A countywide transformation model for improving population health, access, equity, quality, utilization, and value
Counties are positioned to organize the local systems that shape Medicaid outcomes: managed care, public health, behavioral health, safety-net care, human services, hospitals, community organizations, housing, and social services.
Elevation Health Partners (EHP) helps counties align those systems around defined populations, shared outcomes, value-based care, usable data, and accountable implementation. The model combines stakeholder alignment, governance, data transformation, financing, provider and community-partner capability, technical assistance, and measurement into one operating structure.
The Opportunity for Counties
Countywide accountable transformation organizes the partners, information, financing, and delivery capabilities that influence outcomes for a defined population to:
Define priority populations and the quality, access, utilization, equity, experience, and cost outcomes the local system will improve.
Align county departments, managed care plans, providers, hospitals, behavioral health, public health, CBOs, housing, social services, and community voices around shared responsibilities.
Create governance, workgroups, referral and care pathways, implementation expectations, and escalation processes.
Build shared data and information infrastructure for population identification, coordination, performance feedback, and accountability.
Connect managed care, value-based payment, public funding, provider incentives, and community investment to the operating model.
Strengthen provider, CBO, workforce, care-management, and improvement capability across the local delivery system.
Measure value, refine implementation, transfer capability, and scale effective approaches.
Build, strengthen, or adapt the local model
EHP can build an accountable transformation model from the ground up, strengthen an existing county collaborative or delivery-system initiative, or adapt proven structures such as accountable communities, whole-person care programs, regional Medicaid collaboratives, and ACO-like models to local authority, populations, partners, data, and financing.
The EHP Accountable Transformation Model for County Government
Shared accountability works when the local system has a common operating structure. EHP connects population priorities, partner roles, data, financing, local capability, implementation, and measurement into a repeatable countywide model.
1. Define the accountable population and outcomes
Establish who the model is intended to serve and what success means across the local system.
- Priority populations, geographies, disparities, and high-opportunity segments
- Quality, access, utilization, equity, experience, cost, and population-health outcomes
- State Medicaid, waiver, public-health, behavioral-health, and local priorities
2. Convene and align accountable partners
Bring the organizations that influence those outcomes into a common structure with meaningful community participation.
- County departments and public systems
- Managed care plans, hospitals, provider organizations, FQHCs, and specialty partners
- Behavioral health, CBOs, social services, housing, schools, employers, and community partners
3. Build governance and the shared operating model
Define how the collaborative works day to day and how decisions, dependencies, escalation, and accountability function.
- Governance, decision rights, workgroups, and partner roles
- Referral, care-management, and community-clinical pathways
- Implementation milestones, communication routines, issue resolution, and community engagement
4. Build the data and information infrastructure
Create the information environment required for coordinated care, population management, and shared accountability.
- Data governance, sharing agreements, privacy/security, and common measure specifications
- EHR, health-plan, HIE/CIE, public-health, referral, and social-service data connections
- Population identification, risk stratification, closed-loop referrals, dashboards, analytics, and performance feedback
5. Align financing and accountability
Connect the operating model to the payment, incentives, and funding that support shared outcomes and sustainable participation.
- Managed-care contracts, value-based arrangements, quality incentives, shared savings, and risk readiness
- PMPM/PUPM, fee-for-service, grant, waiver, public-health, and community funding
- Provider/CBO economics, staffing and caseload assumptions, billing rules, and sustainability
6. Assess readiness and build local capability
Determine what county teams, providers, health plans, and community partners need to execute reliably.
- Leadership, workforce, contracting, workflow, technology, and data readiness
- Population-health, care-management, behavioral-health, and quality-improvement capability
- Training, playbooks, learning collaboratives, coaching methods, and train-the-trainer
7. Implement, improve, and target support
Move the model into day-to-day operations with support matched to need, complexity, and performance.
- Shared change packages, workflows, standard work, and implementation milestones
- Cohort technical assistance, office hours, peer learning, and action planning
- Direct EHP coaching for priority providers, complex barriers, pilots, and high-need populations
8. Measure value, sustain, and spread
Use a balanced measurement model to determine where the transformation is creating value and where to expand.
- Quality, clinical, access, utilization, equity, experience, and cost outcomes
- Participation, adoption, implementation maturity, and partner capability
- Sustainability, financing, capability transfer, and spread across the county
Value-based care is integrated across the model
EHP connects payment strategy to care-delivery transformation. Contract terms, quality incentives, shared savings, utilization, total cost of care, staffing, billing, and sustainability inform the population priorities, data requirements, provider capabilities, workflows, and performance routines needed for accountable care.
Accountable Transformation: Roles Across the Ecosystem
EHP helps counties organize the people, infrastructure, data, and resources already responsible for population health and Medicaid performance around the Accountable Transformation Model.
County leadership and public agencies establish shared priorities, populations, outcomes, governance, and accountability.
Health plans, health systems, providers, behavioral health, public health, and community partners carry the model into day-to-day delivery through care management, population health, clinical workflows, community services, referrals, and improvement activities.
