ISSUE BRIEF SPRING 2021 - Advancing Value and Equity in the Health System The Case for Accountable Communities for Health
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| ISSUE BRIEF
SPRING 2021
Advancing Value and Equity
in the Health System
The Case for Accountable Communities for Health| ISSUE BRIEF | SPRING 2021
Advancing Value and Equity in the Health System
The Case for Accountable Communities for Health
ABSTRACT
Accountable Communities for Health (ACHs) are an increasingly prominent
model for addressing health and health equity using multi-sector, community-
based partnerships, data and analytics, and an integrated portfolio of community
interventions in service to a shared collective vision. The “value case” for an ACH
often lies in the long-term, however, and many ACHs face a challenge demonstrating
the early value of their work to key stakeholders. In this paper, we examine an
alternate framework for defining and assessing value that moves beyond “ROI”
to capture the transformational nature of an ACH’s work through the lens of three
brief case studies. By defining what value looks like along the full spectrum of an
ACH’s model and not just its outputs, we hope to give ACHs the tools to sustain
momentum in their work while they build toward the ultimate goal of improving
outcomes in key measures of community health and health equity.
INTRODUCTION
Reflecting the nation’s growing attention to agenda, however, we must move beyond a focus
systemic racism and the disparate effects of the on purchasing and financing arrangements—and
COVID-19 pandemic, policymakers are increasingly short-term changes in health outcomes—and build
working to address health inequities and the social the capacity to collectively address the widespread
determinants of health that contribute to them. and systemic root causes of inequity.
Work to improve health outcomes has often Achieving the twin goals of advancing both health
focused on value-based care and purchasing, and health equity is now the central challenge of
which provide greater flexibility to providers and health reform, and it is not a challenge the health
incentivizes health systems to improve care. care systems can address alone. Health inequities
These strategies may help address equity-related are intersectional, the product of what happens
concerns: a recent announcement by the Centers in the health care system but also in many other
for Medicare and Medicaid Services encourages sectors of the community. No single partner or
states to promote more value-based purchasing in system holds all the levers necessary to mount an
the Medicaid program,1 which serves a population effective response. Rather, multi-sector partnerships
most affected by inequity and with many health- are needed to support this broader vision of
related social needs. If equity is to move to the health reform, and such partnerships require an
center of the health policy and transformation infrastructure to support and sustain them.With more than 125 examples in communities across designed to mutually reinforce one another for
the United States, Accountable Communities for optimal impact.
Health (ACHs) are designed from the ground up to • Sustainability: ACHs are designed to address
support multi-sector, community-based partnerships ongoing collective work, so most include a
that work collaboratively to address health and health mechanism for sustaining the work through
equity. Although ACHs vary widely, nearly all share a establishing community wellness funds, driving
few core components:2 value-based payment transformation and
supporting related strategies.
• Shared Vision: ACHs hold a common vision for
community partners who want to work together ACHs have emerged through a variety of investments
through collective action to address shared by philanthropy and government. The federal
challenges. government has supported several versions of the
• Equity: ACHs form around a common model, directly through its Accountable Health
commitment to advancing equity in the Communities at CMS and SIM, and indirectly through
community through direct work on health and Medicaid waivers—approving demonstrations at
in addressing upstream determinants or root the state level. Similarly, in places like California,
causes. coalitions of philanthropic funders have pooled
• Governance: ACHs support a shared decision- resources to provide support for emerging ACHs
making structure partners can use to decide on working to address shared community health
and act together around challenges. challenges. But regardless of how they emerge, all
versions of the ACH model are designed to seek long-
• Community Voice: ACHs are strongly and term financial sustainability that goes beyond their
authentically connected to community voice and initial catalytic investments.
wisdom, often “bridging” systems and residents to
ensure their work genuinely reflects community ACHs are community entities, organized to address
priorities and is sensitive to community context. population health and health equity in a way that
• Backbone: Every ACH has a trusted backbone recognizes the interdependent forces and factors at
organization responsible for facilitating alignment work while holding and executing a shared vision
between all ACH members and the community. around health and health equity. ACHs may focus on
More than administrative, these distinct priorities, but all start with the simple idea
well-trained and connected that the community’s most critical
challenges are complex, and no
“
conductors bring essential skills
single partner controls enough
and resources to the table. Achieving the
levers to address them alone.
