NCFAHP at the Forefront of Accountable Care Communities

Maggie-Sauer“Accountable Care Community (ACC): a collaborative, integrated, and measurable multi-institutional approach that emphasizes shared responsibility for the health of the community, including health promotion and disease prevention, access to quality services and healthcare delivery.  The ultimate goal of the ACC is a healthier community.”  (Source: Healthier by Design: Creating Accountable Care Communities)

In health care, these are exciting times – or, some may say, frightful!  For the purposes of this newsletter, let’s stay on the positive side of the transformation and change underway.  For the first time, the work of health-care providers and communities can be formally linked and measured in tangible ways.

At NCFAHP’s Board of Directors retreat in November 2012, we began to consider our role in facilitating the development of a new Accountable Care Organization (ACO) model: a model that would include the expertise and services from community partners from the start of the ACO. Too often, ACOs create new services and hire providers to provide health and wellness services, health coaching, etc., rather than relying on community partners. Adding new service lines and providers seems unnecessary when the community is the better choice.

To date, meaningful participation of community health partners in these models has been lean, or often nonexistent. But Akron, OH, has been a pioneer in a new model that takes fuller advantage of community-based partners – an Accountable Care Community (ACC). A 2012 report by Austen BioInnovation Institute cites Community Care of NC as an early model of this approach. Akron’s model takes it one step further by including local growers to provide fresh fruits and vegetables and the National Park system to provide opportunities for better health through walking, kayaking or other physical activity.

The Institute reports that, while the Accountable Care Community may share characteristics with the ACO, there are also factors distinguishing the two:

  • “ACC encompasses not only medical delivery systems, but the public health system, community stakeholders at the grassroots level and community organizations whose work often encompasses the entire spectrum of health.
  • ACC focuses on the health outcomes of the entire population of a defined geographic region, rather than a defined and targeted population of health consumers selected by an ACO for their efforts at payment and care delivery reform.”

man-with-hands-upNatural systems of community care do not follow prescribed patterns of grouping community members together by patient type, but they do organize themselves and health behaviors according to the culture, leadership and priorities within the population. The ACC simply makes sense. Furthermore, as Dr. Janine Janosky, Vice President, Center for Clinical and Community Health Improvement at the Institute states: “As we think about the Accountable Care Community, we have the opportunity to impact the quality of life, and also the economic vitality of our community…”

woman-with-hands-upAt NCFAHP, the programs are designed to fit together and complement one another for the purpose of filling gaps to create relationships, services, training, and data compilation that do not “fit” in other places.  Workforce data to power the decisions in local communities to actively participate in the recruitment and, most importantly, retention of health-care providers is essential to the ACC.  Jackie Fannell’s work with Practice Sights provides some insight to this work.

classroomSince October 2014, the Foundation’s Bernstein Fellows program has emphasized the Fellows’ leadership role in creating accountable care communities. Communities are overwhelmed by the intricacies of the Accountable Care Organization model and see the opportunity and need for their participation in this complex structure. The Fellows are engaged and interested in creating a “place at the table” in their own communities and across North Carolina.

Part of the NCFAHP vision is to engage in innovation to:

  • Create strategies that significantly affect existing systems
  • Build on emerging elements within existing systems
  • Create new systems or strategies by creating partnerships resulting in unique opportunities to combine/refine services and resources
  • Improve on existing strategies or systems

The Fellows Program faculty includes individuals and organizations interested in promoting the ACC model across North Carolina.  True to the model, NCFAHP is not interested in duplicating the work of our colleagues, but instead leveraging the work to heighten awareness and create momentum.  We would like to thank the following individuals for providing inspiration and information to the Fellows:

