CACHI Is Transforming Community Health Through Partnership

CACHI is a public-private partnership that is transforming California's health system. (Video by CACHI, photo by East San Jose PEACE Partnership.)

Accountable Communities for Health (ACH) is a groundbreaking new model for addressing community health issues. Until now, the various community institutions worked in silos to improve individual and community health. For example, hospitals and health plans focused on providing traditional health care. Meanwhile, community-based organizations focused on addressing social determinants of health—such as poverty, community violence, unemployment and food deserts—rarely having an opportunity to collaborate with the local hospital. Schools, public safety organizations, parks and local businesses developed their own strategies that focused on their isolated sectors. Meanwhile, the community residents were seldom involved or consulted.

However, to achieve health equity, all these institutions must work together. And that is what an ACH does. It brings together different actors within a community—clinical providers, the public health department, schools, social service agencies, community organizations, residents and others—in a collective effort to address the complex issues that community is facing.

ACHs are starting to pop up across United States, but the ones in California showed just how powerful and transformative this health model can be. Currently, California has 13 ACHs in 13 communities across the state. Each ACH focuses on their community, but they are all part of a network called CACHI—California Accountable Communities for Health Initiative—which acts as a central hub. Each ACH acts as a catalyst that brings partners together and facilitates everything from data collection and clear communication, to vision setting and collective direction.

If each ACH is a network of local actors, CACHI is a network of networks. Ultimately, CACHI envisions a health system that is capable of fundamentally changing health outcomes by coordinating interventions, promoting prevention, and organizing resources to focus on the most effective strategies.

When it was first launched in 2016, CACHI was a proof of concept Cal Wellness was excited to support, along with other health funders. Since then, the 13 ACH sites across California have been so effective that the state included $15 million in the most recent budget to support this innovative model. CACHI is now getting ready to launch 25 more ACH sites.

We spoke with Barbara Masters, executive director of CACHI, to learn how they are using a partnership model to transform the health system and build a healthier, more equitable California. Our conversation has been edited and condensed for clarity.

We can't keep doing health care the same old way. There is no magic pill. It has to be a collective enterprise. And the ACH table is designed to facilitate that. Barbara Masters, CACHI

Tell us about CACHI? What exactly are ACHs?

Barbara Masters: California Accountable Communities for Health Initiative (CACHI) launched in September 2016, following a planning process that was initiated during the Let's Get Healthy California task force formed by then Governor Brown and then HHS Secretary Dooley. The goal of the task force was to figure out what the state could do to make it the healthiest state in the country. Subsequently, California received a federal State Innovation Models grant to continue its planning process. I led the task force work group on community health.

At the time, there were very early ideas around accountable communities for health in other states. That model really resonated with our work group, so we dug into it and developed the idea of an accountable community for health for California. A number of private funders, including Cal Wellness, were excited about that vision and agreed to collectively invest in this initiative to pilot and test it out.

So what is an accountable community for health, or ACH? It’s a new approach to our health system that emphasizes collective problem solving, incubating new ideas, aligning activities, and facilitating greater collaboration and linkages to envision and make real this broader, more expansive vision for a health system.

We know that health care alone cannot improve community health or advance greater equity. Social drivers of health—or social determinants of health—contribute more than 50 percent of our health status. And yet, medical care alone is being asked to solve those problems. And it can't.

Health care is a piece of the puzzle. But there are a lot of other pieces that are currently disconnected and an ACH is there to try to bring all these pieces together. It's designed to take a more holistic approach and bring other sectors and systems together with health care. Most importantly, an ACH ensures that the communities that have experienced the greatest inequities are central to designing the solutions.

We can't keep doing it the same old way. There is no magic pill. It really has to be a collective enterprise. And the ACH table is designed to facilitate that.

What makes the ACH model different from the existing models?

Barbara Masters: ACH model's added value is that there is now a place with a designated backbone entity whose job it is to facilitate and coordinate linkages between organizations, sectors, and systems.

Partnerships are hard and they do not happen on their own. They are often beset by past hurts and past negative experiences. You have to build trust. You have to build relationships. And it's not just one-by-one or two-by-two, but across a range of organizations, systems, and sectors. And that takes time. And it takes trust for people to engage with each other to find a path forward together.

