In the United States, keeping people healthy has long been a priority for individuals, communities, employers, and policymakers. The prevailing method of doing this has been through medical care, primarily after people are already sick. Research on the factors that affect health outcomes shows that access to, and use of, medical care is only one of many factors that influence health and well-being.1,2 Traditional health care is designed only to provide (and pay for) clinical care, not to address the other drivers of health that affect health outcomes (e.g., social and economic factors, health behaviors, physical environment, policies and programs that influence these factors). Because clinical care and genetics each account for only 20 percent of the variation in health outcomes, these other drivers must be addressed to improve health and well-being.3
One strategy that has shown promise in bridging the gap between health care and social service providers is the Accountable Care Community (ACC) model, a regional multisector partnership that shares responsibility for coordinating and financing efforts to address multiple drivers of health. ACCs bring together traditional health care with its focus on preventing and treating illness, community-based partners whose focus is on creating the conditions necessary for good health, and those who purchase and pay for health care.
Fundamentally, ACCs acknowledge that communities have a shared responsibility to ensure the health and well-being of all members of the community.4 ACCs seek to fulfill this shared responsibility through cross-sector collaboration that most often includes community members, businesses, education, the health care delivery system, public health, social services, housing, transportation, and human services organizations.5 ACCs can improve the health and well-being of communities by developing shared goals, systems, and sustainable funding among partners.
THE TASK FORCE ON ACCOUNTABLE CARE COMMUNITIES
Across the country and state, there is growing recognition for the need to integrate the drivers of health into the conception of health and health care in order to improve health and health equity and control rising costs of care. There is growing interest in ACCs as an emerging and promising model for how to more fully address the health and well-being of communities while reducing costs.
There are currently no ACCs in North Carolina, although there are health care systems and community groups beginning to engage in activities similar to those of ACCs. With a need for leadership and recommendations on how communities can develop these partnerships, the North Carolina Institute of Medicine, with funding from The Duke Endowment and the Kate B. Reynolds Charitable Trust, convened the Task Force on Accountable Care Communities.
The Task Force's vision is for communities across the state to convene stakeholders in sectors relevant to health-related social needs to develop and implement ACCs. The goal of these partnerships is to improve health outcomes, strive for health equity, and reduce health care costs by addressing many of the key drivers of health. Each community should develop both short- and long-term goals to address community health needs along with a plan and strategy to systematically achieve those goals. In the short-term, human services organizations can help provide services to meet immediate needs, such as food insecurity and housing stability. In the long-term, ACCs can work to address the policies that have created the circumstances for those needs.
Recommendation 1.1:
Promote Accountable Care Communities to improve health of community members.
COLLABORATING FOR BETTER HEALTH
The work of ACCs begins with convening cross-sector partners to assess community health issues and develop strategies to address individual and community needs. Governance, financing structures, and evaluation mechanisms should be discussed and planned out to sustain the ongoing work of the partnership. To address individuals' short-term needs, partners can use a screening and referral process to begin to address issues on the individual level. To address the root causes of community needs for the long-term improvement of population health, the ACC partnership should advocate for the consideration of health and well-being in local policies across all sectors.
Recommendation 2.1:
Promote health and well-being in all policies.
Additionally, it is important to consider the effects of local policies and ACC activities on health equity in the community.
Recommendation 2.2:
Evaluate health equity effects of Accountable Care Community and county-based programs and activities.
In order to address health and well-being in all sectors of policy and to achieve health equity, siloes of local systems and government must be connected. Although many of the organizations that may be involved in an ACC are recipients of funding that comes through state agencies, collaboration across sectors is difficult in systems that have traditionally been siloed (e.g., health care, housing, transportation, education).
Recommendation 2.3:
Provide guidance on cross-agency collaboration to address drivers of health.
At the local level, leadership to develop an ACC model can come from a variety of sources, from community groups to health care systems. ACCs should involve stakeholders from local government, public health, health care systems, and the community. If such collaborations do not already exist, local health departments can play a vital role in bringing these interests together.
Recommendation 2.4:
Support local health departments to be leaders in Accountable Care Communities.
Local hospitals and health care systems can contribute their expertise in health care, financial and property resources, and influence on population health of the community. Non-profit hospitals are required to provide community benefits, such as charity care, donations to community groups, and community-building activities (e.g., investments in housing) to maintain their tax-exempt status.6 The population health effects of these contributions are typically not reported but could give insight into how they are currently helping the community, and identify potential areas for greater population health improvement.
Recommendation 2.5:
Report results of hospital and health care system community benefits.
Inconsistent regional areas for state programs can contribute to the challenge of developing cross-sector partnerships and can be a factor in the willingness of some stakeholders to become active partners in an ACC.
Recommendation 2.6:
Align policies for state Department of Health and Human Services regions and understand implications of regionalized programs on Accountable Care Community partner participation.
