Advancing and Promoting Community Health: Opportunities for Accountable Communities for Health and Community Health Centers The Funders Forum on Accountable Health and Geiger Gibson/RCHN Community Health Foundation Research Collaborative Policy Issue Brief January 2021 Helen Mittmann, MAA Jeffrey Levi, PhD Janet Heinrich, DrPH, RN, FAAN Feygele Jacobs, DrPH, MS, MPH Rebecca Morris, MPP Peter Shin, PhD, MPH About the Funders Forum on Accountable Health The Funders Forum on Accountable Health is a project of the Department of Health Policy and Management at the George Washington University Milken Institute School of Public Health. The Forum is a common table for the growing number of public and philanthropic funders supporting accountable communities for health initiatives to share ideas, experiences, and expertise. It is a shared venue for funders to explore potential collaborations and consider how to assess the impact of these investments over time. About the Geiger Gibson / RCHN Community Health Foundation Research Collaborative The Geiger Gibson Program in Community Health Policy, established in 2003 and named after human rights and health center pioneers Drs. H. Jack Geiger and Count Gibson, is part of the Milken Institute School of Public Health at the George Washington University. It focuses on the history and contributions of health centers and the major policy issues that affect health centers, their communities, and the patients that they serve. The RCHN Community Health Foundation is a not-for-profit foundation established to support community health centers through strategic investment, outreach, education, and cutting-edge health policy research. The only foundation in the U.S. dedicated solely to community health centers, RCHN CHF builds on a longstanding commitment to providing accessible, high-quality, community-based healthcare services for underserved and medically vulnerable populations. The Foundation’s gift to the Geiger Gibson program supports health center research and scholarship. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 2 Executive Summary Accountable Health Communities model in 28 sites across 22 states, which supports bridge organizations Accountable Communities for Health (ACHs) are multi to serve as “hubs” in local communities to address the -sector, community-based partnerships that aim to health-related social needs of Medicare and Medicaid address community health and social needs, and beneficiaries by linking clinical and community service Community Health Centers (CHCs) provide important providers. A second example is the California community-based healthcare services for underserved Accountable Communities for Health Initiative and medically vulnerable populations. Given the (CACHI), a privately funded demonstration that critical role that both ACHs and CHCs play in currently supports 13 unique ACHs in communities addressing health-related social needs and social across the state. determinants of health, a survey of ACHs on CHC engagement was conducted to better understand While ACHs may differ in regard to their funding opportunities and challenges for CHC participation in sources, their focus, and the populations they serve, ACHs. This survey, along with follow-up conversations they share a number of common elements (Figure 1). with ACH and CHC representatives, confirmed that This includes an emphasis on bringing different ACHs and CHCs are natural partners in the effort to sectors together in a collaborative and shared advance community health by building multi-sector governance approach to address high-priority health coalitions that address health-related social needs and and social needs to improve the health of individuals social determinants of health. A majority of ACHs that and their communities as a whole. This approach is responded to the survey reported CHC participation in consistent with that of community health centers their ACH under contract or other formal (CHCs). engagement, and CHCs frequently participate in ACH CHCs are local, non-profit community-governed governance. Despite this level of participation, health care providers which by mission and mandate however, the research also revealed that the nature of offer comprehensive primary and preventive care to this participation varies greatly, and strong underserved populations and high-need communities, partnerships do not always exist. This may be less as well as numerous other services which address because the ACHs and CHCs do not share the same health-related social needs and social determinants. In vision for a community’s health, and more because of 2019, 1,457 CHCs (both grant funded and “look-alike” a need to build relationships, provide financial health centers which meet all health center program incentives, remove practical obstacles, and better requirements but do not receive federal grant funds) define the shared value of such partnerships. operating in more than 13,000 urban and rural locations provided care and services to nearly Background 30,000,000 people. Approximately nine in 10 health Accountable Communities for Health (ACHs) are multi center patients are low-income, one in five are -sector partnerships that bring together health care, uninsured, nearly one in two patients rely on public health, social services, and other local partners Medicaid, and one in four are best served in a to address the unmet health and social needs of the language other than English. Health center patients individuals and communities they serve. The Funders also include 5.2 million public housing patients, about Forum on Accountable