In Atlanta a person’s ZIP code is often the biggest predictor of his or her health status. The region’s staggering health disparities were made clear in a map released by Virginia Commonwealth University and the Robert Wood Johnson Foundation in 2015 that vividly shows how short distances can translate into large differences in health. (See “Short Distances to Large Gaps in Health” below) In some Atlanta communities people are expected to live 84 years, while just a few miles away life expectancy is only 71 years.
This special supplement examines the organizations and programs that are addressing social inequalities in housing, transportation, work, and other parts of society that create disparate health outcomes.
The good news is that a coalition of diverse organizations called the Atlanta Regional Collaborative for Health Improvement (ARCHI) came together to address this issue. ARCHI offers a promising systems approach to reducing health disparities and creating place-based change for people living in the metropolitan area. The coalition’s origins, and its early efforts, could serve as a model for organizations seeking solutions to health inequality in other cities.
Archi’s Origins and Structure
In 2011, 12 Atlanta leaders, including representatives from the Atlanta Regional Commission, the United Way, and the Georgia Health Policy Center, convened to discuss how hospital community benefit efforts and collective impact could be used to address the city’s health disparities. They agreed that incremental improvements to various programs weren’t the answer and that a new approach was needed. The group became the core of the 15-member ARCHI steering committee, which includes representatives of area hospitals, insurers, state and local public health agencies, behavioral health providers, the US Centers for Disease Control and Prevention, educators, federally qualified health centers, and community members.
The steering committee recommended that ARCHI’s leadership should be shared between the United Way, the Atlanta Regional Commission, and the Georgia Health Policy Center, with each organization’s representative being an equal participant on the three-member executive leadership team. The team provides strategic direction for the collaborative as well as ongoing staff support. The team also convenes, sets the agenda for, and presides over the steering committee. The steering committee’s primary responsibility is to articulate and promote ARCHI’s vision of creating and sustaining a healthy population and a vibrant economy in Atlanta, with all citizens having an equal opportunity for health.
The broader ARCHI collaborative consists of more than 100 diverse organizations, agencies, and individuals in Atlanta. Membership is open to any organization that (or individual who) embraces its goals.
Funding for the collaborative has evolved. Initially, the three leadership groups provided considerable in-kind support. Steering committee members all contributed core funding. The steering committee realized the importance of broadening ARCHI’s support and funding, but in a way that allows members to do so in a way that works best for their organizations. Local and national health delivery systems, along with the federal government, provided additional funding to support backbone functions. The collaborative’s long-term funding plan includes increased use of financing mechanisms that capture and reinvest cost savings (derived from improved health outcomes) to further the goal of health equity.
To identify the Atlanta area’s health challenges and develop potential solutions, ARCHI first reviewed the areas health-care delivery system and analyzed health data. It produced a collaborative, regional health assessment, along with short- and long-term improvement plans designed to encourage members to invest according to their individual interests and needs.
This phase of ARCHI’s work culminated in a work session in 2012 where 70 stakeholders (including business, insurers, physicians, hospitals, community and faith-based organizations, and educators) were introduced to the Fannie E. Rippel Foundation’s ReThink Health computer modeling tool that had been calibrated for Atlanta. ReThink Health allows communities to test innovative ideas for redesigning their health-care systems. Loaded with extensive data on resident health and area health-care systems, the tool enables stakeholders to run intervention and investment scenarios, simulate their short-and long-term impacts on a region’s population and economy, identify opportunities, set priorities for action, and measure progress. Interventions can be simulated individually or in combinations to study the likely impact over time on multiple metrics of health, care, cost, productivity, equity, spending, savings, and return on investment.
Meeting participants devised scenarios that they thought would give Atlanta the best overall outcomes in health, productivity, equity, and health-care system efficiency. The six most promising scenarios were presented at the work session, and a set of priorities emerged. A majority of participants supported the scenario titled Atlanta Transformation.
This scenario now forms the basis of ARCHI’s agenda. It includes four intervention priorities: encouraging healthy behaviors; increasing income and economic prospects; increasing care coordination; and expanding health insurance coverage.
