By Clese Erikson, Dora Hughes, Janet Heinrich, Helen Mittmann and Jeffrey Levi
There is growing recognition that advancing population health and health equity requires multi-sector partnerships that address both upstream and downstream needs of individuals and communities. One such approach is the Accountable Communities for Health (ACH) model, which is being implemented in over 100 diverse communities across the nation.
The most prominent ACH model is the Center for Medicare and Medicaid Innovation (CMMI)-funded Accountable Health Communities model, through which participants screen patients for health-related social needs and help at-risk patients access housing, food, transportation and other social services. Private foundations are funding ACHs through BUILD (Bold, Upstream, Integrated, Local and Data-driven) grants and California Accountable Communities for Health Initiative (CACHI) grants, while state-sponsored ACHs have been implemented in several states including Oregon, Washington and Idaho.
The ACH movement is relatively new, with most sites opening within the last five years. However, ACH participants are already reporting improvements in how healthcare, public health, and social services are being delivered in their local communities. To better understand the nature and scope of ACH impact, the Funders Forum on Accountable Health developed case studies of ten ACHs over an 18-month period between January 2018 and June 2019. The case study participants represented a mix of rural and urban areas, target populations and stages of formation, as well as sources of public and private funding.
The individual case studies provide compelling examples of ACH impact that vary by local community. The case studies also reveal a recurring theme: successful ACHs can leverage the power of convening partners around a common table, where all stakeholders have an equal voice. Specifically, the in-depth case study interviews found that the cross-sector collaborations fostered by ACHs both contributed to and resulted from robust infrastructures, established relationships, community engagement and “doing business differently.” These early outcomes offer important insights and clarity regarding ACH potential to drive population health improvement in the long-term.
Building the Infrastructure
The case study ACHs received public and private grants ranging from $250,000 over two and a half years to $6 million over five years. Funds primarily supported ACH infrastructure functions, relating to convening stakeholders, training and education, workforce investments including hiring navigators, as well as data management and information technology.
Importantly, these grants enabled the communities to invest in backbone organizations (also called bridging organizations), which were critical for building and maintaining robust infrastructures. Of note, the type of backbone organizations varied considerably across the 10 sites that included health departments, hospitals, quality improvement organizations, health information exchanges, non-profits and local and county governments. The case study participants reported that the type of entity was less important than the backbone’s breadth and strength of relationships within the community; a history of collaboration with at least some of the ACH partners; and reputation as a “trusted agent.”
Participants also noted that the backbone’s organizational leadership needed to be skilled at facilitation to help the partners build trust and collaborate effectively. These leaders were not always subject matter experts but, as one participant from Idaho stated, “[they] can almost always say, ‘I have somebody I think you should talk to.’”
While most case study ACHs had participated in prior cross-sector collaborations, these activities were often siloed and health-system focused. In addition, some ACH partners had competed for grant funds or patients, questioned each other’s motives, or were unaware of how much their work overlapped. ACH leaders were forced to confront and overcome these issues.
Case study participants emphasized the importance of creating an inclusive atmosphere where everyone was welcome to participate, and of focusing the conversation on how they could help each other. For example, the Stockton ACH described their approach working with school principals as, “Let’s wipe the slate clean as to where we have been. What can we do differently?” Initially defensive, when principals realized that community leaders were genuinely asking, “How can we help?”, coming together led to a productive conversation.
Establishing meaningful relationships required considerable amounts of time to understand community partners’ activities, assess available resources and identify opportunities for collaboration. One site reported biweekly meetings for 18 months, which enabled partners to “learn each other’s specialty enough to speak each other’s language and leverage ties within the community.” As an example, the Southwest Health Collaborative in Idaho recalled a discussion led by emergency medical services on the difficulty of getting older, rural patients to vision appointments, leading to joint home visits with a large optometrist network.
In most cases, the organizational representatives who attended these cross-sector meetings were donating their time, without new funding to support their participation. However, case study participants credited these meetings as being one of the most valued contributions that partners have made to support ACHs.
Listening to the Community
ACH leaders stressed the importance of backbone organizations having enough time and resources to engage heavily in community outreach. Importantly, most sites spent at least six to 18 months working with the community to establish a shared agenda for the ACH. Sites credited this intense field work and the resulting community-wide agreement on a shared vision as providing an important guidepost for decisions on how to prioritize initiatives or allocate funds, or even whether to apply for new grants. Notably, the CACHI sites invested in leadership training for community residents to ensure they are active participants in ACH decision-making processes. Similarly, the Communities that Care Coalition ACH in Massachusetts trained young people in leadership skills so they could advocate effectively via speaking at regulatory hearings, town council meetings and school committee events.
Community engagement efforts are especially important to create buy-in from traditionally less powerful partners. For example, the Greensboro Housing Coalition in North Carolina held focus groups of a large, dilapidated housing project to understand resident needs and priorities. Although the Cottage Grove neighborhood is largely African American, the community includes immigrant refugees from Burma and Vietnam, so focus groups required multiple translators to ensure all voices were heard. Taking time to include all residents, regardless of background, was important in building the trust to allow inspectors into their apartments to document squalid conditions. This in turn provided important evidence that enabled the ACH to obtain city bonds and attract private investors to refurbish substandard apartments that were contributing to high rates of pediatric asthma admissions.
Doing Business Differently
Although most ACHs are relatively new, many have reported important changes in practice at the community level. Such changes reflect implementation of strategies that better aligned existing resources or invested new funding to address community needs.
Increased alignment of existing resources frequently focused on enhanced cross-sector coordination. For example, in Imperial, Calif., the public schools and medical community all agreed to use the same form for documenting asthma medications. In southwest Idaho, behavioral health providers co-located at schools, which minimized missed appointments and maintained Medicaid reimbursement eligibility. In northcentral Idaho, emergency medical services established a direct line to a case manager at the local health system to better coordinate care for patients with high emergency department use.
In some sites, ACHs worked with universities to link environmental data with health outcomes data to identify areas of greatest need. For example, in Imperial, Calif., academic partners conducted analyses of state data to determine where asthma rates were highest. In Greensboro, N.C., the local university cross-referenced data on poor housing conditions with data on pediatric asthma admissions to document the impact of substandard housing.
Regarding strategies involving new resources, sites stressed the importance of transparency and community engagement. All stakeholders understood that funding strategies represented the collective priorities established and endorsed by all ACH participants.
Several of the ACHs secured multimillion-dollar local investments to support new initiatives. The BUILD site in North Carolina, for example, facilitated public funding and private investment to remediate substandard housing associated with high asthma admissions. The CACHI site in Imperial, Calif., had accumulated over $8 million in a “Wellness Fund” to support ACH priorities; the Cascade Pacific Action Alliance was planning to develop a Wellness Fund as well. Finally, the Stockton, Calif., site had planned to organize a meeting with local, state, and national foundations to align investment strategies for improving local economic opportunities and population health.
As the ACH movement continues to gain traction, it is important to understand the short-term, community-level changes that can be expected to affect longer-term population health improvement. The 10 case studies documented the vital role of the ACH infrastructure, which served as the foundation for ACH activities. Participants reported the necessity for established, meaningful relationships and authentic community engagement. In addition, despite relatively early stages of implementation, the ACHs provided numerous examples of change in practice, reflecting alignment of existing resources and increased investments to address community need. At their core, and perhaps most critically, the case studies highlight the power of convening community stakeholders around a common vision, an act that contributes to ACH success and long-term sustainability.