Build health crosswalk 7.7.16

The BUILD Health Challenge: Crosswalk of Similar Initiatives Updated 7/7/16
BUILD Health Crosswalk
National Initiatives Supporting
Bold, Upstream, Integrated, Local, and Data-Driven
Initiatives
Courtney Bartlett
July 7, 2016

Background
The goal of this survey is to identify initiatives that align with the goals of the BUILD Health sites. The document shows where there might be
overlap between BUILD sites and other programs with similar objectives, target populations, or funding streams.
Some ways you can use this guide include:
 Find new opportunities for funding that align with your project goals
 Identify organizations working on collaborative or upstream health interventions
 Spark new ideas for collaborative approaches to public health
Please let me know if you have any questions or suggestions for future improvement.
Courtney Bartlett
Courtney.bartlett@duke.edu
Contents
On the following page, you will find a crosswalk providing a graphic overview of current funding initiatives that are active in the 18 BUILD
Health Challenge communities, with colors indicating whether they are aware of and/or connected with the current BUILD partners in that
city. NOTE: The colors may not accurately reflect connection levels. If you see a color that should be updated, please notify Courtney
Bartlett.
On page 11, you will find a list of the specific partners working on each initiative, organized by city.

Crosswalk
BUILD Site
6|18
A
C
H
A
H
EAD
B
H
PN
C
H
SC
C
H
P
C
M
M
I
C
TSA
D
A
SH
FreshLoH
ealthiestC
&
C
InvestH
ealth
N
G
-AC
OP2P
PH
TC
PlayEveryw
here
PR
C
100R
C
R
EA
CH
R
eThinkSC
A
LE
X X X X X X X X
X APCP, HCIA, SIM X X X X X**
X
APCP, BPCI, HCIA,
MAPCP, SIM
X X X X X
X APCP, BPCI X X X X X X X
X APCP, BPCI HCIA, SIM X X X X X X X
X APCP, BPCI, CPCI, SIM X
X
APCP, BPCI, CPCI, HCIA,
SIM
X X
X
APCP, BPCI, CPCI, HCIA,
SIM
X X X X
ACO, BPCI, HCIA, SIM X X X
X X X BPCI, HCIA, MAPCP, SIM X X X
X X BPCI, HCIA, ACO, SIM X X X**
X HCIA, APCP, SIM X X X X X X
HCIA, APCP X X
HCIA, BPCI, APCP X X X X X
X HCIA, SIM, BPCI, APCP X X X X
HCIA, BCPI
HCIA, SIM, BPCI, APCP X X X X X X
X X HCIA, BPCI X
Colorado Springs,
CO
Albuquerque, NM
Baltimore, MD
Bronx, NY
Chicago, IL
Cleveland, OH
Springfield, MA
Denver (Aurora), CO
Denver, CO
Des Moines, IA
Detroit, MI
Houston, TX
Los Angeles, CA
Miami, FL
Oakland, CA
Portland, OR
San Bernardino, CA
Seattle, WA
Partners overlap and there is a connection
between BUILD and this initiative
Partners may overlap, but we are not aware of a
formal connection – more investigation is needed.
Different partners participating in this initiative and
BUILD. We are not aware of a connection at this time.

Legend
 6|18 = CDC Six-Eighteen Initiative
 ACH = Accountable Communities for
Health.
 AHEAD = Alignment for Health Equity and
Development
 ACO = Accountable Care Organization
 AHC = Accountable Health Communities
Model
 APCP = FQHC Advanced Primary Care
Practice Demonstration
 BHPN = Build Healthy Places Network
 BPCI = Bundled Payments for Care
Improvement Initiative
 CHP = Community Health Peer Learning
Program
 CHSC = Culture of Health Sentinel
Communities
 CMMI = Centers for Medicare and
Medicaid Innovation
 CPCI = Comprehensive Primary Care
Initiative.
 CTSA = Clinical and Translational
Science Awards
 DASH = Data Across Sectors for Health.
 FreshLo = Fresh, Local, and Equitable
 Healthiest C&C = Healthiest Cities and
Counties Challenge
 HCIA = Healthcare Innovation Award
 MAPCP = Multi-payer Advanced Primary
Care Program
 NG-ACO = Next-generation ACO Model
 P2P = Pathways to Pacesetter
Communities.
 PHTC = Regional Public Health Training
Centers
 PlayEverywhere = Play Everywhere
Challenge
 PRC = CDC Prevention Research
Centers
 100RC = 100 Resilient Cities
 REACH = Racial and Ethnic Approaches
to Community Health
 ReThink Health
 SCALE = Spreading Community
Accelerators through Learning and
Evaluation.
 SIM = State Innovation Model

