Five years ago, Washington State launched a collaborative regional Accountable Communities of Health (ACH) model to improve the health of communities across the state. These ACHs have evolved into independent organizations that are integral to the state’s health system transformation efforts. A 2019 evaluation by the Center for Community Health and Evaluation found this ACH model has largely succeeded in building robust regional coalitions to improve the health of their communities.
Washington’s ACHs take diverse approaches to improving health through projects such as:
- The Pierce County ACH’s Community HUB, which coordinates community health worker services for at-risk pregnant women throughout the county, and
- The Olympic Community of Health’s establishment of a regional opiate treatment network.
The ACH projects have aligned with the state’s broader Medicaid transformation effort, which was catalyzed through funding from a four-year State Innovation Models (SIM) test grant.
In their early stages, ACHs prioritized projects designed to improve health-related social and economic conditions. The goals of Washington’s Medicaid transformation demonstration include integrating physical and behavioral health, rewarding outcomes instead of volume in most Medicaid provider payments, addressing the needs of aging populations, and improving health equity.
“A great deal of success locally has been because of the convening role ACHs were able to play. I can’t emphasize enough how important that is in transformation.” – Washington State Medicaid Director MaryAnne Lindeblad
ACH Projects Move Transformation Forward
When Washington’s five-year Section 1115 Medicaid Transformation Project (MTP) was approved in 2017, ACHs designed regional MTP projects that sought to improve clinical care and preventive services while leveraging collaboration across clinical and community organizations to account for social determinants of health. In order to carry out these Delivery System Reform Incentive Payment (DSRIP) projects, ACHs had to build up their organizational infrastructure to the point where they could both develop project plans and distribute the funds to regional partners needed to get the projects off the ground. Given the time-limited nature of these funding sources, sustainability is emerging as a priority for ACHs.
ACHs conduct DSRIP projects on such topics as:
- Improving transitional care – when a patient moves from one health care setting to another. The Cascade Pacific Action Alliance is working to coordinate services when patients leave the hospital, in order to improve patient health and reduce preventable hospital utilization.
- Improving the integration of physical and behavioral health care. The Spokane region’s ACH, Better Health Together, is working to help patients move between the physical, behavioral, and oral health care systems to receive more integrated care. The evaluation also highlighted the work of the Cascade Pacific Action Alliance, which brings together school districts, physical health clinicians, and behavioral health providers to improve behavioral health coordination for children in the region.
- Increasing access to oral health services. North Sound ACH is working to integrate oral health and primary care in community-based settings.
While DSRIP performance accountability focuses primarily on clinical care, the state also encourages ACHs to address health equity, the social determinants of health, and the health of the whole community:
- The Greater Columbia ACH created a Community Health Fund with DSRIP dollars to address health-related needs, such as nutrition, transportation, and housing, in its region.
- The North Sound ACH requires each MTP partner to participate in an equity and Tribal learning series, and they rotate their meeting locations so that location does not bar any one partner from participating. They also begin each meeting by acknowledging the original inhabitants of the land, according to the evaluation.
- The evaluation reported that the HealthierHere ACH established a Community and Consumer Voice Committee, which developed an equity tool to “assess impact and consumer voice.”
Balancing State and Local Roles
As states develop accountable health models that tackle a variety of regional priorities, state agencies often assume the role of key convener for accountable health entities and their local or regional partners. This convening role can help regional entities learn from each other and can inform state approaches so states can balance local or regional goals with broader statewide initiatives.
Just as states convene regional entities, Washington’s ACHs are taking on a critical role in convening their own local partners and supporting efforts to align regional strategies and priorities for much of the state’s health transformation work. The state required ACHs to develop into autonomous nonprofits with the ability to allocate funds and sustain organizational infrastructure. In the process, ACHs have built trusting and collaborative relationships with their regional partners. That successful relationship-building has led to ACHs themselves emerging as key regional players, which effectively positions them to take the lead on other statewide initiatives and activities, according to the evaluation.
As ACHs take the stage regionally, state policymakers are working to balance local expertise with statewide leadership. To allow ACHs to fully capitalize on local and regional knowledge, the state built some flexibility into their structure, such as allowing the ACHs to determine who to include in their governance structures, within state guidelines.
At the same time, the state is responsible for efficiently advancing statewide goals, and certain overarching issues may require a common statewide approach. For example, efficient technology infrastructure or workforce development may call for a statewide solution rather than multiple local approaches. “Consider what would be best served by a statewide coordinated approach to reduce fragmentation, versus a regional approach,” suggested Washington State Health Care Authority Medicaid Transformation Manager Chase Napier.
Conclusion
The recent evaluation of Washington’s ACH model shows the promise of ACHs in moving the state toward health system transformation. While other states’ accountable health models seek to balance local innovation and state coordination, the recent evaluation found that Washington’s ACH model may give states a helpful roadmap for incorporating local and regional voices to improve the health of individuals and communities statewide.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
