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All Health Care Is Local, Revisited: What Does It Take to Improve?

By Sarah Klein, Martha Hostetter, and Douglas McCarthy
All Health Care is Local Revisited
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Some U.S. communities perform consistently well on The Commonwealth Fund’s Scorecard on Local Health System Performance. Hoping to learn what drives health system change, we decided to look at a different set of standouts on the most recent scorecard: the most improved.

We found that just a handful of regional health care markets — 14 of 306 — advanced on a majority of the 2016 local scorecard’s 33 trending indicators of health care access, quality, cost, and outcomes. Half were communities that had poverty rates above the national average, demonstrating that the capacity to improve is not limited to those areas with ample resources.

To learn more about the most improved, we profiled four geographically diverse communities: Akron, Ohio; Paducah, Ky.; Pueblo, Colo.; and Stockton, Calif.  We asked leaders of public health departments and other government agencies, health plans, hospitals, health clinics, and nonprofit community organizations what they thought might account for the progress they’ve made.

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In Stockton, news of rising health system performance was a welcome break from a long string of dismal headlines about crime, home foreclosures, and the city’s bankruptcy.

In Pueblo, where nearly half of the population lives below the poverty line, leaders were similarly pleased to hear that their collaborative efforts to improve health and health care seemed to be paying off.

In Paducah, dramatic increases in health care access were one of several recent civic achievements, from attracting world-class artists to funding a college scholarship program.

In Akron, where the poverty rate is closer to the national average, leaders have been hard at work tackling health problems common in the Rust Belt — obesity, infant mortality, and opioid addiction.

Augmenting lessons from an earlier set of Commonwealth Fund case studies, the profiles describe strategies that leaders in these communities used to improve residents’ health and care. They offer concrete examples of how leaders “stopped admiring the problem,” in the words of Pueblo community leader Matt Guy, and began working together to increase access to care, promote delivery system reforms, and address nonmedical determinants of health, including food insecurity and unstable housing. In contrasting these communities with others we examined that didn’t improve as much, certain factors stood out as contributing to their gains:

Local governments act as catalysts for change.

In Akron, the health department and city and county governments have found opportunities for collective action, most recently for raising awareness of symptoms of mental illness and reducing health disparities. Such collaboration, which is threaded into the fabric of this “big small town,” was promoted by a former county official who encouraged the health, housing, transit, aging, and social service agencies to pool their efforts to improve residents’ quality of life. In one instance, the county combined funds from multiple agencies to purchase baby cribs for low-income families; since that time, there have been very few infant deaths from cosleeping.

Stockton’s city council sought to curb child obesity by requiring restaurants serving children’s meals to make water or low-fat milk the default beverage, replacing typical offerings of soda or chocolate milk. The public health department also offers neighborhood stores financial incentives to sell produce from the region’s many farms. In Pueblo, the health department led a public–private initiative that halved the teen pregnancy rate, in part by encouraging youth development. Recently, the city’s fire department began partnering with health care providers to connect frequent users of the emergency response system with a regular source of care.

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Health care and other community organizations cooperate to achieve common goals.

There is a striking degree of cooperation between independent and, in some cases, competing organizations in these communities. Health care providers might share specialists or one organization might send staff to work in another. In Stockton, the Health Plan of San Joaquin, a county-sponsored Medicaid managed care plan, sends nurses to provide training and coaching to primary care clinicians. Akron’s Area Agency on Aging embeds field coaches in local hospitals to talk with seniors about their needs for rehabilitative services and support after discharge.

Seeking to increase the collective impact of their efforts, some of these communities formed coalitions. The nonprofit Pueblo Triple Aim Corporation, for example, brings local health care providers together with government agencies, business leaders, social service agencies, philanthropists, and educators to coordinate health care improvement efforts and address health problems exacerbated by poverty. Stockton’s nonprofits, health plans, and health systems are working together through the Healthier Community Coalition to offer services to residents affected by violence and trauma.

