Minnesota Accountable Health Model

Skip to: Content

Accountable Communities for Health

Communities impact health. Much of what makes a person healthy depends on where they live, work, and play. Keeping a person healthy, especially one with complex needs, often requires community support and a team of clinical and community providers to work together. However, there are barriers that make it hard for clinical providers and community partners to effectively work together.

Accountable Communities for Health (ACH) meet the clinical and social needs of a defined population through person-centered, coordinated care across a range of providers. Minnesota is evaluating if community-led ACH models result in improvements in quality, cost, and experience of care. About $5.6 million, or 14 percent, of Minnesota’s State Innovation Model funds are dedicated to 15 ACH grant projects.


In Minnesota, ACHs projects are locally planned and led. Communities identify a target population—people in geographic area, a patient population, or a segment of a community—with substantial health and social needs. ACHs bring together community partners that contribute to a person’s health, such as local public health boards, behavioral health, social services, long-term care, primary care, and schools. ACH teams use formal business agreements to integrate services through enhanced referrals, transitions management, and implementation of new practice guidelines. In order to address population-specific needs, each ACH projects features a unique mix of partner organizations and a focus on prevailing health and social conditions.

Required Components

Each ACH grant project features the following components:

  • • Community-led leadership
  • • Care coordination between multi-sectoral partners
  • • Population-based prevention
  • • Measurement and evaluation
  • • Partnership with an Accountable Care Organization (ACO)
  • • Participation in an ACH learning community
  • • Sustainability planning
  • • Health equity focus
  • Past Success

    The Minnesota Accountable Health model, and the structure of an ACH, is built on the work of community care teams. These are locally based teams that partner with primary care practices, hospitals, behavioral health, public health, social services, and community organizations to ensure strong, coordinated support for the whole patient. In 2011, Minnesota competitively funded three community care teams—Ely, Mayo, and HCMC—to learn how communities and a broad group of providers could work together effectively. A video from Ely shows how community partnerships created healthy futures. The three original community care teams received sole-source ACH funding in late 2014.


  • Accountable Communities for Health: Perspectives on Grant Projects and Future Considerations’ Report (October 2016)
  • ACH grant projects webpage
  • SIM ACH Resources and Literature Review
  • Community Care Team Final Report and Interview Summary
  • Community Care Team Project Summary
  • Developing a Community Care Team (PDF)
  • Printable Fact Sheet