Crosswalk: additional program details by initiative
Initiative
Funding
Period
Once or
Ongoing
National or
Regional Funder(s) TA Partners Health Issue Local Partnerships Delivery Reform
6|18 1/2016 –
12/2016
Once National,
8 states
CDC ASTHO, CHSC,
CMS, NAMD, NGA,
NNPHI, RWJF
 Asthma
 Tobacco
 Unintended Pregnancy
Prevention
 Public Health Agency
 Medicaid Agency
Yes, some state strategies
will address delivery system
reform with Medicaid.
ACH Not funded,
this is a
model.
Ongoing N/A N/A Prevention Institute  Food
 Physical activity
 Tobacco
There is potential for
other topics.
 Healthcare
 Public health
 Other orgs that impact
health in the region
Yes, ACH’s should build up
and align funding with
existing prevention funding
streams as well as explore
ways to create a new
funding mechanism.
AHEAD 5 pilot cities
for 5 yrs:
(10/2014 –
10/2019)
Ongoing – next
will engage 8-10
sites for 3-4 year
implementation
period
National,
5 pilot cities
Kresge Public Health Institute
Reinvestment Fund
NNPHI
Carsey Institute
Center on Social
Innovation and
Finance
 Sustainable
infrastructure
 Quality housing
 Access to healthcare
 Job opportunities
 Education and youth
development
 Child care
 Violence prevention
 Access to healthy food
 Safe places and
spaces/physical
activity
 Hospital
 Public health agency
 Financial institution
Businesses
 Government
Unclear
ACO Shared
Savings
(accepting
applications)
Advance
Payment (no
longer
active)
Pioneer
(2012 –
present)
Ongoing -
433 Shared
Savings
35 Advance
Payment
19 Pioneer
National CMS/CMMI N/A  Care coordination
 Triple aim
 Doctors
 Hospitals
 Healthcare providers
 Suppliers
Medicare Shared Savings
Program—helps a Medicare
fee-for-service program
providers become an ACO.
Advance Payment ACO
Model – a supplementary
incentive program for
selected participants in the
Shared Savings Program.
Pioneer ACO Model—
designed for early adopters
of coordinated care.
AHC Accepting
Applications
early 2016.
Awardees
announced
fall 2016. 5
year
Once National CMS/CMMI N/A  Care coordination
 Clinical-community
linkages
 Housing instability and
quality
 Food insecurity
 Utility needs
 Interpersonal violence
Eligible applicants are
community-based
organizations, healthcare
provider practices,
hospitals/health systems,
academic institutions, local
government entities, tribal
organizations and for-profit
Initiatives to accelerate the
development and testing of
new payment and service
delivery models

implementati
on period.
 Transportation needs and not-for-profit local and
national entities. Must
agree to partner with: state
Medicaid agencies, clinical
delivery sites, and
community service
providers
(FQHC)
APCP
Three years;
concluded
10/31/2014.
Once, ended National.
434
participating
sites
CMS, HRSA CMS, HRSA  Patient-Centered
Medical Home
 Care Coordination
Doctors and other health
professionals working in
teams
This demonstration project
tested the effectiveness of
doctors and other health
professionals working in
teams to coordinate and
improve care for Medicare
patients. FQHCs were
expected to achieve Level 3
PCMH recognition, help
patients manage chronic
conditions, and actively
coordinate care for patients.
BHPN 3/2016 –
9/2016
6 month grants,
once
3 BUILD
sites
Kresge
Foundation,
BHPN
n/a Planning activities to
increase collaboration
between health sectors
and community
development
 Community
Development Financial
Institutions (CDFIs)
 BUILD sites
BPCI Model 1 =
4/2013 –
12/2016
Model 2,3,4
= 10/2013 –
9/2018
Once National CMS/CMMI n/a  Care coordination
 Improved patient care
 Lower costs
Hospitals/health systems The Bundled Payments for
Care Improvement initiative
(BPCI) comprises four
broadly defined models of
care, which link payments
for multiple services
beneficiaries receive during
an episode of care. Under
the initiative, organizations
enter into payment
arrangements that include
financial and performance
accountability for episodes
of care. These models may
lead to higher quality and
more coordinated care at a
lower cost to Medicare.
CHP January
2016-2017
(17 months)
Once National, 10
Participant
communities
; 5 Subject
Matter
Expert
communities
Academy
Health
ONC, NORC,
National Partnership
for Women &
Families
Data N/A

CHSC 2015-2020 (5
years)
Once 30
communities
nationwide
RWJF – no
funding only
monitoring
RTI Observation only:
 How communities are
developing (or not
developing) a Culture
of Health,
 Data used to track
development
N/A N/A
CPCI 10/2012 –
fall 2016.
Four year
initiative, in
progress
Seven U.S.
regions
CMS/CMMI CMS  Risk-stratified care
management
 Access and continuity
 Planned care for
chronic conditions and
preventive care
 Patient and caregiver
engagement
 Coordination of care
across the medical
neighborhood
 State Health insurance
plans
 Primary care practices
CMS/commercial and state
health insurance plans to
offer population-based care
management fees and
shared savings
opportunities to participating
primary care practices to
support the provision of a
core set of five
“comprehensive” primary
care functions.
CTSA 2006 -
present
Ongoing 50+ sites
nationally
National
Center for
Advancing
Translational
Sciences
N/A  Train and cultivate the
translational science
workforce;
 Engage patients and
communities in every
phase of the
translational process;
 Promote the
integration of special
and underserved
populations in
translational research
across the human
lifespan;
 Innovate processes to
increase the quality
and efficiency of
translational research,
particularly of multisite
trials; and
 Advance the use of
cutting-edge
informatics.
Medical Research
Institutions. Research
teams include scientists,
patient advocacy
organizations and
community members.
DASH 1/2016-
6/2017 (18
mo)
Once National, 10
sites
RWJF DASH National
Program Office, led
by the Illinois Public
Health Institute in
partnership with
the Michigan Public
Health Institute
 Data sharing
 Information technology
Public health, health care,
human services, and other
sectors
N/A