  • Patrick Woodie, President, NC Rural Center, Misty Herget, Director of Leadership and Chilton Rogers, Director of Community Engagement
  • Ruth Petersen, MD, MPH, NC Division of Public Health, Section Chief for the Chronic Disease and Injury Section.
  • Greg Randolph, MD, MPH, Director of the Center for Public Health Quality and Professor of Pediatrics and Adjunct Professor of Public Health at the University of North Carolina at Chapel Hill.
  • Grace Terrell, MD, CEO Cornerstone Health Care, P.A. a multiple specialty medical group in the Piedmont Triad region of North Carolina with more than 370 providers and 1800 employees who practice at fifteen separate hospitals.
  • Chris Collins, Director, NC Office of Rural Health and Community Care
  • Julian Bobbitt “Bo”, Partner, Smith Anderson Law Firm
  • Robin Tutor-Marcom, MPH, OTR/L, Director, NC Agromedicine Institute, East Carolina University
  • Kellan Moore, MPH, Executive Director and Willona Stallings, MPH, Care Share Health Collaborative
  • Kim Schwartz, MA, Chief Executive Officer, Roanoke Chowan Community Health Center
  • E. Benjamin Money, Jr., MPH, President and CEO, NC Community Health Center Association

The Accountable Care Community is the “glue” bringing these elements together in a comprehensive manner. Accountable Care Communities is a “whole- person, whole- community approach.”

The work continues with this team. Stay tuned, more to come!

-Maggie Sauer

CEO & President

Joanne Rinker PortraitJoanne Rinker describes her mission succinctly: “The work that I do is focused on helping health departments identify and implement evidence-based interventions in their county to improve the health of the people in their population.”

The Bernstein Fellow is convinced that local health departments can play a valuable role in implementing Affordable Care Communities (ACC).

“I have this passion for my health department population,” Joanne said. “I want the health department to have a seat at the table in an Accountable Care Community.  I know that they provide services that other organizations and providers in their community are not offering.  Instead of duplicating services, which is more expensive and requires additional FTE hours, ACCs need to bring the local health department to the table to allow them to provide the service, and in turn reimburse them financially for the cost savings.”

Joanne, who will complete the Bernstein Fellow program later this year, has insight and perspective born of experience and education. The native New Yorker attended West Virginia University, where she completed both her bachelor’s and master’s degrees. She came to North Carolina after graduation to begin working with diabetes self-management education programs.  Joanne became a Certified Diabetes Educator (CDE) and worked for multiple education recognition programs for diabetes patients around the state.

In 2006, Joanne joined the N.C. Division of Public Health where she, along with Laura Edwards, started a state-administered program that helped local health departments throughout North Carolina gain ADA recognition for their diabetes education programs. While Joanne was the coordinator, it was the largest ADA accredited site in the United States.

In the summer of 2013 Joanne received the opportunity to join The Center for Healthy North Carolina as its Director for Training and Technical Assistance. Her role is whole-health focused rather than diabetes-specific, and focuses on helping health departments select and implement evidence-based interventions in their communities.

Joanne’s vast experience and established relationships with administrators and communities in most of the 100 counties across North Carolina have enabled her to better provide support and training to communities and local staff around the state.

Joanne’s Bernstein Fellows project very much supports improving community coalitions’ access to evidence-based interventions and showing how those projects can benefit an ACC.  She worked to conduct a large-scale survey with active and inactive Healthy Carolinians partnerships throughout the state to find out how the partnerships wanted to receive technical assistance, and what technical assistance they needed.  She then worked with the Care Share Health Alliance to develop and execute webinars to provide the necessary training and assistance.

Some of the most requested webinar topics included Collaboration and Coalition Building, Meeting Facilitation with Community Members, Evidenced-based Intervention 101, Evidence-Based Selection and Evaluation 101.  The audience for each webinar consists of a range of public health professionals, including health directors, public health nurses and health educators.

The webinars have already seen great success. Attendance has reached as high as 100 participants.  Although they officially wrap up in August, Joanne and her team have so many ideas for additional content to cover and audiences to reach that they have planned another 6-month series.  The series will continue August 2015 until March 2016. In the meantime, the team is conducting a follow-up survey to determine if any of the partnerships have been able to build capacity because of the technical assistance provided by the webinars.

