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Leading Local Health Care Transformation: A Public Health, ACO, and Primary Care Collective

State: NY Type: Promising Practice Year: 2020

The Clinton County Health Department (CCHD) serves Clinton County, New York, a rural community situated in the furthest northeast section of the state. Clinton County's population (82,128) is limited in its ethnic and racial diversity; over 90% of residents are White/non-Hispanics, followed by 4.2% Black/African American, non-Hispanics and 2.8% Hispanic/Latinos.  16.6% of all residents live below the poverty level. Despite low ethnic and racial diversity, many special populations exist within the community. It is often through these special populations that health and health care experiences are considered and interventions are designed with an equity intent.

As clinical care extends outside hospital and provider office walls, the gap medical services that once were once offered by local health departments (LHDs) are no longer needed. This provides LHDs a unique opportunity to redefine their contributions and consider innovative approaches to health planning and community health.  Current health system transformation is requiring healthcare providers to improve both the quality of and access to care while also reducing health care costs. This is a challenging ask and will require contributions of all health system partners in order to truly impact population health but LHDs often struggle to identify an active role in local health care system changes and transition. 

This submitted practice partnered the CCHD with the Adirondacks Accountable Care Organization (ACO) to work collaboratively with local primary care providers on practice level quality improvement projects and a coordinated community-based patient education campaign. The project aimed to improve practice performance while simultaneously increasing patient awareness and practice of preventive health behaviors.

CCHD developed a full evaluation plan for this collaborative initiative prior to implementation.  The plan included a number of process measures and multiple, longer term, outcome objectives.  This was done intentionally to allow collaboration successes to be captured and shared relatively early on, while also capturing actual impact to the target health measure and local health system, data which will, admittedly, have a delayed availability.

The pilot project garnered an overall participation rate of 73% among targeted provider practices (n=11 local primary care practices) and 63% of the participating practices experienced an improvement in their health care transition process (n= 8 participating primary care practices). Data that will confirm impact on longer term, outcome objectives (local health system performance data) is still pending but practice based evaluation outcomes and community campaign reach statistics are demonstrating shorter term successes.  

Collaboration among all health system partners is essential for truly impacting population health and realizing lofty health system performance goals related to reducing costs and increasing quality of care. By leveraging the strengths of each partner, working strategically to introduce efficiency in change processes and creatively including patient education, this submission serves as an example of how all sectors of the health care system can work together through this period of unpreceded change. It also demonstrates how local health departments are well positioned to assist, if not lead, these kind of projects, thereby successfully identifying a role for local public health in health system transformation work.

Local health departments often struggle to identify an active role in local health care system changes and transition, yet have an immense capacity to contribute to, and even lead, this work.

As clinical services are extended into the community, public health's traditional role as a gap service provider is often diminished. One of public health's current challenges is to identify new approaches to health promotion and community health as it redefines its role. Local health departments have the resources and capacity to reach individuals on a community-level, whereas many health care providers (HCPs) are limited to direct patient-provider communications. Quality improvement initiatives, led by Accountable Care Organizations (ACOs), are a common strategy to improving our local health care system. However, even the best improvements on the practice-level still require an element of patient responsibility. LHDs have the capability to support and reinforce these practice-level initiatives on the community-level. Instead of working independently on quality improvement projects with local medical providers, our organization collaborated with our local ACO, identifying and utilizing each of our strengths for a larger impact on our community's health.

This project partnered the CCHD with the Adirondacks Accountable Care Organization (ACO) to work collaboratively with local primary care providers on practice level quality improvement projects and a coordinated community-based patient education campaign. The project aimed to improve practice performance while simultaneously increasing patient awareness and practice of preventive health behaviors.

Our pilot-project topic, the pediatric-to-adult health care transition, was selected based on metrics identified by the local ACO as needing improvement; specifically, attendance of well visits by persons 7-11 years, 12-19 years, and 20-44 years of age. When youth establish preventive health behaviors, such as attendance of well visits, at a younger age these behaviors are more likely to continue into adulthood. An effective transition from a pediatric-style of care to adult health care is central to young adults' adherence to preventive health care. Yet, published literature consistently shows that most youths and young adults, including those with special health care needs and their parents, receive limited or no transition preparatory transfer assistance, or facilitated integration into adult health care. According to the 2017-2018 National Survey of Children's Health, nationally 82.2% of adolescents with special health care needs (SHCN) and 85.8% of adolescents without special health care needs did not receive services necessary for transition to adult health care. In New York State these metrics are not much better, with only 18.9% of adolescents with SHCN and 16.4% of adolescents without SHCN receiving services necessary for transition to adult health care.

