Financing community partnerships for health equity: Findings and insights from cross‐sector professionals

Abstract

Objective

To enhance understanding of financial alignment challenges facing cross‐sector partnerships (CSPs) pursuing health equity and offer insights to guide research and practice.

Data Sources and Study Setting

We collected data through surveys and interviews with cross‐sector professionals in 16 states, 2020–2021.

Study Design

We surveyed 51 CSP leaders and received 26 responses. Following administration of the surveys to CSP leaders, we also conducted interviews with cross‐sector professionals. The data are analyzed descriptively, comparatively, and qualitatively using thematic analysis.

Data Collection/Extraction Methods

For quantitative survey data, we compare partnership responses, differentiating perceived levels of alignment among partnerships certified by the Pathways Community HUB Institute (PCHI), partnerships interested in certification, and partnerships without connection to the PCHI® Model of care coordination. For interviews, we engaged CSP professionals and those who fund their work. Two research team members took notes for interviews, which were combined and made available for review by those interviewed. Data were analyzed independently by two team members who met to integrate, identify, and finalize thematic findings.

Principal Findings

Our work supports previous findings that financing is a challenge for CSPs, while also suggesting that PCHI‐certified partnerships may perceive greater progress in financial alignment than others. We identify four major financial barriers: limited and competitive funding; state health service delivery structures; cultural and practice divides across healthcare, social service, and public health sectors; and needs for further evidence of cross‐sector service impacts on client health and costs. We also offer a continuum of measures of financial sustainability progress and identify key issues relating to financial incentivization/accountability.

Conclusion

Findings suggest a need for public policy reviews and improvements to aid CSPs in addressing financial alignment challenges. We also offer a measurement framework and ideas to guide research and practice on financial alignment, based on empirical data.

What is known on this topic

• Social determinants of health (SDOH) affects population health and must be addressed to improve health outcomes and enhance opportunities for reaching health equity.

• Cross‐sector partnerships (CSPs) pursuing health equity are being developed and implemented across the USA to address SDOH, and existing work suggests that they are facing challenges with finances and accountability.

• Evidence on CSP impacts is mixed, but there is some evidence of positive impacts associated with CSPs that maintain fidelity to the Pathways Community HUB Institute Model (PCHI®).

What this study adds

• Confirms that sustainable financing and accountability are challenges for CSPs and suggests that certified Pathways Community HUB (PCH) leaders perceive greater financial alignment progress than do other CSP leaders, particularly in incentivizing accountable progress toward shared goals.

• Identifies barriers to CSP financial alignment, including funding availability, health service delivery structures, cultural and practice divides across service sectors, and uncertainties about CSP impacts on health outcomes and costs.

• Provides a continuum of measures to characterize CSP progress in initiating, supporting, establishing, expanding, and achieving sustainable financing.

1. INTRODUCTION

A growing body of evidence suggests that social determinants of health (SDOH) must be addressed to improve population health and enhance health equity for those facing challenging, often generational, socioeconomic circumstances. ¹ , ² , ³ , ⁴ Existing initiatives address a variety of risks (e.g., lack of housing, medical home, and employment) that can affect health outcomes. ⁵ , ⁶ Many of these initiatives also involve collaborations across service sectors (healthcare, public health, and social service). ⁷ , ⁸ , ⁹ A key challenge facing cross‐sector partnerships (CSPs) is to sustainably fund them while holding participating service providers accountable for results. ⁵ , ⁷ , ⁸ This article seeks to improve our understanding of this challenge and ways that CSPs are addressing it.

While CSPs hold promise for meeting the needs of at‐risk populations and take multiple forms, ¹⁰ , ¹¹ evidence of their impacts on health outcomes is sparse or mixed. ¹² , ¹³ , ¹⁴ There have been efforts to inventory and build knowledge about large numbers of CSPs, ⁶ , ⁸ , ¹⁵ , ¹⁶ but we know of no effort to inventory and characterize them comprehensively across the USA. Still, we do know that CSPs vary widely, and at least some appear to be yielding positive health outcomes. ⁹ , ¹⁷ , ¹⁸ CSPs may be led by entities inside or outside of the healthcare sector. Their target audiences and objectives also vary and include reducing hospital readmissions; ¹³ addressing specific SDOH needs such as housing, nutrition, and/or transportation; ⁶ and reducing poor birth outcomes for under‐resourced women. ¹⁷ , ¹⁸

Landers and colleagues have advanced a framework for studying the alignment of cross‐sector organizational efforts to provide “everyone in the United States a fair and just opportunity for health and well‐being.” ¹¹ It suggests that to optimize their work, CSPs must work toward achieving four core areas of alignment (CAAs): a common purpose, including a shared vision and priorities; shared data for viewing and measuring progress; robust governance structures that include local representation and voice in guiding the work and strong decision‐making processes; and long‐term sustainable funding that incentivizes and holds partners accountable for progress. CSPs achieve financial alignment when financial sustainability and effective systems for ensuring incentivization and accountability are in place (hereafter referred to as incentivization/accountability).

