Aligning Systems for Health: Glossary of Terms
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Note: Terms in italics are defined elsewhere in this glossary.
Acceptance of responsibility.
Accountable Care Community
A broad coalition of community stakeholders (e.g., health providers, social services, local government, community-based organizations) that collaborate in order to address population health, including addressing the social determinants of health. Success is impacted by the ability to share resources, responsibility, and data, and thereby improve coordination and efficiency of service delivery. Also known as an accountable health community.
Accountable Care Organization (ACO)
A value-based model of care that encourages doctors, hospitals, and other health care providers to form networks that coordinate patient care. Initiated by Medicare, ACOs have the goal of better coordinating care and eliminating wasteful or duplicative services. Providers share in cost savings produced by providing more efficient care, but can also be at risk for not meeting performance goals.
Accountable Communities for Health
Cross-sector, community-based partnerships (e.g., health care, housing, social services, public health, economic development) that plan and implement strategies to improve population health and health equity. By leveraging resources and sharing responsibility across multiple sectors, the model aims to enhance clinical-community linkages with the goals of improving health outcomes and reducing costs within a geographic community.
Accountable Health Communities
A Center for Medicare and Medicaid Innovation model designed to address a gap between clinical care and community services. The model is currently being piloted in 30 communities to identify and address health-related social needs of Medicare and Medicaid beneficiaries. Pilot sites are evaluating whether systematic clinical-community collaboration through screening, referral, and community navigation services will impact health care costs and reduce health care utilization.
Aligning across sectors emphasizes coordination that extends beyond working together on a single project. Aligned systems require that sectors think and work together in fundamentally new ways to improve the health and well-being of the people and communities they serve in ways that are built to last.
A form of community engagement in which the input of community members is valued and meaningfully incorporated from the beginning of the design process.
Deliberately and proactively managing patient care activities and sharing information among all providers along the continuum of care to achieve safer, efficient, and more effective care. This includes transitions of care, as well as linkages to community resources.
An approach, first defined in 2011 by John Kania and Mark Kramer, that relies on a systematic approach involving cross-sector coordination to achieve progress toward shared objectives. The authors identified five requisite factors associated with successful collaborations focused on large-scale social change: common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support structure. (Kania J, Kramer M. Collective impact. Stanford Social Innovation Review. 2011:36–41.)
Nonprofit organizations that work at a local level to improve life for residents, often through direct service delivery but not necessarily focused on health care (e.g., religious, social, sports, education, human services, environment, youth development).
Community Development Sector
A sector with roots in urban revitalization efforts that invests in low- and moderate-income communities through the development and financing of affordable housing, businesses, community centers, health clinics, job training programs, and services to support children, youth, and families. These efforts are inherently multisector, involving both public and private organizations, sharing the goal of strengthening the economic, physical, and social environments of low-income communities.
Process of working collaboratively with groups of people who are affiliated by geography or interests.
Active community engagement ensures that community members are heard and integrated at the beginning of the design process (e.g., cocreation). Elevation of community voices in the design of and decision-making for aligning efforts is deeply entwined with building trust and shifting power dynamics.
Comprehensive System Capital
A dense network of cross-sector community collaboration.
Coordination that extends beyond working together on a single project. Aligned systems require that sectors think and work together in fundamentally new ways to improve the health and well-being of the people and communities they serve.
The World Health Organization defines equity as “the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.” Equity encompasses both health equity and racial equity and includes both processes and outcomes. It is widely acknowledged that addressing equity is a critical goal of aligning across sectors and, ultimately, critical for improving community well-being.
External Factors Affecting Urgency
Outside influences and pressures that spur a sense of urgency for sectors to align (e.g., state or federal pilot initiatives or policies, public health crises).
Factors Affecting Success of Aligning
Softer elements impacting the success of developing aligned systems, including interpersonal dynamics, trust, community engagement and accountability, stakeholders’ mindset, and backbone support.
Health Care Sector
The health sector includes the organizations, programs, and services that help individuals obtain access to personal health services to prevent, treat, or manage diseases and injuries, including services for physical health conditions, mental health conditions, substance abuse, and developmental disabilities. This sector includes the providers, purchasers, and payers of these services, as well as the suppliers of associated products and technologies, such as pharmaceutical products and health information technologies.
Ensures everyone has the opportunity to be as healthy as possible. This is accomplished through elimination of disparities in health outcomes and determinants of health, as well as removal of structural barriers to achieving both (i.e., racial equity).