Studies have found the most common obstacles to an ideal pediatric-to-adult health care transition to be a lack of communication, coordination, and differing practice styles between pediatric and adult health care providers. Transferring medical records is often difficult due to the different electronic medical record systems used in pediatric versus adult care. Without guidelines and protocols in place to guide practitioners, an ideal handoff does not occur. In addition, there are often differing views between pediatric and adult providers as to who is responsible for ensuring that this transition takes place; ultimately, it's a shared responsibility between providers. Lastly, without proper preparatory guidance, young adults and parents are left to navigate this transition alone. In many instances, children either stay with their pediatrician until their mid-to-late twenties, or they age out” of their pediatric office at a younger age and simply stop visiting any medical providers. Without ever establishing care with an adult care provider these young adults receive no preventive care, only visiting urgent or emergency care centers when medical complications arise. This is an expensive and avoidable care alternative to the local health care system and one that was identified as an issue by providers in our community.

At the time of our pilot project initiation, Clinton County was home to approximately 22 primary care provider practices, specifically 3 pediatric practices, 17 adult practices, and 2 family practices; 50% of these practices participate with the local ACO. For our pilot project we approached the 11 ACO participating practices (consisting of 3 pediatric practices, 5 adult practices, and 3 family practices). Of the 11 medical practices approached, 8 chose to participate (2 pediatric practices, 3 adult practices, and 3 family practices). Participation of practices in our pilot project was voluntary; however, targeted practices were required to complete a quality improvement (QI) project as part of their participation in the ACO.

Of the 82,128 residents in Clinton County, youth and young adults between the ages of 10 and 24 years of age represent 23% of the population, according to the 2010 U.S. Census. In addition, there are 8,241 family households with children under 18 years of age in Clinton County. While the practice-level work of our project was occurring, a simultaneous community campaign aimed to increase awareness and engagement among adolescents and parents. CCHD's community campaign distributed lighthearted and engaging messages urging young adults to take charge of their health, including scheduling their annual wellness visit. In total, 34 messages were shared with the public via Facebook, Twitter and Instagram and viewed over 12,650 times. A blog featured on the topic garnered over 1,450 views. Messages were also disseminated through a series of Public Service Announcements (PSAs) airing on local radio stations and made available to community partners and medical practices, through a partnership with the SUNY Plattsburgh Communications Department.

In the past, our agency and the ACO would have worked on separate quality improvement projects with medical providers, with no coordinated community campaign. While studies have found that patients who are more activated have better health outcomes and care experiences, patient education has historically occurred at the patient/ provider level only, with no coordinated messaging across the community. For this project, we coordinated all efforts. Everyone involved worked toward the same goal with the same approach, and consistent messaging was present across the community. We utilized strengths and skills of our ACO and CCHD to increase the impact of individual efforts.

This project was supported by many evidence-based practices. Integration of public health with primary care and accountable care organizations has been cited in published literature by key influential entities, including the American Academy of Family Physicians and the Institute of Medicine.1,2 The public health detailing approach has also been shown to be effective in influencing changes in clinical practice behavior.3 The pilot project focus, the transition from pediatric to adult health care, was guided by a clinical report by the Transitions Clinical Report Authoring Group, comprised of representatives from the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP), as well as Got Transition®, a program of the National Alliance to Advance Adolescent Health.4,5 The Transitions Clinical Report provides practice-based quality improvement guidance on key elements of transition planning, transfer, and integration into adult care for all youth and young adults, including recommended health care transition processes and implementation strategies.4 In alignment with the Transitions Clinical Report, Got Transition® details the Six Core Elements of Health Care Transition and offers validated qualitative and quantitative assessment tools as well as a wealth of supporting materials.

The program outlines Six Core Elements that define the basic components of health care transition support, offers validated qualitative and quantitative assessment tools, and provides a wealth of supporting materials, including customizable tools for different practice settings.5

Reference list

  1. Integration of Primary Care and Public Health (Position Paper). AAFP Home. http://www.aafp.org/about/policies/all/integprimarycareandpublichealth.html. Published October 20, 2015. Accessed December 13, 2019.
  2. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, D.C.: The National Academies Press; 2012.
  3. Dresser MG, Short L, Wedemeyer L, et al. Public Health Detailing of Primary Care Providers: New York City's Experience, 2003–2010. American Journal of Public Health. 2012;102(S3). doi:10.2105/ajph.2011.300622.
  4. White PH, Cooley WC; Transitions Clinical Report Authoring Group; American Academy of Pediatrics; American Academy of Family Physicians; American College of Physicians. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics. 2018;142(5):e20182587. Pediatrics. 2019;143(2). doi:10.1542/peds.2018-3610.
  5. Got Transition®. GotTransition.org. https://www.gottransition.org/index.cfm. Accessed December 13, 2019.