Landers and colleagues suggest that CSPs may address individual‐, organizational‐, and system‐level changes as they pursue enhanced health and well‐being for the communities they serve. One CSP model that operates at all three of these levels is the community‐led Pathways Community HUB Institute Model of care coordination (PCHI® Model), administered by the Pathways Community HUB Institute (PCHI). The PCHI Model necessitates relationships across typically siloed sectors, including health, social services, government, criminal justice, funding, and insurance. Under this model, an independent nonprofit entity, a Pathways Community HUB (PCH), coordinates a network of community‐based organizations (CBOs) that hire community health workers (CHWs) to enroll and support participants. CHWs live in the same communities as the participants they serve and build trusting relationships with them through home visiting. CHWs identify all individually modifiable risk factors that the participant or household may be experiencing. ¹⁹ The PCH negotiates payer contracts on behalf of the network, receives payment from payers based on the CHW engagements and the achievement of outcomes (mitigating risks), and distributes funds to the CBOs proportionate to the outcomes and engagements that their CHWs have achieved. This payment structure provides incentives to support high‐needs participants. Furthermore, all identified risks and their mitigations are recorded, codified, and tracked, allowing for a shared system‐wide framework for reporting and measuring impact. Multiple studies of PCHs have documented positive impacts for under‐resourced populations, including enhanced utilization of prenatal care, ¹⁹ verified reduction of chronic disease risks, ²⁰ and improved birth outcomes. ¹⁷ , ¹⁸ , ²¹

Studies suggest that financing, incentivizing, and ensuring provider accountability for effective services are among the biggest challenges for CSPs. ⁵ , ⁷ , ⁸ However, research on these financial challenges is not well developed. Based on insights from cross‐sector service professionals across the USA, we begin to address this knowledge gap in this article. We do so by investigating three research questions (RQs): (RQ1) To what degree do CSP leaders believe that financial alignment presents challenges to their cross‐sector work? (RQ2) What are major barriers to financial alignment and how are CSPs addressing them? (RQ3) How can we measure and achieve progress toward financial sustainability and establish systems for holding service providers accountable for results?

2. METHODS

Using surveys, interviews, and published work on their use, ²² we gathered information on 26 CSPs aimed at improving health equity and their financial circumstances in 2020–2021. We collected survey data first and used what we learned from it to inform who we sought to interview and what we sought to learn from them. Our interviews focused particularly on two CSP networks, which our survey data revealed had made significant progress in their financial alignment efforts. Interviews were also conducted with CSP funders and partners who were not tied to those two networks. Data collection protocols and tools were reviewed and approved by Kent State University's Institutional Review Board. In addition, significant portions of the data collected and findings based on them have been reported elsewhere. ⁷ , ²³

2.1. Participants

We obtained lists of potential CSPs to survey from the national Care Coordination Learning Network (CCLN) and the Georgia Health Policy Center (GHPC). CCLN seeks to enable information sharing on multi‐sector community care efforts—many (but not all) of which are based on the PCHI Model. From GHPC, which had been working to collect information on CSP efforts nationally, we obtained a list of CSPs not tied to the PCHI Model. From these sources, we identified 51 partnerships pursuing health equity, distributed surveys to them between March 2020 and September 2021, and received responses from 26 partnerships across 16 states, a 51% response rate.

2.2. Data collection

2.2.1. Survey

We invited partnership leaders to self‐complete an online self‐administered survey, which asked them to rate the extent to which organizations in their partnerships were aligned across CAAs on a 5‐point Likert scale (5 indicating “very high” and 1 “very low” alignment). The survey also included open‐ended questions eliciting CSP leader responses on barriers to financial alignment, steps taken to address those barriers, the successes their CSPs experienced in taking those steps, and key milestones of financial alignment progress. Appendix A includes questions posed in these areas.

2.2.2. Interviews

We conducted interviews with professionals who deliver and finance cross‐sector services for at‐risk populations to clarify survey responses and better understand varying practices and perspectives regarding financial sustainability and incentivization/accountability. Most interviews were conducted with stakeholders from partnerships that responded to our initial survey, based on CSP leader survey responses suggesting their CSPs had made notable financial alignment progress. These networks included a certified PCH‐led network in Wisconsin and a CSP in California that did not use the PCHI Model. We also conducted follow‐up interviews with funders, organizational partners, and CSP leaders who were not connected to the Wisconsin and California CSPs. Interviews were conducted by phone and/or using the online meeting platforms, Zoom and Microsoft (MS) Teams. The interviews were based on scripts that varied across the CSPs surveyed (depending on their survey responses) and roles of those interviewed (CSP leaders, funders, and organizational partners). Two research team members participated in each interview and combined their notes, which were then provided to the interviewees for review and comment. In total, we conducted 26 interviews with professionals involved in financing and/or delivering CSP services, including six CSP leaders who were also surveyed.

2.3. Data analysis

To analyze our data, we used a methodological approach that integrated quantitative data from the survey and narrative insights shared by respondents in their survey and interview responses. This approach enabled us to quantify indicators of financial alignment progress across categories of CSPs, identify barriers to this progress, and understand key steps and ideas underlying it.

We compared the 26 CSP survey responses to assess the extent to which CSP leaders perceive that financial alignment challenged them compared to the other CAAs. Survey respondents were categorized into three groups: certified PCHs, CSPs that were pursuing PCHI Model Certification and/or using portions of the PCHI Model, and CSPs using partnership approaches other than the PCHI Model. We used descriptive statistics to characterize the distributions of the survey responses, and we present them in tabular format see Table 1. Because our sample size was relatively small and contained cells with less than five observed values, we assessed associations between CSP types and CAA responses using Fisher's exact tests.

TABLE 1.

Perceptions of alignment around purpose, data and measurement, finances, and governance.