Secondly, CACHI makes sure that community voice is at the table, especially in communities that have the most inequities. Community voice has a real, meaningful and authentic role at the table. And that does not happen magically on its own. There has to be outreach to community and trust building with community. Because many communities do not trust systems and system leaders because they haven't had good experiences in the past. So, you need to be able to bring community residents into this table. And the table needs to have training about how to interact with community and how to listen to community.

Can you share a success story from one of the 13 ACHs?

Barbara Masters: The ACH under the umbrella of the San Diego Wellness Collaborative created something called Neighborhood Networks. It is a social enterprise in which the ACH acts as a fiscal intermediary to break down the barriers between health plans, community-based organizations (CBOs) and community health workers.

How does it work? A managed care plan will identify a patient population that needs a community health worker to work with them and connect them to the right social services, food or other types of social needs. However, the managed care plan doesn’t have the ability to do that themselves. But they can work with and through the ACH community-based organization to connect their patients to qualified community health workers.

You can see in this example how the San Diego Wellness Collaborative is broadening our conception of what a health system is. One, it enables CBOs to contract with managed care plans, something they are rarely able to do because it takes a fair amount of financial wherewithal. Two, it enables a fairly new community-based workforce called community health workers to be a part of the health system and to receive Medi-Cal funding.

Through the ACH and its relationship with the CBOs and community health workers, we now have a more prevention-oriented system to help patients get the care and the range of services that they need, not just medical care. This intermediary, matchmaking role that the San Diego Wellness Collaborative, the San Diego ACH, has demonstrated is a really important model that can be replicated in other parts of California and other states.

Can you tell us about East San Jose PEACE Partnership? This ACH is such a great example of what this model can do.

Barbara Masters: East San Jose PEACE Partnership is the ACH in East San Jose. There had been a history of violence in that community and challenges around gentrification. It's a poor community. And so they came together to work on community violence. The table consisted of the backbone organization, the public health department and the local community organizing group, SOMOS Mayfair. They spent a year or two building partnership and building trust with the community.

In this clip, Masters explains how the ACH in East San Jose pivoted during the pandemic to support their community.

This is such a powerful example of what this kind of work can do. It was not in our original vision that COVID was going to hit. But, like other ACHs, they pivoted and used their ability to coordinate to marshal collective resources to the residents who needed it most. We saw that in West Sacramento and we saw that in Long Beach. Because they had partnerships with food banks, housing and other community organizations, they could immediately activate that kind of network to respond to COVID-19.

What are the top three challenges you've faced over the last six and a half years?

Barbara Masters: COVID was a huge challenge. Public health departments are a part of ACHs and they had to be all hands on deck for COVID. Which meant they could not focus on the work the ACH originally planned to do. Even community groups had to shift gears and prioritize COVID response. And, while that was a challenge, it gave the ACHs an opportunity to demonstrate their value. They showed that they were able to pivot quickly and contribute to the community response.

Two, systems change work is hard. It takes time and it's ongoing. And that can make it tough to sustain, to keep people engaged, especially if there's a leadership change or an external curve ball like COVID. We found that you don't want to spend all your time planning. You need to take action. You need to celebrate wins and recognize progress. Because we're ultimately talking about transformation, and that is a tall order. This work is never done. And so there's this need to keep sustaining it and seeing the value and the progress that you've made. I think that is an ongoing challenge that ACHs have.

Three, I think people don't fully appreciate that this work takes investment. It takes recognizing that this kind of civic infrastructure doesn't happen on its own and that it needs dedicated funding. It's not a lot of money, but it is money. That is a huge challenge and we're going to keep making the case for going forward.

An effective backbone organization brings a range of skills and talents to engage communities, ensure community voice is elevated, facilitate coordination among partners, problem solve and conflict solve. That is real work, it's skilled work, and it's not paid for anywhere. Right now, backbone entities take a little bit here and a little bit there, and weave together funding. But there needs to be designated funding for them.

What's next for CACHI?

Barbara Masters: We are excited because the state legislature gave us $15 million to spread and scale the model. The $15 million will help support our current 13 ACHs and help us set up 25 new ones.

We really believe in the ACH model. We think it is the way of the future. And we're not alone in this work. There are ACHs or ACH-like entities all over the country. The federal government is seeding them. Other states and other private philanthropies are seeding them. They're all different varieties and variations on a theme, but the basic core aspects of an ACH are pretty consistent. We hope to provide some leadership as we are all working to keep the momentum going.