The COVID-19 pandemic is renewing calls for solutions to long-standing health disparities, as data reveal that disadvantaged populations, including Blacks, Hispanics, and Native Americans, are more likely to contract the virus, require hospitalization, and die from the disease.
One promising approach to reducing health inequities is the accountable community for health (ACH) model. ACHs are cross-sector partnerships that aim to improve health outcomes for vulnerable populations by addressing social determinants of health, such as food and housing insecurity.
More than 100 ACHs are currently in place across the United States. For instance, seven California foundations have established the California Accountable Communities for Health Initiative to support 13 ACHs, bringing together health care providers, social service organizations, public health departments, schools, and other stakeholders to improve health in their communities.
The federal government is also investing in the model to help address Medicare and Medicaid beneficiaries’ health-related social needs. For example, the Center for Medicare and Medicaid Innovation’s (CMMI) Accountable Health Communities model currently has 29 ACHs. CMMI recently launched a second model, Integrated Care for Kids, focused on children.
So far, emerging evidence has shown ACHs to be effective at providing coordinated, integrated care. However, there is not yet evidence that the model successfully increases health equity, which the World Health Organization defines as everyone having “a fair opportunity to attain their full health potential.” A commitment to health equity is at the core of the model, but the model does not use a standardized health equity framework or measures to systemically evaluate equity.
Given their mission and population served, ACHs might benefit from a clear commitment to equity and social justice in their leadership structure and operations, as well as in specific community interventions and policy changes. We propose a framework to assist ACHs in pursuing a health equity pathway.
Broadly Define Social Determinants of Health
The term “social determinants of health” is often narrowly defined to address only social needs, like housing insecurity or health literacy. This ignores underlying and often harder-to-fix systemic and structural drivers of health inequities — including racism, political systems, and economic policies — that lead to disadvantages for people of certain races and ethnicities, income classes, genders, and sexual orientations. A broader construct helps explain why people of color are disproportionately harmed by COVID-19 and other health conditions.
To attain meaningful improvements in health equity, ACHs will need to take on these systemic issues in their communities. After all, disparities are often “shaped by the distribution of money, power and resources.”
Conduct an Internal Evaluation
One of the initial steps ACHs can take on a health equity pathway is to examine their own internal structures, functions, and operations. They can start by:
- holding leaders accountable for fostering health equity
- reviewing and revising mission and vision statements to include health equity
- developing inclusive recruitment policies and protocols
- training staff on equity and cultural competency.
Implement Equity-Focused External Interventions
Externally, ACHs should engage community partners on two parallel tracks. The first is implementing a targeted portfolio of interventions. This involves collaborating with diverse, multisector, community-based groups to identify, design, and implement interventions at the individual and community level that can address specific socioeconomic challenges, such as transportation or food insecurity or helping uninsured people sign up for insurance.
The second track involves addressing systemic and structural drivers of inequities in the community, such as the level of investment in low-performing schools, affordable housing, and accessible transportation. To catalyze change in these arenas, ACHs can engage policymakers, influence local decision-making, and mobilize or support community advocacy work.
Assess Health Equity Improvements
ACHs will need to continually measure and evaluate their actions and interventions to determine progress in attaining health equity. There are a variety of metrics available. The choice of metrics should be driven by purpose, which may include ACH performance evaluation, informing local funding decisions, or mobilizing community support.
In addition to quantitative metrics, ACHs will want to continually evaluate health equity in their communities, by asking such questions as:
- How is the community changing?
- How has the power dynamic shifted among community partners?
- Are the health improvements at the individual and community level equitably distributed?
- Are these health improvements sustainable?
This framework is still in the pilot stage and it will be important for ACHs to test and refine it as they work with other stakeholders in their communities. However, the framework does provide a meaningful path forward for ACHs seeking to measure their health equity impact.