To take effective action to improve community health, ACCs must understand the needs of the community and use collective decision-making to determine priorities and interventions. Communities around the state will develop ACCs in different ways and gather important lessons learned along the way. Bringing communities together to share these lessons and learn from each other can help disseminate knowledge and develop a sense of camaraderie.
Recommendation 2.7:
Provide technical assistance to Accountable Care Communities.
NORTH CAROLINA OPPORTUNITIES FOR HEALTH
The North Carolina Department of Health and Human Services (NC DHHS) has a vision to “optimize health and well-being for all people by effectively stewarding resources that bridge our communities and our healthcare system.” 7 To do this, NC DHHS has created a statewide framework for healthy opportunities that includes:
Developing standardized screening questions for unmet resource needs,
Supporting the development of NCCARE360, a web-based resource platform,
Mapping social drivers of health indicators,
Building infrastructure to support the recommendations of the Community Health Worker Initiative,
Implementing Medicaid transformation through Medicaid Managed Care, and
Testing public-private pilots of ACC-style models focused on individuals enrolled in Medicaid.7,8
These initiatives will be instrumental in helping to develop or support ACCs throughout the state, in particular the standardized screening questions and NCCARE360 resource platform. Nine mandatory screening questions will ask about food, housing/utilities, transportation, and interpersonal safety and three optional questions will cover the nature of the needs and whether help is wanted.9 The NCCARE360 resource platform is being developed with the goal of “mak[ing] it easier for providers, insurers and human services organizations to connect people with the community resources they need to be healthy.”10 Medicaid Healthy Opportunities Pilots will allow NC DHHS to test an ACC-style model with a population enrolled in Medicaid and utilize Medicaid funding to pay for health-related social services.
Recommendation 3.1:
Provide technical assistance to Healthy Opportunities pilots.
Developing public knowledge and support for these initiatives will help ensure their success.
Recommendation 3.2:
Develop stakeholder support for state Healthy Opportunities initiatives.
IMPLEMENTING OPPORTUNITIES FOR HEALTH
Taken together, the standardized screening questions and the NCCARE360 resource platform can provide the technical base for ACC efforts to screen and refer individuals with health-related social needs. These resources can save ACCs from spending time and money developing their own systems.
Recommendation 4.1:
Develop and deploy the standardized screening questions and NCCARE360.
At the same time, protection of personal data and securing informed consent for data usage can help maintain the trust of individuals using these resources.
Recommendation 4.2:
Ensure individuals are informed about personal data collection and sharing.
The NC DHHS is encouraging organizations addressing individual health-related social needs to implement the screening questions and NCCARE360 platform. The greater the application of these resources, the greater the potential for positive impact on health throughout the state.
Recommendation 4.3:
Implement screening and referral process across health care payers, providers, human services, and social service entities.
If ACC partners choose to develop their own information technology and data-sharing tools, their work will need to be interoperable with state-based data systems.
Recommendation 4.4:
Facilitate data sharing and compatibility.
The work of screening, connecting individuals to community resources, and managing their care/cases can be done by a wide range of professionals. Health care organizations, payers, and other stakeholders will need to consider the roles of community health workers and care managers in addressing health-related social needs as part of overall ACC efforts.
Recommendation 4.5:
Develop, expand, and support the health care workforce to better address health-related social needs and health equity.
Discussions around ACC activities often position human services organizations as the providers of services to meet individuals' health-related social needs. However, the human services sector is not adequately prepared to meet all identified needs due to funding and other organizational challenges.
Recommendation 4.6:
Strengthen the human services sector.
EVALUATION AND PROCESS IMPROVEMENT
Evaluation of process and outcomes is an important step in understanding the effect ACC efforts have on the community and health-related metrics. Measuring where an ACC is in the process of addressing community issues and how well programs are working to address needs is vital to knowing what steps should be taken to improve those programs, and thus improve the intended outcomes. The NC DHHS and their partners should incorporate evaluations of statewide efforts to address health-related social needs. Although the wording of the screening questions is being piloted, the various approaches to conducting the screening (i.e., telephone versus in-person interview and electronic or paper completion) should also be reviewed to provide guidance for optimal methods.
Recommendation 5.1:
Evaluate methods for screening for health-related social needs.
An evaluation of the data gathered using the standardized screening questions can help to inform ACCs' efforts to address health-related social needs. State-produced public reports of these analyses can help to identify areas in the most need and areas that are making progress in addressing community needs.
Recommendation 5.2:
Evaluate data gathered through the standardized screening process.
The NCCARE360 resource platform will gather a wealth of information on community needs throughout the state. This data can inform the quality improvement process for the platform and help communities understand the volume and types of service needs. As the platform is used to identify needs and link people to resources, communities can learn where resource gaps or limitations exist.
Recommendation 5.3:
Evaluate data gathered through NCCARE360.
