Accountable Health Communities (AHCs): Community-based partnerships formed across multiple sectors such as healthcare, housing, social services, public health, employment training and economic development to focus on a shared vision and responsibility for the health of a community. ACHs pursue an integrated approach to health that focuses not solely on the clinical setting but on how the broader community can support healthcare’s “Triple Aim” of better care for individuals, better health for populations, and lower healthcare costs.
Acute care: Includes actions to improve health that are highly time-sensitive, individually-oriented, and curative. It encompasses a range of clinical health-care functions including emergency medicine, trauma care, pre-hospital emergency care, acute care surgery, critical care, urgent care, and short-term inpatient stabilization.[i]
Alternative Payment Model (APM): A payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.(source: https://qpp.cms.gov/apms/overview)
Behavioral health: Mental/emotional well-being and/or actions that affect wellness. Behavioral health problems include substance use disorders; alcohol and drug addiction; and serious psychological distress, suicide, and mental disorders. Problems that range from unhealthy stress or sub-clinical conditions to diagnosable and treatable diseases such as serious mental illnesses and substance use disorders are included. These illnesses and disorders are often chronic in nature, but people can and do recover from them with the help of a variety of interventions, including medical and psychosocial treatments, self-help, and mutual aid. The phrase “behavioral health” is also used to describe service systems that encompass prevention and promotion of emotional health; prevention of mental and substance use disorders, substance use, and related problems; treatments and services for mental and substance use disorders; and recovery support. [http://www.samhsa.gov/data/national-behavioral-health-quality-framework]
Biomedical research: The area of science devoted to the study of the processes of life, the prevention and treatment of disease, and the genetic and environmental factors related to disease and health. Utilizing biotechnology techniques, biomedical researchers study biological processes and diseases with the goal of developing effective treatments and cures.[ii]
Braided Funding: The mechanism by which stakeholders coordinate funding from individual sources in order to arrange and pay for a total plan of health services and supports and eliminate the need for duplicative services. (adapted from the National Academy for State Health Policy: https://nashp.org/wp-content/uploads/2016/02/Jean1.pdf)
Capacity building: The process of improving an individual’s, family’s, organization’s or community’s ability to succeed. In the case of organizational capacity building, this includes increasing skills and knowledge; increasing the ability to plan and implement programs, practices, and policies; increasing the quality, quantity, or cost-effectiveness of programs, practices, and policies; and increasing sustainability of infrastructure or systems that support programs, practices, and policies.[iii] (See Organizational Effectiveness)
Capital support: Grants whose primary purpose is to support an organization’s infrastructure through new construction, expansion, renovation or replacement of an existing facility or facilities; including the purchase of any capital assets.
Care coordination: Deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. [From AHRQ]
Care management: A team-based, patient-centered approach designed to assist patients and their support systems in managing medical conditions more effectively. [From AHRQ]
Collaboration: A group of individuals or organizations working together to address common goals. Partnerships involve a formal relationship of mutual respect and trust, coordination of administrative responsibility, establishment of reciprocal roles, shared participation in decision-making, mutual accountability, shared risk, and transparency.[iv]
Collaborative partnerships: Alliances that are used to improve the health of a community. They encourage people to work together and make a difference.[v] For example, an effort to improve community health might involve public health officials, medical professionals, health ministries, and community members. Because these partnerships bring people together from all parts of the community, their efforts often have the weight to be successful.
Community: A group of people who share a common place, experience, or interest. We often use this term for people who live in the same area: the same neighborhood, the same city or town, and even the same state or country. People may also consider themselves part of a community with others who have had similar experiences. Finally, a community may be formed of people interested in the same things.[vii]
Community-based clinic: Healthcare providers (1) that are physically and socially embedded in communities; (2) for whom service to low-income and vulnerable populations is a primary mission; and (3) that provide preventive care, primary care, behavioral health services, and/or oral health services.
Community capacity building: Building the capacity of individuals within a community to work together to improve community health by working directly with individuals or through organizations that do so.
Community Centered Health Home (CCHH): A new model aimed at strengthening the contribution of health centers to improve population health and the health of their patients by better addressing community/social determinants of health. CCHH is a model for effectively bridging community prevention and health service delivery, as described by The Prevention Institute.
