Frequently Asked ACH Questions

An Accountable Community of Health is a group of leaders from a variety of sectors in a given geographic area with a common interest in improving health. Participating, among others, are health and long-term care providers, health insurance companies, public health agencies, school districts, criminal justice agencies, non-profit social service agencies, legal services organizations, tribes, and philanthropic agencies. With support from the state, they are voluntarily organizing to coordinate activities, jointly implement health-related projects, and advise state agencies on how to best address health needs within their area. They are not intended to duplicate or replace existing services.

There are nine ACHs that together cover the entire state, with the boundaries of each aligned with the state’s Medicaid regional service areas.

Community-based, cross-sector coalitions dedicated to improving health at the local level have existed in Washington for many years. Recognition or support from the state has been limited and inconsistent, including a grant program in statute since 2006, but not funded since 2008. Their potential was explicitly revisited and acknowledged in Washington’s 2013 State Health Care Innovation Plan. It called for creating a new partnership between the state and these types of organizations that would draw on the unique strengths of each.

At the same time, other states were moving in a similar direction with their health reform efforts, and their success with “Accountable Communities” gave Washington further reason to pursue its own version – built on existing organizations, but designed to serve other interests called out in the Innovation Plan. State legislation passed in 2014 provided criteria and funding for two community of health pilot sites.

Additional specifications and funding to support ACHs were included in the State Innovation Model Test Award received by the state from the federal government later that year.

Because working with community-based, cross-sector coalitions is an effective and efficient way to transform the health system in the state. In developing its Innovation Plan, the state sought an approach that:

• Takes advantage of local knowledge and relationships to drive change in places where individuals are directly served;
• Allows those involved at the local level to each focus on what they do best, but in ways connected to and complementary of the contributions of others nearby; and
• Addresses through this collaboration both clinical care and social factors affecting health such as poor nutrition and inadequate housing. The state understands these things will not happen if they depend solely on random, informal contacts, but require the structure and intentional action brought by ACHs.

Primary support for ACHs, in the form of grants and technical assistance, comes from the Health Care Authority (HCA), the state agency leading the implementation of Healthier Washington. Working with the Department of Social and Health Services and the Department of Health, HCA establishes grant criteria, evaluates applications and makes the awards, and monitors performance and compliance with the terms and conditions of the grant. Technical assistance to support the development and initial operation of ACHs is being provided by a team of outside experts and consultants under contract with the HCA. Internally, these three agencies are looking at their own programs to determine if and how they might be better aligned to model the same collaboration expected at the local level, while eliminating any inadvertent obstacles to ACH success.

ACHs are similar in matters of statewide significance or where necessary for them to function as part of Healthier Washington. Each ACH, for example, shares the same general purpose, has (or will have) a formal governance structure and bylaws, and includes representation from a diverse and broad cross-section of entities. Each ACH will also play a similar role in projects implemented statewide, such as the Practice Transformation Support Hub. ACHs are different based on regional preference and priorities, such as the details of their governance structure, the particular entities participating, and the projects each undertakes in response to the unique health concerns of their region.

ACHs are administered and self-governed at the regional level along general guidelines in the state’s funding criteria. This gives each ACH discretion to do what works best for its region, but also means that none are organized or operate in exactly the same way.

For some ACHs, the backbone organization is a local public health agency. For others, it is a non-profit organization with a history of health reform activity in the region.

While the backbone organization may help develop the governance structure, it does not itself govern the ACH. Each ACH is instead governed by its local participants under a structure they design. It typically involves a board or committee to discuss issues brought to it and to make decisions.

The challenge for each ACH is to involve enough people in governance that the appropriate regional interests are represented, but to do so in a way that decisions get made and the organization remains functional. Achieving this balance will continue to result in creative, bottom-up approaches, the merits of which Healthier Washington is intended to test.