Core alignment area (CAA)	CAA measure	# (%) of cross‐sector network coordinators reporting high or very high levels of alignment, by cross‐sector alignment approach
		Certified PCHs (n = 9)	CSPs interested in PCHI certification (n = 8)	Other cross‐sector partnerships (n = 9)	Total (n = 26)
Purposes	Partners share vision	8/9 (89%)	6/8 (75%)	8/9 (89%)	22/26 (85%)
	Partners operate according to shared priority outcomes	8/9 (89%)	4/8 (50%)	5/9 (56%)	17/26 (65%)
Data and measurement	Partners use (i.e., take actions based on) shared data and measurement system	5/9 (56%)	3/8 (38%)	2/9 (22%)	10/26 (38%)
Finances	Network produces sustainable financing	3/9 (33%)	1/8 (13%)	1/9 (11%)	5/26 (19%)
	Financial system has in place incentives and accountability for results consistent with vision and priorities***	8/9 (89%)	2/8 (25%)	2/9 (22%)	12/26 (46%)
Governance	Governance engages those involved in cross‐sector efforts to participate***	7/9 (78%)	6/8 (75%)	2/9 (22%)	15/26 (58%)
	Governance guides strong decision‐making structures and processes	5/9 (56%)	4/8 (50%)	3/9 (33%)	12/26 (46%)

Abbreviations: CSPs, cross‐sector partnerships; PCHI: Pathways Community HUB Institute; PCHs, Pathways Community HUBs.

^***Statistically significant difference across CSP types at the 0.05 level, based on Fisher's exact tests. The stars indicating statistical significance are placed on the rows for which Fisher's exact tests yielded statistically significant differences across CSP types (for financial alignment for incentivization/accountability, two‐tailed p‐value was 0.003; for engagement in governance, two‐tailed p‐value was 0.014).

Based on narrative responses to survey questions on barriers, steps taken to address them, the perceived success of the steps taken, and follow‐up interview discussions in these areas, we identified key barriers to financial alignment, the impacts of these barriers, and ways that CSPs were working to address them. Members of our research team condensed narrative findings in these areas, and we present them in tabular form see Table 2. We also use selected quotations drawn from the survey and interviews to illustrate our findings.

TABLE 2.

Barriers to financial alignment and strategies to address them.

	Barrier	Description	Impact of barrier	Key responses/examples (state)
Barriers for financial alignment	1. Limitations on funding availability	Need for sustainable funding is great; the availability of funds is limited	Creates competition instead of cooperation and collaboration	Competition for grants impacts partnerships (OR) Grants fund limited numbers of grantees, making it difficult for grassroots organizations (WI) Differing funding requirements can inhibit service integration (CO)
	Strategies	Relationship building, including with key state policymakers, key community groups, healthcare providers, health plans, and managed care organizations (MCOs). Seeking more diverse funding sources (including reimbursement‐based funding).
	2. State health service delivery structures	Need for state policy reforms to enable stronger financial support for cross‐sector service partnerships	Inhibits cross‐sector partnerships and long‐term financial stability for provision of cross‐sector services	Need state‐level systems for coordinating and delivering funds (WI) State should fund SDOH mitigation more fully (CA) State does not cover outcome‐based reimbursement for their organization's services (NM) Reimbursement does not cover full cost of services (OH/MI)
	Strategies	Pursue policy‐based solutions from state legislators and agencies such as state grants, expanding the range of covered services, funding CHWs, cross‐agency coordination mechanisms, and paying for services and outcomes, not just referrals. Building relationships for needed state policy changes.
	3. Interorganizational divides in cultures, attitudes, and practices	Needs for healthcare providers/payers to learn value and importance of non‐medical service professionals and for public health and social service agencies to learn systems for reimbursement by healthcare payers more fully.	Non‐medical professionals might not get reimbursed for services, may be underutilized, or improperly assigned to health services. Healthcare providers and payers may lose confidence in non‐medical services.	Healthcare systems may bring CHWs into practice rather than have them work in community to address SDOHs (WI) Healthcare payers want social service/public health agencies to properly document services for healthcare reimbursement (OH) Recognize and support the (varied) work of CHWs (TX/PA)
	Strategies	Healthcare funders and social service/public health stakeholders must learn more about each other's perspectives and requirements. Demonstrate the value of CHWs, the organizations that employ them, and the variable ways they may be used productively. Demonstrate the value of social and public health services and the organizations that provide them.
	4. Uncertainty on the degree to which cross‐sector services improve health outcomes and reduce costs	Evidence and understandings of positive impacts associated with addressing SDOHs could be more fully developed	It is challenging to show a positive return on investment (ROI) and to achieve sustainable accountable financing without doing so	Healthcare systems and payers do not share information on health outcomes tied to the social/public health services provided (CA) General need to improve data and measurement systems and to invest in efforts to support ROI analyses
	Strategies	Work to build and publicize evidence on CSP impacts on ROI, costs, and the health and well‐being of at‐risk individuals and populations. Enable stronger advocacy and communications about the impacts they are achieving.

Abbreviations: CA, California; CO, Colorado; MI, Michigan; NM, New Mexico; OH, Ohio; OR, Oregon; PA, Pennsylvania; TX, Texas; WI, Wisconsin.

CHW, community health worker; CSP, cross‐sector partnership; SDOH, social determinants of health.