• Data & Analytics: Most ACHs twin goals
recognize that shared data of advancing In this paper, we define and
across sectors is as important both health and health advance the value proposition of
as connecting the work. They ACHs as a promising approach
equity is now the to addressing structural
support collective, data-
informed action. central challenge of fragmentation across the health-
health reform, and it producing continuum. Without a
• Portfolios of Interventions:
ACHs focus less on specific is not a challenge the different way of measuring value,
interventions or programs, health care system can our long-term efforts to address
and more on ensuring the address alone.” inequity will be condemned
community’s various programs prematurely as failing.
are coordinated, aligned and
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 3“
WHY AN ACH APPROACH?
Health is
a multi-
dimensional
Health is a multi-dimensional challenge, shaped that yields a challenge, shaped
by opportunities and experiences across multiple disconnected and
by opportunities and
systems, but our approaches to building and chaotic approach,
maintaining health are often fragmented and producing experiences across
exacerbate inequities. We use distinct and separate suboptimal multiple systems;
systems to manage physical, mental, dental and outcomes but our approaches
social health. We also manage the upstream, that can be to building and
preventive aspects of health, such as food and overwhelming, maintaining health are
housing, through different systems. dehumanizing often fragmented and
Clinical and community outcomes are profoundly and un-
exacerbate inequities.”
interconnected with bidirectional impacts—health approachable,
outcomes influencing outcomes in other systems especially for
and vice versa. Yet they are rarely considered historically excluded communities.
together when developing and funding programs, Ultimately, compartmentalized approaches are
services and interventions. unlikely to ever solve multi-dimensional problems.
Despite overwhelming evidence of this
connectedness, we have built a non-system
EVIDENCE OF IMPACT
The evidence base for the longer-term impacts interventions to address substance use, opioid
of ACHs is still developing, as are the tools overdoses fell by 45% relative to baseline.6
and methodologies available to assess an
ACH’s value. A meta-analysis of 25 collective Still, to date there are few studies that adequately
impact efforts (ACHs are a form of collective assess the full spectrum of an ACH’s efforts and
impact) found clear evidence of contribution to impact, largely because ACHs themselves are
population change in at least 8 sites, including complex and often place-informed initiatives
impacts on diverse goals such as teen birth rates operate at multiple levels, from policy to
and youth justice involvement.3 programmatic, in ways that are intentionally
designed to build upon, align and integrate
Other work has demonstrated an association existing local energy and efforts. Capturing the
between multi-sector population health work unique or additive impact of the ACH can be
and community mortality rates.4 Cottage Grove challenging in the near term, and not easily
ACH in Greensboro, N.C. was able to decrease differentiated from these related activities and
childhood asthma hospital admissions by initiatives. As researchers continue to refine
improving substandard housing, saving millions methods for assessing the impacts of such multi-
in Medicaid dollars.5 And when Staten Island faceted work, ACHs and their proponents are left
Performing Provider System (PPS) integrated data with a relative dearth of tools that can be used to
and launched an integrated multi-sector set of definitively assess the model’s value.
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 4THE VALUE CHALLENGE
A key challenge ACHs face is how to demonstrate An ACH creates value in its community long
the value of their work, especially in the early before the long-term financial impacts of its
stages of implementation. By design, ACHs work are apparent:
seek to shift policy and fundamentally change
how systems work together. Their work, and • When an ACH works to align the visions of
the value it creates in the community, is not disparate partners, it creates value by paving
strictly transactional. While every ACH ultimately the way for integrating resources in the
hopes to demonstrate a strong financial return community to increase the total impact of
on investment (ROI) for health care and other collective work.
systems, assessing ROI is difficult—particularly • When an ACH helps amplify community
without discrete programmatic interventions. It voice, it creates value by helping ensure
is even harder when multiple interventions are shared work is done with rather than to or for
in play and, more broadly, when systems change communities, and that equity remains at the
work has long time horizons and numerous center of that work.
confounding factors.
• When an ACH creates a structure for shared
New ways of working can create value for a decision-making, it creates value by ensuring
community even in the absence of an immediate that systems working to address multi-
ROI. Indeed, much of the value of an ACH may be dimensional problems have access to multi-
submerged like an iceberg, with a small portion dimensional solutions.
of the value visible while most of the benefits
exist beneath the waterline and thus out of sight. ACHs make things happen in communities that
As one group of evaluators noted, value can be would not otherwise have been possible, creating
“difficult to measure, to monetize and sometimes enduring infrastructure that can be used to
even to see... Calculations of value can risk activate change or improvements on a wide array
focusing only on the part that is visible, generating of community priorities. The value proposition
misleading information and encouraging poor of an ACH exists along the entire spectrum of the
decision-making.”7 model, not just its outputs.