FreshLo 4/2016 –
4/2017.
Once. Option to
apply for 2-year
implementation
grant after 12
months.
National
20 Planning
Grants
Kresge
Foundation
Kresge Arts and
Culture and Health
Programs
 Project management
 Partnership
development
 Community
engagement
 Strategic
communications
 Policy development
 Neighborhood-scale
initiatives that use food
as a strategy for
creative community
revitalization
Non-profit organizations
and local government
agencies
N/A
Healthiest
Counties
and Cities
Application
deadline
5/31/16.
Finalists
announced
8/1/16
Funding
through
2018.
Once National,
cities,
counties and
federally
recognized
tribes
Aetna
Foundation,
APHA,
NACCHO
CEOs for Cities  Tobacco Use
 Nutrition
 Physical Activity
 Community Safety
 Built Environment
(Food Quality,
walkability, bikeability,
and transit use
 Housing Affordability
 Educational
Attainment
 Living Wage
 Children exposed to
secondhand smoke in
the home
 Air Quality
 Water Quality
Cross-sector team should
include at least one
representative from public,
private, non-profit, the
community and
philanthropic sectors be
included. E.g. government,
non-profit organizations,
local, state and county
public health departments,
health care organization
systems, educational
institutions, etc.
N/A
Invest
Health
6/2016 –
12/2017
Once National: 50
mid-sized
cities in 31
states.
RWJF
Reinvestme
nt Fund
 PATH
 Policylink
 UnitedHealthcare
 Federal Reserve
Bank
 The ARC
 Health Impact
Project
 NeighborWorks
America
 Access to quality jobs
 Affordable housing
 Environmental hazards
 Health Equity
 Nutritious food
 Reducing crime rates
Public sector, community
development, and an
anchor institution
(preferably academic or
health-related). Selected
teams also include
members from public
school districts, community
organizations, and local
philanthropies.
n/a
HCIA Round 1:
5/2012
Round 2:
6/2012
Once; funding for
three years
National –
107 sites
CMS/CMMI N/A  New care delivery and
payment models
 Behavioral health &
substance abuse
 High risk patient
targeting
Healthcare orgs, research
institutions, public and
private sector partners.
Funds new ideas, and new
payment and service
delivery models to deliver
better health, improved care
and lower costs to people
enrolled in Medicare,
Medicaid and Children's
Health Insurance Program
(CHIP), particularly those

 Community resource
planning and
prevention
 Primary care redesign
 Disease specific
with the highest health care
needs.
MAPCP 11/2010 –
present
Once Began with 8
states (ME*,
MI*, MN,
NY*, NC,
PA, RI*,
VT*)
*Continuing
through
2016
CMS/CMMI N/A  PCMH
 Cover care
coordination
 Access to healthcare
 Patient education and
other services to
support chronically ill
patients.
State Medicaid agency,
private insurers
The demonstration will
evaluate whether advanced
primary care practice will
reduce unjustified utilization
and expenditures, improve
the safety, effectiveness,
timeliness, and efficiency of
health care.
NG-ACO Round 1:
2016
Round 2:
2017 –
currently
accepting
applications
Once: two rounds National, 18
sites
CMS/CMMI N/A Care coordination Provider organizations CMS will partner with ACOs
that are experienced in
coordinating care for
populations of patients and
whose provider groups are
ready to assume higher
levels of financial risk and
reward. This is in
accordance with the
Administration’s goal of
tying 30 percent of
traditional, or fee-for-
service, Medicare payments
to alternative payment
models, such as ACOs, by
the end of 2016 -- and 50
percent by the end of 2018.
P2P 10/2015 –
3/2017
Once National RWJF Institute for
Healthcare
Improvement (IHI),
Community Solutions,
Communities Joined
in Action (CJA), and
the Collaborative
Health Network
(CHN)
Same as SCALE below Must put together a team
that represents various
sectors (e.g., health care,
education, public health,
etc.)
N/A
PHTC Ongoing Ongoing National, ten
centers
HRSA N/A Workforce development Recipients are accredited
schools of public health or
another public or nonprofit
private institutions
accredited for the provision
of graduate or specialized
training in public health
N/A
PlayEvery
where
Finalists
announced
July 2016.
Once National, 50
cities across
the US
RWJF,
Target,
Playworld
U.S. Department of
Housing and Urban
Development, the
 city redevelopment and
design
 child health
The challenge will reward
applicants who provide
community-driven
N/A

Awardees
announced
in Sept 2016
National Endowment
for the Arts
solutions that integrate
play into everyday life and
unexpected places—
sidewalks, vacant lots, bus
stops, open streets, and
beyond.
PRC 2014-2019 Ongoing National, 26
centers
HHS CDC  Behaviors and
environmental factors
that affect chronic
diseases
 Injury
 Infectious disease
 Mental health
 Global health
 Poverty and equity
accredited schools of
public health or schools of
medicine with a preventive
medicine residency
program
N/A
100RC 12/2013=Firs
t cohort of 32
cities.
12/2014 =
Second
cohort, 35
cities
5/2016 =
Third and
final cohort,
37 cities.
Three times
Funding lasts for
at least two
years, and
potentially for
three.
International
104 Total
cities
The
Rockefeller
Foundation
Rockefeller
Philanthropy Advisors
Partners from the
private, public,
academic, and non-
profit sectors
 Aging Infrastructure
 Drought
 Earthquake
 Endemic Crime and
Violence
 Flooding
 Infrastructure Failure
 Lack of affordable
housing
 Landslide
 Poor Transportation
System
 Social inequity
 Tsunami
 Water Management
Issues
 Wildfire
Qualifications:
Innovative mayors, a
recent catalyst for change,
a history of building
partnerships, and an ability
to work with a ride range of
stakeholders.
None
REACH REACH
2014 = 2014
– 2017.
Ongoing, 3 year
grants.
National, 20
basic
implementati
on
awardees,
29
comprehensi
ve awardees
CDC N/A  Proper nutrition
 Physical activity
 Tobacco use and
exposure
 Chronic disease
prevention
 Risk reduction and
management
opportunities
 Health equity
Awardees include:
governmental and
nongovernmental
agencies, including state
and local health depts,
tribes/tribal organizations,
universities, and
community-based
organizations
N/A
ReThink Not currently
funding
communities
Previously funded
4 sites, plus a
QIO project with
5 regions
National ReThink
Health
ReThink Health  Quality improvement in
Medicaid
 Community
engagement
 Chronic disease
Teams of healthcare,
public health, insurers
(QIOs).
ReThink Health helped five
regions and their respective
state quality improvement
organizations (QIOs)
explore innovative ways to
improve health and health