Bernstein Group DiscussionJoanne was part of a recent Bernstein Fellows educational event focused on ACCs.  The speakers demonstrated the benefit to communities across the country and discussed why focusing on building ACCs is timely.  Joanne and the other fellows agreed that it was very energizing to learn how ACCs can be so beneficial and why health professionals should make a point to be a part of the process.

“It was good to hear that there are functioning, successful ACC’s around the country,” she said.  “We learned that there is a time when the ACC may lose money in the initial startup, but many have shown that they then see themselves gaining money and being able to pay back any start-up funds needed to get organized and fully functional.  This will cost money but, in the long-term, the goal is for it to be cost-effective.”

Joanne speaks highly of the Bernstein Fellows program in general, and says it has been an incredibly valuable experience for her over the past two years.

“Not only are we learning, but we are also developing relationships with professionals who have the same end goal in mind,” she said. “The Bernstein Fellowship is such an amazing way to honor Jim Bernstein!  I have been honored to be part of this.  I know how important his work was, and still is, and I hope that myself and the other fellows can make a meaningful contribution to rural public health in North Carolina!”

Jackie_FannellRural areas are hard pressed to attract and place skilled clinicians, and loan repayment for health care education plays an important role in attracting clinicians to rural or underserved areas. When you recruit a clinician to a small rural or underserved area, and provide no community support, there is a possibility that this individual may not be happy, and ultimately will not stay once their service obligation has been met.

There has to be a partnership. There has to be support. And there has to be buy-in from the entire community so that the clinician feels welcomed as a part of that community from his or her first day on the job.

This is where the Practice Sights Retention Management System comes in.  Currently being utilized by an 11-state collaborative, each of which operates the program independently, data provides states and staff of incentive programs with information to make clinicians’ service experiences as positive and productive as possible.

Practice Sights collects data in the form of questionnaires sent to clinicians and practice administrators via email. The Cecil G. Sheps Center for Health Services Research (Sheps Center) provides expertise on data collection, analysis and dissemination. The questionnaire clinicians receive three months after the start of their service obligation asks about their background, their reasons for applying to the program (needing financial assistance and/or wanting to provide care to an underserved population or area) and their needs, values and expectations of their current position and community.  Annual and end-of-contract questionnaires will ask about their current work, whether the role is meeting their professional goals, etc.  The questionnaires will also ask them to rate their satisfaction with various aspects of their community and practices. Alumni questionnaires are sent periodically and ask clinicians if they are at the same site and, if not, to provide information about their current work.


The rich data collected by Practice Sights allows state program administrators to identify problem areas so that they can work with site administrators to improve overall clinician retention in rural areas. The challenge, notes Jackie Fannell, Program Manager for Practice Sights, comes in getting clinicians to respond to the questionnaires, — particularly program alumni, who are no longer obligated under their contract.  Most states are now seeing over 50% response rates across the board. While this leaves room to grow, it still provides a rich set of data to help improve clinician retention.

Practice Sights plans to bring more states into the collaborative and continue to grow the program. There is no other system that collects data on clinician retention in this manner and it will become more valuable and have even greater impact moving forward and the aggregated data shows trends and reveals what is working and what is not.

Community factors have been shown to greatly impact physician retention. The findings of a 2012 report prepared for the Multi-State/NHSC Retention Collaborative by the Sheps Center calls for programs to help communities learn the important role they play in clinician retention and the things they can do to promote retention, engage community leaders and intervene early — before small problems escalate — when clinicians encounter difficulties with their communities. Efforts to build Accountable Care Communities in North Carolina and other states could be an important step in bringing communities into the health-care conversation. Including community input and participation in health care from the start could help ensure acceptance and support for new providers, rather than waiting until issues arise or only including community voices as an afterthought.

Accountable Care Communities are an important part of clinician recruitment and retention in rural areas. With Accountable Care Communities, the community is involved with all aspects of the health-care environment, and is more vested in supporting and including clinicians and their families in the community. Practice Sights, in turn, plays an important role in helping create Accountable Care Communities, with its data driving the awareness of where community and other support is lacking, as well as allowing communities to become better-equipped to receive and support new clinicians from day one.