“
New ways of working can create
value for a community even in the
absence of an immediate ROI.”
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 5HOW ACHs GENERATE VALUE
These “below the waterline” components of ACH • Establishing collective accountability
value arise from the very components or activities among stakeholders and the community
needed to build the ACH as a forum to engage to drive sustainable systems changes
people around a common purpose and vision: and, ultimately, outcomes by facilitating
cross-sector and organizational relationships, data sharing and using common measures
meaningful engagement of residents, trust between to support a common understanding of the
partners and with the community, and distributed problem, develop solutions and demonstrate
leadership at multiple levels. outcomes. Through such collective
accountability, collaboration shifts from
These core tenets enable the ACH to play at least an add-on activity to becoming part of the
three key roles that shift ACHs from coordinating “culture” and way of doing business.
and carrying out strictly transactional activities to
becoming engines of transformational change: • Leveling the playing field so community
voice has a real say in defining the
• Catalyzing alignment, innovation and problem and advancing solutions that
new ways of working together to eliminate prioritize equity. Organizations, sectors
ineffective, siloed, program-by-program and residents come to the table with unequal
interventions. ACHs collectively problem power. By centering equity and community
solve, align interests and incubate new ideas. voice through intentional and meaningful
Moreover, with this infrastructure, ACHs can resident engagement, ACHs shift power and
rapidly pivot to address emerging issues and resources to produce more equitable outcomes
crises, such as COVID. and facilitate greater community cohesiveness.
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 6CATALYZING ALIGNMENT
ACHs are often seen as “neutral conveners” in
“
communities, bringing together partners with
disparate goals and interests to help facilitate ACHs are
collaborative action. ACHs are a natural fit for this often in the
role because they do not have the same narrow
position
financial or programmatic interests as other players.
They represent diverse and multiple interests, have to create value in
strong community engagement strategies and a community by
can help represent community voices as part of engaging partners
important decisions. They also serve as a critical to work together
nexus of the community’s equity work. toward mutually
As a result, ACHs are often in the position to create beneficial goals.”
value in a community by engaging partners to work
together toward mutually beneficial goals.
Case Study | Catalyzing Alignment
Maximizing the Total Community Impact of Housing Vouchers
The Healthy Living Collaborative (HLC) was The HLC recognized the potential
a collective impact initiative in Vancouver, interconnections of these systems’ distinct
Washington, that has since merged with challenges: some of the families whose children
Southwest Washington ACH (SWACH). HLC/ were missing school might have unstable housing
SWACH boasts a robust array of over 40 cross- situations, just as housing instability might be
sector partners, a shared governance model and an important complication for medically fragile
strong community engagement mechanisms patients in the health care system. But the
facilitated by a strong network of neighborhood- available resources were relatively fixed—no
based community health workers and peer health massive infusion of new funding was coming to
specialists. Like many communities, Vancouver solve any of these big community challenges.
faced an acute shortage of affordable housing and As the convener, the HLC pulled these partners
a years-long waitlist for housing vouchers, which together to explore the possibility of changing
the community identified as a key determinant of how the system was currently deploying available
the kind of health inequities HLC was designed to resources to align partners’ interests and
help address. maximize the total amount of positive impact the
community could realize.
At the same time, the HLC’s educational partners
signaled that schools were facing significant The idea was simple: the community didn’t have
challenges with chronic absenteeism, and their enough vouchers to go around, so some kind of
health care partners were challenged managing waitlist was necessary. Given that, could some
high cost patients with significant medical and portion of the existing vouchers be prioritized
social complexity. for families with school-aged children or for
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 7Case Study | Catalyzing Alignment
Maximizing the Total Community Impact of Housing Vouchers (Continued)
those who were facing complex health care the systems in question as clients, the HLC
challenges? This was truly a “health in all policies” was able to gather feedback directly from the
approach—reshaping housing policy in a way that communities most likely to be impacted by the
might maximize the impact of available resources changes. And because of its connections across
on important community health and vitality the community and years of hard-earned trust as
outcomes for other sectors. A limited resource a neutral convener, the HLC was able to represent
in one sector (housing) would be deployed in a the opportunities and challenges transparently
manner intended to optimize outcomes in two and honestly in order to advance the community
others (education and health care). This was conversation and ensure everyone involved was
systems change in action. comfortable with the proposal.