Health System Transformation
Efforts to reform the U.S. health system (public health, health care, insurance, and other sectors) in terms of financing and service delivery. These changes include improving the efficiency and effectiveness of organizations, service delivery, and payment models, with the ultimate goal of improving population health and equity and increased collaboration with community-based efforts. Efforts are often focused on the Triple Aim.
Services provided to improve public health, safety, and economic conditions for a community or to people in a crisis or with a chronic problem to stabilize their life and find self-sufficiency. Services may include counseling, mental health or substance use treatment, or providing for basic needs (e.g., shelter, food).
Individual, Organizational, and System-Level Enablers
Recognition that when building aligned systems, core components are being impacted at multiple levels simultaneously — individual, organizational, and system.
A fully integrated health and human services system that provides colocated services directed through strong, collaborative leadership with blended and braided funding, interoperable data systems, and policies and programs that essentially merge the personalities and cultures of the individual systems into one.
An entity that serves a convening role and works intentionally and systematically across various sectors to achieve improvements in health and well-being.
Internal Factors Affecting Capacity
Factors within organizations that enable change, including leadership, workforce, information infrastructure, workflow, communication, quality improvement, incentives, financial management, backbone capabilities, accountability, and the ability to manage progress.
Aligning across sectors seeks to address complex, long-entrenched challenges. While some shorter-term progress may be identified through short-term outcomes, more meaningful progress may take a generation or more to be measured. These longer-term outcomes include meeting the goals and needs of communities and the people living in them, health equity, and racial equity.
Results including both intended and unintended consequences. Can be measured for short-term and long-term impact.
The health outcomes of a group of individuals, including the distribution of such outcomes within the group. Population health recognizes that outcomes include factors outside of traditional health care delivery, including social determinants of health.
Aligning across sectors is challenging because of the inherent differences in dominance among sectors and between sectors and individuals. These differences in power can result from imbalances in resources, perceived value, historical practices, influence, or experience.
Public Health 3.0
Launched in 2016 by the U.S. Department of Health and Human Services, this model views public health agencies as chief health strategists. Efforts expand upon previous capacity-building efforts of traditional public health and rely upon engaging other sectors and community partners to address social determinants of health to create collective impact.
Public Health Sector
The public health sector includes the organizations, programs, and activities that work to create the conditions in which people can live healthy lives, including activities to prevent disease and injury and promote health for the population at large. This sector includes governmental public health agencies working at local, state, and federal levels. A defining feature of the public health sector is its focus on actions designed to protect and improve health at a population level, rather than purely at an individual level through delivery of personal health services.
Involves the elimination of systemic, institutional, and individual barriers that deny equal opportunity to groups based on race or ethnicity (e.g., Black, Indigenous, Hispanic, or other people of color). It is understood that this differential treatment results in racial inequities that are deeply tied to the inability to achieve health equity.
Shared Data and Measurement
A feature of aligned systems that enables sectors to collectively and systematically gather, organize, and share data between entities, and the process of using this information to track progress.
A feature of aligned systems characterized by sustainable methods with appropriate incentives and shared accountability.
A feature of aligned systems in which infrastructure has leadership, appropriate roles, and defined relationships.
A feature of aligned systems in which sectors share a mutual understanding and commitment to a vision and priority outcomes.
The results of aligning across sectors include outcomes of short-term and long-term impact. Short-term impact may include changes to mindset (both individual and institutional), practice (including programs), and policy.
Social Determinants of Health
The conditions in which people are born, grow, live, work, and age that inﬂuence health.
Social Services Sector
The social services sector includes the organizations, programs, and services that work to address fundamental human needs and promote social well-being. This sector includes organizations and programs that provide education, housing, income support, employment assistance, diversity and inclusion initiatives, food assistance, transportation, legal assistance, disability support services, and criminal justice or juvenile justice services.
Designing systems change to ensure solutions are built to last, rather than temporary due to funding constraints, lack of incentives, or structures that do not produce permanent connections.
Framework developed by the Institute for Healthcare Improvement that refers to the simultaneous pursuit of better quality of patient care, better health for populations, and lower per capita costs.
Both relational trust — earned through shared experiences and backgrounds — and transactional trust — earned through interactions and give-and-take — are necessary in collaborative efforts. Trust may need to be rebuilt or regularly renewed.
Coordination of health, behavioral health, and social services in a patient-centered manner. Like coordinated care, whole-person care has the goals of improved health outcomes and more efficient and effective use of resources.