Community health: A field within public health concerned with the study and improvement of the health of biological communities. Community health tends to focus on geographic areas rather than people with shared characteristics.
Community prevention: Applying innovative practices to reduce rates of preventable illness and injury and better aligning resources to address the factors that shape health and safety outcomes.
Comprehensive clinic: A clinic that provides a full complement of services, including preventive, primary care, behavioral health services, and oral health services.
Cultural competence: Describes the ability of an individual or organization to interact effectively with people of different cultures. To produce positive change, (health) practitioners must understand the cultural context of the community they serve, and have the willingness and skills to work within this context. This means drawing on community-based values, traditions, and customs, and working with knowledgeable people from the community to plan, implement, and evaluate activities.[viii]
Early childhood development: There is no time in life when the brain develops more rapidly than during the first years. We’re defining those first years as ages pre-natal to age three. It is not day care. By building children’s brains from the earliest ages, we are shaping their future learning, behavior, and health. With this in mind, EHF will support action based on science to give our youngest community members the best possible start in life. We will invest in innovative programs with promising evidence that provide a direct benefit to young children and build lasting support systems for parents and caregivers.[ix]
Episcopal Diocese of Texas: A territorial unit of administration within The Episcopal Church consisting of a number of individual parishes, under the pastoral oversight of a bishop. The Episcopal Diocese of Texas (EDOT) encompasses 57 counties in southeast and central Texas and is overseen by Bishop C. Andrew Doyle. The EDOT is home to more than 10 million people – a little less than half the population of Texas – and is the service area for the Episcopal Health Foundation. Click here for a map of the Diocese and visit the www.epicenter.org for more information on its leadership, history, parishes, and activities.
Equity: As defined by the World Health Organization (WHO), equity is the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification.
Health: A state of complete physical, mental, and social well-being and not merely the absence of infirmity.[x]
Healthy community: A community that continuously creates and improves its physical and social environments to enhance health and to help people support one another to achieve health and well-being.
Health disparity: A type of difference in health that is closely linked with social or economic disadvantage. Health disparities negatively affect groups of people who have systematically experienced greater social or economic obstacles to health. These obstacles stem from characteristics historically linked to discrimination or exclusion such as race or ethnicity, religion, socioeconomic status, gender, mental health, sexual orientation, or geographic location. Other characteristics include cognitive, sensory, or physical disability.[xi]
Health equity: When all people have the opportunity to attain their full health potential and no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance.
Health inequality: Differences, variations, and disparities in the health achievements of individuals and groups of people.[xiii]
Health inequity: A difference or disparity in health outcomes that is systematic, avoidable, and unjust.[xiv]
Health system: As defined by the WHO, the people, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health.
Integrated behavioral health: The care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.
Integrated healthcare: The management and delivery of health services so that clients receive a continuum of preventive and curative service, according to their needs over time and across different levels of the health system. Integration is best seen as a continuum rather than as two extremes of integrated/not integrated. Integration is about the organization of various tasks which need to be performed in-order-to provide a population with good quality health services.[xvii]
Intermediary: A person or service that is involved as a third party between two or more end points in a communication or transaction.
Low-income: EHF uses the measure of 200% Federal Poverty Level (FPL) to define low income populations. The FPL is a measure of income issued every year by the US Department of Health and Human Services. Federal poverty levels are used to calculate eligibility for Medicaid and the Children’s Health Insurance Program, among other benefit programs. For more information on the federal poverty level see healthcare.gov. or view chart at: https://aspe.hhs.gov/poverty-guidelines.
Mental health: A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.[xviii]
Needs assessment: A systematic procedure for determining the nature and extent of health needs in a population, the causes and contributing factors to those needs, and the human, organizational and community resources which are available to respond to these.[xix]
Organizational Effectiveness (OE): OE is how well an organization is at achieving its intended outcomes.
Pay for Performance: An umbrella term for initiatives aimed at improving the quality, efficiency, and overall value of health care. These arrangements provide financial incentives to hospitals, physicians, and other health care providers to carry out such improvements and achieve optimal outcomes for patients. (source: https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/full/)
Pay for Success (PFS): Pay for Success financing models are cross-sector partnerships in which investors pay upfront for social service and then government, healthcare, or other back-end payers repay the investment if and only if agreed-upon outcomes are achieved.