Drawing on CSP responses to survey questions about milestones for financial alignment progress, overcoming financial alignment barriers, and follow‐up interview discussions in these areas, we also identified common steps that CSPs were experiencing as they worked to enhance their financial sustainability. We analyzed these narrative data using a thematic approach. Two research team members independently developed notes from the narrative data and then met to identify and resolve discrepancies through discussion and consensus. Based on these data, we defined five common stages of progress in enhancing the financial sustainability of CSPs and identified measures of their accomplishment. We present these five stages as a CSP Financial Sustainability Measurement Continuum see Table 3. The narrative survey and interview responses we received on incentivization/accountability were not as deep and consistent as those for financial sustainability, so we were not able to develop a similar continuum of progress stages for this element of financial alignment. Rather, we share ideas presented by respondents on factors to consider in assessing and making progress on financial incentivization/accountability.

TABLE 3.

Cross‐sector partnership Financial Sustainability Measurement Continuum: Descriptions of key stages and measures of their accomplishment.

	Stage/name	Description	Measure of accomplishment (for each stage)
Aligning for sustainability	1. Initiated	Cross‐sector stakeholders and organizations align purposes, demonstrate success, and obtain initial funding.	Initial funding in place, with documented cross‐sector community purpose.
	2. Building support	Funding support from multiple funders.	Multiple funding sources committed to supporting the cross‐sector initiative.
	3. Established	Reimbursement funding tied to services provided to under‐resourced participants.	At least one service‐based reimbursement funding agreement tied to client services in place.
	4. Growth and expansion	Reimbursement funding from at least one source sufficient to cover participant service costs.	Service‐based reimbursement agreement(s), which ties dollars to participant services at volume and/or fee levels sufficient to cover participant service costs.
	5. Sustainable	Reimbursement funding sufficient to support both participant service costs and fixed costs/investments over time.	Service‐based reimbursement agreement(s) in place, which are sufficient to cover both participant services and fixed costs over time.

3. RESULTS

To what degree do CSP leaders believe that financial alignment presents challenges to their cross‐sector work?

CSP leaders identified significant challenges to financial alignment—particularly in relation to financial sustainability. We also observed differences between leaders of partnerships that had achieved PCHI Model certification, those which were working toward it, and those who did not use the PCHI Model regarding the extent of alignment they perceived across the four CAAs.

Table 1 summarizes the survey responses. It suggests that producing sustainable financing is the most challenging CAA area for achieving alignment. Just 19% (5/26) of respondents indicate that the organizations comprising their network were highly or very highly aligned in relation to producing sustainable finances. Other challenging alignment areas were data and measurement (10/26 or 38%), the strength of decision‐making structures and processes (12/26 or 46%), and the use of finances to support incentivization and accountability (12/26 or 46%), respectively.

Table 1 also reveals differences in reported levels of financial alignment across types of CSPs. One‐third (33%) of certified PCHs reported high or very high levels of alignment around financial sustainability, which exceeds the levels reported by CSPs pursuing PCHI certification (13%) and CSPs not using the PCHI Model (11%). Furthermore, the certified PCHs indicated relatively high levels of perceived alignment around financial incentivization/accountability (8/9 or 89%) compared to CSPs that were pursuing PCHI certification (2/8 or 25%) and other CSPs not using the PCHI Model (2/9 or 22%). This latter difference was statistically significant (at the 0.05 significance level) based on the Fisher's exact test conducted.

Narrative survey and interview responses also highlight the value of the PCH Model in helping to foster progress toward financial sustainability and incentivization/accountability. One Director of a certified PCH, for example, indicated that “we have secured contracts with our 2 largest MCOs (Managed Care Organizations) in our market and are in process on contracts with 3 more.” They also indicated that the “Pathways HUB model is absolutely set up to” ensure that “financial arrangements incentivize and hold participants accountable for results consistent with (their) mission and priorities” (see question wording—Appendix A). A certified PCH Director in Michigan added, “We are only paid for outcomes … if there are no positive outcomes, we do not get paid. It is a strong incentive to highly perform.” While the relatively small size of our sample means one cannot draw strong conclusions from the Table 1 data and these comments, they do suggest that Directors of certified PCHs in our sample are perceiving greater progress toward financial alignment than other CSP leaders in our sample.

What are major barriers to financial alignment and how are CSPs addressing them?

In Table 2, we present four reported barriers to financial alignment. Below, we highlight key insights summarized in the table and describe ways that CSP leaders reported addressing these barriers.

1. Limitations on funding availability.

   CSP leaders consistently suggested that the success of their search(es) for funding was the key to their long‐term success. However, they also reported that achieving sustainable financing is challenging due to limited funding availability and strong competition. A CSP leader from Oregon said, “This is a world of zero sum competition…. It is a landscape of many problems and scarce resources.” A CSP leader from Michigan added that “…financial constraints and resources are the barriers … We agree on the needs, (the barrier) is trying to get funding to meet those needs.”

   Many partnerships also reported relying on grant funding as their main source of funding. The CSPs that have moved beyond sole reliance on grant funding often relied on reimbursement‐based funding, and they reported that it came from both Medicaid MCOs and commercial health plans. This source of funding is more stable than grants but also has limitations, including not being sufficient to cover the full cost of the services being reimbursed and being applied to too few clients to achieve economies of scale. A CSP leader from Ohio said that their “MCO contracts are narrow in who and how they pay for outcomes” and indicated that they “are not yet providing fully sustainable funding.” A CSP leader from California added that “(w)inning and sustaining contracts at sufficient volume with adequate payment” is a key barrier to their financial sustainability.

