Community Development Innovation Review
October 4, 2018
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Community Development and Accountable Communities for Health: New Opportunities for Mental Health Promotion
Historically, mental health treatment was limited to direct clinical services for individuals with mental health conditions. Although many appreciated the importance of upstream external factors to mental health, such as community conditions, addressing these factors was not seen as the role of health care. The health care sector did the best it could with the individual during clinical visits, and the rest was left to public health, social service providers, or even politics. For example, psychotherapy sessions could work through the effects of trauma, and psychotropic medications could ameliorate related distress; however, it was considered the duty of public officials and the role of criminal justice or child welfare systems to prevent trauma from occurring.
In recent years, the lines between what is considered mental health care and what is not have begun to blur. Part of this results from the overall increase in focus on social determinants of health across all of health care—which have particular importance for mental health, as this paper explores. Part of this also results from the rise of the “recovery model.” After a history of abuses, in addition to a general overreliance on institutionalization, a civil rights movement began to advance a recovery model of mental health treatment, which focused on ensuring that individuals with lived experience set their own goals for meaningful participation in community life and determined what they needed to get there. 1The recovery model did not carry with it the notion of “cure,” any more than community development activities result in a singularly defined “ideal” community, but rather was seen as a process of achieving wellness and reaching one’s potential. To progress in this process, health care must engage sectors beyond the clinic walls to ensure that the desired opportunities to participate in community life are accessible, and that individuals with mental health conditions are supported in pursuing them.
Despite the obvious parallel efforts in improving the lives of communities and individuals, the health care and community development sectors have not yet extensively engaged with each other in the emerging partnerships that seek to prevent mental health conditions or promote recovery as we understand the concept today. Health care has only begun to experiment with working across sectors, and health care‒community development partnerships offer the opportunity for a different and more transformative change than previous initiatives. The community development sector brings new ways to address social determinants of health and promote recovery by improving community conditions to create affordable housing, jobs, accessible recreation, retail outlets, and more robust social services, among countless other ways that public and private investments can be leveraged to produce change in communities. As a result, the community development sector could achieve profound gains in mental health, and with recent health care reform efforts, the opportunity for partnership is greater than ever.
This article explores how the community development and health care sectors can partner to improve mental health, using the specific example of the Accountable Health Communities Model. It focuses on how community development could help to address health-related social needs (HRSNs) and promote recovery by incorporating the research on mental health promotion and the expressed goals of individuals into the field’s existing activities, such as lending and service delivery.
Accountable Communities for Health: Community-Wide Approaches to Mental Health
Although there are many currents in the tide of health care reform, the movement from Accountable Care Organizations (ACOs) to Accountable Communities for Health may offer an inflection point in whole-community approaches to mental health, as well as offer a critical opportunity for partnership with community development.2 ACOs are groups of health care providers who take on financial risk for the costs of quality care of a population of individuals, with an opportunity for the providers to share in some of the savings they produce. ACOs began as a Medicare demonstration under the Affordable Care Act but have expanded across Medicaid and commercial health insurance.3 The movement toward ACOs also set off waves of other health care alternative payment models, as Medicare, Medicaid, and commercial insurance experimented with new ways of getting away from fee-for-service and toward pay based on value.4
The original ACO model is limited in its ability to promote sustained reforms. When an ACO is able to achieve certain quality benchmarks while reducing costs each year, the ACO can share in some of those annual savings. Although ACOs can make health care delivery more efficient, they do not necessarily maximize human health and decrease long-term costs. The ACO model disfavors interventions that take more than a single year to generate health care savings, or that improve health outcomes outside of narrow clinical quality measures. Many of the most impactful interventions in health, and especially mental health, require more than one year to show savings and change outcomes, and so further reform is needed beyond the ACO model.
The Accountable Communities for Health model has emerged to address some of these shortcomings.5 In this model, health care systems are positioned as a single stakeholder in a broader, more inclusive community health system developed to advance a shared vision for the community. In one specific version, the Accountable Health Community Model (AHCM), the federal government offers payments for health care providers to join with other community organizations in a collective impact arrangement (see Figure 1).6 In an AHCM, a community integrator or “bridge organization”—a public or private entity acting as a neutral community convener—brings together both the health and non‒health care stakeholders to identify community needs, set a shared vision of success, and coordinate to ensure continuous progress toward the goals. Health care providers in the AHCM screen for HRSNs—also known as social determinants of health, such as food, housing, utilities, transportation, and intimate partner violence—and the integrator or backbone makes connections to all sectors that can address the needs identified. Although the movement toward Accountable Communities for Health is still emerging and the details of the payment and delivery models are still being defined, AHCMs offer a good case study for understanding how community development as a sector could help drive the further development of healthy communities, with specific implications for the mental health of populations.
