Tracing the Origins of the Texas Accountable Communities for Health Initiative (TACHI): Assessing Community Readiness

This is the third in a blog series chronicling the TACHI journey from planning to implementation.

by Emily Heberlein, PhD
Assistant Project Director
Georgia Health Policy Center

Building an Accountable Community for Health (ACH) – a local platform for bringing stakeholders and community residents together to transform systems to improve community health – requires a different level of governance, coordination, and sustainable financing than most community collaboratives have historically practiced. Conducting a readiness assessment at the outset can help with this transformation.

Why do an ACH readiness assessment
The readiness assessment process can create an understanding of each community’s capacity to incorporate the ACH model into their collaborative by defining and assessing the core ACH elements. We intended the Texas Accountable Communities for Health Initiative (TACHI) readiness assessment to: 

  • Serve as a level-setting, informative tool for local collaborative partners.
  • Guide the next steps for the collaborative’s work and technical assistance (TA) – at each site and across TACHI.

While the six TACHI sites had high capacity for collaborative work and strong existing partnerships, we did not expect that sites would be at a high level of readiness to build an ACH at the time of the assessment.

How did TACHI conduct the assessment?

Developing the assessment tool. One of our early TACHI evaluation activities was developing the readiness assessment tool. We started with an established tool used by the California Accountable Communities for Health Initiative (CACHI) and refined it to create a tool and process that would work best for TACHI. During the fall of 2020, we:

  • Reviewed other similar tools, as well as various papers and publications on ACH frameworks.
  • Gathered feedback from subject matter experts at CACHI as well our partners, Episcopal Health Foundation (EHF) and the Parkland Center for Clinical Innovation.
  • Revised the CACHI assessment to streamline it for use as an online survey and added two elements: community engagement and equity, both areas of growing national and local importance.

The final readiness assessment survey addressed nine key ACH elements and included two questions on external context and community capacity. The nine elements are:

  • Shared Vision and Goals
  • Partnerships
  • Leadership and Governance
  • Backbone
  • Data Analytics and Sharing Capacity
  • Sustainable Financing
  • Portfolio of Interventions
  • Community Engagement
  • Equity

Each ACH element is a vital aspect of the ACH model; progress in each element provides insight into a collaborative’s readiness to launch an ACH. The elements are more interrelated than sequential. While developing an ACH is not a linear process, several elements are foundational. Without a strong foundation in shared vision and goals, partnerships, governance, and community engagement, substantial progress in other elements will be slowed.

In the TACHI survey, participants rated readiness using a five-point scale based on their assessment of their site’s progress compared to a list of criteria. The scale ranged from ‘not started’ to ‘high readiness,’ with an ‘unsure’ option for those who did not have enough knowledge or information on their ACH collaborative’s plans or previous work on an element. The complete scale is as follows:

  • Not started: none of the criteria are perceived to be met
  • Early in progress: started work on one or more of these criteria, but the majority of criteria haven’t been addressed yet
  • Midway in progress: for at least half of criteria, we have addressed and would consider completed, with work still to do
  • High readiness: while there may still be future progress to be made, we consider at least 75% of these areas to be substantially addressed
  • Unsure: do not have enough knowledge

Each element also included open-ended questions on gaps, challenges, and next steps, including TA needed. The two questions on external context and community capacity were open-ended as well.

Conducting the assessment. We designed a two-stage assessment process. First, we invited site partners to use individualized survey links to complete the readiness assessment after coordinating with site leaders to confirm their lists of partners participating in the process. Their responses reflected their understanding of their collaborative’s readiness. Second, we facilitated group discussions of the collective, site-specific survey results with each sites’ partners.

  • Fifty-seven individuals responded to the survey out of 58 invited (98% response rate).
  • We facilitated group discussions with the six TACHI sites between mid-December 2020 and mid-January 2021. Fifty people in total attended these discussions, representing 26 organizations across the six sites; each site had between three and seven organizations represented. Each site discussed their survey results and ultimately reached consensus on their level of readiness across the nine elements.

Following the facilitated discussions, final reports were prepared and distributed to each site in February 2021.  Aggregate results across the six sites were presented to participants, EHF and PCCI at a March 2021 TACHI Learning Session.

What did we learn from the assessment?

At the time of the readiness assessment, the sites were relatively early in their ACH development. While strong partnerships and backbone organizations were largely evident, operationalizing the ACH elements was a new endeavor. The pandemic limited opportunities for community engagement and potentially impacted community priorities and needs compared to the pre-pandemic period. Each site had a range of readiness levels across the nine elements.

The readiness assessment process provided a useful reflection of sites’ readiness to implement an ACH model in their individual communities during the first months of TACHI. The patterns observed in the results are in line with what we might expect for a group of sites at this stage of an initiative. While readiness levels at the end of 2020 varied at the site level, sites held in common several priorities for next steps and TA needs.

  • Partners identified similar next steps, largely centered on completing vital tasks for developing the ACH infrastructure, i.e., governance structure, vision, aligned goals and value proposition. 
  • Common ACH elements requiring TA included: governance, equity, data analytics and sharing capacity, and sustainable financing. Sites expressed eagerness for information on best practices and successes from other ACH initiatives.
  • Capacity and experience tended to translate to higher levels of perceived readiness (e.g., backbone, partnerships, data analytics and sharing), while sites tended to be at similar stages in forming their ACH.
  • While cohesion among a core group of partners was generally evident across sites, most identified challenges around how and when to bring in additional partners.
  • Continued learning and capacity building on the ACH model will support sites in their work during the planning period.
  • Time, competing priorities and constant adaptation to a changing pandemic (including limited ability to meet in person) presented substantial challenges for sites’ progress.

We also found that designing an engaging process for site partners is as important as developing a comprehensive assessment tool.

  • Participants gained an understanding of the ACH model through completing the online survey individually.
  • The meetings provided a useful forum to learn about the ACH model and connect with each other.
  • The process also helped backbone organizations and partners identify next steps, and for some, suggested an overall roadmap for their work by prioritizing their next steps.

What’s next with the readiness assessment?

While we will not repeat the same assessment process, we will be measuring progress in addressing each of the nine foundational ACH elements near the end of the TACHI planning period in December 2021. We believe our experience, and that of the participants, with this TACHI readiness assessment will pave the way forward for enhancements in the tool and the administration process.  At the same time, the information gathered from this first TACHI readiness assessment will expand our existing database to allow more insightful strategic planning and benchmarking that can benefit future communities interested in establishing an ACH.     

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