But changing how systems work is never risk The housing voucher prioritization system that
free. Would the community accept such a shift emerged in Vancouver was the result of vision
in resources? Was this approach consistent with and hard work from many people in multiple
the community’s shared goals around improving community systems, but its path to fruition was
equity across its systems? Would the data made possible because of the essential elements
sharing necessary to make such an approach of an ACH—in this case, a trusted neutral convener
work pass muster? Might there be unanticipated with strong community engagement that could
consequences, especially for historically facilitate the difficult conversations, seed trust,
underserved or marginalized communities? With and ultimately seal the deal, as well as a shared
real reputational risks for all involved, there was governance structure that supported collective
understandable reluctance about proceeding decision making, and data and analytics capacity
without some reassurances in place. that could help the distinct systems involved in
the deal navigate the regulatory challenges of data
Just as it had been positioned to initiate the sharing necessary for their collaborative action to
talks, the HLC was poised to help mediate succeed. These elements were strengthened by the
these concerns and move the deal forward. HLC’s eventual merger with SWACH, allowing the
Through its robust multi-sector partnership full benefits of the ACH model to be realized.
council, which included scores
of organizations and agencies The “value” offered by the ACH in
“
from across the community, the The HLC this case wasn’t in staffing some
HLC was able to vet the idea with pulled these new program or launching some
other players whose clients or partners new intervention. Rather, value was
stakeholders might be impacted together to explore the generated by facilitating a deal that
possibility of changing
by the change. And with its changed the way systems work
how the system was
strong community engagement currently deploying together to maximize their collective
infrastructure, including a available resources to impact on shared outcomes, thus
network of neighborhood-based align partners’ interests catalyzing alignment and helping
community health workers and maximize the total systems in the community work
rooted in the region’s highest amount of positive together to find multi-sector solutions
risk communities and with impact the community to complex problems and cement
could realize.”
lived experience navigating those innovations into practice.
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 8ESTABLISHING COLLECTIVE ACCOUNTABILITY
“
The ACH structure creates the conditions
for participating stakeholders—individuals, Collaboration
organizations and sectors—to transcend their becomes
respective internal interests by collectively
maximizing financial and non-financial resources to
part of the
support a common goal or address a shared need. ‘culture’ and way of
Data is shared and common measures are used to doing business.”
facilitate a shared understanding of the problem
and solutions, and to demonstrate outcomes.
Collaboration becomes part of the “culture” and
way of doing business.
Case Study | Collective Accountability
The Regional Supportive Housing Impact Fund
When an ad-hoc coalition of health care with other regional housing efforts, focusing
systems, regional philanthropic foundations, particularly on connecting very low-income
housing providers and advocates came persons with complex health challenges to
together to discuss homelessness in Portland, deeply affordable supportive housing options
Oregon, they were prompted to action by that include the services they need to remain
one inescapable fact: the housing crisis stable and housed. To create maximum
represented a multi-dimensional challenge flexibility for aligning with other regional
whose effects rippled across multiple systems efforts, RSHIF would braid and blend funding
throughout the community. The group had from across sectors and partners, then nimbly
already pooled resources in an unprecedented deploy those funds in ways that maximize their
cross-sector investment, with health systems total community impact.
and foundations pitching in over $23 million
to support the construction of a major new An interconnected community data system,
housing and services center on the city’s hard- including health care, public safety and
hit outer eastside, but they knew addressing housing data, would be used to identify
the crisis would require more than a one-time high-leverage investment opportunities,
donation. They wanted to build on that initial to empirically assess the impact of those
success to create an enduring mechanism for investments on community outcomes, and
collective investment and action to address to identify shared savings that could be
housing and homelessness in the city. reinvested in the fund. A shared governance
structure would be developed to oversee the
The group spent several years working on a fund’s strategy, ensuring broad representation
new plan: RSHIF—the Regional Supportive and community-informed decision-making
Housing Impact Fund—a flexible, data-driven would always be at the center of RSHIF’s work.
