tings of chronically ill elderly patients through 
methods such as active inpatient management, 
variations in initial length of stay, enhanced 
discharge planning, and psychosocial interven-
tions. 
‘‘(H) Delivering health behavior assess-
ments and interventions to improve physical 
health outcomes for patients and aid in the 
management of chronic health conditions. 
‘‘(I) In coordination with law enforcement 
agencies and judicial entities, interventions tar-
geted at providing mental and physical health 
services (including, as appropriate, substance 
use disorder services) to individuals convicted of 
criminal offenses for purposes of mitigating re-
cidivism. 
‘‘(4) INNOVATIONS ADDRESSING SOCIAL DETER-
MINANTS OF HEALTH.—The term ‘innovations ad-
dressing social determinants of health’ means inno-
vations implemented by an eligible hospital that seek 
to address social determinants of health that nega-
tively impact the health outcomes of applicable indi-
viduals, including the following: 
‘‘(A) Improvements in electronic health 
records to better integrate mental health, med-
VerDate Sep 11 2014 
22:27 Apr 07, 2025
Jkt 059200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H2590.IH
H2590
ssavage on LAPJG3WLY3PROD with BILLS
ical care, and social care (such as screening for 
social factors, facilitated or closed loop referral, 
risk stratification, and shared records with com-
munity-based organizations). 
‘‘(B) Personnel-supported ‘wrap around’ 
services for at-risk individuals with mental and 
physical health comorbidities (such as nutrition 
and diet counseling, social services referral, res-
piratory therapy, medical-legal assistance, fi-
nancial counseling, consumer education, phar-
macy education, asthma education, and referral 
to food resources such as referral to the SNAP 
program, the WIC program, a food bank, case 
management assistance, employment or edu-
cation support, intimate partner violence, and 
behavioral health support). 
‘‘(C) Home and community-based services 
that provide collaborative care to address men-
tal and physical health comorbidities through 
health behavior services, nutrition support, 
medication management, transitional care, tele-
health, mobile integrated health care, para-
medic-based home visitation, or utilization of 
community health workers. 
VerDate Sep 11 2014 
22:27 Apr 07, 2025
Jkt 059200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H2590.IH
H2590
ssavage on LAPJG3WLY3PROD with BILLS
‘‘(D) Hospital-based interventions (such as 
same day primary care services, skilled nursing 
interventions, substance use disorder and be-
havioral health treatment coordination of care, 
collaborative care models, discharge planning 
and medication reconciliation, long-term care 
management, and post-traumatic injury man-
agement). 
‘‘(5) INDIVIDUAL WITH MENTAL AND PHYSICAL 
HEALTH
COMORBIDITIES.—The term ‘individual 
with mental and physical health comorbidities’ 
means an individual who is challenged by serious 
mental illness or serious emotional disturbance as 
well as 1 or more of the following conditions or char-
acteristics: 
‘‘(A) Has or is at risk for one or more 
chronic conditions (as defined by the Sec-
retary). 
‘‘(B) High-risk pregnancy. 
‘‘(C) History of high utilization of acute 
care services. 
‘‘(D) Frail elderly (defined by impairments 
in activities of daily living). 
‘‘(E) Disability, including traumatic brain 
injury. 
VerDate Sep 11 2014 
22:27 Apr 07, 2025
Jkt 059200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H2590.IH
H2590
ssavage on LAPJG3WLY3PROD with BILLS
‘‘(F) Critical illness or injury requiring 
long-term recovery. 
‘‘(6) VULNERABLE
COMMUNITY.—The term 
‘vulnerable community’ means a geographic area 
served by an eligible hospital characterized by a pop-
ulation that has a statistically significant number of 
individuals 
with 
mental 
and 
physical 
health 
comorbidities, indicators of poor population health 
status, low-income status, or status as a USDA-rec-
ognized food desert. 
‘‘(g) EVALUATION AND REPORT.—Not later than 1 
year after the date of completion of the program under 
this section, the Secretary shall submit to Congress a re-
port containing an evaluation of the activities supported 
by the program. Such report shall include the following: 
‘‘(1) A description of each such activity, includ-
ing— 
‘‘(A) the target population of such activity; 
‘‘(B) how such activity addressed the ad-
verse social determinants of health in such pop-
ulation; and 
‘‘(C) the role of community-based organi-
zations and other community partners (such as 
nonprofits and units of local government) in 
such activity. 
VerDate Sep 11 2014 
22:27 Apr 07, 2025
Jkt 059200
PO 00000
Frm 00015
Fmt 6652
Sfmt 6201
E:\BILLS\H2590.IH
H2590
ssavage on LAPJG3WLY3PROD with BILLS
‘‘(2) Evidence showing whether and how each 
such activity advanced any of the following objec-
tives: 
‘‘(A) Improved access to care. 
‘‘(B) Improved quality of care. 
‘‘(C) Improved health outcomes. 
‘‘(D) Amelioration of disparities in care. 
‘‘(E) Improved care coordination. 
‘‘(F) Reduction in health care costs (in-
cluding such reductions under this title and 
title XIX and such reductions occurring for un-
insured individuals). 
‘‘(G) Reduction in health care utilization 
(including with respect to inpatient admissions, 
utilization of emergency departments, and room 
and board provided to individuals). 
‘‘(H) Reduction in non-medical public ex-
penditures. 
‘‘(I) Changes in patient and provider satis-
faction with care delivery. 
‘‘(J) Reductions in involvement with the 
justice system, including reductions in recidi-
vism. 
‘‘(3) A description of the metrics used to track 
the implementation and results of each such activity. 
VerDate Sep 11 2014 
22:27 Apr 07, 2025
Jkt 059200
PO 00000
Frm 00016
Fmt 6652
Sfmt 6201
E:\BILLS\H2590.IH
H2590
ssavage on LAPJG3WLY3PROD with BILLS