Health has identified more 1.5 million homeless patients, and over one million than 100 ACH-type initiatives across the country, agricultural workers. Because CHCs are federally which may also be referred to as accountable care mandated to operate in underserved communities – communities, coordinated care organizations, and heavily impoverished areas where health care accountable health communities, among other titles. resources are difficult to access and where social As one example, the Center for Medicare and needs such as food, employment and housing are Medicaid Innovation (CMMI) at the Centers for more difficult to address – they understand the Medicare and Medicaid Services (CMS) seeded the unique health and social needs of the neighborhoods Geiger Gibson / RCHN Community Health Foundation Research Collaborative 3 Figure 1. Essential Elements of Accountable Communities for Health Source: George Washington University, 2020 they serve. survey instrument.) Given the critical role that both ACHs and CHCs play in This report reviews key findings from the survey and a addressing population health and social determinants set of actions federal policy makers could undertake to and health-related social needs, it would appear that increase the likelihood of ACHs and CHCs working ACHs and CHCs are natural partners in efforts to more closely toward a shared goal. elevate community health through multi-sector, collaborative work. While a review of the Funders Key Findings Forum Inventory of Accountable Communities for The survey was conducted to identify health centers Health—a catalog of existing ACHs and their participating in ACHs, determine the structures and descriptions based on both publicly available data and processes established for CHC engagement, targeted outreach to leaders in the field— showed understand the roles and functions played by CHCs that CHCs participated in ACHs located in at least 16 within the ACH, and identify opportunities for and states, the extent to which health centers participate or challenges to CHC participation. Respondents were are invited to participate in ACHs was unclear. permitted to skip questions, and the data presented is During the summer of 2020, the Funders Forum, in analyzed based on the number of respondents who consultation with the Geiger Gibson Program in answered each question, not the number of Community Health Policy, conducted a survey of ACHs respondents who submitted the survey. This study was to better understand CHC engagement within ACHs institutional review board exempt. and identify opportunities and challenges for CHC ACHs frequently partner with CHCs, and CHCs participation. This survey was distributed electronically often participate in the governance of ACHs. to all sites included in the Funders Forum inventory of ACHs, and representatives from 33 sites responded for While there is great variation in the nature of CHC a response rate of approximately 22%. Respondents participation in ACHs, 25 of the 33 survey respondents were geographically diverse and represented a range reported that CHCs participated in their ACH under of ACH-type initiatives. The survey results were contract or other formal engagement. Respondents presented to a subset of eight ACH and CHC identified a total of 77 participating CHCs; the number representatives from four states, and a number of of participating CHCs varied with each ACH’s policy recommendations emerged from these geographic scope and ranged from one to 12 with an discussions. (See Appendix I for a detailed description average of three participating CHCs per ACH. of the survey methodology, and Appendix II for the Additional information about the nature of CHC Geiger Gibson / RCHN Community Health Foundation Research Collaborative 4 engagement was provided by 23 ACH respondents, Other areas where CHCs often play leading or with 19 reporting that at least one CHC participates in supporting roles include assessing community health the governance of the ACH. In addition, 12 sites needs, serving as a resource/linkage to other human reported that they do not provide funding for CHC services, building community engagement and trust, programs, nine provide funding for at least one of providing expertise in addressing social determinants, their participating CHC’s programs, and two did not and sharing data. Alternatively, transportation, know if they provide funding. training community health workers, and training community leaders and advocacy were areas in which Eight respondents reported no current CHC participating CHCs were reported as playing the participation in their ACH under contract or other fewest lead or supporting roles. (Figure 4) formal engagement, but of the seven sites that provided additional information five reported that In addition, 20 respondents described the types of they maintained informal relationships with CHCs and social and support services their ACHs offer through collaborated as needed (Figure 2). collaborating organizations (Figure 5). The services ACHs most often provided through CHCs Participating CHCs provide a number of participating in the ACH were mental health services services and have leading or supporting roles (12 sites) and substance use services (nine sites). in various programs. Respondents reported that Approximately half of the ACH respondents also in addition to providing core health care and related reported providing services related to family and services (Figure 3), participating CHCs also play community support (10 sites), housing support (nine important roles in various ACH functions (Figure 4). sites), food