Issue Brief

INTEGRATING
PUBLIC HEALTH INTO
STATE INNOVATION MODELS

August 2015

he Affordable Care Act is designed to shift the focus

of the health system from treating illness to keeping
people healthy, which is also a primary focus of the
public health system. One way this shift in priorities is
being attempted is through the State Innovation Model,
or SIM, program, which currently funds the efforts of
34 states to improve population health and the delivery
of health care while also decreasing costs. The federal
government also requires states to describe their
strategies for improving population health in SIM plans.

One widely accepted definition of

population health is, the health
outcomes of a group of individuals,
including the distribution of such
outcomes within the group.
Kindig D, Stoddart G. What is Population Health? Am J
Public Health.
2003 March; 93(3): 380383

The public health system should take an active role

in each SIM program, as the success of any effort to
improve population health must address the various
complex factors that influence health outcomes. Health
is determined outside the doctors office, and the
clinical care an individual receives has only a small
effect on an individuals health when compared to the
social determinants of health, the conditions in which
people are born, grow, live, work, and age, and which
are shaped by the distribution of money, power, and
resources at the global, national, and local levels.
Negative social determinants are often prevalent in
underserved communities, and addressing these root
causes of poor health makes the biggest difference in
improving population health. The field of public health,
which often serves as a safety net for underserved
communities, can help SIM plans meet their population
health goals by addressing the social determinants in a
way the health care system currently does not.

Integrating Public Health into State Innovation Models

The public health system assesses the health status of

communities, develops policies to improve individual
and community health, and assures that essential
health services and information are publically available.
These three core functions assessment, policy
development and assurance enable the public health
system to address social and environmental health
problems at the community level. Incorporating public
health practitioners into SIM can broaden the plans to
encompass the social determinants of health.
This issue brief explores successes and challenges
experienced by public health practitioners in early SIM
states. It is designed to assist state officials designing
and implementing SIM plans in effectively working
with public health practitioners. When developing this
issue brief, APHA first reviewed SIM plans and testing
proposals of states to identify plans with strong public
health components. To provide real world context to SIM
development and implementation, APHA conducted key
informant interviews.
Defining Public Health
APHA defines the public health system
as the subset of the overall health
system focused on promoting and
protecting population health and
wellness. Public health system functions
include: tracking and analyzing
health trends; ensuring the safety and
cleanliness of air, water, and food;
educating the public about health
issues; designing and implementing
health policies and programs; and
convening stakeholders to address
social and environmental factors that
have an impact on health. When
used in this issue brief, public health
practitioners refers to governmental
health departments, community-based
organizations and other organizations
that provide services and supports.

Challenges for integrating public health

into SIM

SIM initiatives can benefit from collaboration between the

complementary skills of the public health and health care
systems. One of the key opportunities and challenges to
improve health presented by SIM is aligning the efforts of
public health and health care.
Differences in training and scope of services
between public health and clinical care

Differences in training and vocabulary both limit

collaboration between the health care and public health
systems. For example, medical schools focus on clinical
care for individuals, whereas public health practitioners
are trained to provide interventions and services that can
improve the health of communities. The health care system
and public health system also conceptualize population
health and prevention in different ways. The public health
system has a broad view of population health, whereas a
primary care provider might only consider his or her patients
as a population to care for. Similarly, public health prevention
efforts encompass social and environmental factors;
prevention in the health care system often focuses on
services delivered to individuals in clinics. These differences
in training and scope of services often separate practitioners
in the public health and health care systems in their day-today work. When opportunities like SIM arise, and are often
led by the health care system, the lack of past collaboration
makes it difficult for public health representatives to take
part and advocate for all the field has to offer.
Emphasizing clinical care compared to the social
determinants of health

In many states, those in charge of developing SIM plans

believe the solution to improving health and reducing
costs can be found in making the health care system
more efficient. Public health practitioners in some states
cited a lack of a past working relationship with medicallyfocused state SIM staff and a lack of outreach by these
officials as the main difficulty in getting involved in SIM
planning and implementation. SIM plans that focus solely or
predominantly on the clinical health care system risk losing

Integrating Public Health into State Innovation Models

the public health perspective needed to address the social

determinants of health, rather than just treat illnesses in a
clinic. For example, public health interventions focused on
housing and community preventive services can improve
health and result in savings in the health care system.
Emphasis on short-term return on investment

Even in situations where the public health and health care

systems have good working relationships, the need to
demonstrate short-term results is a challenge. Many public
health initiatives take time to demonstrate a positive result.
An interview participant explained that public health
practitioners in his region have to first play a supporting
role in a six-month, clinically focused reform in order to
show short-term success. Local public health departments
partnered with emergency departments to guide their
frequent users to community preventive services. The
program is testing whether hospitals and community-based
organizations can work together to improve health outcomes
and save money. Larger scale programs that identify and
assist people outside a clinical setting and do more to
address the social determinants often require a longer time
frame.
Promising practices for states integrating
local public health into SIM

The innovation models with the most potential incorporate

public health practitioners as full partners. This list of
promising practices describes integrating public health
practitioners in SIM development and components states are
including in their plans to effectively engage public health.
Include public health in the development of
SIM plans

The best way to incorporate a public health perspective is

to include public health practitioners in SIM development
and implementation. The federal requirement to include
strategies to improve population health makes SIM the ideal
opportunity to forge relationships between local public
health practitioners and clinical care providers.

