Being an ACH backbone: A conversation with kitty bailey (part 1)

This post is the first of two based on interviews with Kitty Bailey, CEO of the San Diego Wellness Collaborative.


This post is the first of two based on interviews with Kitty Bailey, CEO of the San Diego Wellness Collaborative.

With a grant from the California Accountable Communities for Health Initiative in 2016, the Collaborative became the backbone organization for the San Diego Accountable Community for Health.

Kitty is a technical advisor for TACHI, with a special focus on providing guidance related to backbone functions. While every ACH backbone will have a unique journey – influenced by community and state contexts – the San Diego experience provides some useful lessons for TACHI sites.


Could you tell me a little bit about the San Diego Wellness Collaborative, and how the ACH fits in?

The San Diego Wellness Collaborative  builds health equity for the entire population in San Diego County through a set of multi-sector initiatives, including Be There San Diego, which is a community-clinical collaborative working with leadership from all the clinical teams in San Diego; Neighborhood Networks, which is a social enterprise that connects Medicaid managed care organizations with community health workers; and the Accountable Community for Health, which takes an upstream perspective and works towards achieving health equity with a diverse set of partners.

In a lot of ways, the whole San Diego Wellness Collaborative operates as  an ACH, where we  address all parts of the “stream.” Upstream is the ACH work, midstream is the Neighborhood Networks, and then downstream is Be There San Diego.

By keeping the upstream work of the ACH separate from the other two initiatives (Be There and Neighborhood Networks) we stay focused on making an impact on the population level social determinants of health through the partnerships.   The ACH avoids getting into detailed discussions around clinical care and contract discussions. We focus on those discussions at Be There and Neighborhood Networks. 


As an ACH backbone, what are your key functions?

First, we are responsible for all grant management and grant maintenance. We need to be good fiscal stewards of the grant dollars.

Second, we manage the governance structure for the ACH. Over the years it has changed to be responsive to the priorities of the ACH.  Our governance structure has included several work groups, including data and metrics work group, a community engagement work group, sustainability and financing workgroup and a portfolio of interventions work group.

Lastly, building upon the basics of financial stewardship and governance, we are responsible for building the ACH partnerships.  Building partnerships is a core function and allows us to do all of the other work that fuels an ACH.   The Collective Impact field has created some great resources on backbone functions and getting started as a backbone, including a podcast episode.

Can you talk about the major roles that you play as a backbone leader?

There’s the defined roles around setting agendas, convening the partners, and aligning agendas amongst multiple partners.

And then there’s the softer skills that often don’t get named, which are more about the way we do work. We have to be creative, and hold a vision for a future where these partners are working together in new ways, because we’re trying to disrupt the status quo. You have to come to the table with a different kind of mindset of how to align partners around a shared vision. Bringing the partners along with you on the vision is one of the most important things you can do as a backbone leader.

Another important role is to be plugged into what’s going on in your community at all levels, and be able to curate conversations. It is a very important mindset for a backbone leader to be a curious learner.

One of the ways I think about our next ACH meeting agenda is what’s got me curious lately? What am I unclear about? What have I been hearing our partners talk about? Then bringing a set of speakers together to highlight those emerging topics.


Can you tell me more about curating community conversations? As a backbone leader, what do you need to do to curate these conversations?

You have to have the ability to be multilingual as a backbone leader. You’re being multi-lingual between the clinical world, the public health world, healthcare administration, and community. It’s important to embrace the role as an interpreter and bridge. For example, I can see that when the Medicaid managed care organization medical director is making a point and it’s not landing for the community organizations. And vice versa. My role is to be able to see that, and translate it in ways that the other sectors can get.

Nobody’s going to come with expertise in all of those fields. Part of the role as a backbone leader is to gain enough expertise so that we can be fluent in different languages, and that takes investment to go out and listen. The backbone leader has to have a lot of little conversations to understand organizational priorities. Everybody’s operating out of a need to accomplish something at an organizational level. Our job is to find where we can get those things to line up to get better outcomes because we’ve done something together. Sometimes it’s difficult to find those places, but they exist.


The TACHI sites are in their second year–the first year was learning about the model and the second started implementation. What was going on in year two of your ACH journey?

In year two our primary activity was establishing the stewardship group (a small oversight body) and recruiting a broad set of partners to participate in “stakeholder meetings” and work groups. We created charters and governing documents for all of the work groups. We created partnership guidelines. We created a code of conduct  that defined how we wanted to show up and act together in our meetings.  We also dove into the data and metrics to create our priority indicators and secondary indicators.


What about the portfolio of interventions? Many of the TACHI sites are starting to focus on this element now.

We created in the first two years an approach to the portfolio of interventions (POI), but we had not yet started working on the portfolio of interventions. We spent a lot of time thinking about it with a set of highly engaged partners. 

Prior to digging into the POI we developed a shared agreement on what would contribute to our end goal of lifelong cardiovascular health.  We called these the “protective factors,” and it included things like nutrition, not smoking, physical activity, etc.   Once we had the protective factors for lifelong cardiovascular health, we pursued a more specific set of actions for one of those which for us was access to nutritious foods.   A subset of our partners then did some deep work to develop a set of objectives and action plans around nutrition. 


What were some of the challenges?

One important thing to say is that we had a lot of very hard meetings.

Like at the stewardship group, our governing body, some of our partners were using language like redistributing dollars. Some of our other partners didn’t like that language. Other partners thought it was going to be a more traditional healthcare project. When they found out it was something much more upstream, they decided they were going to pull out.

At the data and metrics work group, the most challenging part was the conversations between the county epidemiologists and community members. There were some  painful moments in trying to  have a meaningful dialogue where both partners felt engaged. Additionally, when our partners realized the limitations of available public data sets it was a real shock.

At the POI table the hardest part was narrowing down and picking nutrition and the sub region of San Diego County. Some of our clinical partners wanted to pick something much more clinical, much more downstream. Some people had to be disappointed in order for us to get to the final POI that we were going to start with.

It was tough. The first two years were very, very challenging. My role as the backbone leader was to maintain a sense of optimism around the broader work and vision.  

As the backbone leader you have to believe that this work is required to get to health equity, to create this table, to have these hard conversations actually meant we were doing the work. Knowing that the hard conversations themselves were the indicator that we were on the right track.