Catalyzing alignment and systems transformation through cross-sector partnerships: Findings from the California Accountable Communities for Health Initiative.

OBJECTIVES: To describe the impact of Accountable Communities of Health (ACHs) on organizational and community partnerships and explore how ACHs contribute to systems change. DATA SOURCES AND STUDY SETTING: The California Accountable Communities of Health Initiative (CACHI) was a 5-year, $17 M investment in community health transformation in 13 ACH sites. Data sources include two surveys, key informant interviews, small group conversations, and ACH meeting observations and document review. STUDY DESIGN: This was a mixed-methods, observational study. Surveys conducted in 2021 and 2022 focused on ACH progress in building organizational and community partnerships and ACH impact on partners and systems, respectively. Interviews and small group conversations were conducted toward the end of the CACHI grant period and designed to complement the surveys. DATA COLLECTION: Survey respondents included ACH backbone agency staff and partner organization representatives (n = 141 in 2021 and 88 in 2022). Semistructured individual interviews and group conversations were conducted with 40 ACH backbone staff and partners. Documents were collected via grant reporting and directly from ACH staff. Data were analyzed descriptively and thematically. PRINCIPAL FINDINGS: ACHs appear to have supported organizational partnerships and collaboration. Seventy-six percent of survey respondents reported that their ACH had strengthened organizations' ability to work together and 65% reported developing new or deepened connections. While ACH participants reported a better understanding of community needs and priorities, progress on community relationships, and greater attention to equity and racial justice, many saw room for improvement on meaningful community engagement. Systems changes and precursors of systems change observed across ACH sites included strengthened partnerships, enhanced knowledge, increased capacity, more collaborative ways of working, and new funding streams. CONCLUSIONS: The ACH model is effective at strengthening organizational partnerships and catalyzing other systems changes and precursors including enhanced knowledge, increased capacity, more collaborative ways of working, and new funding.

Exploring power building capacity at the ecosystem level: A case study of a justice-oriented organizational network.

Community organizing and base building groups operate as part of a larger ecosystem of organizations, each with complementary capacities necessary to build power and achieve social change. Analytic approaches to assessing power in organizational networks can generate data to inform strategy, identify gaps, and help nurture organizational ecosystems that support communities in building and exercising power. This article uses a network of 43 justice-focused organizations in the Bay Area, California and their 267 reported connections as a case study to assess the feasibility of measuring power building capacities using social network analyses. We evaluated network capacity for different power-building capacities and explored the relationships between organizations' positions in the network and their access to capacity. We found that justice-focused organizations were more likely than their connections to have mature capacity for creating alliances and coalitions and for research/legal strategies, whereas their connections were more likely to report mature capacity for community organizing. Most participants in the network were connected within one degree to an organization that was mature in organizing and base building. These results highlight the potential to assess community power building capacities within networks of organizations to identify ecosystem strengths and weaknesses and opportunities for strategic development.

Patient Centred Medical Home (PCMH) transitions in western Sydney, Australia: a qualitative study.

BACKGROUND: Patient Centred Medical Homes (PCMHs), increasingly evidenced to provide high quality primary care, are new to Australia. To learn how this promising new healthcare model works in an Australian setting we explored experiences of healthcare providers in outer urban Sydney, where a number of practices are transitioning from traditional Australian general practice models to incorporate elements of PCMH approaches. METHODS: We collected qualitative data from semi-structured interviews with healthcare providers working in a range of transitioning practices and thematically analysed the data. We interviewed 35 participants including general practitioners, practice managers and practice nurses from 25 purposively sampled general practices in western Sydney, Australia, seeking maximal variation in practice size, patient demographics and type of engagement in practice transformation. RESULTS: Interviewees described PCMH transformation highlighting the importance of whole of practice engagement with a shared vision; key strategies for transformation to PCMH models of care including leadership, training and supportive information technology; structures and processes required to provide team-based, data-driven care; and constraints such as lack of space and the current Australian fee-for-service general practice funding model. They also reported their perceptions of early outcomes of the PCMH model of care, describing enhanced patient and staff satisfaction and also noting fewer hospital admissions, as likely to reduce costs of care. CONCLUSIONS: Our study exploring the experience of early adopters of PCMH models of care in Australia, informs the international movement towards PCMH models of care. Our findings provide guidance for practices considering similar transitions and describe the challenges of such transitions within a fee-for-service payment system.

Realising the potential of health needs assessments.