   Respondents also noted the impacts of this barrier to financial sustainability and identified strategies to address them. Competitive grants lead to greater competition for the limited funding, rather than cooperation and collaboration among agencies. Several strategies were offered by respondents to address this situation, many of which involved building relationships. Another strategy was to seek more and diverse funding sources, including coupling grants and reimbursement funding and expanding reimbursement‐based funding to new payers.

2. State health service delivery structures.

   Partnership leaders identified the need for policy reforms to enable stronger financial and programmatic support for CSPs in their states. A CSP leader in Michigan indicated that “…agencies are still siloed due to funding streams and contracts that dictate focus of their work to one priority outcome vs. all (whole person) priority outcomes.” CSP respondents also argued that state and national policy changes are needed for CSPs to achieve long‐term financial sustainability. They emphasized that changes in “legislation,” “Medicaid” coverage(s), state policies, and laws for Medicaid/Medicare reimbursement were necessary over the long term to enable continued cross‐sector service provision.

   Respondents also described their strategies for pursuing policy‐based solutions from state legislators and agencies. These included increasing state grant funding, obtaining service‐reimbursement‐based funding for CSP services, increasing funding levels for covered services, expanding the range of services reimbursed, targeting payments to align with desired outcomes, and ensuring sufficient volumes of clients and services to reach economies of scale for service delivery. Another concern was related to Medicaid payment systems that did not recognize billable services from CHWs, who play significant roles for multiple partnerships in our sample.

   Respondents also focused on building relationships and constituencies for needed policy changes at the state level. Among responding partnerships who were using and/or pursuing the PCHI Model, many discussed relationship building, networking, presenting to and working with policymakers, advocating, and other similar observations when asked how to overcome barriers to sustainable financing. By contrast, responses from partnerships not connected to the PCHI Model focused more on data systems and the need for reimbursement changes. However, members of one non‐PCHI CSP that had experienced significant funding success emphasized the importance of “learning players and systems…” and state policy changes which “…include social determinants of healthcare management as a benefit.”

3. Interorganizational divides in cultures, attitudes, and practice.

   A third barrier to financial alignment raised by multiple professionals relates to cultural, attitudinal, and practice divides between healthcare and social service organizations. CSP leaders suggested that there is a need for healthcare providers and payers to better understand the value and importance of non‐medical services and the CHWs and other professionals who provide them. A certified PCH director in Wisconsin suggested there “is a need for a mindset change in the world of clinical care, as (some) want to view CHWs as Medical Assistants and that is not their role. CHWs need to be in the community and be supported in that work. They will be more effective in producing investment returns and bringing in revenues if they pursue clients and get them plugged into health services.”

   Healthcare payers and providers expressed different concerns. They pointed to a need for social service organizations to understand and respond to client needs in ways that are consistent with healthcare practices. For example, one MCO payer in Ohio raised questions about the capacities of some social service providers and indicated that some of them have little “claims‐based” experience working with healthcare payers and lack familiarity with processes associated with reimbursement funding.

   Healthcare funders and social service stakeholders offered differing perspectives about addressing cultural, attitudinal, and practice barriers. One healthcare funder argued that social service and public health organizations comprising CSP networks need to work on building their billing and healthcare capacities and build trust and understandings across organizations that fund and deliver CSP services. Other respondents suggested that recognizing and supporting the work and value of CHWs and the organizations that utilize them would likely help healthcare providers and payers better understand the value of these kinds of professionals and the ways they can assist with patient care more effectively.

4. Uncertainty on the degree to which cross‐sector services improve health outcomes and reduce costs.

   SDOHs are now widely acknowledged to influence health, but evidence and understanding of positive impacts associated with addressing them could be more fully developed. ²⁴ , ²⁵ , ²⁶ By expanding knowledge regarding returns on investment (ROIs) associated with funding for services provided by CSPs, these partnerships and their payers could target their investments more effectively. More generally, efforts to build a more complete evidence based on the value of mitigating SDOH risks for under‐resourced populations may yield greater confidence in the value of cross‐sector services. While many (but not all) of the partnerships we consulted expressed confidence in the services they provide and the existence of evidence tying those services to enhanced health, ¹⁷ , ¹⁸ , ²¹ many of them also emphasized that they were working to build and publicize evidence concerning their impacts on health outcomes and costs. A CSP leader from New Hampshire indicated there is a need to build “a strong business case,” justifying investments in CSP services. A Michigan CSP leader agreed, suggesting that, “…return on investment studies are important in showing the value” of their CSP services.

How can we advance efforts to measure and achieve progress toward financial sustainability and establish systems for holding service providers accountable for results?

How can we measure progress in financial alignment for CSPs focused on serving under‐resourced populations? To what degree can we account for financial alignment around both sustainability and incentivization/accountability? These questions are difficult, but the data collected provide some guidance, particularly around sustainability. The responses we received on incentivization/accountability are less revealing, but do yield valuable insights, which we share below.

Some respondents pointed to the ratio of grant funding to reimbursement contracts as a measure of financial stability. These respondents referenced reimbursement contracts of varying kinds, including payments based on per member per month (PMPM) criteria, while others—typically those that are PCHI certified or pursuing certification—focused on payments that reimburse based on verified outcomes. Either way, respondents suggested that increasing the number of payers providing reimbursement contracts to fund CHWs and cross‐sector services is key to achieving financial sustainability.

In Table 3, we present a five‐stage framework for measuring CSP progress on financial alignment for sustainability. Stages 1 and 2 involve aligning community stakeholders and organizations around common purposes, demonstrating success, and obtaining funding. Potential measures of progress associated with these two stages include the presence of a unified purpose or vision among community stakeholders and funding from at least one source in stage 1 and from multiple sources in stage 2.

