At least 12 states are developing accountable health models to improve health and control costs by addressing health-related community needs, such as transportation, recreation, and housing. Their goals include building healthy communities and improving health equity through cross-sector partnerships, and their organizational and governance structures are evolving to reach these goals.

In these accountable health entities, a state-level coordinating group designates and supports community-based organizations or coalitions that invest in, or are accountable for, improving population health and health equity. Generally, states provide direction to the local government agencies, community organizations, health systems, or other partners that convene accountable entities about how they should govern them. Some states encourage rather than require certain facets of governance, while other states are more prescriptive. Frequently, states ask local accountable health leaders to establish a governance structure that outlines key requirements, such as defining:

• The groups to be represented on governance committees;
• The roles of committee members;
• An effective decision-making process; and
• A clear statement of financial and fiduciary responsibility.

An effective governance structure can ensure the efficient operation of the accountable entity, and can also help highlight local goals and perspectives alongside state priorities.
In developing a comparison table of accountable entity governance structures, the National Academy for State Health Policy (NASHP) examined the overall goals and functions of each governing body and their required representation. The methods by which states hold entities accountable for their operations, such as mandatory reporting or open meetings requirements, were noted. For example:

• The development of conflict-of-interest and anti-nepotism policies is an early milestone for California’s Accountable Communities for Health.
• Colorado requires its Regional Accountable Entities to publicly post their conflict of interest plans.

NASHP also examined the language states used to ensure that the local community was meaningfully engaged in the operations of the accountable entity. For example:

• Oregon requires consumer representatives to constitute a majority of its community advisory councils.
• Rhode Island requires its community advisory committees to include a certain number of Medicaid beneficiaries who represent populations served by the accountable entities.
• Washington State does not prescribe specific community engagement strategies, but expects its Accountable Communities of Health to include the perspectives of consumers and community members in their decision-making in a manner tailored by community leaders to reflect local needs.

Just as community representation is crucial to identifying community needs, representation from service providers, clinicians, and state and local government is key to addressing those needs. States encourage broad representation from providers, community service organizations, and others who affect the health of communities. For example:

• The California Accountable Communities for Health Initiative requires their collaboratives to include hospitals, health plans, clinics, and providers serving the area. It also encourages participation of behavioral health providers, housing agencies, food systems, labor organizations, schools, parks and recreational organizations and agencies, faith-based organizations, dental providers, and transportation and land use planning agencies.
• Minnesota requires local public health department officials to be active partners in Accountable Communities for Health, and encourages participation by local health plans and health systems and local government officials.

Building meaningful community engagement into state health initiatives is a strategy that resonates far beyond accountable health entities. NASHP will be publishing an analysis of the role that community engagement has played in tax-exempt hospitals’ community health needs assessment process later this year. As states continue to prioritize community health initiatives, the question of who represents the community and how best to include their voices is becoming increasingly important for states.
The state models NASHP features in its chart are in varying stages of maturity, with key governance decisions still to come in many states. NASHP will continue to support states participating in its accountable health workgroup, and will share best practices from states working to align state and community health and prevention priorities to achieve health equity and help all residents thrive.

Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.