The goal of the project was to connect public health, the regional accountable care organization, and local primary care providers in an effort aimed at coordinating practice-level quality improvement (QI) projects with a community-based education campaign intended to improve practice performance while simultaneously increasing patient awareness of their responsibilities. In doing this we sought to leverage the skills and experience of each entity in a coordinated, synergistic approach. There was an intent to eliminate duplication of effort and competition among the partners, especially for health care provider time and attention to identified issues. There was also intent to reduce, if not eliminate, mixed and competing messaging related to the chosen health care metric.

CCHD has long served as the county's chief health strategist, convening partners from all sectors, providing the traditional public health services of a local public health department but also leading the local public health system in policy, systems and environmental changes (PSE) for well over a decade. Well established, existing relationships with health stakeholders across the area affords CCHD access to residents through a variety of programs and opportunities offered by partners. In addition, the agency's multidisciplinary staff enhances its ability to implement complex projects that necessitate health knowledge, political savvy, promotional skill and fiscal responsibility. CCHD served as lead coordinator for this pilot project, offering its partner facilitation and public health detailing skills, the ability to reach the community at large, and experience in crafting messages to the partnership. CCHD staff dedicated to the project managed practice specific projects (coordinating visits and routine check-ins with practices, assisting practices in overcoming obstacles, convening partners, etc.), maintained awareness among partners, completed evaluation activities and have taken a lead role in disseminating project results and outcomes, among other activities. In total the project period lasted 10 months, from November 2018 to September 2019.

To apply this approach, CCHD and the Adirondacks ACO convened in mid-November 2018 and considered a number of current population health issues and potential topics. The pediatric-to-adult health care transition was selected as the pilot-project topic, based on metrics identified by the ACO as needing improvement; specifically, attendance of well visits by persons 7-11 years, 12-19 years, and 20-44 years of age. Once the topic was identified, CCHD and the ACO worked together to develop project objectives, a timeline, and to identify evidence-based resources available for use in the project. Got Transition® and the Center for Health Care Transition Improvement, a cooperative agreement between the Maternal and Child Health Bureau and The National Alliance to Advance Adolescent Health, was identified as a key resource for this project. The program outlines Six Core Elements of Health Care Transition that define the basic components of health care transition support, offers validated qualitative and quantitative assessment tools, and provides a wealth of supporting materials.

Project process objectives included: completing pediatric to adult health care transition QI projects at 100% of targeted health provider practices; progress in meeting the Six Core Elements of Health Care Transition demonstrated by at least 80% of targeted practices; participation in the community education campaign by 100% of Clinton County school districts; sharing of community campaign messages through 90% of targeted partner organizations social media platforms.  Project outcome objectives included: increasing compliance with the wellness visit by 5% across all payers; and wellness visit compliance reaching the 90th percentile for all payers.

In December 2018, CCHD and the ACO shared an overview of the initiative, including timeline and project objectives, with local medical providers at a recurring Pediatric Initiative Meeting; pediatric, family, and adult providers, medical staff and school nurses were invited to attend. Eleven medical practices participating with the ACO were identified as target sites for our pilot project, including 3 pediatric practices, 5 adult practices, and 3 family practices. During the months of January and February 2019, CCHD and the ACO completed a 15 minute staff in-service with each of the eleven targeted practices, at which time practices were asked to identify a practice champion team lead and complete baseline assessments. Once completed, ACO staff collected these baseline assessments during their regularly scheduled visits.