In the collective impact arrangement of the AHCMs, the community development sector plays two critical roles in improving population health, specifically mental health: (1) leveraging funds to ensure that the HRSNs of the community are met; and (2) intentionally investing in holistic, community-driven approaches to confer mental health benefits across the population.
The Connection Between Health-Related Social Needs (HRSNs) and Mental Health
AHCMs currently screen for a battery of HRSNs, which include housing instability, food insecurity, transportation problems, utility help needs, interpersonal safety, financial strain, employment, family and community support, education, physical activity, and disabilities.6 Each of the HRSNs have independent effects on mental health across a population. They may affect the risk of developing a new mental health condition or developing a more challenging prognosis for an existing mental health condition. The HSRNs also have implications for the risks of children in families, including the likelihood of developing mental health conditions and the likelihood of having access to effective services when needs arise.
Many of the HRSNs are related to financial strain, which directly contributes to mental health risk. It also makes accessing treatment more challenging. Studies have found, for example, that financial strain is associated with a greater likelihood of reporting mental health problems, independent of the experience of any current hardship8 or the specific source of the economic insecurity.9 The financial strain of parents also impacts the mental health of their children. The cumulative time spent in poverty in early childhood predicts mental health as a young adult—principally due to the increased risk of exposure to stressors and adverse events. On the converse, cash transfers to individuals or families experiencing financial strain may improve mental health and decrease the likelihood of developing mental health conditions in certain populations.11
Specific consequences of financial strain can also pose their own risks. For example, housing insecurity and experiencing homelessness exposes individuals and families to new stressors and adverse events that increase the likelihood of developing or exacerbating a mental health condition.12, 13 On the other hand, secure access to high-quality housing is associated with improved mental health for adults14 and children,15 and even some improvements to housing can measurably enhance mental health.16 Similarly, food insecurity is demonstrated to negatively impact the mental health of adults17 and their children.18 This is partly from financial strain, but also because of the impact of food insecurity on diet and nutrition.19 The nutrient quality of the food can influence the mental health of adults and the developing brains of children, and research has found a direct relationship between diet quality and mental health in children and adolescents.20
Outside of their contributions to financial stability, employment and education as HRSNs can also promote or undermine mental health for both adults and their children. Employment and education offer a range of benefits: potentially meaningful social roles, opportunities for social engagement and connection, structured time, and a path to build self-efficacy, identity, and a sense of value—all of which underlie mental health and development.21 Family and community support offer fewer formal structures for similar supports with related risks for adults and children. Women’s social isolation, for example, is associated with maternal depression and also mental health challenges in their children.22, 23
Leveraging Funding to Ensure Community Needs Are Met
The ACHM’s focus on these HRSNs creates profound new opportunities to improve population mental health. However, in screening for these HRSNs, the AHCM model assumes there will be a vibrant third sector in place to meet the needs identified, especially if the right stakeholders are at the table. But, for example, what if a community does not have that third sector to provide adequate supported housing, or does not have organizations devoted to addressing intimate partner violence? In some cases, there may be federal, state, or local funding available for services, but no community organization equipped to provide them. In other cases, there may be no pre-existing funding stream, although potential long-term savings (as explored further below) or political will generated by the AHCM may build interest in creating new funding streams. Although these funds may cover ongoing operating costs, startup capital or other kinds of financing may be needed for a new organization or a division of an existing organization to be able to launch and begin addressing HRSNs. These are precisely the kinds of problems the community development sector solves.
Notably, many of the effective interventions for preventing and treating mental health conditions offer substantial long-term returns on investment to state and local agencies. Effective treatment or prevention can result in less health care utilization, less grade retention and special education use, less criminal and juvenile justice involvement, and higher tax revenue from increased labor productivity. Economic modeling from the Washington State Institute for Public Policy (WSIPP), a statutorily defined and nonpartisan entity that advises Washington State on costs and benefits for different social investments, concretely demonstrates these savings.24 For example, Communities That Care is an evidence-based system for helping communities effectively implement new interventions to prevent mental health and substance use conditions.25 The approach is grounded in community-driven data that use prevention science to promote healthy youth development and improve youth outcomes. WSIPP estimates that Communities That Care, a program that costs about $593 to implement in a community, eventually results in over $3,148 of total societal benefit, including $863 of taxpayer benefit over time from reductions in criminal justice costs, decreased health care costs, and increased tax revenue.26
Because of the savings associated with prevention and recovery in mental health, the entities on whose shoulders these mental health care costs often fall, such as counties and states, may be willing to structure tax credits or other outcomes-based financing approaches. Such upfront financing helps the community development sector in investing or making loans as part of AHCMs and similar models to address mental health. Other members in the collective impact of AHCMs can be valuable allies in pushing for this policy change to support sustained engagement of the community development sector.