resource pool designed to work in tandem
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 9Case Study | Collective Accountability
The Regional Supportive Housing Impact Fund (Continued)
After several years of collaborative work and Because of its ACH-like structure, Health Share
the development of a strategic framework, was well positioned to address the specific
however, the coalition found itself facing a pair concerns that had impeded RSHIF’s launch
of seemingly intractable challenges regarding by deploying several critical elements of an
how to operationalize the framework. First, ACH: a backbone structure with mature fiscal
the fund was designed to integrate and deploy and operational elements that could help
funding from many different players with diverse launch and sustain RSHIF, a shared governance
interests, some of whom were competitors in the model for collaborative decision-making, a
community. Who could be trusted to house such a strong community engagement system via
shared effort and make strategic decisions about its community advisory council and other
major community investments without favoring established avenues for enhanced community
one interest over another? And even if the interests engagement, and a data and analytics
of major supporters and funders could be infrastructure that could be expanded to support
balanced, who could also ensure that the interests the RSHIF vision and provide transparency
of community members—especially those in around key accountability metrics and reporting.
historically excluded or marginalized communities
who would not be major RSHIF funders but for The work of developing RSHIF happened outside
whom the fund’s investment decisions would of Health Share, with a group of concerned
have real and tangible consequences—would be partners coming together with a vision to build
adequately and authentically represented in the something genuinely innovative and enduring
fund’s governance and decision-making? in their community. Years of work went into a
framework for collective impact in the supportive
In the end, the coalition needed a place to hold housing space, but when it came time to turn
collective accountability for the work—someone that framework into reality, the challenges of
who could step forward to balance the many real-world implementation in an environment
interests involved and of diverse interests and agendas
anchor the community’s were daunting, and there was
“
commitment to being real risk that the progress made
accountable to those In the end, would simply dissipate.
interests. The coalition the coalition
approached Health Share needed a In this case, the value of the
ACH was less about generating
of Oregon—one of the place to hold collective
state’s Coordinated Care the initial innovation, which
accountability for the arose organically out of existing
Organizations (CCOs)
work—someone who community efforts, and more
that hold many of the key
functions of an ACH and could step forward about providing a cohesive,
acts as the state’s closest to balance the many trusted platform supporting
equivalent—and asked it to interests involved and collective accountability
among the initiative’s
inherit the RSHIF strategic anchor the community’s
framework, operationalize stakeholders and community
commitment to being members for sustainable
it and be accountable for its
accountable to those systems change.
shared community vision
and outcomes. interests.”
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 10LEVELING THE PLAYING FIELD
ACHs are multi-dimensional, interdependent, efforts to care for people who are already facing
interconnected efforts that connect and integrate health challenges. And all of this important work
efforts across the health continuum. An ACH may across the health continuum needs to occur
simultaneously work to address the “upstream” within the context of community voice and power,
structural conditions that shape health experiences recognizing that there are historical power gaps
and outcomes across the life course, mitigate between the systems that control many of these
the “midstream” effects of individual exposure to important health levers and the communities most
health risk factors and improve the “downstream” impacted by them.
Case Study | Leveling the Playing Field
Neighborhood Networks in San Diego
The San Diego Accountable Community for and a tendency for institutions to arrive with the
Health (San Diego ACH) was formed to create a answers had profoundly damaged trust in some of
“wellness system” to create health and wellness the very systems SDACH intended to integrate and
for all San Diego communities with an initial activate. To be successful, the ACH needed first to
focus on lifelong cardiovascular health. The earn the community’s trust back.
work has focused on connecting and integrating
health systems and community-based efforts A key factor for building and maintaining trust
designed to address the key social and structural was developing a viable post-CACHI funding
determinants of poor cardiovascular health. sustainability plan for the ACH that would disrupt
Launched as part of the California Accountable the typical pattern of fragmented, grant-to-grant
Communities for Health initiative (CACHI), the programing that left the community feeling exploited
San Diego ACH’s (SDACH) comprehensive and and without a viable strategy for improvement.
integrated portfolio of strategies has yielded a Efforts to establish a Wellness Fund were met with
comprehensive approach to tracking progress skepticism from the larger health systems and
using population-level health data, a focused institutions in the region whose investment priorities
effort on nutrition in the North Inland Region of differed from the ACH and the community.
