As states test new care delivery models that focus on integrated, patient-centered, and value-driven care, a number of state Medicaid agencies have established multi-sector partnerships focused on addressing population health. Often called Accountable Communities for Health (ACH), these models bring together partners from a broad range of sectors — health care, behavioral health, public health, and social service — using community-driven approaches to tackle both clinical factors and social determinants that influence health.
ACHs go beyond most delivery system and reform efforts to focus on community-wide prevention services and strategies that improve the health of an entire population, aligning nicely with the Centers for Disease Control and Prevention’s Three Buckets of Prevention. Building on research demonstrating that multi-sector partnerships significantly reduce mortality from chronic conditions, such as cardiovascular disease and diabetes, these population-based models may help close geographic and socioeconomic disparities in health outcomes, and complement care delivery innovations at the clinical level. Although these efforts are starting with Medicaid, the vision for ACHs is to have multi-payer participation.
Pioneering states, including California, Michigan, Minnesota, and Washington, are testing new ACH models and several other states are pursuing ACH-like approaches. Even though each of these states has approached the development of ACHs slightly differently, core elements among state ACH models are emerging. These include:
- Working within a defined geographic area;
- Developing a clear mission across stakeholders;
- Creating a governance structure or identifying a backbone operating organization;
- Forming multi-sector partnerships that span health and social services organizations, as well as criminal justice, education, and transportation;
- Identifying priority focus areas, such as certain health conditions or target populations;
- Creating data sharing and management structures to monitor population health; and
- Establishing stable financing to support activities to address priorities, and ensure sustainability.
Models in two states — Washington and Michigan — are highlighted below.
Washington’s Accountable Communities for Health
Washington’s ACHs are a key component of Healthier Washington, the state’s reform plan unfolding under its Medicaid Transformation waiver and Delivery System Reform Incentive Payment program. The ACH effort is using a collaborative regional approach to build healthier communities; integrate physical and behavioral health care delivery; and move toward value-based reimbursement. The nine ACHs, each aligning with the state’s Medicaid purchasing regions, cover the entire state. Each ACH has the autonomy to establish its own governance structure and target health priorities under broad state guidelines. Since the first two ACHs were launched in 2015, each conducted a community needs assessment and resource inventory, using this information to identify regional health priorities.These include: access to care, behavioral health integration, chronic disease prevention and/or management, obesity/diabetes prevention, and oral health care, among others. The state is proposing to use its Section 1115 Medicaid demonstration waiver to enable the ACHs to act as the primary point of accountability for the state. As such, the ACHs will convene providers and other partners to coordinate health transformation activities, implement interventions, connect clinical and community-based organizations, and track regional health improvements.
Michigan’s Community Health Innovation Regions
Michigan’s Community Health Innovation Regions (CHIRs) are consortia of community partners, government agencies, business entities, and health care providers that focus on improving population health within a specific region. Launched in 2016 through the state’s Blueprint for Health Innovation, the CHIRs serve five defined geographic regions throughout the state, with an emphasis on high-risk Medicaid beneficiaries. The target populations include: individuals with frequent emergency department (ED) utilization; individuals with multiple chronic conditions; and healthy mothers and babies. CHIRs are required to focus on ED utilization during the first year of the program but, depending on resources, may choose to address one or both of the other target populations in later years. The CHIRs are expected to work closely with the Accountable Systems of Care (accountable care-like organizations), patient-centered medical homes, Medicaid health plans, and other organizations in their regions to develop a community health needs assessment and define population health goals and initiatives to address medical, behavioral health, and social support needs. The CHIRs are required to develop a multi-payer financing model that aligns investments across organizations to support sustainability.
The population health focus and multi-sector nature of ACH models provide an opportunity for states to make significant inroads toward improving health outcomes and addressing existing health disparities. States can use ACHs to expand health care delivery beyond the traditional clinical care delivery system by establishing community-level interventions aimed at addressing a wide-range of health and social issues affecting whole populations.