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
|   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                                    4
THE 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                                   5
HOW 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                             6
CATALYZING 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                                     7
Case 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                                                8
ESTABLISHING 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                                 9
Case 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                                          10
LEVELING 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                                              11
Case 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                                13
END 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.

           ADVANCING VALUE AND EQUITY IN THE HEALTH SYSTEM | SPRING 2021                                                       14
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