Population health: A framework that focuses on a group of individuals within a specific geopolitical area and recognizes that the health of a population is more than just the clinical aspects of care and includes social, economic, environmental and individual behavioral and genetic traits. Health status is tracked over time and at the subgroup level, for example by disease, care costs and how happy individuals are with their care.
Population health management: The management of health and outcomes for subpopulations such as the population of patients served by a health center. This management includes the design, delivery, coordination and payment of health-quality healthcare services to manage the “Triple Aim” for a population using the best resources we have available within the healthcare system. [From NACHC]
Poverty: When a person or group of people lack human needs because they cannot afford them. Human needs include clean water, nutrition, health care, education, clothing, and shelter. The U.S. Social Security Administration originally developed the definitions that are used to help calculate and determine poverty. Families or people with income below a certain limit are considered to be below the poverty level. [xxi]
Primary care: Primary care is described as comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the “undifferentiated” patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.).
Provider: A provider is a professional engaged in the delivery of health services, including physicians, dentists, nurses, podiatrists, optometrists, clinical psychologists, etc. [From RWJF}
Restricted grant: Funding that supports specific activities carried out over a defined period and/or are planned in-order-to achieve a specific result or goal.
Routine service provision: An organization’s activities which relate to its general operating. In the context of EHF’s work, EHF does not fund routine service provision for public agencies, emergency assistance organizations, child care or after-school programs.
Rural or Non-Urban: EHF monitors three county population categories: urban (a county with at least one metropolitan area – a population cluster over 50,000), counties with small cities and towns (counties with at least one population cluster of10-49,000 people), and rural (counties containing population clusters of fewer than 10,000).
Serve and return interactions: Interactions between a developing child and an adult caregiver that shape brain architecture. When an infant or young child babbles, gestures, or cries, and an adult responds appropriately with eye contact, words, or a hug, neural connections are built and strengthened in the child’s brain that support the development of communication and social skills. (Summarized from Harvard University’s Center on the Developing Child, http://developingchild.harvard.edu/science/key-concepts/serve-and-return/)
Social determinants of health: Conditions in which people are born, grow, live, work and age. These determinants are generally classified in six domains: economic stability, neighborhood and physical environment, education, food, community and social context, and healthcare system.
Socioeconomic status: A composite measure that typically incorporates economic, social, and work status. Economic status is measured by income. Social status is measured by education. Work status is measured by occupation. Each status is considered an indicator. These three indicators are related but do not overlap.[xxiii]
Specialty care: Specialty care is health care focused on improving the well-being of certain specialized categories of health, as opposed to general and overall health and well-being. [From RWJF]
Strong health systems: EHF seeks to strengthen the health system by developing more high-quality, integrated preventive, primary, oral and behavioral health services that provide community-based care with a focus on wellness.
Transformation: Transformational change emphasizes systemic and organizational change that is sustained over time and cannot be ‘undone’. Transformation is not an ‘event’, but a dynamic process. It is distinct from innovation and creativity because it is designed to bring about complete change.
Upstream – An approach that is primarily concerned with identifying and preventing the causes of illness and injury.
Unrestricted grants: Funding that supports an organization’s day-to-day expenses in furtherance of its mission rather than specific projects or programs; may also include support to build organizational infrastructure.
Value-based payments: Value-based payment (VBP) rewards the cost-effective improvement of the health and well-being of a population. This systematic method of paying for care shifts away from pure volume-based payment (e.g., fee-for-service) to payments that incentivize the Triple Aim (better health, better experience of care, lower total cost of care per capita). Because value-based payment models are aimed at strengthening the link between health outcomes and payment, they are encouraging providers to take into account the social, behavioral and economic factors that influence health.
Vulnerable populations: Groups that are not well integrated into the healthcare system because of ethnic, cultural, economic, geographic, or health characteristics. This isolation puts members of these groups at risk for not obtaining necessary medical care, and thus constitutes a potential threat to their health.
Wellness: Wellness is the optimal state of health of individuals and groups. There are two focal concerns: the realization of the fullest potential of an individual physically, psychologically, socially, spiritually, and economically, and the fulfillment of one’s role expectations in the family, community, place of worship, workplace, and other settings.[xxv]
[xvii] World Health Organization, Technical Brief No. 1, 2008