In stages 3 and 4 of the continuum shown in Table 3, CSPs are solidifying ongoing funding sources that reimburse them for client‐specific services, typically from healthcare payers. In these stages, CSPs are also building capabilities to track and bill for client‐specific services. Potential measures of progress include the presence of at least one client service‐based reimbursement funding contract (Stage 3) and progress in expanding funding by increasing the number of reimbursable clients, the number of reimbursement‐based contracts, and/or fee amounts for services to levels sufficient to pay for client‐specific costs (stage 4).

In stage 5, CSPs achieve longer‐term sustainable financing to support their services. Substantial portions of their funding come from reimbursement‐based contracts, which provide revenue sufficient to pay for the full range of services provided—including both client‐specific and ongoing fixed costs. Stage 5 was not reported to have been fully achieved by any of the partnerships in our sample; rather, it is portrayed here as an end goal in the CSP Financial Sustainability Measurement Continuum.

Viewed broadly, Table 3 provides a framework for assessing progress of CSP efforts to develop sustainable financing. However, based on information provided by the CSPs consulted, there may be conditions necessary for community partnerships to even reach stage 1 of the continuum. Some of those interviewed commented about the need for “advocacy,” both within the communities served and at higher levels of government where public health and healthcare funding policies are often established. At the community level, there were comments about the advocacy, education, and relationship‐building processes that are necessary to provide a foundation for the common purpose(s) and initial funding identified in stage 1. Respondents also described needs for education and trust‐building efforts to bridge cultural and practice divides across social services and healthcare sectors.

In addition, after CSPs are established (potentially with some initial funding), some respondents suggested that there is value in advocacy efforts at the state level, whereby CSPs combine efforts and form coalitions to foster greater state‐level support. Such advocacy directed at legislators and state agencies may be an iterative part of the process of building broader support for CSPs at the state level and may become more common as multiple partnerships within a particular state move from earlier to later stages in the CSP Financial Sustainability Measurement Continuum. As funding and support are secured and progress is reported, then returning to state policymakers to highlight these successes may help expand state support.

Unfortunately, the data collected on incentivization/accountability are not sufficiently cohesive to guide development of a measurement framework like the one presented in Table 3. To some degree, this is because the networks consulted were focusing primarily on achieving sustainable revenues, rather than on ensuring that revenues were used to incentivize and hold partners accountable to shared goals. Even so, respondents did propose measures to demonstrate progress in developing financial arrangements that incentivize and hold CSP service providers accountable for results. The PCHI Model was mentioned by PCH‐associated respondents as a framework designed to achieve incentivization/accountability. Other responses addressed measuring specific outcomes, such as health outcomes and estimated ROIs. Still other responses were more specific to individual partnerships, such as one partnership in California that mentioned bonuses provided to leaders of cross‐sector efforts that realize high levels of performance. Overall, there is still need for greater depth of thought on ways to incentivize and hold parties accountable for progress toward shared goals. The CSP professionals consulted offered ideas in this area, and some have foundations in PCHI certification requirements.

First, respondents noted that financial incentivization/accountability requires financial resources, so measuring alignment for incentivization/accountability requires financial empowerment through sustainable resource flows. One CSP funder commented on the value‐based structure of the PCH model but pointed out that money needs to be there to create the incentives. They envisioned a future “tipping point” on volume and impact that would aid both sustainability and incentivization/accountability. One prerequisite to effective incentivization/accountability may therefore be achieving sustainable flows of resources sufficient to incentivize and hold partners accountable for the results they achieve.

Second, measures of incentivization/accountability should address the magnitude to which payment arrangements incentivize and hold partnership members accountable for results. PCHI's Model certification requirements are illustrative in this regard. They require that 50% of all payments to certified PCHs be based on outcomes tied to the Model's nationally standardized Pathways. They also require that certified partnerships have at least two outcome‐based contracts producing these payments.

Third, measures of incentivization/accountability should address how payments made to the partnership are distributed among the organizations and individuals contributing to its work. PCHI Model certification requirements suggest that partnerships distribute revenues among their partners based on their respective contributions to participant‐specific outcomes. A certified PCH director in Wisconsin said they reimburse their partners based on the outcomes they achieve and also recommended that those partners use a “60/40 (agency/CHW) split to incentivize the CHWs” to achieve needed risk reductions.

Finally, financial alignment measures for incentivization/accountability should recognize the degree of consistency between payment structures and the partnership's vision and priorities. For CSPs focused on at‐risk populations, this means that progress relating to incentivization/accountability should focus on outcomes that matter to participants, in addition to metrics tied to funder costs such as PMPM payments. Scholars of value‐based payment systems (VBPs) have made this argument, ²⁷ and it is at least generally consistent with PCHI's outcome‐based payment structures.

4. DISCUSSION

Our findings and the measures of financial sustainability proposed above have implications for CSP practices, public policy, and research. For practice, the CSP Financial Sustainability Measurement Continuum (Table 3) provides a roadmap for building funding flows to support cross‐sector alignment, based on the experiences of CSPs across the country. The issues we identify for building progress toward greater incentivization/accountability suggest areas where practitioners may want to focus energy as they address incentivization/accountability issues.

