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

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General ACH Information & Similar Initiatives

Analysis of California’s state budget finds that health care spending has skyrocketed, leaving fewer dollars to fund programs that prevent illness at the community level

Lown Institute

Provides a vision and definition for a transformed health system to support community health and advance equity and compares and contrasts it with the current system

Tool Kit - May 2019

Upstream Communications Toolkit

Provides tools to improve communications about the social determinants of health to help health care, public health and human services leaders find common ground.

Health Begins

Provides a policy compendium highlighting a promising set of federal, state and (occasionally) local policies to achieve health system transformation goals

Altarum Health Care Value Hub

National effort to advance holistic, value-based, person-centered health care that can successfully impact the social determinants of health.


Profiles and outlines key factors behind the success of California’s HiAP approach, and highlights several policy achievements

Center for Health Care Strategies

Explores a variety of state-level multi-sector actions for addressing the social, economic, and environmental factors that impact health

Center for Health Care Strategies

Describes commonalities of multi-stakeholder collaboratives regarding their structure, initial successes, barriers and best practices

Case Study - May 2018

Healthy Homes Des Moines Case Study

Describes how a BUILD grantee reduced pediatric asthma through home improvements and education.

BUILD Health Challenge

Provides an overview of social determinants of health as well as emerging federal and state initiatives to address them.

Kaiser Family Foundation

Shares information about Accountable Health initiatives supported by various public and private funders.

George Washington University

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

Provides a planning guide and curriculum for implementing a resident engagement strategy

ReThink Health

Lays out a conceptual framework to organize delivery system and payment reform with health equity, and provides a menu of policy options for reducing health inequities.

Families USA
Report & Toolkit - Mar 2018

Engaging Communities with Lived Experience

Describes the way in which community leaders & community champions formed partnerships with one another as part of 100Million Healthier Lives (report links to Toolkit)

100 Million Healthier Lives

Classifies best practices according to three key outcomes: resident awareness and participation, feedback and input, and active resident leadership.

ReThink Health

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 an online collection of 100+ papers, toolkits, and other resources on privacy and other legal issues related to data sharing

Data Across Sectors for Health & Public Health Law Network
Toolkit - Mar 2019

De-Identification Toolkit

Supports a broad audience of health officials, community organizations, and data managers in developing a modern information infrastructure to provide actionable data

Network for Public Health Law

Identifies the five most common data challenges from the BUILD cohort, as well as reflections and solutions from the practitioners involved.

BUILD Health Challenge
Website - May 2018

California Healthy Places Index

The Index, along with an interactive map, provides overall scores and data on specific areas that shape health, like housing, transportation, and education.

Public Health Alliance of Southern California

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

Funders Forum on Accountable Health interviewed leaders in ten communities, including Imperial and Stockton, CA, to better understand their progress & challenges.

George Washington University

Provides learnings from the Ripple Foundation/ReThink Health Ventures Initiative, which worked with six multisector partnerships working to transform health.

Mt. Auburn Associates

Provides findings and lessons learned from Washington State's experience implementing ACHs.

Center for Community Health and Evaluation

Provides findings from evaluation of the Parks After Dark program, including savings to the county as well as health and social outcomes for youth and young adults.

UCLA Center for Health Policy Research

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

Provides detailed information about MHSA funding and how CACHI communities can access those resources in support of their goals.

Third Sector Capital Partners and CACHI

Determines the ROI of health-related social needs to help CBOs and their health system partners plan sustainable financial arrangements for high need patients

Commonwealth Fund

Shares early lessons and recommendations for establishing locally-governed Wellness Funds to support multi-sector collaboratives and prevention.

CACHI and JSI, Inc

Describes results of an initiative in which seven sites pursued a pooled community wellness fund to address primary prevention of chronic conditions.

Georgia Health Policy Center
Toolkit - Dec 2018

Beyond the Grant

Offers modules with practical, user-friendly tools to answer common financing questions and develop action plans for moving beyond the grant.

ReThink Health

Provides a wealth of resources regarding how to bring various funding streams together through the use of two mechanisms: braiding and blending.

Trust for America's Health

Proposes how a properly governed, collaborative approach to financing could enable health stakeholders to earn a financial return on their social determinants investments

Health Affairs

Describes six prominent or emerging forms of impact investments that may be applicable financing approaches for an Accountable Communities for Health

ReThink Health & CACHI

Explores opportunities for Medi-Cal to support community health initiatives such as CACHI and how managed care plans can align resources and partner more effectively


Describes various methods for valuing the tangible and intangible benefits of an Accountable Community for Health

Minga Analytics & CACHI

Provides step-by-step guidance for how to develop a business case for investing in the social determinants of health, along with specific examples.


Recommends a new approach for updating the current rate-setting methodology to advance Medi-Cal’s goals of improving health outcomes and promoting efficient resource use.

California Health Care Foundation

Provides practical advice for state Medicaid agencies and managed care organizations interested in implementing SDOH strategies within managed care.

Academy Health & Nemours

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

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

Provides an assessment tool and process for identifying strengths and weaknesses of a collaborative's current leadership efforts

ReThink Health

Provides a playbook to guide community developers toward partnerships with hospitals and healthcare systems to improve health and equity

Building Healthy Places Network

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

Describes four case studies to identify core partnership components.

Center for Health Care Strategies

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 a framework for primary care providers to establish social needs screening and referral programs in concert with human services partners.

United Hospital Fund

Examines 40 Medicaid managed care contracts and 25 approved § 1115 demonstrations across the country to identify common themes for how to support SDOH-related activities.

Center for Health Care Strategies

Provides an organizing framework, with examples, to help hospitals and health systems take both internal and external actions to become more "upstream"

Moving HealthCare Upstream

Provides a compilation of resources, strategies, and case studies regarding community benefits strategies to promote healthier food access and healthy food systems.

Health Care Without Harm

Provides toolkits and resources to help hospitals and health systems build community wealth through inclusive hiring, investment, and purchasing.

Democracy Collaborative

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

Website - Mar 2019

ChangeLab Solutions

Provides a wealth of resources and tools to improve community health, focusing on policy and environmental change approaches

ChangeLab Solutions
Website - Feb 2019

Healthy Food Access Portal

A go-to-resource that harnesses an array of data and information for planning and implementation of policies, programs, and projects to improve access to healthy foods

The Food Trust, PolicyLink and Reinvestment Fund

Repository of high quality research that advances efforts to identify and address social risks in health care settings


Provides resources from trauma-informed care leaders to help improve outcomes and reduce avoidable health care service use and costs in health care and other settings.

Center for Health Care Strategies

Provides resources and examples to advance implementation of CDC’s 6|18 Initiative by Medicaid, state and local health departments, and other payers and purchasers.

Center for Health Care Strategies and CDC
Report - Jun 2018

Making the Case for Prevention

Makes the case for why states should invest in chronic disease prevention as part of a comprehensive approach to chronic disease.

Academy Health & Nemours
Website - Mar 2018

Win-Win Project

Provides a standardized, unbiased economic analysis of interventions to help public-health officials make informed decisions and engage in cross-sectoral collaboration.


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

Washington State Institute for Public Policy

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