ACHs are funded partly with grants from the Washington State Health Care Authority (HCA), using money from the State Innovation Model grant issued by the federal Center for Medicare and Medicaid Innovation (CMMI). These funds allow each ACH to have part-time staff for design and initial development, and hold necessary regional meetings.

In 2014, the legislature also made a state general-fund appropriation to the HCA for two pilot ACHs. ACHs supplement these funds with in-kind contributions and grants from other private and public sector organizations, some who participate in the ACH. The grant from CMMI also funds staff and consultants at the HCA and other state agencies who partner with and support ACHs statewide.

ACHs are working with the state to develop financial sustainability plans. These plans will likely draw on both local and state resources, including additional state grants and contracts, and the reinvestment of any savings that the ACHs help generate in health care or other areas.

ACHs do not have regulatory authority. They are community-based organizations acknowledged in state statute. They will be called on, as are many others, to provide state agencies with advice and recommendations and help implement state programs. Although some receive administrative support from a local public health agency, ACHs themselves are not political subdivisions of the state and have not been delegated any independent authority to regulate or otherwise control activities of individuals or institutions within their region.

Although not granted any unique statutory authority, ACHs otherwise have the same general powers enjoyed by any organization. What each does is determined by agreement of their local participants based on their governance structure and process. Among other things, they can agree to accept grants or otherwise contract with outside parties, including the state. An ACH doing so would then be expected to execute the contract, and be subject to any of its terms and conditions, including performance standards.

Medicaid Managed Care Organizations (MCOs) are active participants in ACHs throughout the state, and some have contributed funding and other resources. Independent of their participation in ACHs, however, the state will continue to contract with MCOs as the risk-bearing entities for Medicaid. There is no intent to transfer this risk-bearing function to ACHs.

More details on expectations surrounding the ACH-MCO partnership can be found on the Healthier Washington website.

ACHs will evaluate health needs within their region, take local action on those needs, and where appropriate, advise state agencies. Given Medicaid’s importance to health, ACHs will join others in providing feedback on the design and operation of the program, and how it might be improved, particularly from a local perspective.

As Medicaid changes to better integrate physical and behavioral health care, and to link clinical care with other community services, the collective, multi-sector insights of ACHs will be critical to designing a supportive payment structure. However, ultimate legal and financial responsibility for Medicaid contracting, including monitoring and oversight, will remain with the state.

The waiver application proposes that the Health Care Authority (HCA) contract with ACHs to coordinate Medicaid transformation projects within their region. In this role, an ACH will oversee projects intended to further the goals of Healthier Washington. This could include soliciting, reviewing or helping prepare project applications, distributing state funds to those within the region responsible for implementation, and reporting on progress. This role is consistent with the general purpose and developing capacity of ACHs to facilitate regional collaboration towards improved health.

The HCA has begun negotiating the terms and conditions of the waiver with the federal Centers for Medicare and Medicaid Services. If they reach agreement and the application is approved, the state will allow ACHs the time and resources needed to prepare for and carry-out the particular expectations it makes of them. If an ACH is not ready it will not be given this responsibility, with the state then contracting with another organization to implement this portion of the waiver.

More information about the waiver, including the application and directions on how to provide input as it progresses, is available on the Healthier Washington website.

Formal designation as an ACH by the Health Care Authority is a step in the organization’s development process that qualifies it for additional state grant funding. It generally recognizes the ACH has the basic infrastructure to continue building a successful organization. Designation requirements include:

• Balanced, multi-sector representation;
• The launch of community engagement activities;
• The ability to perform basic financial and administrative functions;
• Initial identification of regional health needs and priority projects; and
• Establishment of an initial budget, including a plan for continued funding.

Designation is an important benchmark that demonstrates progress and potential, and qualifies an ACH for additional grant funding to support its ongoing development. However, it does not change the general role or legal status of the ACH, or indicate a readiness to take on all conceivable ACH functions.

For details on ACH designation, including the relevant criteria and process, see the Healthier Washington website.

