Citation: Jeffrey Levi, David D. Fukuzawa, Shao-Chee Sim, Patrick Simpson, Marion Standish, Carolyn Wang Kong, Anne F. Weiss. “Developing A Common Framework For Assessing Accountable Communities For Health”. Health Affairs Blog. October 24, 2018. https://www.healthaffairs.org/do/10.1377/hblog20181023.892541/full/ Copyright © 2018 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.
Three streams of evidence and experience have recently converged to stimulate public and private funders’ interest in sustainable collaborations that support health care, public health, social services, housing, and other sectors to work together to improve health in their communities.
First, we have monitored the growing evidence base suggesting that social determinants of health, such as stable housing, access to nutritious food, and economic stability, can influence health outcomes and health care use, especially for patient populations with complex health care and social needs in low-income and vulnerable communities. Second, we have supported, and learned from, multisector collaborative efforts to improve community health. Third, we have observed and invested in the evolution of care- and service-delivery models that often incorporate community-based health targets and improvement efforts.
The Accountable Community for Health (ACH) models have emerged as a strategy for structuring relationships and coordinating activities and funding among the multiple sectors that support the health of communities. These sectors include health care, public health, education, housing, transportation, social services, and business. In different settings, people may use the phrases “Accountable Care Community,” “Coordinated Care Organization,” or “Accountable Health Community,” among others, but their meanings are similar.
The Funders Forum on Accountable Health is a collaborative housed at the George Washington University. It has brought together public and private funders of accountable health initiatives, including Blue Shield of California Foundation, the California Endowment, the Episcopal Health Foundation, the Kresge Foundation, the Robert Wood Johnson Foundation, and the W.K. Kellogg Foundation. (Each of the coauthors of this post works at one of these foundations.)
The forum has identified more than 100 communities where ACH-type interventions are being undertaken. The arrangements vary in scope, funding source, and focus. Some primarily create systems for linking to and providing health-related social supports for individual beneficiaries, while others examine community-wide needs that can be addressed through policy and systems changes. They have at least three features in common, though: mechanisms for accountability for health outcomes and cost containment; the ability to share data about health; and financing streams for short-term and longer-term activities.
Accountable Communities For Health In Practice
ACHs and similar structures are being tested in communities across the country with support from diverse sources, including
- The Centers for Medicare and Medicaid Services (CMS) supports ACH projects through several initiatives such as
- The Accountable Health Communities Model, a $157 million CMS Innovation Center model, supports thirty-one community initiatives to address health-related social needs through enhanced clinical–community linkages to improve health outcomes and reduce costs. The center recently announced a plan for an ACH that focuses on children and is called the Integrated Care for Kids Model.
- State Innovation Models (SIM) grants have been used across the country to support ACHs. For example, about $5.5 million, or 14 percent, of Minnesota’s SIM funds over four and a half years were dedicated to ACHs working to address health problems within communities by coordinating support systems to keep people healthy.
- Delivery System Reform Incentive Payment (DSRIP) waivers are also a mechanism being used to advance ACHs. Washington State has established Accountable Communities of Health in each of its regions to help achieve the DSRIP program’s goals to build health system capacity, integrate physical and behavioral health services, and target certain populations using care coordination to serve the “whole person.”
- CACHI (California Accountable Communities for Health Initiative): The California Endowment, Blue Shield of California Foundation, Kaiser Permanente, and Sierra Health Foundation have joined together in California to support fifteen community initiatives that link health care systems, community resources, and social services in a given area to address community-identified health needs and promote ACHs as a new model for health.
Public and private funders are eager to learn from a number of other major community-focused initiatives that share many of the features of ACHs, including
- BUILD (Bold, Upstream, Integrated, Local, Data-driven) Health Challenge: In more than thirty-five communities across the country, funders such as the W.K. Kellogg Foundation, the Robert Wood Johnson Foundation, the Kresge Foundation, the Episcopal Health Foundation, and the de Beaumont Foundation are working together with local leaders to address the social and economic factors, such as healthy housing, that affect health outcomes.
- Hospital community benefit initiatives and related policy incentives: As one example, Nationwide Children’s Hospital in Columbus, Ohio, has partnered with the City of Columbus, United Way, and community development organizations to create the Healthy Neighborhoods Healthy Families (HNHF) initiative, which combines a variety of funding sources, including the hospital’s community benefit funds and local and state government grants. The HNHF initiative also has used low-income housing tax credits to support home revitalization efforts.
Assessing Diverse Models
Given this diversity of approaches to addressing identified community priorities, there is a compelling need to understand how these ACH-type efforts are working and what elements are common across all of these initiatives. To better understand the essential elements of ACHs, the Funders Forum on Accountable Health convened a broad range of public and private funders, evaluation experts, and people actually working on accountable community initiatives to develop a common assessment framework to delineate common elements, as well as a set of assessment questions designed to clarify how these ACHs compare functionally and show which elements have the greatest impact on population health.
The common assessment questions are meant to shed light on two key lines of inquiry:
- Which elements, and in what “dose,” are central to the success of an ACH?
- Which of the various approaches to ACHs will best match the needs of a given community?
These questions are based on a set of principles that were developed by the forum to describe an ACH. The assessment questions, in turn, provide an opportunity to test how the principles are executed in practice.
The assessment framework identifies three overarching categories: readiness, common elements, and outcomes. The assessment questions developed by the forum focus on the ACH common elements. Those questions include
- To what extent is the community working together to address identified needs? How have relationships among community partners and residents changed?
- To what extent are community partners aligned behind a shared vision and purpose for action?
- To what extent and in what way is mutual accountability (among community partners and residents) built into the ACH?
- To what extent are the activities of the community sustainable and aligned with the shared vision?
- What is the portfolio of interventions (that is, the coordinated set of activities that can include policy and systems change) that advance the vision?
- Is the ACH financially sustainable?
- Is there capacity for continuous learning?
- What are the data systems that support the portfolio of interventions?
- To what extent are data and metrics being used to understand the progress or unintended consequences of the ACH?
- How are interventions regularly adjusted, started, and/or ended based on new data from multisector partners and on community input?
The diversity of the ACH models being implemented is a strength, because each ACH must respond to the needs of the community in which it operates, and the various models offer the opportunity for researchers to compare structures and approaches. However, such diversity also complicates our ability to recognize which model(s) should be brought to scale in which communities.
The funders participating in development of these assessment questions believe that using a common assessment framework across ACH models will help them and policy makers make critical decisions when evaluating and potentially expanding and scaling the ACH approach.
The ACH models may help more communities work together to coordinate activities across sectors and align them to shared health goals.