A selection of informational materials to promote further understanding and development of the ACH model

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General ACH Information & Similar Initiatives

Review of the literature that describes the fundamentals of ACHs including common characteristics, major challenges, and variations in stakeholder engagement.

George Washington University and National Academy of Medicine

Describes core elements of an accountable community for health for children and families.

Website - Jun 2017

Moving Healthcare Upstream

A partnership between Nemours and the UCLA Center for Healthier Children, MHCU provides case studies and resources regarding innovations to improve community health

Moving Healthcare Upstream
Website - Jun 2017

ReThink Health

ReThink Health conducts research, develops tools and new approaches to help cross-sector teams tackle regional health and healthcare redesign

ReThink Health

A scan of 17 multi-sector community health efforts across the country.

Academy Health

Describes the experience of a learning lab of 10 ACHs in Vermont

Public Health Institute

Review of state efforts to develop and test ACH models within the federal SIM initiative

Center for Health Care Strategies

Provides an overview of whole person care pilots and examples of projects in California safety net systems.

California Association of Public Hospitals and Health Systems

Profiles four states implementing ACHs

National Academy for State Health Policy

Outlines the ACH model as it is emerging in California and provides examples of relevant collaborations throughout the country

Prevention Institute

Describes critical elements of an Accountable Community for Health and goals of the Initiative


Provides lessons from states implementing population health improvement approaches under State Innovation Model grants

Institute of Medicine

Consumer, Community Engagement and Equity

Findings from Truth, Racial Healing & Transformation effort including policy recommendations that can help achieve health equity.

Trust for America's Health

Supports nonprofit hospitals, health systems, and other stakeholders to translate data from Community Benefit Insight into better community investments.

Public Health Institute

Issued by the National Quality Forum (NQF), the roadmap guides healthcare providers and payers to use quality performance measures to eliminate healthcare disparities.

National Quality Forum
Website and Toolkit - Aug 2017

Health Equity Guide

Offers a set of strategic practices, including case studies, that health departments can apply to more meaningfully and comprehensively advance health equity.

Human Impact Partners

Provides strategies for incorporating an equity lens into planning processes.

Spark Policy Institute

Offers tools, information, case studies and other resources to help non profits develop and improve core competencies on community engagement

Building Movement Project
Report - May 2017

What is Health Equity?

Provides a framework, definition and principles of health equity


Provides comprehensive data about the extent of disparities in California and a roadmap for how to achieve health and mental health equity.

California Department of Public Health, Office of Health Equity

Data & Data Sharing

Provides several use cases to demonstrate how a public health agency can use electronic health data to address a public health challenge and overcome legal barriers

De Beaumont Foundation

A nationwide learning collaborative that helps communities build capacity to address the social determinants of health through multi-sector data sharing collaborations

All In
Website - Jul 2017

Let's Get Healthy California

Tracks process on indicators aligned with six overarching goals, based on the Triple Aim, in support of a shared vision for health.

California Health and Human Services Agency

A 10-item screening tool, developed by the federal CMS, to enable clinicians to identify patient needs that can be addressed through community and social services.

Centers for Medicaid and Medicare Services and National Academy of Medicine
Website - Jun 2017

County Health Rankings

Data that help communities assess how health is influenced by where people live

County Health Rankings

Explores strategies that states are using to capture SDOH information on Medicaid beneficiaries

Center for Health Care Strategies

Commissioned by the State Health and Human Services Agency, tool kit provides resources to help communities assess and engage in data-sharing across sectors.

Center for Healthcare Organizational and Innovation Research and CACHI

Identifies a set of core measures to enhance the understanding and focus on better health and well-being for Americans.

National Academy of Medicine

Idenfies priority social and behavioral data that can be incorporated into patient electronic health records


Evaluation and Impact

Provides a mechanism for a multi-sector collaborative to assess its readiness along seven core elements


The Trust Fund supported nine grantee partnerships over four years, with documented improvements.


Using 16 years of data, the study finds that supporting multisector health activities may help close geographic and socioeconomic disparities in population health

Health Affairs

Commissioned by California Health and Human Services Agency, the report provides an evaluation framework for ACHs

Blue Sky Consulting and CACHI

Provides early evaluation findings of the first year of Washington state's ACH initiative

Center for Community Health and Evaluation

Financing, Sustainability and the Wellness Fund

Explores practical strategies that states can deploy to support Medicaid managed care plans and their network providers in addressing social issues.

Commonwealth Fund

Outlines a potential model, call the Healthy Community Funding Hub, to help coordinate and sustain funding for community health improvement.

TFAH and Deloitte Health Solutions

Explores the business motivation for investing in community health, the processes involved, and the challenges stakeholders faced when pursuing these initiatives.

National Academy of Medicine

Provides and categorizes a wide array of funding options by the sources and the process by which the money is acquired.

ReThink Health

Provides policymakers with cost-benefit results, based on literature, of a wide variety of public policies.