Population-level assessment and planning has traditionally been the role of public health departments but in establishing Primary Health Networks (PHNs), the Australian Government has instituted a new mechanism for identifying community needs and commissioning services to meet those needs. If PHNs are to achieve the vision of nimble organisations capable of identifying and addressing local health needs via integrated health and social services, several things need to occur. First, PHN funding schedules must become more flexible. Second, the Federal health department must maintain an open dialogue with PHNs, permit waivers in funding schedules to suit local conditions and be prepared to back innovations with seed investment. Third, health data exchange and linkage must be accelerated to better inform community needs assessments and commissioning. Finally, PHNs must be encouraged and supported to develop collaborations both within and outside the health sector in order to identify and address a broad set of health issues and determinants. By following these principles, PHNs may become leading change agents in the Australian healthcare system.

From micro to macro: assessing implementation of integrated care in Australia.

Many countries and health systems are pursuing integrated care as a means of achieving better outcomes. However, no standard approaches exist for comparing integration approaches across models or settings, and for evaluating whether the key components of integrated care are present in different initiatives. This study sheds light on how integrated care is being implemented in Australia, using a new tool to characterise and compare integration strategies at micro, meso and macro levels. In total, 114 staff from a purposive sample of 38 integrated care projects completed a survey based on the Rainbow Model of Integrated Care. Ten key informants gave follow-up interviews. Participating projects reported using multiple strategies to implement integrated care, but descriptions of implementation were often inconsistent. Micro-level strategies, including clinical-professional service coordination and person-centred care, were most commonly reported. A common vision was often described as an essential foundation for joint work. However, performance feedback appeared under-utilised, as did strategies requiring macro-level action such as data linkages or payment reform. The results suggest that current integrated care efforts are unevenly weighted towards micro-level strategies. Increased attention to macro-level strategies may be warranted in order to accelerate progress and sustain integrated care in Australia.

Financial effect of instituting Deficit Reduction Act documentation requirements in family planning clinics in Oregon.

BACKGROUND: The study was conducted to estimate the long-term costs for implementing citizenship documentation requirements in a Medicaid expansion program for family planning services in Oregon. STUDY DESIGN: A decision-analytic model was developed using two perspectives: the state and society. Our primary outcome was future reproductive health care costs due to pregnancy in the next 5 years. A Markov structure was utilized to capture multiple future pregnancies. Model inputs were retrieved from the existing literature and local hospital and Medicaid data related to reimbursements. One-way and multi-way sensitivity analyses were conducted. A Monte Carlo simulation was performed to simultaneously incorporate uncertainty from all of the model inputs. RESULTS: Screening for citizenship results in a loss of $3119 over 5 years ($39,382 vs. $42,501) for the state and $4209 for society ($63,391 compared to $59,182) for adult women. Among adolescents, requiring proof of identity and citizenship results in a loss of $3123 for the state ($39,378 versus $42,501) and $4214 for society ($63,391 instead of $59,177). CONCLUSION: Screening for citizenship status in publicly funded family planning clinics leads to financial losses for the state and society.

The impact of citizenship documentation requirements on access to medicaid for pregnant women in Oregon.

The federal Deficit Reduction Act of 2005 mandated citizenship documentation from all Medicaid applicants as a condition of eligibility and was implemented in Oregon on September 1, 2006. We assessed whether new citizenship documentation requirements were associated with delays in Medicaid authorization for newly pregnant eligible applicants during the first nine months of DRA implementation in Oregon. We conducted a pre-post analysis of administrative records to compare the length of time between Medicaid application and authorization for all newly pregnant, Medicaid-eligible applicants in Oregon (n = 29,284), nine months before and after September 1, 2006. We compared mean days from application to authorization (McNemar's), and proportion of eligible applicants who waited over 7, 30 and 45 days to be authorized (Pearson's coefficient). The mean number of days women waited for authorization increased from 18 days in the 9 months before DRA implementation to 22.6 days in the post-implementation 9 month period (P ≤ .001). The proportion of eligible applicants who waited 7, 30 and 45 days increased significantly following DRA implementation (P ≤ .001). The proportion of eligible applicants who were not authorized within the standard 45-day period increased from 6.9 to 12.5% following the DRA. Implementation of new citizenship documentation requirements was associated with significant delays in Medicaid authorization for eligible pregnant women in Oregon. Such delays in gaining insurance coverage can detrimentally affect access to early prenatal care initiation among a vulnerable population known to be at higher risk for certain preventable pregnancy-related complications.

Evidence that the citizenship mandate curtailed participation in Oregon's Medicaid family planning program.

The 2005 federal Deficit Reduction Act made proof of citizenship a requirement for Medicaid eligibility. We examined the effects on visits to Oregon's Medicaid family planning services eighteen months after the citizenship requirement was implemented. We analyzed 425,381 records of visits that occurred between May 2005 and April 2008 and found that, compared to the eighteen-month period before the mandate went into effect, visits declined by 33 percent. We conclude that Medicaid citizenship documentation requirements have been burdensome for Oregon Family Planning Expansion Project patients and costly for health care providers, reducing access to family planning and preventive measures and increasing the strain on the safety net.