San Diego mixing program level and population Faced with this circumstance, SDACH leadership
health data, a robust learning community worked to develop a program that would both
that provides an opportunity for community generate revenue and fulfill the core mission of
organizations and healthcare organizations the ACH. Establishing a network of community
to learn together, and the development of a health workers (CHWs) was identified as a viable
Community Health Worker initiative. strategy to align these two goals. A community-
As the SDACH worked to assemble its multi-sector based workforce—comprised of people with
coalition of partners, it included an extensive deep expertise in and knowledge of their
community engagement process to ensure own communities—could anchor the entire
strong roots in the communities themselves. This experience in a trusted human connection,
process revealed that for many communities thereby increasing engagement and helping
in the region, a long history of historical racism, people navigate and access the resources that
underinvestment in community-driven efforts, best match their needs and context wherever
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 11Case Study | Leveling the Playing Field
Neighborhood Networks in San Diego (Continued)
they may lie on the health continuum. A network of for services that generate tangible value by improving
CHWs with shared lived experience could both help health and reducing the costs of care.
draw people back into the new, more connected
system San Diego ACH was building and create a richly For members of the community, it provides a
textured, multi-dimensional approach for supporting “one-stop” entry point into a comprehensive set of
and building community health that leverages the health supports anchored in a human connection
ACH’s position as a multi-sector convener of major and guided by a trusted community member
systems. As such, SDACH would be working with— with shared cultural and lived experiences. And
rather than on behalf of—the community members for the community-at-large, it provides a concrete
most impacted by historical inequities. mechanism to lift up the most crucial health related
social needs being identified by the neighborhood
This vision became Neighborhood Networks, which navigators for further action by the ACH.
is a service designed to address the health and
social needs of community residents with complex An ACH is the perfect place to hold this community
challenges that complicate their ability to achieve value. Indeed, these essential elements of an ACH are
and maintain good health. A network of CHWs exactly what it takes to create it: a mutually reinforcing
(called Neighborhood Navigators) taps into the portfolio of interventions that can address both the
ACH’s cross-sector network of partners to provide upstream drivers of health and their downstream
community-based solutions for care management consequences; a backbone structure that is trusted
and health promotion. Acting as the hub, SDACH links by diverse partners with distinct interests to hold
patients or clients referred from some partners, such essential functions; a data sharing infrastructure that
as health plans, to community care organizations that can connect work across sectors; a strong community
host trained Neighborhood Navigators positioned engagement structure that can assure solutions are
to assess each client’s health-related social needs, grounded in community wisdom and participatory
explore their context and preferences, and connect principles; and a sustainability mechanism predicated
them with the array of services best suited to their on the value produced by the ACH’s work for
needs and circumstances. SDACH also provides downstream stakeholders, such as health plans and
necessary infrastructure, such as contracting and hospital systems.
reimbursement for the community organizations By leveraging these components to create something
doing the field work, data sharing, training and quality new, San Diego ACH brough value to the community
improvement support for its partners to better foster effort by leveling the playing field, giving
connection and coordination of care and services community-based organizations access to more
across the health continuum. resources and a critical role to play in the success of
This innovative service provides the region’s health plans. Through
“
a clear value for everyone. For authentic resident engagement
partners like health plans, it SDACH would and efforts to align the goals
provides access to a community- be working of larger systems with those of
organizations representing the
based network of services that with—rather
can comprehensively address communities, the ACH positioned
than on behalf of—the itself to re-engineer how health is
the complex, multifaceted drivers
community members created and supported for some
of poor health and high cost of
care outcomes. For participating most impacted by of the region’s most vulnerable
community-based organizations, historical inequities.” populations.
it provides a way to be reimbursed
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 12“
CONCLUSION: TRANSFORMATIONAL CAPACITY AS VALUE The essential
elements of
ACHs are inherently transformational enterprises In this paper, an ACH are
endeavoring to change the way people interact we presented inherently valuable to
with systems, and the way systems interact with three mini case communities because
each other to generate improved health and studies—from they allow things to
health equity for their communities. This kind of Washington,
systems change is no small task. Even modest Oregon and happen that otherwise
changes to how systems interoperate can take California, might not, and they
years to achieve. The value to any change effort respectively— represent a tangible
is typically assessed by comparing the costs that represent capacity for change.”
or effort required to produce it to its relative three different
impact on outcomes we care about. Return on ways an ACH can
investment (ROI) is the operative framework— create value even
we want to see if an ACH’s work can ultimately before the effects of its work are apparent. These
improve health, lower the total costs of health are by no means isolated examples. Many of the
care, reduce recidivism in the jail system or some 125+ ACHs currently operating around the United
other collectively defined outcome. And until States are hard at work creating comparable value
those outcomes are produced, we are tempted to in their communities. The true value of examples
withhold judgement about whether it was “worth like these lies in the architecture for change that is
it” or merits continued investment and effort. created and persists in each community after the
The ROI framework is also transactional in nature. building is done.