 Built environment
 Access to care
care and lower costs for
Medicaid beneficiaries.
SCALE 4/2015-
4/2017
Once; two years
of funding.
National,
four mentor
sites with 20
pacesetter
sites
RWJF Institute for
Healthcare
Improvement,
Community Solutions,
Communities Joined
in Action, and the
Collaborative Health
Network.
Click here for full list
 Aging Well
 Equity and Social
Determinants of Health
 Child Health
 Behavioral Health and
Wellness
 Healthy Living
 Veterans
 Health Systems
Transformation
 Improvement
Capability in
Community
 Sustainable Financing
 Leadership
Development
 Partnership and Co-
design
 Culture of Wellbeing
 Students and
Workforce
Must put together a team
that represents various
sectors (e.g., health care,
education, public health,
etc.)
N/A
SIM 12/2014 –
12/2018 (4
years)
Currently in
Round 2, unclear
if there will be
additional rounds.
National, 11
Test and 21
Model
Design
states.
CMS/CMMI ASTHO, CDC, more  Population health
 Integrating primary
care/behavioral health
 Telehealth
 Expanding HIT
 Value-based payment
structures
 PCMHs
State health departments
and Medicaid agencies
Development and testing of
state-led, multi-payer health
care payment and service
delivery models that will
improve health system
performance, increase
quality of care, and
decrease costs for
Medicare, Medicaid and
Children’s Health Insurance
Program (CHIP)
beneficiaries—and for all
residents of participating
states.

Legend
 Funding Period – What is the start/end date for the current
funding cycle
 Once or ongoing – Is this a one-time funding opportunity? Or will
there be additional cycles?
 Location – Is this a national initiative? Or regional?
 Funder(s) – who funds the project. *Indicates financial support.
 TA Partners – what national organizations partnered to support
sites with TA.
 Health issues – Does it target a specific health issue? Or is it
multi-issue?
 Local Partnerships – Do they encourage partnerships between
multiple entities? (e.g. hospital, primary care, public health,
community)
 Delivery Reform – Is there a component related to the healthcare
delivery system reform? (e.g. payment models – to distinguish
between CMMI-type models and population health/SDH
initiatives.
ADDITIONAL INFORMATION
 ACH = Accountable Communities for Health. Also includes: San
Diego County, California’s Live Well San Diego Initiative; Pueblo
County, Colorado’s Pueblo Triple Aim Coalition; Summit County,
Ohio’s LiveHealth Summit initiative; and Lane County, Oregon’s
Trillium Community Health Plan.
 AHEAD = Alignment for Health Equity and Development, funded
by Kresge. Also in Boston, Atlanta, and Dallas.
 Core Partners = Names of three core partner organizations for
each site (hospital/health system, public health department,
community org/local non-profit)
 BHPN = Build Healthy Places Network. Partnered with Kresge to
issue the Joining Forces Planning Grants to Albuquerque,
Houston, and Springfield BUILD sites. Grants of $20,000 were
issued for sites to work with community development orgs.
 CHP = Community Health Peer Learning Program, funded by
ONC and led by Academy Health. Also includes: Austin,
Cincinnati, Santa Maria Valley in southern California, New
Orleans, Humboldt County in Northern CA, a multi-county region
in Southwest Washington State, Nashville, Burlington, VT. *The
following are SME communities for CHP: Minneapolis, San
Diego.
 CHSC = RWJF sponsored 30 communities/regions including:
States/Region: Oklahoma, Vermont, Tennessee, Chickasaw
Nation, North Central Nebraska (9-county region: Antaloupe,
Boyd, Brown, Cherry, Keya-paha, Knox, Holt, Pierce, and Rock
Counties). Northeast: Allegheny County, PA; Danvers, MA;
Oxford County, ME; New Haven, CT; White Plains, NY.
Southeast: Baltimore, MD; Louisville, KY; Mobile, AL; Granville
County, NC; Adams County, MS; Tampa, FL. Midwest:
Milwaukee, WI; Sanilac County, MI; Monona County, IA; Finney
County, KS; Toledo, OH. Southwest: Midland, TX; Harris County,
TX; Maricopa County, AZ; San Juan County, NM. West: San
Diego County, CA; Tacoma, WA; Stockton, CA; Butte, MT;
Rexburg, ID.
 CTSA = Clinical and Translational Science Awards, funded by
NIH.
 DASH = Data Across Sectors for Health. Also includes: San
Antonio, Dallas, New York City, Portland ME, St. Paul and
Ogema, MN, and Pittsburg.
 FQHCs = Federally Qualified Health Centers
 Freshlo = Fresh, Local & Equitable: Food as a Creative Platform
for Neighborhood Revitalization” – the initiative is a joint effort by
Kresge’s Arts & Culture Program and Health Program. 26 cities.
 Healthiest C&C = Healthiest Cities and Counties Challenge.
Partnership between the Aetna Foundation, the American Public
Health Association and the National Association of Counties and