During February to mid-March 2019 the ACO and CCHD reviewed baseline assessments and identified potential QI projects and available resources for each practice. Of the 11 medical practices approached, 8 chose to participate; 2 pediatric practices, 3 adult practices, and 3 family practices. At the end of March 2019, participating providers were invited to reconvene at a Pediatric Initiative Meeting to discuss baseline assessments as a health care community, and identify potential barriers to project implementation. In addition, providers were asked what key messages adolescents and their parents in our community were lacking. From March to May 2019, 1:1 meetings were held with each practice champion and in-house stakeholders, as practice-specific projects were identified and implemented. CCHD and the ACO worked with practices to integrate the Six Core Elements in a way that supported each practice's own workflow and practice needs. For meetings, CCHD and ACO staff coordinated schedules so that at least one representative from each agency was present at all meetings with practices. Throughout the project period, ongoing technical assistance was provided to practices. CCHD and the ACO communicated frequently with each other during this period, primarily by email and telephone, as well as in-person before and after meetings with practices.

As practice-level QI projects were underway, CCHD staff developed a community campaign, highlighting key messages identified by providers and utilizing resources from Got Transition®. CCHD and the ACO recognized that beyond establishing policies and implementing best practices at the practice-level, the initiative required that patients, including parents and adolescents, be informed and understand their role in taking charge of their health. A blog and engaging social media messages were created by CCHD and shared with the public via Facebook, Twitter and Instagram. CCHD utilized existing relationships and contact information with school nurses at all middle and high schools in Clinton County to seek their participation in the project, primarily through the sharing of campaign messages with their students via social media. CCHD also collaborated with the Communications Department at the State University of New York (SUNY) at Plattsburgh, who developed a series of Public Service Announcements (PSAs) for the project. Staff presented the project to students mid-April 2019, and just over one month later, received 8 finalized carefully curated quality PSAs, at no cost. These PSAs aired on local radio stations through in-kind time, and were made available to community partners and medical practices. Lastly, CCHD created individualized campaign materials for medical practices as requested, such as postcards reminding young adult patients to schedule their annual well visit.

Practice-level QI projects were completed between May- June 2019, and qualitative and quantitative post assessments were collected from practices through August 2019. In September 2019, CCHD and the ACO formally met to discuss project successes, barriers and lessons learned. Since project completion, this information has been shared with a number of groups, including with health care providers at a Pediatric Initiative Meeting in late September 2019, with all Clinton County school nurses at the annual School Nurse Professionals Meeting hosted by CCHD each fall and with the ACO's regional practice transformation workgroup in December.

There were minimal costs associated with this project. The CCHD used three core staff to collaborate with the ACO; recruit and complete staff in-services and 1:1 meetings with practice champions; provide ongoing technical assistance to practices; present periodic project updates to key stakeholders; develop and implement the associated community campaign; and share project outcomes to key local and regional stakeholders. There were also minimal costs associated with printing and developing practice-specific guidance materials. Overall the biggest commitment was time, not materials. An estimated total of approximately 180 hours of staff time were devoted to this project over a 10 month timeframe. Position responsibilities for all involved staff include community partner engagement, education of local provider practices, contributing to sustainable and effective health system change work and disseminating health messages to the community. Therefore, CCHD fully supported the investment of staff time into this project and if such time was not dedicated to this collaborative initiative, said time would have been devoted to other similar but less collective efforts.  

CCHD developed a full evaluation plan for this collaborative initiative prior to implementation.  The plan included a number of process measures and multiple, longer term, outcome objectives.  This was done intentionally to allow collaboration successes to be captured and shared relatively early on, while also capturing actual impact to the target health measure and local health system, data which will, admittedly, have a delayed availability. CCHD was responsible for determining results of the three process measures, including distributing, collecting and analyzing any evaluation tools utilized as part of the evaluation plan. The regional ACO is responsible for extracting the data related to the two outcome measures.   

Process Measure 1: 100% of targeted health provider practices will have completed a pediatric to adult health care transition QI project by July 1, 2019.

11 pediatric and adult primary care practices in Clinton County were targeted. The practices were chosen based on practice involvement with the Adirondacks ACO and Adirondacks ACO data. The data was collected from insurance data claims. Each office was recruited by identifying key contacts in each practice based on the current relationships with the Adirondacks ACO. Adirondacks ACO reached out to specific office managers to set up brief 15 minute in-services with staff members where CCHD introduced the project.  Prior to the individual staff meetings the CCHD presented at the pediatric initiative meeting which included a broader audience of pediatric providers, adult primary care providers, and school nurses. Of the offices targeted, 10/11 accepted introductory visits and 8/11 (73%) participated in the pediatric to adult health care transition QI project. Commitment to other projects, and time constraints, were some of the most commons barriers offered that prevented practices from participating.

Process Measure 2:  80% of targeted practices will demonstrate progress in meeting Got Transition's Six Core Elements of Health Care Transition by July 1, 2019.

