9 Core Elements


The ACH model is one response to addressing the complex health needs in our communities.

The ACH is: An aspirational model—accountable for the health and well-being of the entire population in its defined geographic area and not limited to a defined group of patients. Population health outcomes are understood to be the product of multiple determinants of health, including medical care, public health, genetics, behaviors, social factors, economic circumstances and environmental factors. An ACH supports the integration of high-quality medical care, mental and behavioral health services, and social services (governmental and non-governmental) for those in need of care. It also supports community-wide prevention efforts across its defined geographic area to reduce disparities in the distribution of health and wellness.

The Prevention Institute’s engagement with Vermont provided a set of recommendations for an ACH structure. The recommendations include 9 Core Elements (listed below). This peer learning opportunity is in part to support the exploration and integration of these core elements into your ACHs to give structure, form and tools for a robust ACH. Some of you may have identified these already, some of you may not have done so and some may want to enhance what has already been done as a result of new learning’s.

9 Core ACH Elements identified by the Prevention Institute are listed below with identified resources under each element area:


An effective ACH mission statement provides an organizing framework for the work. A strong mission defines the work as pertaining to the entire geographic population of the ACHs region; articulates the ACHs role addressing the social, economic, and physical environmental factors that shape health; and makes health equity an explicit aim.

Vision and Mission Statements
Shared Purpose Drives Collaboration

Multi-Sectoral Partnership

An ACH comprises a structured, cross-sectoral alliance of healthcare, public health, and other organizations that impact health in its region. Partners include the breadth of organizations that are able to help it fulfill its charge of implementing comprehensive efforts to improve the health of the entire population in its defined geographic area.

Partnership Self Assessment
Collective Impact Resources
Embracing Emergence: How Collective Impact Addresses Complexity
Partnership Tool Kit
Team Blueprint: A tool for building a strong partnership foundation
Guide to Ecocycle Mapping – A guide for systems thinking

Integrator Organization

To maximize the effectiveness of the multi-sectoral partnership, it is essential for the ACH to have an integrator organization. The integrator helps carry the vision of the ACH; build trust among collaborative partners; convene meetings; recruit new partners; shepherd the planning, implementation, and improvement efforts of collaborative work; and build responsibility for many of these elements among collaborative members.

Quarterback Model Video
Community Quarterback Model
Collective Impact Backbone Resources
Habits of a Systems Thinker
Collaborating for Equity and Social Justice https://www.myctb.org/wst/CEJ/Pages/home.aspx


An ACH is managed through a governance structure that describes the process for decision-making and articulates the roles and responsibilities of the integrator organization, the steering committee, and other collaborative partners.

Webinar Recording – Principles of Sound Governance
PPT- Principles of ACH Governance
ChangeLab Solutions ACH Governance Report
Maine Accountable Communities of Health Governance Structure
King County, WA ACH Structure
Puzzling the Governance of Collective Impact- Canada
Bridgespan Collective Initiatives
How to guide – Build the Collaborative Governance

Data and Indicators
An ACH employs health data, socio demographic data, and data on community conditions related to health (such as affordable housing, food access, or walkability) to inform community assessment and planning, and to measure progress over time. It encourages data sharing by partners to inform these activities. Equally important, an ACH seeks out the perspectives of residents, health and human service providers, and other partners to augment and interpret quantitative data.

Webinar: Making data work for the Public’s Health
Webinar – Key data for community health needs assessment
Webinar: Community Health Needs Assessment
Results Based Accountability
Vermont Health Rankings – 2016
Connect 2 Health
Healthy Vermonters 2020
Vermont Hospital Community Health Needs Assessment
Vermont State Health Improvement Plan Appendix A
Mobilizing Assessment through Planning and Partnership

Strategy and Implementation

An ACH is guided by an overarching strategic framework and implementation plan that reflects its cross-sector approach to health improvement and the commitment by its partners to support implementation. The process for developing this framework includes a prevention analysis that identifies community conditions that are shaping illnesses and injuries across the community. The implementation plan includes specific commitments from healthcare, local government, business, and non-profit partners to carry out elements of the plan.

State Levers to Advance Accountable Communities for Health
Registry of evidence based programs for youth
Exploring a Community Service Model
National Quality Forum Action Guide
CDC 6-18 Initiative: Accelerating Evidence into Action
The Community Guide
Guide to Clinical Preventative Services (US Preventive Services Task Force))
MMWR Weekly Reports 
NACCHO Model Practices Clearinghouse
National Guideline Clearinghouse (Agency for Healthcare Research and Quality)
Promising Practices Network (RAND Corporation)
what-works-for-health(County Health Rankings What Works 
Community Health Improvement Navigator
Practical Playbook
StartUp Health – Entrepreneurs in Health Care
CDC – Community Health Navigator
JSI-PI ACH Portfolio Approach 2_2016
Measuring and Increasing Dose HIghlighted
A Physician’s Guide to Climate Change and Health Equity
A toolkit to help hospitals and health systems build community wealth
http://National League of Cities – addressing health disparities
Roadmap to Community Integrated Care

Community Member Engagement

Authentic community engagement is a well-recognized best practice in the field of community health that requires commitment from the highest levels, designated staff, and commensurate resources to ensure effective integration into ACH processes and systems. Authentic community engagement recognizes and harnesses residents’ own power in identifying and addressing challenges, while also creating leadership for and buy-in of the work in a manner that acknowledges and builds upon existing community assets and strengths.

VT Community Assessment ToolKit
Sonoma County Best Practices in Community Engagement
Asset Based Community Development
Spectrum of Community Engagement
Stanford Social Innovation Review – Community Engagement


An ACH employs communications platforms to build momentum, increase buy-in amongst its partners, recruit new members, and attract grant investment to support its work, and share successes and challenges with others. Communications is also a key tool for framing solutions in terms of community environments and comprehensive strategies.

Thought Exchange Software
Social Media Strategy Worksheet
Slack Communication Software

Sustainable Financing
An ACH requires resources to support both its integrator function and ACH implementation work by others. An ACH makes use of existing and new funding sources and better aligns them to advance broad community goals.

ACH Sustainable Financing
Bending the cost curve: Four Policy Recommendations 
Vermont Business for Social Responsibility
Field Guide for Health Sector Leadership
Build Healthy Places Investment Resources 
Sustainable Financing: Jim Hester and Mary Pittman Webinar
Sustainable Improvements in Population Health

General ACH information

Draft Population Health Plan vermont-population-health-plan-september-2016

PPT on the Vermont Population Health Plan

Jenney Samuelson Presentation  from September 30, 2016: 2016-09-30-ach-v6

List of WA state ACH sites; document has links to their websites : achs_at-a-glance_updated_09-01-2016

Att 3b National ACH Profiles – Draft Copy
Att 3a PI Accountable Communities for Health Research – 6-16-2015

NASHP webinar: Advancing Health through Accountable Communities: A Conversation with States

HeidiKleinACH SlidesJuly2016      Presentation Heidi provided to Vermont State Health Care Innovation Models Committee