administered by CEOs For Cities. The partnership empowers
small to mid-size U.S. cities and counties to create a positive
health impact.
 Invest Health = Collaboration between Robert Wood Johnson
Foundation and Reinvestment Fund. Grants to mid-sized cities.
See website for list of cities.
 P2P = Pathways to Pacesetter Communities. Pathway to
Pacesetter (P2P) is a program that supports communities in
accelerating their improvement journey. The goal of Pathway to
Pacesetter is to support local leaders at every level of a
community to be successful and multiply their effectiveness in
achieving their existing vision and goals. For those that applied
to SCALE but were not ready or not accepted.
 PRC = CDC Prevention Research Centers. The Prevention
Research Centers work as an interdependent network of
community, academic, and public health partners to conduct
prevention research and promote the wide use of practices
proven to promote good health. PRCs work with at-risk
communities to promote health and prevent chronic diseases
such as cancer, heart disease, and diabetes. In 24 states total.
 PHTC = Regional Public Health Training Centers. Provide
education, training and consultation to State, local, and Tribal
health department staff. Also in Atlanta, Boston, Iowa City, New
Orleans, Pittsburg, Tucson.
 Resilient = 100 Resilient Cities. 100 cities throughout the world,
funded by Rockefeller Foundation.
 REACH= CDC funded. Click hyperlink for full list of cities.
 ReThink Health = Also in Atlanta, Upper Connecticut River
Valley, Pueblo, CO, Columbia, SC.
**ReThink Health helped five regions and their respective state
quality improvement organizations (QIOs) explore innovative
ways to improve health and health care and lower costs for
Medicaid beneficiaries. The five communities were: Baltimore,
Maryland; Houston, Texas; Monroe, Louisiana; the State of
Arkansas; and the State of West Virginia. Part of a special
innovations project for the Centers for Medicare and Medicaid
Services (CMS)
 SCALE = Spreading Community Accelerators through Learning
and Evaluation. Also in Algoma, WI; Atlanta; Boston;
Cattaraugus Co, NY; Cheshire Co, NH; Hennepin, Co, MN;
Jackson, MI; Laramie Co, WY; Maricopa Co, AZ; North
Colorado; Oklahoma City, OK; Pueblo, CO; Raleigh, NC; Salt
Lake City; San Francisco; San Gabriel Valley, CA; Sitka, AR;
Summit County, OH; Waterville, ME; Williamson, WV.
 W2W = Way to Wellville. Currently not in any BUILD site
locations. The five grantees are: Clatsop County, Oregon;
Greater Muskegon, Michigan; Lake County, California; Niagara
Falls, New York; and Spartanburg, South Carolina. The
challenge sponsor is HICCup (Health Initiative Coordinating
Council, www.hiccup.co), a nonprofit that encourages new
models and markets for the production of health.

For more national program and grant information by city/state, see the Trust For America’s Health, Healthy Communities Navigator.
OTHER NOTEWORTHY INITIATIVES NOT INCLUDED:
Systems for Action = Four new research studies aim to improve health across entire communities by integrating the delivery and financing of medical
care, public health, and social services. As part of the new Systems for Action: Systems and Services Research to Build a Culture of Health Research
Program, the Robert Wood Johnson Foundation today announced $1 million in funding to support studies led by the Los Angeles County Department of
Public Health, Drexel University, Michigan State University, and the University of Delaware. The Systems for Action National Coordinating Center, housed
at the University of Kentucky College of Public Health, will manage these studies as part of its national portfolio of research focused on systems and
services research.
Promise Zone Communities = – high poverty areas in select urban, rural and tribal communities. Through the Promise Zone Initiative, the Federal
government will work strategically with local leaders to boost economic activity and job growth, improve educational opportunities, reduce crime and
leverage private investment to improve the quality of life in these vulnerable areas.

Parallel Initiatives: City-Level Breakdown
ALBUQUERQUE, NM
CORE PARTNERS:
 Adelante Development Center, Inc.
 Presbyterian Healthcare Services
 First Choice Community Healthcare
ACH: Bernalillo County, New Mexico’s Pathways to a Healthy Bernalillo
County initiative
CMMI Model Grant:
 APCP Demonstration: First Choice Community Healthcare, Inc.
 BPCI Model 2: Lovelace Medical Center and Desert Orthopedic
Center
 HCIA: University of New Mexico Health Sciences Center
 SIM Round 2: State of NM
CTSA: University of New Mexico Clinical and Translational Science
Center
FreshLo: Partnership for Community Action
Playworks Everywhere: Downtown ABQ Mainstreet Initiative (JUEGO:
El Way-Go)
PRC: University of New Mexico Health Sciences Center
REACH: Presbyterian Healthcare Services
SCALE:
 Bernalillo County Community Health Council: Presbyterian
Healthcare Services-Community Health, Bernalillo County
Community Health Council, Presbyterian Healthcare Services-
Community Health, NM Department of Health/Health Promotion,
Albuquerque P. Community Aim – 1000 people in the
International District and the South Valley will set and reach their
goals for walking by December 2016.
BALTIMORE, MD
CORE PARTNERS:
 Druid Heights Community Development Corporation
 City of Baltimore Health Department
 R Adams Cowley Shock Trauma Center, University of Maryland
Medical Center
Other Partners: Promise Heights -- UMB SSW, Communities United,
Roberta's House, University of Maryland
CMMI Model Grant:
 APCP: Sinai Community Care
 HCIA: Johns Hopkins School Of Nursing MD
 Innovation Advisors Program: David Baker DrPH, MBA (Sinai),
Janet Will BSN, MSN, Maxine Vance BSN, MSN, PhD
 SIM Design Award Round Two: State of MD
 Strong Start for Mothers and Newborns Initiative: Bayview
Medical Center, East Baltimore Medical Center, Johns Hopkins
Outpatient
Culture of Health Sentinel Community
CTSA: Johns Hopkins University Institute for Clinical and Translational
Research
DASH: Baltimore City Health Department
P2P: Healthy Babies Collaborative: MedStar Franklin Square Medical
Center
Playworks Everywhere: Parks & People Foundation (Nature Play
Space Pop-up in Mondawmin Community of Baltimore City)
PRC: Johns Hopkins University
ReThink: Delmarva Foundation for Medical Care