security and nutrition (nine sites), Respondents reported that two areas where transportation (nine sites), and personal and participating CHCs most often play leading roles interpersonal safety (nine sites) through referral to include reaching underserved areas and populations CHCs not participating in the ACH. Services frequently and managing chronic diseases and coordinating care. provided through other non-CHC organizations Figure 2. ACH-Reported Reasons CHCs Do Not Participate Under Contract or Other Formal Engagement Notes: Results reflect the responses of 7 ACH representatives from across the country. Respondents were permitted to identify up to three reasons CHCs do not participate under contract or other formal engagement, and some respondents only identified one or two. Source: George Washington University analysis, 2020 Geiger Gibson / RCHN Community Health Foundation Research Collaborative 5 Figure 3. Top ACH Services Provided by Participating CHCs Notes: Results reflect the responses of 23 ACH representatives from across the country about 59 of 77 participating Community Health Centers. Source: George Washington University analysis, 2020 Figure 4.CHC Participation and Roles in ACH Functions Notes: Results reflect the responses of 23 ACH representatives from across the country about the types of roles CHC play in their ACH. Source: George Washington University analysis, 2020 Geiger Gibson / RCHN Community Health Foundation Research Collaborative 6 Figure 5. Social or Support Services the ACH Provides Through Collaborating Organizations Notes: Results reflect the responses of 20 Accountable Communities for Health representatives from across the country. Respondents were able to indicate if they provided a service through more than one type of collaborating organization. Source: George Washington University analysis, 2020 Figure 6. ACH-Reported Challenges to Active and Broader CHC Participation in ACHs Notes: Results reflect the responses of 13 ACH representatives from across the country. Respondents were permitted to identify up to three challenges, and some respondents only identified one or two. Source: George Washington University analysis, 2020 Geiger Gibson / RCHN Community Health Foundation Research Collaborative 7 Strengthened CHC capacity, staffing, and building that engages CHCs with public health, other funding, as well as shared technology for health care providers, and social services – the building blocks of an ACH. In other assessments done data sharing, are needed in order to achieve by the Funders Forum, we have found that active and broader CHC participation in communities that received funding under the now- ACHs. defunct Communities Putting Prevention to Work and Respondents were asked to identify and rank Community Transformation Grant programs had a leg challenges to active and broader CHC participation in up in building their ACH capacity. The Centers for their ACH, and of the 13 that answered the question Disease Control and Prevention, along with the Health nine identified existing limitations in CHC capacity, Resources and Services Administration (HRSA), should staffing, or funding as their top challenge (Figure 6). re-engage in such community-building efforts. The second most-cited challenge was a lack of shared Give CHCs (and other federal grantees) more technology for data sharing, followed by the ACHs flexibility in how they spend their grants if stating that they have other partnership priorities. Eight respondents described missed opportunities they participate in an ACH. resulting from these challenges, citing capacity issues, CHCs derive most of their revenue from patient resource limitations, and competing interests and services, primarily through the encounter-based priorities that “prevent or delay [CHC] engagement in Prospective Payment System (PPS). They also receive transformation.” grant funding from HRSA that supports core functions, care for the uninsured, and special Policy Findings purposes. With greater flexibility in how they may A majority of ACHs that participated in the survey spend their grants, health centers might be able to reported CHC participation in their ACH under devote more resources to the essential work of contract or other formal engagement, and CHCs addressing social determinants and community need. frequently participate in ACH governance. Despite the Explore support for CHCs as backbone level of participation, however, the research also revealed that the nature of this participation varies organizations for ACHs. greatly, and strong partnerships do not always exist. Most CHCs engage in community-based partnerships Based on these findings, federal policy makers could that focus on social needs, many CHCs convene these undertake a series of steps that together could partnerships, and some take the lead in developing increase the likelihood of ACHs and CHCs working and fostering community-based capacity to address more closely. These include: those needs. In some communities, CHCs are already performing an ACH-like function. In addition to Provide opportunities for stronger clarifying the role of current CHC core grant funding relationship building between CHCs and in supporting ACH participation, one-time quality other key stakeholders that may participate improvement grants could be given to individual in an ACH. CHCs or a consortium of CHCs that wish to be the Trust and pre-existing opportunities to work together “start-up” backbone organization for a nascent ACH. are often the “magic sauce” of a successful ACH Primary Care Associations, nonprofit state or regional