these groups might struggle with bandwidth to analyze the SDoH data. Moreover, some providers do not have the time to administer the test; in other cases, patients do not always fill out the forms.

In addition, REACH ACOs have the challenge of building trust and collaboration strategies with diverse communities. For example, some patients in rural communities may not attend appointments at the recommended frequency, making it challenging to care for and offer interventions to said patients properly.

Further, once data is collected and collaboration efforts are put in place, risk-bearing groups have the challenge of measuring and demonstrating the impact of the interventions they provide to patients, which can prove challenging.

Opportunities Abound to Improve Health Outcomes

Despite the challenges, REACH ACOs stand to gain by pursuing effective health equity plans that address SDoH. First and foremost, they can simultaneously improve health outcomes for their patient populations while reducing costs for underserved populations. That is the holy grail of such endeavors, and with the right tools in place, it can become a reality.

Moreover, risk-bearing organizations can strengthen community partnerships and trust through efficacious plans, such as connecting people to opportunities that address their unique situations. For example, a patient who does not have reliable transportation may benefit from virtual visits. A diabetic patient living in a food swamp could see improvements by receiving medically tailored meals. When ACO REACH groups show they understand what SDoH each patient faces and move away from a one-size-fits-none approach, it fosters trust in the community.

Additionally, by creatively addressing SDoH for patients, REACH ACOs have the opportunity to foster innovation and learning. For example, coming up with creative ways to connect patients to community resources. Connecting patients with these resources can fall to care managers. With so much at stake, care managers take care to match patients with appropriate resources properly. However, doing so well makes a big difference.

Leveraging Local Data for SDOH Identification and Intervention

With so much riding on the success of health equity plans, REACH ACOs need support in flagging SDoH risk factors and curating targeted intervention recommendations. Four key considerations will help set them up for success: 
1. Use local data: information collected should go beyond a zip code, even within a neighborhood, to be as accurate as possible. 
2. Data-informed interventions: tools should flag specific SDoH impacting patients and offer targeted intervention recommendations.
3. Easily-integrated tools: platforms should flag the most vulnerable populations, and offer suggested interventions.
4. Continuous iteration: groups should have tools in place to ongoingly update plans as new information becomes available. 

Next Steps for REACH ACOs

With so much on the line, ACO REACH organizations need to act, and they can do so in a thoughtful, planned way that can garner positive results for them in terms of both improved ROI and better patient outcomes. To start, they can turn to platforms that leverage local data and spatial analytics to identify and address SDoH for their patients. They can also set themselves up for success through ongoing adjustments and periodic evaluations of the plans they implement to make sure their patients receive supportive interventions, even as their circumstances change. In the end, ACO REACH organizations that encourage collaboration and knowledge sharing among other ACOs and stakeholders can do quite a bit to advance health equity successfully. And when they do, both their ROI and their patients will benefit greatly.


Take your Health Equity program to the next level. Discover how our Equity Equalizer™ Platform uses location data and advanced analytics to identify individual patient health barriers and close gaps in care, enhancing patient outcomes.

Location data is
healthcare data.

Unlock the power of spatial analytics in healthcare.