Our findings also have implications for policymakers. Multiple respondents called attention to the importance of state policies for CSP finances. While states are working on advancing and reforming Medicaid initiatives, ²⁸ the CSP professionals we consulted suggested they could take more action to evaluate current partnership efforts and collaborate with stakeholders to improve state support. Our findings also indicate that there would be value in considering investments in health, public health, and social services more broadly, perhaps especially in areas such as Medicaid and Medicare where the federal government sets payment policies for healthcare providers. There have been multiple reform initiatives, but many of them—such as the HITECH Act investments and Hospital Readmissions Reduction Program (HRRP) incentives—have sought to improve health and enhance cost‐effectiveness through investments and incentives for insurers and healthcare providers, rather than through payments to community organizations and CSPs to work with under‐resourced persons. More broadly, our findings suggest potential value in further state and federal investments and incentives to enhance health equity using more comprehensive approaches.

Researchers may also benefit from our findings, as they provide a foundation for measuring progress toward sustainable finances and developing incentivization/accountability measures. The measures of sustainable finances presented in Table 3 provide a foundation for more systematic studies comparing CSPs, their developmental paths, and their impacts. Measuring incentivization/accountability is crucial, and observations made by the CSP professionals we consulted and PCHI certification requirements are both instructive in this regard.

While our findings provide useful insights, we must also acknowledge their limitations. First, our survey and interview samples are neither random nor representative of CSPs across the 50 states. While the sample of partnerships that shared their experiences with us is substantial, it is still a relatively small sample that draws heavily from CSPs using the PCHI Model. Indeed, while our Fisher's exact test results suggesting that higher levels of financial alignment for incentivization/accountability perceived by certified PCHs are statistically significant, the small sample underlying those results suggests that further research on relationships between types of CSPs and financial alignment progress is appropriate.

Second, while our findings suggest there are connections between sustainability and incentivization/accountability, they do not provide a simple means for measuring overall financial alignment. It may be beneficial to think further about ways in which these two dimensions of CSP financing might be better integrated with one another to guide overall assessments of financial alignment under the framework of Landers et al. ¹¹

Third, while our findings on financial alignment and ways to measure financial sustainability can inform practice, public policy, and research, investigators may face challenges in operationalizing our measures of financial sustainability in some situations. The measures in Table 3 are conceptually clear and arguably valid and can be assessed using available data sources such as contracts, financial/management reports, and interviews/surveys of CSP staff. However, these data sources have limitations that may produce challenges for reliable measurement. Professionals supporting cross‐sector alignment initiatives have different perspectives, and these differences may affect how they provide information to support efforts to measure financial alignment.

Despite these limitations, there is a need to better understand the financial alignment landscape for CSPs pursuing health equity. Understanding financial alignment can guide efforts to develop CSP initiatives while supporting research to highlight the nature of this enterprise and the challenges and benefits that may flow from it. The findings, measures, and measurement issues identified in this article aspire to contribute positively to these efforts.

CONFLICT OF INTEREST STATEMENT

Ms. Amy Vreeland provided expertise on the Pathways Community HUB Institute (PCHI) Model of care coordination and the delivery of social care services. She discloses involvement in contracted work with PCHI during the time this research was conducted and subsequent employment with PCHI starting in April 2023.

APPENDIX A. QUESTIONS ON ALIGNMENT ACROSS CORE AREAS OF ALIGNMENT AND PROGRESS IN ACHIEVING FINANCIAL SUSTAINABILITY AND INCENTIVIZED/ACCOUNTABLE FINANCIAL ARRANGEMENTS ASKED OF CROSS‐SECTOR PARTNERSHIP (CSP) LEADERS IN OUR SURVEY SAMPLE

A.1. Questions used to assess perceptions of alignment status

1. Purpose—questions on vision and priority outcomes

   1. In your view (or “estimation”), to what degree do the partners involved in your Pathway Community HUB's (“cross‐sector network,” for CSPs not engaged with the PCHI Model) efforts share the “vision” you articulated above for your HUB's success? Please select the one response that best characterizes your view below.

      • ____To a very high degree (all HUB partners share our vision)
      • ____To a high degree (a majority of HUB partners share our vision)
      • ____To some degree (about half of HUB partners share our vision)
      • ____To a low degree (a few HUB partners share our vision)
      • ____To a very low degree (no HUB partners share our vision)
      • ____I do not know
   Please explain why you chose the response you did to the previous question:

   • B
     In your view (or “estimation”), to what degree do the partners involved in your Pathways Community HUB (“cross‐sector network,” for CSPs not engaged with the PCHI Model) operate according to the “priority outcomes” you are currently pursuing, as mentioned above? Please select the one response that best characterizes your view below.

     • ____To a very high degree (all HUB partners pursue our priority outcomes)
     • ____To a high degree (a majority of HUB partners pursue our priority outcomes)
     • ____To some degree (about half of HUB partners pursue our priority outcomes).
     • ____To a low degree (a few HUB partners pursue our priority outcomes)
     • ____To a very low degree (no HUB partners pursue our priority outcomes)
     • ____I do not know

   Please explain why you chose the response you did to the previous question:

2. Data and Measurement Systems—one question only

   1. In your view (or “estimation”), to what degree do partners involved in your HUB (“cross‐sector network,” for CSPs not engaged with the PCHI Model) use (i.e., “take actions based on”) your data and measurement system? Please select the one response that best characterizes your view below.