coalition, and some ACHs reported in the survey that membership organizations that provide training and trust with participating CHCs has been built over time. technical assistance to CHCs and in some cases other However, opportunities for active and broader CHC safety-net providers, might also be engaged to participation in ACHs is often limited by CHC capacity, support or help lead local CHC-ACH engagement and staffing, and insufficient funding (either from the ACH development. Similarly, if COVID-19 recovery funding or in the CHC’s operating budget) to support ACH- is made available to support CHCs in the rebuilding of type activities. Federal agencies should provide funding to communities that will permit coalition Geiger Gibson / RCHN Community Health Foundation Research Collaborative 8 health systems, a permissible or encouraged use of federal agencies would agree to standardize metrics those funds could be to build an ACH-like and data collection approaches. infrastructure that could assure more resilient systems in the future. Concluding Thoughts The Funders Forum has found through this study that Alternative Payment Methods (APMs) for CHCs could be a critical, necessary and able building CHCs should incentivize participation in ACH- blocks for ACHs. Implicit in the ACH model is a type coalitions and delivery of ACH- recognition that long-term, prevention-oriented supported services and community-level improvement in health outcomes occurs only if we interventions. combine both community-level interventions addressing social determinants of health with a focus APMs should support ACH participation and grow on the health-related social needs of individuals. Like over time with cost and demand. More than 20 states ACHs, CHCs are fundamentally about changing how currently use an APM to reimburse health centers for the health system in a community functions, by services provided to Medicaid patients. If the goal of providing greater access to more diverse and an APM approach is to reward improved health comprehensive care and social services, which outcomes, CMS and HRSA should create an improves health outcomes. However, this shift and environment that encourages, along with the delivery transformation toward addressing social determinants of high-quality primary care, addressing the root requires policy makers to break free of the current causes of poor health. CHCs, which were founded to “return on investment” definitions that are confined to support healthy communities, can be leaders in doing short-term interventions addressing individual health so; they are likely to be more successful if they partner outcomes. A social intervention may improve health with others under the umbrella of an ACH. outcomes; a health intervention may improve the Policy makers should standardize approaches social condition of an individual. Accordingly, to data systems and data collection so it is improvement of health outcomes and social easier for entities participating in ACHs to conditions must be valued together. work together. Policy makers should quickly take steps to incentivize ACH-CHC relationships, particularly as safety-net As multiple parties come together, they often arrive at providers seek to recover from the devastating impact the partnership with data systems that do not connect of the COVID-19 pandemic on their operations and and communicate, and these interoperability issues their communities. ACHs and CHCs are playing impede information exchange and data sharing. ACH important roles in pandemic response, serving the survey respondents identified the lack of data-sharing very communities hardest hit by the pandemic and technology as one of the most common challenges to that have also experienced historical inequities and active and broader CHC participation in ACHs. Each discrimination. ACHs and CHCs are both embedded in new government initiative may impose new and and governed by the communities they serve and are different data collection requirements, and the therefore uniquely positioned to respond. However, layering effect often makes participation too the pandemic has taken a financial toll on this burdensome for those already working within the essential safety net; over an eight-month period from health care system. Creating closed-loop referral April-December 2020, health centers have lost an systems that are truly integrated with existing data estimated $4 billion in patient revenue, or nearly 13% systems (as opposed to working in parallel) is even of annual revenue. If health care financing and safety- more challenging for less well-resourced partners, net funding continue to focus on medical care alone, such as social service organizations. A truly committed community providers will continue to struggle to CHC, for example, could end up being funded to use address the underlying and contributing causes of multiple screening tools to determine social needs of poor health. ACHs and CHCs may currently lack critical their clients. This chaotic situation is resolvable, if Geiger Gibson / RCHN Community Health Foundation Research Collaborative 9 resources and incentives necessary to address the Appendix II: Survey Instrument wide and diverse range of social needs together, but the policy recommendations laid out in this brief 1. Name of your Accountable Community for Health present a significant opportunity to facilitate these (ACH) partnerships and improve the health and well-being 2. Name of person filling out the survey of the communities they serve. 