FUNDING AND FINANCING MODELS
At the core of the work of an ACC is the shift from a system that buys medical care to one that buys health. To do this, new financial incentives are needed to re-align the health care system away from volume to value.11 The short-term and long-term funding challenges for ACCs are different. In the short-term, ACCs may need funding to form and for partners to begin working together. In the long-term, data on services delivered, improvements in health, and cost savings/avoidance should provide means to develop financial models to support ACC activities.
Funding for planning and development is needed when ACCs form and begin to explore how partners can better coordinate their work to improve health outcomes. This can be a time-consuming process involving health care organizations, human services organizations, partners, community members, and other stakeholders.
Recommendation 6.1:
Support initial development of local Accountable Care Communities.
Once an ACC has formed and determined how partners will work together and what they will do, there must be funding for implementation. New systems and services will need funding in this stage. Organizations must also hire and/or train staff and redesign their workflows to incorporate new activities and technologies.
Recommendation 6.2:
Funding for local Accountable Care Community implementation.
The Medicaid Healthy Opportunities pilots are designed to allow more substantial investments in non-clinical health-related services with the explicit goal of learning how to finance ‘health’ interventions and incorporate them into value-based payments. To facilitate this learning, the pilot program incorporates both rapid-cycle evaluation and summative evaluation.
Recommendation 6.3:
Support implementation of Medicaid Healthy Opportunities pilots.
Evidence of savings created by the health improvements resulting from ACC-supported programs and services will help develop sustainable funding models. Data collection and analysis is critical to developing sustainable funding models for investments in non-clinical health services.
Recommendation 6.4:
Analyze data to determine costs and benefits of health-related social services.
Along with payer investments and compensation for services, ACCs should consider the potential for local tax revenue and health care system investment for long-term sustainability. While the Medicaid Healthy Opportunities pilots will help to develop some funding strategies, ACCs outside of the pilots will need support and assistance to develop sustainable funding.
Recommendation 6.5:
Develop sustainable Accountable Care Community funding.
Developing sustainable ACCs throughout North Carolina will be a complex effort. If done effectively, these models for collective action could go a long way to address the health-related social needs of community members and improve population health into the future.
ACKNOWLEDGEMENTS
The work of the Task Force would not have been possible without the hard work of the dedicated people who volunteered their time to serve on the Task Force and Steering Committee.
Footnotes
Funded by The Duke Endowment and the Kate B. Reynolds Charitable Trust
TASK FORCE MEMBERS: Miles Atkins (co-chair); Reuben Blackwell (co-chair); Secretary Mandy Cohen, MD, MPH (co-chair); Ronald Paulus, MD, MPH (co-chair); Donna Albertone, MS; Paula Avery; Blair Barton-Percival, MSW; Representative MaryAnn Black, MS, LCSW (D-District 29); Will Broughton, MA, MPH, CPH; Tristan Bruner, MEd.; Brett Byerly; Heidi Carter, MPH, MS; Debra Collins, MS; Kathleen Colville, MSPH, MSW; Giselle Corbie-Smith, MD, MSc; Satana Deberry, JD, MBA; Howard Eisenson, MD; Robert Feikema, MA; Peter Freeman, MPH; Kimberly Green, AAS, NRP; Shauna Guthrie, MD, MPH, FAAP; Mark Gwynne, DO; Robby Hall, MHA; Lisa Macon Harrison, MPH; Nicole Johnson, MDiv, MA; Dee Jones, MBA; Ruth Krystopolski, MBA; Jai Kumar, MPH; Eva Meekins, DNP; Ann Meletzke; Nicolle Miller, MS, MPH, RD, LDN; Kevin Moore; Barbara Morales Burke, MHA; Representative Gregory Murphy, MD, FACS (R-District 9); Sharon Nelson, MPH; Kristin O'Connor, EdM; Abbey Piner, MS, MEd; Brendan Riley; Pilar Rocha-Goldberg; Margaret Sauer, MHA, MS; Kim Schwartz, MA; Linda Shaw, MSW; Pam Silberman, JD, DrPH; Tish Singletary; Senator Erica Smith, MA (D-District 3); Steven Smith, MPA; Anne Thomas, MPA; Sherée Thaxton Vodicka, MA, RDN, LDN; Mary Warren, MS; Resea Willis; Charles Willson, MD, FAAP; Ciara Zachary, PhD, MPH
STEERING COMMITTEE MEMBERS: Jason Baisden; Chris Collins, MSW; Shelisa Howard-Martinez, MPA; Allison Owen, MPA; Melanie Phelps, JD, MA; Joanne Pierce, MA, MPH; Jeffrey Spade, MHA, FACHE
A copy of the full Task Force report, including background information and complete recommendations, is available on the North Carolina Institute of Medicine website: www.nciom.org
References used in this Issue Brief can be found online at www.ncmedicaljournal.com.
More information on the core features of an Accountable Care Community and resources for their development can be found in Partnering to Improve Health: A Guide to Starting an Accountable Care Community at www.nciom.org.
- ©2019 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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