      • ____To a very high degree (all HUB partners take actions based upon our data and measurement system)
      • ____To a high degree (a majority of HUB partners take actions based upon our data and measurement system)
      • ____To some degree (about half of HUB partners take actions based upon our data and measurement system)
      • ____To a low degree (a few HUB partners take actions based upon our data and measurement system)
      • ____To a very low degree (no HUB partners take actions based upon our data and measurement system)
      • ____I do not know

   Please explain why you chose the response you did to the previous question:

3. Governance—questions on engagement and decision making.

   1. In your view (or “estimation”), to what degree does the governance system you have in place engage those involved in the HUB (“cross‐sector network,” for CSPs not engaged with the PCHI Model) to participate in governance structures and processes to support your HUB's work? Please select the one response that best characterizes your view below.

      • ____To a very high degree (all HUB partners are engaged in governance structures & processes to support HUB work)
      • ____To a high degree (a majority of HUB partners are engaged in governance structures & processes to support HUB work)
      • ____To some degree (about half of HUB partners are engaged in governance structures & processes to support HUB work)
      • ____To a low degree (a few HUB partners are engaged in governance structures & processes to support HUB work)
      • ____To a very low degree (no HUB partners are engaged in governance structures & processes to support HUB work)
      • ____I do not know
   Please explain why you chose the response you did to the previous question:

   • B
     In your view (“or estimation”), to what degree does the governance system you have in place guide strong decision‐making structures and processes to support your HUB's (“cross‐sector network's”, for CSPs not engaged with the PCHI Model) work? Please select the one response that best characterizes your view below.

     • ____To a very high degree (the governance system consistently guides strong decision‐making structures & processes to support HUB work)
     • ____To a high degree (the governance system frequently guides strong decision‐making structures & processes to support HUB work)
     • ____To some degree (the governance system sometimes guides strong decision‐making structures & processes to support HUB work)
     • ____To a low degree (the governance system occasionally guides strong decision‐making structures & processes to support HUB work)
     • ____To a very low degree (the governance system rarely guides strong decision‐making structures & processes to support HUB work)
     • ____I do not know

   Please explain why you chose the response you did to the previous question:

4. Finances—questions on sustainability and incentivization/accountability.

   1. In your view (or “estimation”), to what extent does your HUB's (“cross‐sector alignment's) financing system produce sustainable financing for the services provided through your HUB's (“cross‐sector networks,” for CSPs not engaged with the PCHI Model) operations? Please select the one response that best characterizes your view below.

      • ____To a very high degree (all HUB partners have sustainable financial support for their contributions to the delivery of HUB‐related services)
      • ____To a high degree (a majority of HUB partners have sustainable financial support for their contributions to the delivery of HUB‐related services)
      • ____To some degree (about half of HUB partners have sustainable financial support for their contributions to the delivery of HUB‐related services)
      • ____To a low degree (a few HUB partners have sustainable financial support for their contributions to the delivery of HUB‐related services)
      • ____To a very low degree (no HUB partners have sustainable financial support for their contributions to the delivery of HUB‐related services)
      • ____I do not know
   Please explain why you chose the response you did to the previous question:

   • B
     In your view (or “estimation”), to what degree does the financial system your HUB has in place (“your organization's financing system,” for CSPs not engaged with the PCHI Model) incentivize and provide accountability for results consistent with the HUB's (“your organization's” for cross‐sector network's not engaged with the PCHI Model) vision and priorities? Please select the one response that best characterizes your view below.

     • ____To a very high degree (all HUB partners have solid incentives and are held accountable for results consistent with the HUB's vision and priorities)
     • ____To a high degree (a majority of HUB partners have solid incentives and are held accountable for results consistent with the HUB's vision and priorities)
     • ____To some degree (about half of HUB stakeholders have solid incentives and are held accountable for results consistent with the HUB's vision and priorities)
     • ____To a low degree (a few HUB stakeholders have solid incentives and are held accountable for results consistent with the HUB's vision and priorities)
     • ____To a very low degree (no HUB stakeholders have solid incentives and are held accountable for results consistent with the HUB's vision and priorities)
     • ____I do not know

   Please explain why you chose the response you did to the previous question:

   Note: Precise wording on the CAA questions above varied slightly based on CSP type/audience, as indicated above. In general, for CSPs indicating they were using the PCHI Model or pursuing its use, the term “HUB” was used. For CSPs not pursuing use of the PCHI Model, the terms “cross‐sector network” and/or “organization” were used, as appropriate.

A.2. Questions used to assess progress for financial sustainability and incentivization/accountability

1. What barriers inhibit your success in achieving sustainable financing across the organizations in your cross‐sector network?

2. What barriers inhibit financing arrangements which incentivize and hold organizations accountable for results consistent with your vision and priority outcomes?

3. Have you taken steps to address the barriers you mention in response to (the two previous questions)?

   1. Yes_____
   2. No_____

4. What steps have you taken to overcome the barriers to sustainable financing that you mention in response to (the previous questions)?

5. What steps have you taken to overcome the barriers to incentivization and accountable financing arrangements that you mention in response to (the previous questions)?

6. Have these steps (i.e., the steps mentioned in response to the two previous questions) been successful? Why or why not?

7. What milestones would you propose to use to demonstrate the progress of your cross‐sector alignment work in achieving sustainable financing sufficient to maintain your services?

8. What milestones would you propose to use to demonstrate the progress of your cross‐sector alignment work in ensuring that your financial arrangements incentivize and hold participants accountable for results consistent with your mission and priorities?

Hoornbeek J, Chiyaka ET, Lanese B, Vreeland A, Filla J. Financing community partnerships for health equity: Findings and insights from cross‐sector professionals. Health Serv Res. 2024;59(Suppl. 1):e14237. doi: 10.1111/1475-6773.14237