BRONX, NY
CORE PARTNERS:
 Montefiore Medical Center
 New York City Department of Health and Mental Hygiene
 Northwest Bronx Community & Clergy Coalition
Other Partners: MIT Community Innovators Lab
CTSA: New York University Clinical and Translational Science
Institute
CMMI Model Grant:
 APCP: Urban Health Plan, Inc.
 BPCI: Montefiore Medical Center
 HCIA: Bronx Regional Health Information Organization,
Montefiore Medical Center
 MAPCP: State of NY
 SIM: Model Testing Awards Round Two: State of NY
DASH: NYC Department of Health and Mental Hygiene
PHTC: Region II- Columbia University, Health Disparities, Health Equity,
Social Determinants of Health
PRC: New York University School of Medicine and City University of
New York School of Public Health
REACH: Bronx Community Health Network, Inc.
CHICAGO, IL
Core Partners:
 Legal Assistance Foundation (LAF)
 Cook County Health and Hospitals System
 Chicago Department of Public Health
CHP: The University of Chicago Medicine.
The University of Chicago Medicine will provide expertise in
data integration to the CHP Program. As the anchor health care
institution on the south side of Chicago, they convened and
collaborated with community partners to address critical health
issues in their communities. Through their Medical Home
Connection program, they leveraged partnerships with
community health centers to use consistent messaging when
educating emergency department utilizers on the value of using
medical homes for ongoing care. Patient Advocates scheduled
follow up medical home visits for patients who were discharged
from the emergency room. Through an electronic portal they sent
real-time information to the health centers informing them of the
patients emergency room visit and follow up appointment. The
program successfully increased the average show rate to follow
up appointments from 35 percent to 60 percent. With the
adoption of an electronic patient information portal integrated
with the electronic information system, the program expanded.
With the use of data from multiple sources the collaborating
partners have implemented several additional population health
management programs.
CMMI Model Grant:
 APCP: ACCESS at Anixter Center Chicago, ACCESS Grand
Boulevard Family Health Center, ACCESS Madison Family
Health Center, Austin Family Health Center, Chicago Family
Health Center, Circle Family HealthCare Network, Inc., Erie
Humboldt Park Health Center, Heartland Health Center –
Uptown, South Chicago
 BPCI: Mercy Hospital And Medical Center, Presence
Resurrection Medical Center, Presence Saint Joseph Hospital-
Chicago, Swedish Covenant Hospital, Mount Sinai Hospital,
Rush University Medical Center, Northwestern Memorial
Hospital, University Of Chicago Medicine
 Community-based Care Transitions Program: Catholic Charities
of the Archdiocese of Chicago
 Graduate Nurse Education Demonstration: Rush University
Medical Center
 Strong Start for Mothers and Newborns Initiative: ACCESS
Health centers, Erie Family Health Center
DASH: Public Health Institute of Metropolitan Chicago
FreshLo: Inner-City Muslim Action Network
PHTC: Region V University of Illinois at Chicago-Environmental Public
Health

Play Everywhere: Lekotek-a Division of Anixter Center (Stop n' Play),
Urban Initiatives (Shark Park), Rogers Park Business Alliance
(¡Escaleras!), Chicago Children's Theatre (Chicago Children's Theatre:
Dreams on Parade), World Sport Chicago (Perma-PlayStreets),
PRC: The University of Illinois at Chicago
SCALE:
 Proviso Partners for Health: Triton College, Proviso-Leyden
Council for Community Action, Loyola Chicago Stritch School of
Medicine, Proviso East High School, Triton College, Loyola
University Hospital.
100 Resilient Cities: Mayor’s Office
CLEVELAND, OH
CORE PARTNERS:
 City of Cleveland Department of Public Health
 Environmental Health Watch
 The MetroHealth System
Other Partners: Hispanic Alliance Inc
CHP Program: University Hospitals Rainbow Babies & Children’s
Hospital will work to prevent and manage the childhood asthma disease
burden in target neighborhoods in Cleveland, Ohio.
Fostering partnerships among the health care, public health,
housing, social services, environment, and criminal justice
sectors, the organization will use data from electronic health
records, and public and private records, and Medicaid claims to
integrate existing pediatric longitudinal social, environmental,
educational, and clinical data. Through this work, they anticipate
the ability to create an accountable care community to
collectively improve the health and wellness of these Cleveland
neighborhoods.
CMMI Model Grant:
 APCP: Neighborhood Health Care, Inc. dba Neighborhood
Family Practice, NEON Southeast Health Center
 BPCI: Fairview Hospital, Lutheran Hospital Cleveland, University
Hospitals Cleveland Medical Center, Kindred Hospital Cleveland,
Sunset Manor Healthcare Group, Inc., University Manor
Healthcare Group, Inc.
 HCIA: University Hospitals of Cleveland
 Independence at Home Demonstration: Cleveland Clinic Home
Care Services: Medical Care at Home Program Independence
 SIM Model Testing Awards Round 2: State of OH
CTSA: Case Western Reserve University Clinical and Translational
Science Collaborative
Healthiest Counties and Cities Challenge: Cleveland Department of
Health
FreshLo: Environmental Health Watch
Playworks Everywhere: Cuyahoga Metropolitan Housing Authority
(Harmony Park at Lakeview Terrace)
PRC: Case Western Reserve University
REACH: Asian Services in Action, Inc; Cutoba County District Board of
Health; YMCA of Greater Cleveland
SCALE:
 BuckeyeHEAL: Cleveland Metropolitan Housing Authority,
MetroHealth - Center for Reducing Health Disparities, Buckeye
Shaker Square Development Corporation, East End
Neighborhoods House, Fairhill Partners. Community Aim – By
Dec 31st, 2016, the HEAL Coalition will have a sustainment and
capacity building plan that will support the infrastructure for
community leadership for all healthy eating and active living
activities for the Buckeye neighborhoods.
COLORADO SPRINGS, CO
CORE PARTNERS:
 YMCA of the Pikes Peak and Region/LiveWell Colorado Springs
 El Paso County Public Health
 Penrose St. Francis Health Services
Other Partners: El Paso County Public Health, Kaiser Permanente CO
CMMI Model Grants:
 APCP: Family Health Center at Union