A Playbook for Action
The coalition’s next step was to develop a “Playbook for Action” based on the four priorities. Subcommittees were formed to create a plan for each intervention and financing area. The playbook includes evidence-based programs or policy interventions for each priority. For example, to encourage healthy behaviors, the subcommittee focused on proven programs and interventions to reduce smoking and tobacco use, improve diet and nutrition, increase exercise and physical activity, reduce alcohol and drug use, cut the incidence of unprotected sex and sexually transmitted infections, and expand preventive care for physical and mental health.
The playbook also identifies policies and programs (such as living wage policies, tax credits and subsidies, and housing vouchers) that can improve the economic prospects for disadvantaged families. Further, it describes how improved care coordination is possible through integrated information systems, coaching arrangements, and protocols for shared decision making.
The playbook articulates ARCHI’s long-term strategies for financing innovative initiatives related to ARCHI priorities. These include an innovation portfolio, increased use of contingency payments tied to outcomes, and the capture and reinvestment of a portion of the savings generated, which will in turn fund more priority-based initiatives. In the initial phases of the program, however, philanthropic support is necessary. For example, the United Way of Greater Atlanta has provided $3.6 million and national foundations, such as the Robert Wood Johnson and Kresge foundations, have also provided support for ARCHI pilot programs.
The Tri-Cities area in Atlanta, which includes College Park, East Point, and Hapeville, is near the Hartsfield-Jackson Atlanta International Airport. Although there are tremendous assets in this area—including public transportation, strong community cohesion, and green spaces—there are also significant challenges. Many of the storefronts are vacant. Houses are abandoned. Many of the schools receive the lowest rankings. These adverse community conditions fuel health disparities and limit opportunities for residents.
In 2014, ARCHI brought together civic leaders, concerned citizens, health-care providers, faith- and community-based organizations, government representatives, and other community leaders to learn more about health challenges in the Tri-Cities area. ARCHI’s leadership provided administrative support; demographic, socioeconomic, and health data; and technical assistance to inform and guide the event and to catalyze a community engagement process. In addition, the ARCHI playbook provided comprehensive strategies and best-practice solutions to address health disparities in the targeted Tri-Cities pilot communities for the group to consider.
The result? A resident-driven Tri-Cities Stewardship Committee—made up of participants in that original work session—is currently setting the goals for a pilot program and selecting targeted priorities to match the needs and desires of the community.
The Ahead Initiative
Also in 2014, ARCHI was selected as one of five sites for the national Alignment for Health Equity and Development (AHEAD) initiative. AHEAD is a partnership led by the Public Health Institute and the Reinvestment Fund, with support from the Kresge Foundation. The initiative recognizes that real health improvement cannot be achieved by investing in the health-care system alone. It is also dependent on upstream interventions that address social, economic, and community conditions. AHEAD provides technical assistance to selected communities to help them bring together different investment streams to advance community priorities for health.
ARCHI selected East Point as a pilot for the AHEAD initiative. East Point is a city of about 35,000, adjacent to Atlanta, where 43 percent of the children under 18 years old live in poverty.1 Since April 2015, with AHEAD’s support, ARCHI has brought together stakeholders to assess their willingness to consider new and convergent investment strategies and to establish shared goals and evaluation measurements. The outpouring of support has been overwhelming, with many organizations signing on as partners.
Community members have worked with the East Point AHEAD partners to identify priorities, including more stable and affordable housing, expanded opportunities for physical activity, more transportation options, improved health literacy and healthcare access, and increased food security. The group will develop joint investment strategies with unified goals that can maximize the knowledge, resources, and actions of the organizations that have converged to improve the health of East Point residents.
The Tri-Cities pilot and the AHEAD initiative are just two examples of work going on under the umbrella of the ARCHI collaborative. ARCHI understands that no organization can singlehandedly reduce health disparities. From ARCHI’s inception, its leadership has maintained a focus on strengthening the collaboration and the potential power of a collective impact approach. The collaborative provides organizational capacity and a platform for the community to come together to improve health outcomes in metropolitan Atlanta. Working collaboratively offers a pathway for revitalizing physical environments, increasing civic engagement, supporting high-quality education, improving economic well-being, and fostering the positive conditions that promote health.