This resource guide from the University of California Berkeley School of Public Health Center for Healthcare Organizational Innovation Research reviews the evidence about promising condition-specific interventions for three common chronic conditions: asthma, cardiovascular disease, and diabetes.  It is widely recognized that improving population health will require extensive collaboration across many sectors including but not limited to health systems, health insurance plans, public health, education, housing, and transportation among others. There is an explicit need to address the underlying social and behavioral determinants of health through concerted actions that involve all of the above sectors.

While the accountable care organization (ACO) concept of providing financial incentives for individual care delivery organizations to keep their own patients healthy is a step in the right direction, it is insufficient for achieving community-wide population health.  The resource guide was compiled as part of the development and design of  accountable communities for health (ACH), as part of the California State Innovation Model (ACH).  The resource guide was funded by The California Endowment.

An accountable community for health can use a combination of clinical services, community and social services, clinical-community linkages, environmental interventions, and public policy and systems changes to address chronic conditions at the population health level.  A “wellness fund” would administer any external start-up funding and capture health care savings for reinvestment in the ACH. The resource guide identifies the current best evidence about these various interventions, and where applicable, the return on investment or potential health care savings.  However, an ACH would need to determine what combination of interventions might be most appropriate for its specific context.

Although California did not receive funding from the Centers for Medicare and Medicaid Services (CMS) for the implementation of its SIM, it is expected that the concept of ACHs will continue to be one that California  – and potentially other states – seek to implement through other health care reform initiatives and activities.

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