8/11 practices completed and submitted two validated pre and post-assessment evaluations developed by Got Transition. One tool represented a qualitative self-assessment that allowed the practices to determine the level of health care transition currently provided by their practice.  The second tool was an objective scoring tool that allowed a practice to assess progress in implementing Got Transition's Six Core Elements of Health Care Transition.

Got Transition provides tool tailored to practice type (pediatric, family, and adult). While all practices completed both tools pre and post intervention, referenced scores relate to the outcomes of the objective scoring tool.  The maximum number of points a practice could obtain in regards to implementation of the Six Core Elements, young adult engagement, and dissemination was 100. The average pre-assessment score for all 8 offices was 12.1.

After reviewing the pre-assessment data the CCHD and the Adirondacks ACO completed 1:1 meetings with the identified project champions and key stakeholders and pinpointed changes that could be implemented within the office to get them closer to the recommended evidence based transition process. Based on planned projects, CCHD anticipated an average score increase of approximately20 points, if practices were successful in completing their projects. Of the practices who participated, there was an average score increase of 22 points.  Among those practices who made significant system/process changes, there was an average score increase of 43.5 points. Sixty-three percent of the health care offices that participated had implemented practices to help youth and young adults manage their own health care and use health services.

Process Measure 3: 90% of targeted partner organizations will share community campaign messages through their own social media platforms by July 1, 2019.

At the same time of the practice level QI projects, a community campaign was launched to increase awareness among adolescents and parents of their responsibilities. 14 social media messages were created and shared 34 times across 3 different platforms (Facebook, Instagram, and Twitter). The messages were viewed over 12,600 times. A blog was also created on CCHD's website and was viewed 1,479 times. CCHD also worked with the SUNY Plattsburgh Communications Department and produced 8 PSAs that were distributed to 14 regional radio stations. One PSA was selected as a finalist in Best Public Service Announcement” category at the 2019 College Broadcasters, Inc. National Student Production Awards competition. While CCHD continues to work with partners to share and retweet related messages, to date 100% of partners we have connected with have been receptive in sharing messages.  Admittedly, only a few partners have been called upon as use of our own platforms and disseminating approaches have been successful. In retrospect, a goal centered on message reach will ease tracking and provide a more immediate, meaningful measure.  

Outcome Measure 1: There will be a 5% increase in compliance with the wellness visit across all payers by December 1, 2019.  Health system data is pending at time of submission.

The Clinton County Health Department along with Adirondacks ACO looked at health system data to determine longer term health system target measures. In reviewing Clinton County insurance data claims from all payers (public and private), only 61.93 percent of adolescents 12-24 years of age are attending their annual well care visits and only 69.4 percent respectively. The most recent data from www.HealthyADK.org showed that in 2014 66.7 percent of adults aged 18-64 in Clinton County reported having visited a doctor for a routine checkup within the past year. This is below the NYS value of 70.9.The Adirondacks ACO also had information on each targeted health care provider practice on their health care transition process. None had a formal health care transition process, and very few had a health care transition policy. Those who did have a policy, needed to improve upon it in order to meet National Committee for Quality Assurance (NCQA) measures. This is not surprising, given that nationally, 86 percent of youth without special healthcare needs and 83 percent of youth with special healthcare needs are not meeting the national health care transition performance measures (2017-2018 National Survey of Children's Health). In New York State, 83.6% of adolescents without special health care needs and 82.2% of adolescents with special health care needs, ages 12-17 are not receiving services necessary for transition to adult health care (2017-2018 National Survey of Children's Health.)

Data related to the Outcome Measure 1 is anticipated being available by end of Quarter 1, 2020.  Initiative partners will evaluate a change in average across the system related to compliance with annual well care visits and will also evaluate each participating practice's average change pre/post intervention.

Outcome Measure 2: Compliance with the wellness visit will reach the 90th percentile for all payers by December 1, 2020. Health system data is pending at time of submission.

Data related to Outcome Measure 2 is not anticipated until end of Quarter 1, 2021. Even though it may take more time to determine if this pilot project improved system performance, shorter term measure signal gains were made on both the practice and community level. The Clinton County Health Department was able to assist with system changes at the practice level and leverage the capacity of public health to support patients in meeting their individual health responsibilities. This practice is being seen a viable model for the local community that will be can and will be used for future public health/ACO/primary care initiatives. Other communities may also find it a viable model for collective health system improvement initiatives.