Community Development Can Promote Mental Health Recovery
Addressing the HRSNs offers the opportunity not only to mitigate risk but also to promote more positive aspects of mental health recovery. This can improve individuals’ connectedness, hope and optimism about the future, identity, meaning in life, and empowerment—five constructs that flow from the concept of recovery and are often used as a framework under the acronym “CHIME.”27
Thoughtfully designed HRSN interventions can promote the CHIME constructs and profoundly impact the lives of individuals and the community as a whole. For example, parts of an intervention could be delivered by a peer, an individual who has been in a similar situation and now aids others in a staff role to ensure that they feel welcomed and supported, or could involve group-based components or assigned partners that foster opportunities to make new connections and build mutual support. Interventions could also emphasize social activities in the community that are likely to lead to new connections, such as a supported education program that helps individuals to pursue the social opportunities at their school in addition to academic success.
Similarly, interventions can promote hope by beginning with a goal-setting process grounded in an individual’s personal aspirations, while maintaining a consistent emphasis on growth over time. Transitioning away from identities like “patient” or even “program participant” and toward roles like “parent,” “employee,” and “friend” can help build positive identity. Part of this could also involve celebrating the identity of the community and the families that comprise it, in order to reinforce the positive associations with the identities that individuals are transitioning toward. To support meaning, interventions can create opportunities for individuals to help others, such as providing real-time support to peers or delivering services to future cohorts after the individuals “graduate.” As with hope, the interventions can also emphasize goal-setting that results in opportunities to help others, so that participants have a sense of making progress toward roles in the community that allow them to give back. Finally, interventions can empower individuals by reinforcing and increasing the control they have over decisions that affect their lives, including decisions about their community. For example, nutrition and exercise programs could focus on building skills and creating opportunities for individuals to achieve the goals they have set, rather than emphasizing rigid adherence to a specific regimen. Such programs could also include opportunities to participate in the design of policies that shape the food availability and walkability of their community.
The built environment also offers opportunities to promote CHIME. For example, thoughtful housing and community design can include elements that build connectedness and feelings of safety. Similarly, property management strategies could be revisited to become more empowering and contribute to positive identity. Although there is some empirical evidence about the impacts of specific layouts on aspects of mental health recovery and principles that can be applied from behavioral economics,28 community participation in housing and community design may be essential to ensuring that the layout of housing promotes the CHIME constructs. For example, the community development sector can engage potential future residents in design-thinking to propose a layout that would optimize their social health. Investments to meet other HRSNs similarly impact the overall layout of the community and can create additional opportunities to promote CHIME through the built environment.
Investing in Holistic, Community-Driven Approaches to Promote Mental Health
The AHCM is designed to support screening for discrete HRSNs, referrals to a community-based organization, and provision of a program or service to meet the need. However, HRSNs such as housing, employment, and transportation are not isolated needs—they are the interconnected product of social and economic forces interacting in the community. The community development sector has the opportunity to take a more holistic view of these interconnected needs and design a continuum of aligned strategies that provide unparalleled value to the AHCM.
Although the specifics will come from the needs, expertise, and creativity of the community development sector and the communities with which they partner, community-participatory and creative placemaking approaches may offer leads. In community-participatory approaches, community members—including those with mental health conditions or at risk for mental health conditions—engage in every step of the investing process in a way that is designed to promote the CHIME constructs, while producing investments that most effectively meet the needs of that particular community.29 These could be particularly fruitful in communities experiencing persistent problems of chronic homelessness and related criminal justice contacts. For CHIME, community-participatory development can allow structured opportunities for individuals to interact, promoting connectedness; the promise of a healthier community associated with the long-term investing can build hope and optimism about the future; being a valued member of a community-participatory team can help form positive identity; engagement in a common project that will benefit others can contribute to meaning in life; and sharing in decision-making authority over the future of a community can lead to empowerment.30 While community-participatory approaches may lead to slower turnarounds on investments, the independent effects on health and wellbeing offer immediate returns before the investment is even complete, and community insights are critical for innovations that ultimately improve outcomes.
Community-participatory approaches have particular salience in creative placemaking, where community members have the opportunity to express themselves in ways that give shape to their community as a whole, beyond any particular building or business. Tying creative placemaking investments to long-term theories of change that meet the HRSNs of the community and promote CHIME—both for the current residents and for those to come in the following years and even decades—can offer a more transformative approach to an AHCM. With leadership from the community development sector, AHCMs can evolve from a coordinated safety net to a collective impact arrangement that reflects the vision of the community and paves a path toward its future.
Accountable Communities for Health offer one way in which the community development sector can partner with health care to prevent mental health conditions and promote mental health recovery. In this approach, the community development sector can leverage funding to expand the reach of community-based organizations that seek to address the HRSNs of the population while supporting recovery. The community development sector can also focus resources to develop holistic, community-driven approaches that promote mental health. By partnering in such an arrangement as an Accountable Community for Health, the community development, health care, and other sectors can collectively offer a more transformative intervention strategy to advance population mental health.
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