A New Way to Improve Health
With the numerous challenges to delivering quality healthcare today, the need to innovate is enormous! Research (Robert Wood Johnson Foundation and Schroeder et al.) has shown that clinical delivery systems contribute as little as 10-20% of health outcomes when compared to other factors like health behavior, environment, poverty, education, and other social determinates. Wow! What a revelation!
Based on those findings, it is obvious that if health outcomes are to be truly impacted, social factors, people’s environments, and health behaviors must all be considered. Most healthcare providers lack expertise in these fields and, therefore, must partner with those who do have that expertise. When such a coordinated, purposeful, and committed effort occurs that is focused on improving the well-being of a population, the result is an Accountable Care Community (ACC).
Accountable care organizations (communities) are a different healthcare model that involve various entities working together to improve the health and well-being of their population by addressing social challenges to improving health. Parties of interest in these communities include healthcare delivery systems, public health organizations, and community organizations. Accountable Care Community participants share responsibility, resources, and data to improve community health. Accountable care communities (ACCs) are formed to both decrease medical costs and improve health outcomes by placing greater emphasis on dealing with social and economic issues that can determine the quality of one’s health.
And as we all know, as part of the Patient Protection and Affordable Care Act (ACA), providers across the US began work on delivering value-based care within Accountable Care Organizations (ACOs) and Clinically Integrated Provider Networks. However, many of those efforts failed to deliver on the promise of decreasing costs and improving outcomes. One potential explanation was their predominant focus on health care delivery systems alone, and subsequent failure to address social determinants of health.
ACCs, also known as Accountable Health Communities, tackle health and care from a community perspective, attracting multiple stakeholders to share responsibility for addressing multiple determinants of health. ACCs add value to health care settings because they enable the health care system to reach patients in their own environments through local agencies within the social infrastructure that already exists (e.g., schools, businesses, community and faith organizations). Successful ACCs are partnerships between providers and community agencies to attempt to overcome population health challenges.
The most common collaboration is between health care providers and social service organizations, where each works to improve the lives of community members in a way that also improves health outcomes and reduces medical expenditures. A number of examples exist where communities have worked to further collaborations through physical co-location of services. Ideally, the environment facilitates the ability to understand existing and needed resources, identify those within the community with needs and assist them with the navigation across those resources.
The interdependence for information (data) sharing is required to improve coordination efforts and increase efficiency in the delivery of services, the understanding of needs and evaluate the impact of each participant on health utilization and outcomes.
Public health agencies have opportunities to expand beyond their traditional roles in infectious disease control and as safety net providers of medical services. State and local health departments must serve strategically in their communities, and lead health improvement efforts along with health care clinicians and ACCs sectors that include social services, education, transportation, public safety, and community development. Success in this role requires public health to provide leadership on leading policy and systems change interventions including innovative approaches to data systems and a shift to a broader role in interpreting and distributing data from a variety of diverse sources. Public health professionals must also work more closely with health care providers, community-based organizations, and local advocates on promotion efforts that educate and inspire society to incorporate more emphasis on prevention and wellness.
Health systems have many advantages that can help them engage with community partners. First, health providers understand the primary outcomes that need to be addressed for a community. Specifically, health systems have extremely valuable data that provide an in depth understanding of the disease burden within a community and identify current outcomes in terms of cost and utilization of services, provision of preventive services, and control of chronic conditions. Second, health providers also receive the majority of funding directed towards improving health compared to current efforts that address social determinants. Finally, health providers have access to a majority of community members over the course of their lives through private and affiliated provider practices, urgent care centers, and hospital emergency rooms. This provides an opportunity and financial incentive to address the health needs of the entire community, rather than just focusing on contemporary patient populations.
Academic institutions can be important partners when they partner with public health and health care providers. Academic institutions have resources to affect community change and have researchers interested in using data to better inform decision-making. Partnering with universities can bring in expertise and skills, as well as other resources to strengthen the work of the ACC. Additionally, since academic institutions train students in health care and social services, they can be important partners in training the emerging workforce.
State and local policies can support or hinder the work of ACCs; therefore, policy makers must be external thinkers and understand the ACC to effectively govern regarding this initiative. Medicaid reform provides the single most important opportunity to expand the work of ACCs. It is vitally important that policymakers assure Medicaid payments are adequate to attract high quality medical home providers to participate and to support the staffing shortage issues with nurses and other healthcare workers while including critical services to help identify and address social issues.
Recently, the Center for Medicare and Medicaid Innovation provided funding for several ACC models that will be implemented across the country by enrolling high-risk individuals into social services navigation programs and testing the impact of these programs on health care utilization and spending. As the ACC model continues to be implemented across the US, new skill sets must be developed and inclusive of the holistic provision of care that spans behavior and environment, addresses social determinants of health, and helps navigate increasingly complex health care systems. In the future, strong leadership will be needed to realize the opportunities for innovation and shift societal emphasis and resource allocation from advanced health care interventions to investments in core social and economic needs.
The Accountable Care Community is an exciting approach that has tremendous potential to be transformative for health outcomes by addressing social determinants of health. It may currently seem like a “long putt,” but it could be said to be long overdue in this country. ACCs have tremendous upside with successful implementation which will in turn help ensure acceptance and adoption. Better healthcare will translate to better population health, and that is the purpose of the Accountable Care Community.