 BPCI: Penrose-St. Francis Health Services, Colorado Springs
Orthopaedic Group, Emeritus At Bear Creek Long Term Care
Community, Encompass Home Health Of Colorado
 CPCI: Colorado Springs Health Partners P.C., Summit Medical
Clinic, PC, Sunrise Health Care, PC
Playworks Everywhere: Boys & Girls Club of the Pikes Peak Region
(Pride, Purpose, Promise)
AURORA AND DENVER, CO
AURORA / CORE PARTNERS:
 Together Colorado
 Children's Hospital Colorado
 Tri-County Health Department
DENVER / CORE PARTNERS:
 Denver Public Health
 Denver Health and Hospital Authority
 The Civic Canopy
Other Partners: Irving Harris Program in Child Development and Infant
Mental Health (Aurora), Family Leadership Training Institute (Denver)
CMMI Model Grants:
 APCP: Denver Health (Bernard Gibson Eastside Family Health
Center, La Casa/Quigg Newton Family Health Center, Lowry
Family Health Center
 BPCI: Centura Health - Porter Adventist Hospital, Emeritus At
Roslyn Long Term Care Community, Encompass Home Health
Of Colorado
 CPCI: Mayfair Internal Medicine
 HCIA: Denver Health And Hospital Authority CO
 SIM Model Testing Awards Round Two: State of CO
CTSA: Colorado Clinical and Translational Sciences Institute (in Aurora)
FreshLo: Montbello Organizing Committee
PHTC: Rocky Mountain Public Health Training Center run by the
University of Colorado.
Playworks Everywhere: ReArranging Denver (You Are Here), Rocky
Mountain Communities (PLAYce to Play & Learn)
REACH: The Stapleton Foundation for Sustainable Urban Communities,
Colorado Black Health Collaborative, Inc.
DES MOINES, IA
CORE PARTNERS:
 Polk County Housing Trust Fund
 UnityPoint
 Polk County Health Department
Other Partners: Visiting Nurse Services of Iowa, Mid Iowa Health
Foundation, The Trilix Group
CMMI Model Grants:
 ACO: Heartland Physicians ACO, Inc.
 BCPI: Mercy Medical Center Des Moines, Des Moines
Orthopaedic Surgeons Pc, BEC Medical and Dental, East Side
Center
 Next Gen-ACO: Iowa Health Accountable Care
 SIM Testing Awards Round Two: State of Iowa
Invest Health: United Way of Central Iowa, Polk County Housing Trust
Fund, City of Des Moines, Polk County Health Department, Des Moines
University
Playworks Everywhere: Community Youth Concepts (Sidewalk Chalk
Flood 2.0)
DETROIT, MI
CORE PARTNERS:
 Eastside Community Network
 St. John Providence Health System – Community Health
Investment Corporation
 Detroit Department of Health and Wellness Promotion

Other Partners: Detroit Community-Academic Urban Research Center,
Gensler, Detroit Eastside Community Collaborative
CHP Program: Greater Detroit Area Health Council
The Greater Detroit Area Health Council (GDAHC) is a not-for-
profit organization that has extensive knowledge of data
analysis, and performance measurement and data
dissemination. GDAHC currently works as one of seven
initiatives across the country focused on the use of electronic
health records and supporting data to identify population-level
issues, such as antibiotic use for viral infections and appropriate
screening for Vitamin D deficiencies, with a goal to improve
quality, health, and efficiency. They are dedicated to
transparency in data sharing, and have successfully launched a
system of multi-payer data measurement and public reporting of
physician performance on their website (myCareCompare.org).
In addition, they successfully provide aggregated individual
physical level data to physician organizations to guide quality
improvement.
CMMI Model Grants:
 BPCI: Detroit Receiving Hospital, Sinai Grace Hospital
Detroit, Regency Heights-Detroit, Boulevard Temple Care
Center, Hartford Nursing & Rehab Center
 HCIA: Altarum Institute MI, Feinstein Institute For Medical
Research, Henry Ford Health System, Institute For Clinical
Systems Improvement, Michigan Public Health Institute,
TransforMED, Detroit Medical Center, Vanguard Health
Systems, Regents Of The University Of Michigan
 Multi-Payer APCP: State of Michigan
 SIM: Model Testing Round Two
 Transforming Clinical Practices Initiative: National Rural
Accountable Care Consortium
 Next Gen ACO: Henry Ford Physician Accountable Care
Organization Detroit,
 Strong Start for Mothers and Newborns Initiative: St. John
Hospital and Medical Center Detroit
FreshLo: Focus: Hope
Playworks Everywhere: Focus: HOPE (Popup Play at the Library),
University of Michigan Stamps School of Art and Design (FitLIGHT),
Matrix Human Services (The Osborn Community Game-scape).
HOUSTON, TX
CORE PARTNERS:
 The University of Texas MD Anderson Cancer Center
 Houston Food Bank
 Harris County Public Health & Environmental Services
Other Partners: CHI St. Luke's Health, Memorial Hermann Health
System
CMMI Model Grants:
 BPCI: Encompass Home Health Of Houston
 HCIA: Center for Healthcare Services, Christus St. Michael
Health System, Innovative Oncology Business Solutions, Inc.,
MedExpert International Inc., The Methodist Hospital Research
Institute, The National Health Care for the Homeless Council,
The University Of Texas Health Science Center At Houston
 SIM: Model Design Award
 Transforming Clinical Practices Initiative: American College of
Emergency Physicians TX, VHS Valley Health Systems, LLC
 Advanced Payment ACO Model: Physicians ACO, LLC
 Next-Gen ACO Model: Accountable Care Coalition of Southeast
Texas Inc.
 Strong Start for Mothers and Infants: Casa de Amigos Health
Center
Culture of Health Sentinel Community
CTSA: University of Texas Health Science Center at Houston Center for
Clinical and Translational Sciences
Playworks Everywhere: Community Design Resource Center
University of Houston (PLAY Court).
ReThink: Texas Medical Foundation Health Quality Institute