Often, this cooperation was motivated by a shared interest in meeting the needs of vulnerable populations. In South Stockton, one of the city’s poorest neighborhoods, a local network of federally qualified health centers (FQHCs) opened a clinic in a community center that offers job and legal aid programs, a farmers’ market, and life-skills classes. “We can refer our patients to these supportive services, and they can refer to us,” says Christine Noguera, CEO of Community Medical Centers, the FQHC network.

Altruism also plays a role. The Rev. Linda Stetter, director of mission and spiritual care for Pueblo’s St. Mary–Corwin Medical Center, has visited nearly 100 local churches and enlisted religious leaders in promoting health among their congregants. These leaders provide pastoral care to sick members and speak about good nutrition and healthy behaviors.

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Data often guides action.

To measure progress and maintain focus, leaders of health, housing, transit, aging, and other social service agencies in Akron’s Summit County rely on a shared set of indicators to help track morbidity and mortality as well as educational attainment, affordability of housing, and instances of violence, abuse, or neglect that can have an outsize impact on health. In Pueblo, cross-sector collaboratives employ data both to define problems and to secure engagement from diverse leaders. The Pueblo Triple Aim Corporation uses a dashboard to track population health indicators for county residents, compare Pueblo’s performance with other counties, and set goals for improvement. A deep dive into the numbers helped convince employers facing rising health costs and overburdened safety-net providers that making even modest investments in better health could yield significant financial returns over the long term.

Local health system improvement benefits from Medicaid expansion and other public and philanthropic investments.

All four communities we profiled are in states that expanded their Medicaid programs under the Affordable Care Act, and some participated in other initiatives tied to the law, such as the Community-Based Care Transitions Program, which supported Akron’s efforts to reduce unplanned hospital readmissions. Several counties in the Paducah region took advantage of Kentucky’s Medicaid expansion to attract FQHCs to the region, expanding the supply of much-needed primary care providers. In comparison communities in states that did not expand Medicaid, leaders cited financial, workforce, and other barriers to meeting the needs of vulnerable populations.

In Pueblo, Medicaid expansion opened up resources that enabled the FQHC to expand its primary care staff and eliminate a waiting list for accepting new patients. Funding from a state-supported Medicaid Regional Collaborative Care Organization enabled a community mental health center to take on a new care coordination and patient advocacy role through the hiring of nurses who work in primary care practices.

In addition to government funding, philanthropy is important, too. This is particularly the case in Pueblo, where the Pueblo Triple Aim Corporation secured more than $1 million to support its work.

Applying the Lessons: Harnessing the Value of Community Collaboration

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What are the action steps that we can hold ourselves accountable to, and what can we measure to move that needle?
Terry Albanese
Assistant to the mayor for education, health, and families
Akron, Ohio
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In the communities we studied, collaboration across sectors — not just within health care — appears to be central to advancing local health system performance in both large and small ways. Understanding what fosters effective collaboration is more elusive, though it appears to be aided by civic pride and by social capital, defined as “networks together with shared norms, values, and understandings that facilitate co-operation within or among groups.” The social ties in these four regions may be a function of their relatively small size (all have populations under a million), which promotes accountability. It’s also likely that progress on health care may be easier to achieve in lower-performing regions, where there is more room to improve. And, to some degree, health system gains may be attributable to improvements in the local economy following a severe recession.

U.S. communities are certain to face challenges undertaking or sustaining their efforts to improve health and health care, particularly if federal and state support for Medicaid and health system improvement wanes. To build on progress and overcome the tendency to focus on discrete issues, local leaders may need to set high goals for systemwide change, says Bobby Milstein, Ph.D., M.P.H., director of ReThink Health, which helps communities attain the capacity needed for improvement. Terry Albanese, assistant to the mayor for education, health, and families in Akron, says local leaders need to ask questions like “What are the action steps that we can hold ourselves accountable to, and what can we measure to move that needle?” For Pueblo community leader Matt Guy, the key is cultivating a sense of “patient urgency” — slowly building trusting relationships while immediately taking incremental steps toward achieving agreed-upon improvement goals.

Publication Details



Douglas McCarthy, President, Issues Research, Inc.

[email protected]


S. Klein, M. Hostetter, and D. McCarthy, All Health Care Is Local, Revisited: What Does It Take to Improve? The Commonwealth Fund, September 2017.