Building an Accountable Community of Health in Sonoma County

By Arielle Kubu-Jones, Assistant to the Health Officer; Dr. Karen Milman, Sonoma County Health Officer; and Jen Lewis, Special Projects Director

Imagine a community where all residents, regardless of their neighborhood or socioeconomic status, have access to what they need to be healthy.

How would we build this kind of community? If we consider this question and the myriad factors that influence health, it becomes clear that building a healthy community requires strong buy-in from every sector and robust community engagement. Local nonprofits, medical clinics, educators, businesses, faith-based organizations, hospitals and medical groups, elected officials and policy-makers, and residents themselves all need to be involved to make this kind of community a reality. Recognizing the potential for this kind of collaborative approach to address health improvements, Sonoma County convened Health Action in 2007.

Health Action sets a vision of achieving health equity, drawing from existing research to identify public health issues and engaging the community to develop recommendations for how to address them. This research includes the Portrait of Sonoma County which was commissioned by Sonoma County to examine disparities that exist in our community by place and population.

Health Action is evolving our partnership to pilot an accountable community of health. This model is designed to improve health outcomes, reduce disparities, and lower healthcare costs by bringing together a diverse group of local partners to coordinate prevention-focused health strategies across different domains (e.g. clinical services, community programs, community policies, and environmental changes) to improve the health of the whole community. Savings accrued from these prevention efforts are then directed towards additional health improvement programs to create a sustainable model.

ACH Structure

With a newly obtained grant from the California Accountable Communities for Health Initiative, Health Action is piloting an accountable community of health focused on one specific health challenge in our community—cardiovascular disease.  Health Action has already successfully improved hypertension control through cooperative quality improvement across different health care systems. Building on that work, Health Action will coordinate existing and new efforts, such as implementing an improved referral tracking system, allowing a clinician who refers a patient at risk for cardiovascular disease to nutrition education to know if the patient attended the classes, and expanding our healthy retail efforts to ensure residents have access to affordable, nutritious food. Another goal is to ensure that residents are actively engaged in decision-making for this project, because the path to a healthy community needs to be led by the community. The project will also implement methods to consistently collect and share data, analyze savings to reinvest in the project, and evaluate progress to see what’s working and what still needs improvement. After the pilot is completed, Health Action hopes to expand use of the accountable community of health framework to address social determinants of health and other root causes of health inequities.

Building a community where every resident truly has an equal opportunity for a healthy life can only be done through coalition building and creative thinking. This is the vision of Public Health 3.0 and this is the vision of Sonoma County Health Action. It’s a lot of hard work, but we know we can get there.