Over the past year, the United States has witnessed tremendous health inequities from COVID-19 across populations defined by race, ethnicity, geography, and disability. As part of the pandemic response and recovery, communities have taken advantage of existing multisector partnerships to address individual and community-level health and social needs. Indeed, in the recently released National Strategy for the COVID-19 Response and Pandemic Preparedness, the Biden administration commits to:
Facilitate linkages between clinical and social services. Given the increased need for social services during this pandemic, HHS [the Department of Health and Human Services] will identify opportunities and mechanisms to support screening, referral and linkage to social services during COVID-19 testing and vaccination programs, with particular focus on expanding community-based, multisector partnerships that can align health and social interventions. [Emphasis added]
As foundations that have invested in and continue to support expansion of community-based, multisector partnerships, we applaud this commitment. Comprehensive, integrated, and collaborative efforts will be essential to support the most at-risk communities through the remainder of the pandemic. We hope that the Biden administration will support these partnerships as not just a response to the COVID-19 pandemic, but as part of rebuilding and transforming our health system to address health and social inequities that have exacerbated the impact of the pandemic in Black, Indigenous, and people of color (BIPOC) communities across the United States. Indeed, this approach has critical elements that can also address the administration’s commitment to a government-wide approach to racial justice.
In 2016 our foundations joined together to support the Funders Forum on Accountable Health, which convenes public and private funders of Accountable Communities for Health (ACHs) in a learning community. ACHs are multisector partnerships that seek to improve health outcomes by addressing health-related social needs at the individual level and social determinants of health (SDOH) at the community level. These needs and determinants include food security, housing, and nonmedical transportation, among others.
We believe this model and other multisector partnership efforts with similar features provide an opportunity to create a system that advances health, not just health care, with enhanced ability to focus on equity and SDOH and on aligning public health, health care, and social services. As a starting point for our work, we identified basic principles and essential elements of these organizations and developed a common framework for assessing their effectiveness across variations of the ACH model. What we have learned thus far supports a larger investment in and expansion of this model.
The Funders Forum has identified more than 125 ACH-type organizations across the US. They are diverse in their funding sources and also in their structure and organization—from the Centers for Medicare and Medicaid Services Innovation Center’s Accountable Health Communities Model to the California Accountable Communities for Health Initiative, which is privately funded. They have launched in states that have expanded Medicaid and those that have not, such as the Lone Star State, where the Texas Accountable Communities for Health Initiative is spearheaded by the Episcopal Health Foundation, and North Carolina, where the Healthy Opportunity Pilots are funded through a Medicaid Section 1115 waiver. By definition, ACHs working with the Medicaid population are serving those with the greatest health and social needs, but even those ACHs that are separate from the health care financing system are focusing on the needs of those underserved by siloed health and social services systems.
ACHs may have a variety of features, but all share a common vision, embrace an inclusive governance structure that engages community residents and organizations, and collect and share data across sectors to help establish priorities and measure progress for their communities. Many use a collective impact approach as a way to pursue goals. ACHs use evidence about health inequities to advance change and are, above all, about changing how a community creates health and how it shares power—particularly among low-income people, BIPOC, and other populations in underserved areas—which are both central to improving outcomes and advancing equity.
While ACHs are still in their early stages of development, there is already evidence that they have been successful in improving performance in traditional health outcome measures such as reducing emergency department visits and rehospitalizations and decreasing overdose and deaths from opioid use disorder. In some instances, policy changes have been implemented that impact the entire community and population health.
Some Key Lessons
Over the past four years, a number of key lessons have emerged from our Funders Forum work that should be incorporated into any federal initiatives that support multisector partnerships, especially if the goal is to advance equity.
- By developing and strengthening relationships across sectors, ACHs can advance a shared vision of health and well-being in a community.
With the growing recognition that addressing SDOH is a key to advancing the health of communities over the long term comes the acknowledgement that health cannot be improved by the health sector alone. This is the main attribute of the ACH model. All of the ACHs of which we are aware have developed new relationships across sectors, aligning resources to better address priorities in the communities they serve and to advance equity. ACHs have brought together a diverse set of players—from within health and public health; across the social services, such as housing and food assistance; and sectors beyond to include business, banks, and criminal justice, to name a few.
- ACHs have developed new approaches for building accountability to communities into the health system through shared governance in their activities, including strengthening community voices.
If a community is to successfully address SDOH—or at least the health-related social needs of its members—then prioritization and resource allocation should be driven by the needs of community members and expressed through their direct participation in the decision-making process, not by the established health care delivery systems that may have a financial investment in the status quo. Indeed, it is our experience in working with various forms of the ACH model, that power sharing with community residents can begin to address the systemic racism and inequities that are embedded in our health system and that drive disparities in health outcomes.
Empowering communities does not mean ignoring the evidence. We have found that by bringing together multiple sectors and analyzing a broad set of data that affect health outcomes, ACHs are better able to identify community needs. But the assessment of priorities—and the potential portfolio of interventions that could address those priorities—must reflect the perspective of the communities that are being served.
- ACHs can be vehicles for advancing health system reform and can be sustained through flexible financing arrangements.
Our work shows that at least 10 states are implementing ACH-type efforts as part of larger health system reforms. For example, in Washington State, nine regional ACHs are transforming Medicaid under a Section 1115 Delivery System Reform Incentive Payment (DSRIP) program waiver.
As more and more states move toward value-based purchasing (VBP), health care providers will need to be able to address many of the health-related social needs that can improve outcomes and lower costs. Having an ACH-like infrastructure in place can offer those providers some partners for addressing those social needs and increase the likelihood that VBP can succeed. Some of these efforts are already under way. Health Net of West Michigan is working with clinicians using a variety of VBP approaches to provide a systematic process to bridge clinical and community services, which is already resulting in lower use of emergency services and total cost of care.
It is also clear that to fully support the interventions that can address the health-related social needs of community members, we need to tap a variety of health and social programs. For example, the Trenton Health Team, a New Jersey Regional Health Hub, as well as an ACH model, is contracting with the state Medicaid program, the local health department, and health and hospital systems to assure sustainable funding as it works with residents to address health-related social needs and the pandemic.
A longer discussion of key lessons from our Funders Forum work can be found here.
In our grant making, and in the work done by the Funders Forum, we recognize that “one size does not fit all” in supporting and sustaining multisector community partnerships. But we have also learned that a firm commitment to doing business differently by coordinating and aligning sectors, focusing on equity, and prioritizing partnering with community members are critical to addressing the root causes of our country’s health challenges, regardless of the particular variations in the health care delivery system and local community needs across the US.
We are committed to continuing down this path of investing in ACHs and other multisector partnerships because we believe this model—and the notion of the health system being accountable to communities—is one of the most promising approaches to advancing population health. The ACH model, if scaled, will help the US rebuild in the postpandemic period with an equity-focused response to the underlying challenges that exacerbated the pandemic.
We need the federal government to join with us—because only the federal government has the resources and authorities to scale this model to ensure that all communities across the country are able to benefit from this approach.