Collaboration among all health system partners is essential for truly impacting population health and realizing lofty health system goals related to reducing costs and increasing quality of care.  This pilot project sought to do just that, and is an example of how all sectors of the health care system can work together through this period of unpreceded change.

This project required investment of time among all collaboration partners, however, it was not an investment of time beyond what all staff would have already devoted to similar work. Instead, staff time was redirected to this collective projective versus focused on partner specific projects. In addition, it was felt by all partners, 2019 was an ideal time to pilot the collaboration because completing practice based quality improvement projects became a mandate for participating ACO practices this past year. Therefore, again, it did not create additional work but actually brought additional resources to the table to assist practices in completing required work.

While CCHD and the ACO provided technical assistance and support to the provider practices throughout the QI project period, each practice was required to identify a project champion or team.  The champion served as a point of contact but also directly learned the process for leading QI projects within the practices, thereby contributing to the practices' capacity to continue to do this work, whether related to this metric or not.  While all of the practices continue to seek ways to improve the transition of patients from pediatric to adult health care, sustainability was a main factor of consideration in tailoring each individual practice's project.  While similar templates and resources were shared with all participating practices, support was geared towards addressing the identified issues and set goals of each practice.  Because of this focus, changes made within each practice are more sustainable.

There were a number of lessons learned through this process. Using health system data was vital to selecting a project and target measures to focus on. We have learned from previous experience that collecting and analyzing data is the first step in making change in the community. We have also learned that accessing health system data is not easy, and it is often challenging to interpret. This is not likely to change. In order for public health to sustain its efforts in improving the health of the community, it will require shared access to system data and analysis. By working with the Adirondacks ACO we were able to use shared data to work towards a common goal and affect change.

Identifying key contacts within an office is important when initiating a new project. Holding a brief, informative in-service with staff was important to establishing commitment from the practices, and identifying a project champion was key to maintaining contact and engagement of each practice. Tying-the quality improvement project to an NCQA requirement likely significantly supported participation. Offering assistance and resources to support this process was a major selling point for practices, especially for this pilot project.

We learned that shorter practice project periods are feasible and would likely be welcomed by practices. This project spanned over 6 months, which allowed space for competing priorities within the practice to arise. This made it challenging to maintain engagement with certain offices and most projects were relatively straightforward and could be accomplished within a much shorter time frame. CCHD anticipates shortening the project period next time and reducing the number of practices with projects in progress simultaneously. CCHD will instead run multiple project cycles to accommodate all participating practices and allowing a greater extent of personalization to the technical assistance offered.

Using validated evaluation tools allows for consistency in how progress is measured and for easy pre and post measurement. It also eliminated the need to create such tools. The data enabled us to determine where each practice was at in the transition process at the beginning of the project. This helped us to quickly guide offices on what part of the process they should focus their improvement projects on.  It also allowed us to provide nearly immediate feedback on the progress offices were making and successes they were realizing. This feedback was motivating for the partners to receive. Practices have been encouraged to continue to use the evaluation tools beyond the project period as they continue to hone their transition processes.

Due to the success of the social media campaign, CCHD is developing standards to define a social media campaign. This will assure consistency in the future and will allow us to clearly define actions that will be taken to partners. 

There were also a number of lessons learned in relation to partner collaboration. Having a strong, trusting relationship with the Adirondacks ACO allowed us to work together and build upon each other's strengths. The CCHD strengths were in public health detailing and leading collaborative efforts. CCHD also utilized its reach out into the community in a creative way, something the Adirondacks ACO did not have resources for or expertise in; this was a driving force behind forming this partnership. CCHD was also able to access and use Adirondacks ACO health system data, something the health department has done only on a very limited basis to this project.

Partnering with Adirondacks ACO allowed us to reduce the number of requests being made of local messages the provider offices by varying partners. Practices have limited time and resources to devote to projects beyond patient care and often display low engagement down because of these limiting factors. By approaching the offices collaboratively, the practices were more receptive and willing to work with us. 

Under Accountable Care Organizations (ACOs) healthcare providers have to think more expansively about population health and have to develop strategies to comprehensively address patients' health needs. This is new ground for many healthcare providers and assistance is likely to be welcomed. Regional ACOs have access to health system data and work closely with providers but often lack the resources and capacity to influence patient behaviors and disseminate messages.  Assistance in moving providers through QI work is also likely be welcomed.  Local health departments are well positioned to assist, if not lead, these kind of projects, thereby successfully identifying a role for local public health in health system transformation work.

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