Shared data and performance infrastructure connects population identification, care coordination, referral activity, quality, utilization, equity, experience, and cost so partners can see performance and act on it.
EHP designs and facilitates the transformation infrastructure, builds partner capability, supports data and workflow transformation, provides implementation coaching, measures progress, and helps the county refine and sustain the model.
When Counties Bring EHP In
The model is designed for the operational and performance conditions that create urgency for county health and human-services leaders.
NEW MEDICAID OR WAIVER REQUIREMENTS
State or federal requirements create local implementation responsibilities, provider deadlines, new care models, or accountability expectations.
NEW FUNDING OR PROGRAM LAUNCH
The county receives transformation, behavioral-health, rural-health, workforce, equity, or provider-capacity funding and needs a scalable deployment model.
PERFORMANCE BELOW TARGET
Quality, access, utilization, equity, or experience results are below objectives, or performance data show limited or inconsistent improvement.
PROVIDER + CBO READINESS GAPS
Providers or community organizations need support with contracting, program requirements, workflows, reporting, care management, or participation.
VALUE-BASED CARE EXPANSION
Managed care or provider arrangements are creating new expectations for population health, quality, utilization, total cost, care coordination, or risk readiness.
DATA + REPORTING GAPS
Data are fragmented across plans, providers, public agencies, and community partners; shared measures, referral feedback, dashboards, or data-sharing processes need to be strengthened.
CROSS-SYSTEM IMPLEMENTATION VARIATION
Behavioral health, physical health, public health, social services, and community partners are operating with inconsistent workflows, handoffs, or accountability.
CAPACITY, LEADERSHIP, OR TIMELINE PRESSURE
Staffing shortages, leadership transitions, procurement timelines, board/state reporting needs, or implementation deadlines are stretching internal capacity.
How EHP Can Start
COUNTY ACCOUNTABLE TRANSFORMATION READINESS ASSESSMENT
A four- to six-week assessment of priorities, accountable populations, partner alignment, provider/CBO readiness, workforce, data, value-based care, implementation risks, and performance infrastructure, followed by a prioritized roadmap.
STAKEHOLDER + GOVERNANCE DESIGN SPRINT
Stakeholder mapping, engagement strategy, governance, workgroups, decision rights, community participation, operating routines, and implementation roadmap.
DATA + ACCOUNTABILITY INFRASTRUCTURE ASSESSMENT
Inventory data sources, sharing arrangements, interoperability, referral feedback, measure definitions, dashboards, analytics, and performance reporting needed for shared accountability.
PROVIDER + COMMUNITY-PARTNER READINESS PILOT
A focused cohort using readiness assessment, training, workflow support, data improvement, direct coaching, and measurement to create the model for countywide expansion.
Explore County Medicaid & Accountable Health Transformation
EHP can assess the local ecosystem and build a practical transformation model around the county’s current priorities, partners, data, financing, and implementation needs.
Learn more about Elevation Health Partners capabilities and work with County Government
Accountable Health Transformation Across Los Angeles County
Across Los Angeles County, EHP has worked with a locally governed public health plan, the county delivery system, public health, the primary care association, safety-net providers, managed care plans, behavioral health partners, and community organizations. These initiatives demonstrate the operating components of countywide accountable transformation.
LOS ANGELES PRACTICE TRANSFORMATION NETWORK | ACCOUNTABLE PROVIDER TRANSFORMATION AT COUNTY SCALE
L.A. Care Health Plan is an independent local public agency serving Los Angeles County. Through the CMS/CMMI Los Angeles Practice Transformation Network, EHP served as the lead practice transformation coaching firm for 23 federally qualified health centers and more than 800 providers. LAPTN was one of the three top-performing Practice Transformation Networks nationally; EHP was the practice transformation coaching partner across all three. EHP used the TCPi Change Package, Practice Assessment Tool, and 10 Building Blocks to build readiness for value-based care through empanelment, risk stratification, team-based care, population management, utilization management, data/QI, access, care coordination, and alternative-payment readiness. Twenty-one of 23 health centers completed all transformation phases; clinical quality improved 5%-33%; all participating centers adopted risk stratification and empanelment methodologies; and the initiative reported more than $160 million in savings associated with reduced emergency department and hospital utilization. The work created a common transformation infrastructure across a major segment of the Los Angeles County safety net.
LOS ANGELES MATERNAL MENTAL HEALTH ALLIANCE | COUNTY DEMONSTRATION TO STATEWIDE SCALE
The California Health Care Foundation funded the Los Angeles Maternal Mental Health Alliance to test whether a University of Washington Collaborative Care model for perinatal mental health could be implemented in Los Angeles County and prepared for broader scale. EHP co-developed and implemented the model with the Community Clinic Association of Los Angeles County and the University of Washington. Work across more than 16 community health center sites includes recruitment, workflow redesign, care-team roles, clinical training, practice coaching, data/QI, and a regional learning collaborative designed to reach up to 200 primary care sites. EHP is completing the initial five-year phase, and the foundation has approved another five years for statewide expansion.
LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES | PUBLIC DELIVERY-SYSTEM CAPABILITY
EHP has a long history of supporting Los Angeles County Department of Health Services across multiple initiatives. Most recently, Health Net funded EHP support to LA DHS through its provider quality-improvement program, with LA DHS organized as a distinct improvement cohort. EHP delivered intensive training and follow-up focused on clinical leadership capability, standing orders, standard work, huddles, central network data dissemination and action, and depression screening/follow-up workflows. This work connects Medicaid quality priorities to provider-facing improvement, training, workflow implementation, data use, and frontline capability within one of the nation's largest public delivery systems.
Public Health, Medicaid, and Community Infrastructure
LOS ANGELES COUNTY | MEDICAID DELIVERY AND VALUE-BASED CARE REFORM
Since 2021, EHP has helped Los Angeles County health centers implement California’s statewide Medicaid delivery and payment reform, including intensive care-management and community-support models and readiness for alternative and value-based payment. Working through the Community Clinic Association of Los Angeles County, EHP has served as a subject-matter expert and managed-care plan/provider liaison, leading readiness assessments, cross-sector workgroups, direct coaching, and implementation support on contracting, care management, workflows, metrics, operations, and sustainability. Direct coaching cohorts have supported 20 Los Angeles County federally qualified health centers.
STATEWIDE MEDICAID TECHNICAL ASSISTANCE | COMMUNITY-PARTNER CAPABILITY AT SCALE
California created a statewide, publicly funded technical-assistance marketplace to help providers and community-based organizations build the operating capacity required for new Medicaid care-management and community-support services. As a competitively selected vendor, EHP has completed more than 50 customized engagements spanning readiness, workflows, policies, data/documentation, billing/compliance, referrals, workforce training, care management, implementation planning, and financial sustainability. The work demonstrates a scalable model for strengthening diverse local organizations participating in whole-person and value-based care.
IMPERIAL COUNTY | CROSS-SECTOR ACCOUNTABLE COMMUNITY + DATA INFRASTRUCTURE
EHP facilitated a countywide stakeholder process involving Imperial County Public Health, more than a dozen rural health clinics, the region’s two major medical centers, a large regional federally qualified health center, the housing authority, local schools, employer groups, and asthma and social-justice advocacy organizations. Partners selected and operationalized an evidence-based pediatric asthma model connecting emergency and hospital care, primary care, diagnostics, community health worker home visits, schools, social services, and patient self-management. EHP also built the data-capacity and data-sharing strategy, common measures, data-capture approach, and an offline tablet solution for community health workers. The infrastructure linked separate clinical and community interventions to coordinated care and population-level evaluation.
Public health priorities become delivery-system operating models
EHP aligns the population-health aim, target population, partners, measures, and implementation environment, then connects those priorities to workflows, community-clinical linkages, EHR/reporting infrastructure, training, quality improvement, and learning systems.
Data Transformation and Value-Based Care Capabilities
Accountable transformation depends on usable information and aligned economics. EHP brings both capabilities into the county model.
DATA TRANSFORMATION | SHARED INFORMATION FOR ACCOUNTABILITY
EHP brings 20+ years of health information technology experience across EHR optimization, interoperability, health information exchange, population-health platforms, structured clinical data, quality reporting, analytics, referral data, and cross-system integration. Across nearly a decade of HCCN work, EHP supported 27-47 community health centers at a time with EHR/registry optimization, data integration, analytics, interoperability, and care-gap reporting. EHP helped establish the Inland Empire and Central Oregon health information exchanges from the ground up, including governance, operating models, data-sharing requirements, business/sustainability planning, and implementation. EHP also supported San Joaquin County HIE implementation and evaluated linkage of community-service referral and health information for 2-1-1 San Diego.
VALUE-BASED CARE | CONNECT PAYMENT TO OPERATIONS
EHP helps organizations translate value-based contracts into operating priorities and sustainable delivery models. Work spans quality incentives, shared savings, total cost of care, downside-risk readiness, PMPM/PUPM arrangements, utilization and specialty spend, care management, staffing/caseload economics, billing, and performance improvement. In Michigan Community Health Network’s High Impact Performance Program, EHP aligned seven directly coached FQHCs within a 33-health-center network to multiple Medicaid value-based agreements. Comparable measures improved 4.6%-17.9%, averaging about 11%; by December 2024 coached health centers were outperforming non-coached centers on five of six active measures. Meridian quality bonus payments increased 30% from 2022 to 2023 despite a 6% membership decline.
How these capabilities support the county model
Data identifies populations, reveals gaps, supports care coordination, and creates a common performance view. Value-based financing aligns incentives with those outcomes. Provider and community transformation turns the information and incentives into reliable workflows, care models, and measurable results.
Explore County Medicaid & Accountable Health Transformation
EHP can assess the local ecosystem and build a practical transformation model around the county’s current priorities, partners, data, financing, and implementation needs.