Yet increasingly, evidence suggests a need to The next time a group of community partners in
move beyond transactional relationships and SW Washington, Portland or San Diego want to
transform the way people, organizations, systems do something innovative together, the essential
and sectors interrelate and interact to change the elements of collaborative action will have already
trajectory of population health.
been built. The engine doesn’t go away once
To be clear, health and financial outcomes are an ACH completes its first journey. It remains,
important. But the value equation of an ACH poised and ready for the community to select a
includes more than its outputs. The very act of new shared goal, line up the wheel and step on
building an ACH brings value to the community the gas. Indeed, this kind of architecture will be
by creating transformational capacity that can be essential in communities across the country as
used to activate meaningful change in the service policymakers promote stronger emphasis on
of shared goals. value-based approaches that advance equity.
The essential elements of an ACH are inherently
valuable to communities because they allow
things to happen that otherwise might not, and
they represent a tangible capacity for change.
ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021 13END NOTES ABOUT THE AUTHORS
1. Centers for Medicare & Medicaid Services, “RE: Bill J. Wright, PhD, is a research scientist at
Value-Based Care Opportunities in Medicaid,” Providence Health System Center for Outcomes
SMD# 20-004, December 21, 2020, 4. Available Research and Education. CORE works with ACHs in
at: https://www.medicaid. gov/Federal-Policy- Washington, Oregon (called CCOs) and California.
Guidance/Downloads/smd20004.pdf.
Barbara Masters, MA, is the director of the
California Accountable Communities for Health
2. Note: ACHs can be seen as a specific manifesta-
Initiative (CACHI).
tion of the Collective Impact framework, sharing
several common elements and strategies for
Janet Heinrich DrPH, RN, FAAN, is a research
structured collaboration, including creation of a
professor in the Department of Health Policy and
common agenda and structured collaboration to
Management at George Washington University’s
address a shared social problem. ACHs are a way
Milken Institute School of Public Health. She is
for communities to structure collective impact
principal investigator with the Funders’ Forum on
work and pursue shared goals.
Accountable Health.
3. When Collective Impact has an Impact: A Cross- Jeffrey Levi, PhD, is a professor in the Department
Site Study of 25 Collective Impact Initiatives. ORS of Health Policy and Management at the George
Impact and Spark Policy Institute, 2018. Accessed Washington University’s Milken Institute School
12/21/2020 at https://www.orsimpact.com/ of Public Health. He is the director of the Funders’
directory/ci-study-report.htm. Forum on Accountable Health.
4. Mays G, Mamaril C, Timsina L. 2016. Preventable
Karen W. Linkins, PhD, is a principal at Desert Vista
Death Rates Fell Where Communities Expanded
Consulting (DVC). DVC works with ACHs in California,
Population Health Activities Through Multisector
as well as in Washington state.
Networks. Health Affairs, 35:11,2005-2013.
5. Erikson Clese, Mongeo, Marie. Collaborative
Cottage Grove Case Study. Funders Forum
on Accountable Health, 2018. Available at
https://accountablehealth.gwu.edu/sites/
accountablehealth.gwu.edu/files/NC%20-%20
Cottage%20Grove.pdf. CALIFORNIA ACCOUNTABLE COMMUNITIES FOR HEALTH INITIATIVE
6. Staten Island PPS data portal. Data on opioid
deaths available at http://sidrugprevention.
...The Next Generation of Health System Transformation
nyc/see-the-data/overdose-death/. Data on ED
visits available at http://sidrugprevention.nyc/
see-the-data/ed-visits-related-to/. Last accessed
2-1-2021.
7. Rhonda Schlangen and Jim Coe (December
2014). “The value iceberg: Weighing the benefits
of advocacy and campaigning.” Accessed 12-
21-2020 at https://www.betterevaluation.org/
sites/default/files/Advocacy%20and%20the%20
value%20iceberg.pdf.
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