3. Job title of person filling out the survey Appendix I: Survey Approach and 4. Organization Methodology 5. Email The Funders Forum in consultation with the Geiger 6. City Gibson Program in Community Health Policy developed a web-based survey (Appendix II) 7. State administered via SurveyMonkey to better understand 8. Have Community Health Centers (CHCs) ever current community health center (CHC) engagement participated in the ACH? within Accountable Communities for Health (ACHs) a. Yes and identify opportunities and challenges for effective CHC participation with ACHs across the country. This b. No study was Institutional Review Board exempt. With the c. Don’t Know emergence of COVID-19 in the US, the project timeline was modified and extended in 9. Do CHCs currently participate in the ACH under acknowledgement of the fact that many lead contract or other formal engagement? organizations in the ACH community were (and are) at a. Yes the front lines of the pandemic response, and largely b. No, CHCs participated in the past but do focused on responding to the immediate crisis. not currently participate In May 2020, an invitation to participate in the study c. No (skip to question 22) was distributed electronically to a subsample of 20 sites from across the country to gauge response rate 10. How many CHCs currently participate in your amid the ongoing pandemic. The response rate was ACH? relatively favorable (40%), and in June 2020 the 11. What is the name of the most active CHC? invitation was distributed to sites included in the (Respondents may answer questions 11 to 16 Funders Forum inventory of ACH-type initiatives. As of about up to 5 CHCs.) May 2020, the inventory included 152 sites. Several rounds of emails were sent to site representatives to 12. Does the CHC participate in the governance of the encourage participation. Ultimately, representatives ACH? from 33 sites responded, for a response rate of a. Currently approximately 22%. b. Previously In August 2020, Funders Forum staff analyzed the c. No survey results collected in SurveyMonkey. Respondents were permitted to skip questions, and 13. Is there a contractual arrangement with this CHC? the data presented is analyzed based on the number a. Yes of respondents who answered each question, not the number of respondents who submitted the survey. b. No Geiger Gibson / RCHN Community Health Foundation Research Collaborative 10 14. What type of services does this CHC provide? Check all that apply. a. Primary b. Dental c. Behavioral Health d. Pharmacy Services e. Case Management/Navigation f. Home Visiting g. Environmental Assessment h. Social Services Screening i. Social Services Referrals j. Other (please specify) 15. Does the ACH provide funding for CHC programs? a. Yes b. No c. Don’t know 16. If yes, what CHC programs does the ACH provide funding for? 17. Does the CHC participate in other programs or roles? Check all that apply. Activities Role Sharing data ○ leading ○ support ○ none Managing chronic diseases ○ leading ○ support ○ none Training community leaders and advocacy ○ leading ○ support ○ none Building community engagement and trust ○ leading ○ support ○ none Transportation ○ leading ○ support ○ none Reaching underserved areas and populations the ACH has ○ leading ○ support ○ none otherwise not been able to serve Assessing community health needs ○ leading ○ support ○ none Serving as a resource/linkage to other human service ○ leading ○ support ○ none organizations Providing expertise in addressing social determinants of ○ leading ○ support ○ none health Training community health workers ○ leading ○ support ○ none Geiger Gibson / RCHN Community Health Foundation Research Collaborative 11 18. Which of the following types of social or support services does the ACH provide through referrals to local organizations and/or CHCs? Provide Provide through Provide through Does not through CHCs other ACH referral to non-ACH provide in the ACH providers CHC organizations a. Housing support b. Food security/nutrition c. Transportation d. Utility help needs e. Personal/interpersonal safety f. Financial services g. Employment h. Family and community support i. Education j. Physical activity k. Substance use l. Mental health m. Disability services 19. In what other ways do CHCs engage in community-wide prevention or population health initiatives? Please specify. 20. Please indicate below the top 3 challenges to active and broader CHC participation in the ACH. a. ACH currently has other partnership priorities b. ACH is unable to meet CHC reimbursement requirements c. ACH is unable to expand CHC role due to existing limitations in CHC capacity, staffing, or funding d. ACH has not collaborated with CHCs in the past e. ACH has had poor history with CHCs in the past f. ACH and CHCs lacked shared technology (for data sharing) g. ACH partners are currently able to meet client needs h. Other 21. Have there been missed opportunities as a result of these or other challenges? Please specify. 22. You indicated that CHCs do not currently participate in your ACH under contract or other formal arrangement. Please indicate the top 3 reasons why CHCs do not participate in the ACH. a. Our ACH has not considered reaching our to CHCs b. Our ACH does not have many community residents who need CHC services Geiger Gibson / RCHN Community Health Foundation Research Collaborative 12 c. Our ACH has no informal relationship with CHCs and collaborates as needed d. There are no CHCs within our service area e. CHCs are not interested in joining our ACH f. CHC regulations and payment requirements are too burdensome for the ACH to manage Geiger Gibson / RCHN Community Health Foundation Research Collaborative 13