How to do it

Appoint public health officers to key

leadership positions in the development
and implementation process. In

Washington, a county public health officer led

a task force on developing part of the states
SIM proposal. The task force helped develop
the states regional health improvement
coalition model included in the proposal, and
members of the task force, including public
health practitioners, are now involved in
leading one of the states coalitions.
Actively solicit the views of the field. Many
states host community forums to give public
health practitioners and other stakeholders
the opportunity to provide input. Colorado
also created an online platform that public
health practitioners can use to provide
comments on SIM development. Minnesotas
state government collaborated with the
Minnesota Public Health Association to host
SIM development meetings with public health
practitioners. At MPHAs meetings, members
provided direct feedback to SIM officials
and both groups were able to identify ways
to collaborate. For example, MPHA advised
SIM officials on successful community health
improvement coalitions that could serve as a
model for SIM efforts.
Adopt a public health perspective when
defining population health. A public health
perspective, which recognizes the variety
of social and environmental factors that
determine the health of every individual in
a community, is a good starting point for
organizing community stakeholders to think
of potential contributions to SIM plans. It also
turns discussions about ways to improve health
away from health care and toward the social
determinants of health.

Integrating Public Health into State Innovation Models

Public health components to include in SIM

plans

States across the country are incorporating public health into

their SIM plans. Below are some promising first steps states
are taking to include public health in SIM efforts.
Develop Regional Health Improvement Coalitions

Many innovation models support the creation of health

improvement coalitions1, which help identify local health
priorities and engage stakeholders to work together to
develop consensus-driven solutions to improve health. Often
called accountable communities for health, or ACHs, these
coalitions often consist of local public health departments,
hospitals, businesses and employers, and schools, though
each ACH is different. In some states, like Pennsylvania,
ACHs are tasked with disseminating information and
promising practices developed by state health officials. Other
states, like Washington and Minnesota, envision linking
ACHs to Medicaid and other payers in order to provide
reimbursement to community preventive service providers.
These new coalitions serve as a strong starting point for
future collaboration between public health practitioners and
health care providers.
-

Promising practices from Washington

Washingtons SIM plan divides the state

into multiple ACHs. They can include
school districts, churches, communitybased organizations, clinical care providers,
businesses and other organizations that have
a stake in the health of their community. Local
public health departments often convene these
coalitions and work to include representatives
to make sure all sectors are represented.
Members share information and set common
goals. One advanced ACH operated a sixmonth pilot program to coordinate the care of
frequent visitors to the emergency department
with community preventive service providers,
like those focused on addressing chemical
dependence. The ACH evaluated these care
coordination efforts throughout the program
in order to identify best practices and collect

them in a manual for all members to use. The

pilot initiative started in January 2015 and
operated through June 2015.
Integrate public health in payment and
delivery reforms

A main component of SIM is developing ways to redirect

payments away from treatment of preventable conditions
and toward prevention. Some states are developing the
capacity to provide reimbursement to local public health
practitioners for providing community preventive services.
- Promising practices from Minnesota and
Washington

Minnesota is working to integrate its regional

health improvement coalitions into the states
Accountable Care Organization, or ACO,
payment structure. ACHs from that state have
been successful at partnering with ACOs.
Interview participants cited health education
efforts and developing systems for referral to
community preventive services as good early
opportunities for public health practitioners
and ACOs to collaborate.
Washingtons SIM plan describes communitybased Accountable Risk Bearing Entities, or
ARBEs, that collect Medicaid payments and
then distribute those payments to providers,
including local public health departments and
providers of community preventive services.
Though the state is waiting for both ARBEs
and ACHs to fully develop, the SIM plan
envisions these payers working with the states
ACHs to coordinate community resources and
health programs.

Integrating Public Health into State Innovation Models

Reimburse community health workers for

preventive services

Innovation models from across the country encourage

training and increasing the number of community health
workers. Community health workers often operate out of
community-based organizations and can provide preventive
services, like health education counseling, home visiting
and referrals, to people the health care system might miss.
Because they often are members of the community they
serve, they have a deep knowledge of the specific social and
environmental factors affecting their patients. Community
health workers are particularly effective at reaching and
assisting underserved populations, who tend to have poorer
health outcomes. In addition to the preventive health
services they provide, community health workers can also
serve as interpreters, help their patients navigate the health
system and access community preventive services.
Community health workers show a high return on
investment. For example, one study showed working with
community health workers decreased costs by $2,000 per
Medicaid patient with diabetes. Medicaid now reimburses
the workers who deliver preventive services, such as chronic
disease management programs and care coordination that
have been recommended by a licensed health care provider,
and this presents an opportunity to states to make care
more accessible by increasing the use of community health
workers.
-

Promising practices from Utah

Utahs innovation plan advocates for the use

of community health workers and developing
the ability of the health system to effectively
pay for the services they provide. Specifically,
the plan calls on the state to determine
payer demand for purchasing the services
of community health workers. This means

Medicaid and health insurers could develop the

capacity to reimburse local health departments
and other providers that utilize community
health workers.

Author
Jason Coates, American Public Health Association
This publication was made possible by grant number
1U38OT000131-01 from the Centers for Disease Control and
Prevention (CDC). Its contents are solely the responsibility of
the authors and do not represent the views of the CDC.

Utahs plan also looks to community health

workers to enhance the value and quality of
the health system. It does this by calling for the
development of registration and standardized
curricula to improve the quality of care provided
by community health workers.

(Endnotes)
1
For example, see Washington stats Accountable Communities of Health.
See http://www.hca.wa.gove/hw/Pages/communities_of_health.aspx

800 IStreet, NW Washington, DC 20001 www.apha.org

Integrating Public Health into State Innovation Models