Site Profile: Caledonia & So. Essex Accountable Health Community

Accountable Health Community Tackles Poverty to Improve Well-Being
The Caledonia & So. Essex Accountable Health Community (CAHC) employs a holistic approach to improve community health. Participants in the CAHC, established in 2013, believe that reducing poverty is core to improving the health and well-being for the people in Vermont’s Northeast Kingdom region.

The CAHC service area is the hospital service area defined by the state and includes Caledonia county and the southern half of Essex county.  Caledonia and Essex counties are in northeastern Vermont, a rural area that incorporates 18 towns and villages — only three have a population greater than 2,000 people. Caledonia County ranks 5th and Essex County 11th of 14 counties in Vermont with regards to health outcomes. Recent surveys show that rates of food insecurity are high in Caledonia and Essex counties with one in four households and one in three households, respectively, facing food insecurity. Additionally, 41 percent of the regional population is on Medicare and 23 percent is enrolled in Medicaid.

Current Standing: Caledonia County ranks 5 and Essex County 11 of 14 counties in Vermont.

Leader of the Initiative: Local hospital and food bank

Collaborative: Accountable health community has two local organizations serving as the backbone organizations. Collaborative partners include representatives from health, housing, nonprofits and government

Potential Financing Mechanism Being Explored: Streamlining health care and social service costs and CDFI opportunities

Community Goals: Improving the health and well-being of local residents through a focus on poverty reduction.


Collective Impact Model Drives Collaborative

The CAHC uses the collective impact framework to coordinate its work. CAHC partners agreed on a common set of goals, outcomes and success indicators. They then align resources; implement and coordinate practices that have proven to
work for families, children and individuals in their region; and analyze and track progress, with the goal of and breaking program siloes. The CAHC envisions progress that will enable the population of the region to be financially secure, physically and mentally healthy, well-nourished and appropriately housed.

The charter members of the CAHC include community organizations representing multiple local sectors, including Northern Counties Health Care (a federally qualified health center and home health organization), Northeast Kingdom Community Action, Northeast Kingdom Council on Aging, Northeast Kingdom Human Services (mental health), and Rural Edge (housing), as well as the Vermont Foodbank and the Northeastern Vermont Regional Hospital, which jointly serve as the backbone organizations, anchoring the work of the CAHC. The CAHC has two dedicated staff and is funded through a grant from the John and Laura Arnold Foundation Grant and matching funds from the seven lead organizations.

Identifying Community Priorities

Collective impact is driven by a shared vision and common set of goals, outcome, and success indicators. CAHC partners assisted in a 2015 community needs assessment to help inform performance measures and coordinate an implementation plan.

The 2015 community health needs assessment built on the work of the 2012 assessment and found that the three top community health priorities remained the same. They include:

  • Poverty Related Issues
    • Lack of jobs and job training
    • Isolation due to stigma of poverty
    • Affordable housing
    • Food insecurity
  • Substance Abuse/Mental Health
    • Crime related to substance abuse
    • Rural isolation; lack of social support
  • Obesity 
    • Access to healthy foods
    • Time, money and knowledge about programs are barriers to being physically active

Measurable objectives using the principles of Results Based Accountability were identified for initiatives related to each priority area.

CAHC’s Goals for Bridging for Health

CAHC joined Bridging for Health in May 2017 and will begin working with their technical assistance providers on a comprehensive plan that addresses developing and implementing a sustainable financing innovation that rebalances and/or aligns investments in health, while working to improve health equity in the region. The CAHC previously tested capture and reinvest strategies as part of Vermont’s State Innovations Model funding. CAHC is considering focusing on streamlining costs associated with health care and social services, opportunities in partnership with community development financial institutions, and further strengthening their collaboration through increased community engagement strategies, particularly by including those with lived experience.