Washington State Institute for Public Policy

Proceedings of a workshop convened by the Roundtable on Population Health Improvement

National Academies of Sciences, Engineer and Medicine

Provides analysis and examples about why and how Medicaid programs should account for social determinants of health in setting payments and measuring quality

Health Management Associates
National Academy for State Health Policy

Illustrates how state Medicaid agencies and their partners can maximize authority that exists under federal Medicaid and CHIP law.

The Nemours Foundation

Identifies various financing innovations to support population heatlh

Georgia Health Policy Center

Using the ReThink Health Dynamics Model, the authors show results from alternative investment strategies

ReThink Health

Provides tools to analyze funding and develop strategies for braiding and blending, along with case studies and other insights.

Spark Policy Institute

Estimates the average ROI for activities of public health departments in California

American Journal of Public Health

Provides an overview of local health trusts roles and structures

Health Affairs

Overview of community integration structures and emerging innovations in financing

Centers for Disease Control and Prevention

Identifies options for sustainable multi-payer investment in population health

JSI, Inc. and CACHI

Approaches and issues in establishing a reinvestment mechanism


Governance, Leadership and Partnerships

Profile and classify burgeoning initiatives, understand common challenges, and surface solutions to address those challenges.

Commonwealth Fund

Findings from research about the development of multi-sector partnerships and how well they are poised to lead health transformation.

ReThink Health

Provides examples of of partnerships between organizations that offer health and social services offers lessons learned from these in depth cases.

Center for Health Care Strategies

Evaluation results about the role of distributive leadership in complex cross-sector systems change strategies, focused on college and career readiness.

James Irvine Foundation, Equal Measure and Harder + Co.
Website - Jul 2017

Practical Playbook

Provides practical implementation tools, guidance, and resources to advance collaboration between public health and primary care in order to improve population health.

Practical Playbook
Report - Jul 2017

Keys to Collaboration

Identifies four stages of collaboration that are key to the development of partnerships aimed at health equity.

BUILD Health Challenge

Explores the many ways that health care organizations and CBOs are partnering in shared pursuit of better health outcomes

Center for Health Care Strategies

Describes options for governance and legal considerations for different approaches.

ChangeLabSolutions and CACHI

Healthcare Providers, Payers and Systems

Provides insights from hospital executives about how health systems can move upstream to improve community health

BUILD Health Challenge

Describes innovations that safety net providers are implementing to address the social determinants of health.

California Health Care Foundation
Tool - Dec 2017

Community Benefit Insight

Provides direct access to the community benefit spending information from tax-exempt hospitals throughout the United States.

Research Triangle Institute
Report - Oct 2017

Anchor Mission Playbook

Provides guidance for how hospitals and health systems can accelerate their efforts to drive institutional alignment with community needs.

Democracy Collaborative

Findings from a survey of 300 hospitals and health systems to identify what is being done to address health-related social needs and the potential for future efforts

Deloitte Center for Health Solutions

A "playbook" of effective methods, tools and strategies to create new partnerships with hospitals and sustain successful existing ones.

Hospital Research and Education Trust

Case study of a large academic medical center that has implemented an upstream population health strategy


Describes an innovative practice that engages hospital leadership in efforts to align vision, priorities, and initiatives of community benefits with community needs

Health Resources in Action

Provides examples of traditional and less traditional ways that hospitals and health systems can invest in their communities

Center for Community Investment

Examples of effective collaborations between hospitals and community development

Low Income Investment Fund

Explores ways that states have incorporated population health goals into ACOs and other models

Milbank Memorial Fund

Portfolio of Interventions

A high-level overview of local and state public policy strategies to prevent and address asthma: health care, childcare and schools, home environment and the outdoors.

Moving Health Care Upstream

Provides a collection of evidence-based findings of the Community Preventive Services Task Force to guide selection of interventions for an ACH's portfolio.

Community Preventive Services Task Force
Practice Guide - Dec 2017

Best Practices Guide for CVD Prevention

Describes & summarizes scientific evidence behind 8 effective strategies, which involve community-clinical links, for lowering high blood pressure and cholesterol levels.

Centers for Disease Control and Prevention

Provides information regarding financing, certification, education and other elements of Community Health Worker programs across the country.

National Academy for State Health Policy
Website - Jun 2017

Health Impact in Five Years

Identifies non-clinical community-wide approaches that have evidence reporting positive health impacts, results in 5 years and cost-effectiveness and or cost reductions

Centers for Disease Control and Prevention

Outlines key considerations for the design and implementation of ACH-type initiatives focused on trauma and resilience

JSI, Inc

Report to the CA Secretary of Health and Human Services with recommendations from a workgroup established under the State Innovation model design process

CHHS Workgroup

A Review of Emerging Evidence On Interventions for Asthma, Diabetes, and Cardiovascular Care

Center for Healthcare Innovation and Research, UC Berkeley, and CACHI