Many ACHs are still in the planning and development stage and have yet to decide which health improvement projects they will pursue. The Health Care Authority’s Community Transformation Team will compile a list and share information about all of the projects as they are identified.

A project started by the Cascade Pacific Action Alliance (CPAA) as a pilot ACH offers an example of the type of work ACHs across the state may do. CPAA found a need within their region for earlier identification and treatment of children with mental health or chemical dependency issues. They formed a work group, including representatives of school districts, social service organizations, health care providers and others. The work group selected behavioral health screening tools, identified treatment resources within the region, discussed the roles of school staff and treatment providers, and mapped how these roles would be coordinated on behalf of the children. It developed a test site selection process, and in early 2016 began testing the project at four schools.

If you or your organization have any responsibility for the health of your community, through clinical care, social services or otherwise, you should consider becoming involved with ACHs. ACHs represent a formal opportunity to achieve results you will not get working alone. They do this by connecting those with similar concerns and goals, allowing them to share information and coordinate activities. They are also a place to discuss what is expected, and from whom, in transforming health care in the region. And with the cross-sector representation, you will learn when and how to engage others to help residents whose needs are beyond your responsibility or expertise. Becoming involved will also give you a greater voice in identifying regional health needs and advising how to address them.

Those already involved include but are not limited to: health and long-term care providers, health insurance companies, public health agencies, school districts, criminal justice agencies, non-profit social service agencies, legal services organizations, tribes, and philanthropic agencies.

No. Healthier Washington is intended to transform all parts of the state’s health system. As such, ACHs focus not only on a particular sub-population or payment system but represent health across the entire continuum and population within the region, from babies to seniors. Medicaid is expected to lead by example, primarily by changing the way it purchases care and services, with ACHs contributing to this process.

However, Medicaid payment reform and corresponding changes in care delivery will influence – and be influenced – by what goes on in the commercial market. With the right people involved, ACHs can help keep all participants appropriately aligned, avoiding inconsistent approaches that serve primarily to confuse. If you or your organization have any responsibility for the health of your community, either for Medicaid enrollees or otherwise, you should consider becoming involved with ACHs.

No. It is certainly not too late to become involved. The only prerequisites are that you have an interest and/or role – through clinical care or other community services – in the health of residents within the region covered by the ACH, and a willingness to abide by its process. How to best become involved depends on who you are, the resources you have available, and in which of the nine ACHs you are interested.

Statewide associations (such as health care provider associations) should encourage their individual members to engage with their local ACH, with the association’s leadership working with Healthier Washington partners and state agency staff. Other statewide organizations that provide services to residents of more than one region (such as health insurance companies or health systems) will want to be involved at the state level, and at the regional level with as many corresponding ACHs as their resources allow.

To get involved with CPAA please visit our contact page.

Because each ACH is structured differently and is at a different stage of development, seek advice on becoming involved directly from other ACHs in which you have an interest. Contact information for the other ACH backbone leads and administrative support team can be found here.

“Member” was the term initially used in Health Care Authority documents to describe any individual or organization formally involved with ACHs. It was not meant to imply a preferential status for some in the region over others. Going forward the intention is to use the term “participants” rather than “members.”

Like any organization, ACHs have an operational structure in which participants may each have different roles. It is not practical to give everyone a position on the governing board, and a position on the governing board is not the only way to participate. Involvement at the project level will become increasingly important as ACHs develop. ACHs are confronting the challenge of collectively but effectively engaging the large number of entities across multiple sectors with a role in improving health. And as with any innovation, the ACHs will evolve as they determine what works and what does not.

Because agencies are looking to ACHs themselves to help shape relevant state policies, participating at the regional level is a way to influence them.

Organizations that typically, work directly with the state, such as statewide organizations, may continue to contact the Community Transformation Team or other agency staff directly. State agencies are considering development of a more structured, efficient and timely process for gathering state level input on ACH policy. Thoughts on what this should look like are welcome.