LOS ANGELES, CA
CORE PARTNERS:
 National Health Foundation
 Los Angeles County Department of Public Health
 Dignity Health dba California Hospital Medical Center.
CMMI:
 HCIA: Asian Americans For Community Involvement, California
Long-Term Care Education Center, Family Service Agency Of
San Francisco, Foundation for California Community Colleges,
Healthlinknow, Inc.,
 SIM Model Design Award
 FQHC APCP: Asian Pacific Health Care Venture, Inc.,
QueensCare Family Clinics, South Central Family Health Center
 Next-Gen ACO: Prospect ACO CA, LLC
CHP: California Family Health Council
CTSA: University of California, Los Angeles Clinical and Translational
Science Institute
Playworks Everywhere: National Health Foundation (AhMAZE-me
South Central (Enrueda-te South Central), CicLAvia (CicLAvia pLAy)
REACH: AltaMed Health Services Corporation; Community Coalition for
Substance Abuse Prevention and Treatment; Regents of the University
of California, Los Angeles;
SCALE:
 Women of the Skid Row Community: JWCH Institute, Downtown
Women. Community Aim - Improve the health of at least 50
women with or at risk for diabetes in the Skid Row community by
10/1/16.
 San Gabriel Valley Healthy Cities Collaborative: Neighbors
Acting Together Helping All (NATHA), City of Hope, Neighbors
Acting Together Helping All (NATHA), City of Duarte, Duarte
Unified School District (DUSD). Community Aim - Improve
healthy living and well-being in high school youth.
100 Resilient Cities
 Mayor’s Office - http://www.100resilientcities.org/cities/entry/los-
angeles-resilience-challenge#/-_/
MIAMI, FL
CORE PARTNERS:
 Florida Institute for Health Innovation
 Florida Department of Health, Miami-Dade County
 Jackson Health Systems
CMMI Models:
 HCIA
 Transforming Clinical Practices
 FQHC APCP: Jessie Trice Community Health Center
 Next-Gen ACO Model: Baroma Accountable Care, LLC.
P2P: Healthy West Kendall: West Kendall Baptist Hospital.
Playworks Everywhere: City of Miami (iPlay MIAMI Streets)
OAKLAND, CA
CORE PARTNERS:
 Sutter Health Alta Bates Summit Medical Center
 East Bay Asian Local Development Corporation
 Alameda County Public Health Department
CMMI Models:
 HCIA
 BCPI: Webster Orthopaedic Medical Group, Apc
 FQHC APCP: LifeLong Medical Care - Downtown Oakland
Clinic
FreshLo: Planning Justice
Playworks Everywhere: Our City (Our City Oakland), Family Friendly
Oakland (PlayEverywhere Mosaic Trash Can Makeovers)
PRC: University of California, San Francisco
Reach: Mandela Marketplace, Inc.
100 Resilient Cities: Mayor’s Office

PORTLAND, OR
CORE PARTNERS:
 Oregon Public Health Institute
 Providence Health & Services
 Multnomah County Health Department
CHP: Providence Center for Outcomes Research and Education
(CORE)
CMMI:
 HCIA: Providence Portland Medical Center, St. Luke's Regional
Medical Center, Ltd.
 Medicare Advantage Value-Based Insurance Design Model
 SIM Model Testing
 Transforming Clinical Practice Initiative
 BPCI: Orthopedic And Fracture Clinic, Pc, Laurelhurst
Operations, LLC
 CPCI: Cascade Physicians, Northwest, Family Medical Group
Northeast PC, LEMC Internal Med, LGS Internal Medicine, LMG
Northwest, OHSU Family Medicine - Gabriel Park, OHSU Family
Medicine at South Waterfront, OHSU Internal Medicine Clinic -
Marquam Hill, Pacific Medical Group - North Portland, PMG
North Portland Family Medicine, Providence Medical Group,
Rose City Clinic, LLP, The Portland Clinic - East Branch
 FQHC APCP: Old Town Clinic
CTSA: Oregon Clinical and Translational Research Institute
Playworks Everywhere: Hacienda CDC (Portland Mercado) (Viajando
en el Mercado), City of Portland Bureau of Transportation Active
Transportation and Safety Division (Sitton Elementary School and
George Middle School Walking School Bus Stops)
PRC: Oregon Health and Science University
REACH: Multnomah County Health Department
SAN BERNARDINO COUNTY, CA
CORE PARTNERS:
 San Bernardino County Public Health Department
 San Antonio Regional Hospital
 Partners for Better Health
Other Partners: HC2 Strategies, El Sol Neighborhood Center, City of
Ontario, The 20/20 Network, Partners for Better Health, City of Ontario
CMMI:
 HCIA
 BCPI: Community Hospital Of San Bernardino, Saint Bernardine
Medical Center
SEATTLE, WA
CORE PARTNERS:
 Public Health - Seattle and King County
 Swedish Medical Center
 Interim CDA
CMMI:
 HCIA: Seattle Children’s Hospital WA
 SIM: Model Testing Awards
 Transforming Clinical Practices Initiative: PeaceHealth Ketchikan
Medical Center WA, University of Washington, Washington State
Department of Health
 BPCI: Seattle Operations, LLC
 APCP: International Community Health Services - Holly Park,
Neighborcare Health,
CTSA: University of Washington Institute of Translational Health
Sciences
DASH: Public Health – Seattle and King County, Seattle Public Housing
Authority, King County Public Housing Authority
FreshLo: Rainer Beach Action Coalition

Playworks Everywhere: Public Health Seattle & King County (Transit
Play Spaces)
PRC: University of Washington
100 Resilient Communities: Mayor’s Office
SPRINGFIELD, MA
CORE PARTNERS:
 HAPHousing
 Baystate Health
 City of Springfield Health and Human Services
Other Partners: Mercy Medical Center, Mason Square Health Task
Force, Partners for a Healthier Community, Old Hill Neighborhood
Council
CMMI:
 HCIA
 BPCI: Baystate Medical Center, The Mercy Hospital,
 Next-Gen ACO: Pioneer Valley Accountable Care, LLC

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