CONCLUSIONS

Designing Equitable Health Systems

Using Network Analysis

PROBLEM

Transforming the health care system as required by the

Patient Protection and Affordable Care Act of 2010

“A health system consists of all organizations, people,

and actions whose primary interest is to promote,

restore, or maintain health.” World Health Organization

How can we:

Map the system?

Coordinate actors?

Design a more equitable system?

Stephanie Bultema, Senior Researcher, University of Colorado Denver Center on Network Science

Hadley Morrow, Associate Director of Community Engagement, Better Health Together

Amy Riffe, Epidemiologist 2, Spokane Regional Health District Data Center

Stacy Wenzl, Program Manager, Spokane Regional Health District Data Center

Alison Poulsen, Executive Director, Better Health Together

Ansell, Chris and Alison Gash. 2008. “Collaborative Governance in Theory and Practice.” Journal of Public Administration

Research and Theory 18, no. 4: 543-71.

Berwick, Donald M., Thomas W. Nolan, and John Whittington. 2008. “The Triple Aim: Care, Health, and Cost.” Health

Affairs 27, no. 3: 759-769.

Bryson, John M., Barbara C. Crosby, and Melissa Middleton Stone. 2006. “The Design and Implementation of Cross-Sector

Collaborations: Propositions from the Literature.” Special issue Public Administration Review 66, Collaborative Public

Management: 44-55.

Bultema, Stephanie. 2017a. “Better Health Together Community Linkage Mapping: An Assessment of the Regional

Population and Social Determinants of Health Systems. Spokane, WA: Spokane Regional Health District Data Center.

https://srhd.org/media/documents/BHTHealthSystems-AssessmentTechnicalReportOfFindings0.352017.pdf

Carothers, Bobbi J., Amy A. Sorg, and Douglas A. Luke. July 2015. “Baseline Network Assessments: Phase 1.” ReThink

Health. https://www.rethinkhealth.org/wpcontent/uploads/2015/09/ networkmapping _rth.pdf

Emerson, Kirk and Tina Nabatchi. 2015. Collaborative Governance Regimes. Washington, D.C.: Georgetown University Press.

Halfon, Neal, Peter Long, Debbie I. Chang, James Hester, Moira Inkelas and Anthony Rodgers. 2014. “Applying a 3.0

Transformation Framework to Guide Large-Scale Health System Reform.” Health Affairs 33, no. 11: 2003-2011.

Heider, Felicia, Taylor Kniffin, and Jill Rosenthal. 2016. “State Levers to Advance Accountable Communities for Health.”

National Academy for State Health Policy, May 2016.

Luke, Douglas A. and Jenine K. Harris. 2007. “Network Analysis in Public Health: History, Methods, and Applications.”

Annual Review of Public Health 28, no. 1: 69–93.

Marmot, Michael, Shron Friel, Ruth Bell, Tanja A.J. Houweling, and Sebastian Taylor. “Closing the Gap in a Generation:

Health Equity through Action on the Social Determinants of Health.” The Lancet 372, November: 1661-1669.

Provan, Keith G., and H. Brinton Milward. 1995. “A Preliminary Theory of Interorganizational Effectiveness: A Comparative

Study of Four Community Mental Health Systems.” Administrative Science Quarterly 40, no. 1: 1–33.

Towe, Vivian L., Laura Leviton, Anita Chandra, Jennifer C. Sloan, Margaret Tait, and Tracy Orleans. “Cross-Sector

Collaborations And Partnerships: Essential Ingredients To Help Shape Health And Well-Being Health Affairs 35, no. 11:

1964-1969.

Contact: stephanie.bultema@ucdenver.edu

Interactive web-based maps: https://arcg.is/2pH9kuT | Infographic: create.piktochart.com/output/23176905-web-bht-community-linkage-mapping

Data Collection

Electronic and paper survey

Relational, categorical, and open-ended questions

Survey response rate: 34%

Sample

3-phase snowball sampling method to network bounding

Organizations n=564

Partnerships n=9,039

Linkages n=17,417

Tools

Snap Survey, Gephi, Stata, ArcGIS Online, Piktochart

METHODS RESULTS REFERENCES

POPULATION

Better Health Together

Accountable Community for

Health Population and Social

Determinants of Health Systems

The Accountable Community for Health (ACH) Model is used in the

states of Washington, California, Minnesota, and Vermont.

Coordinating entities, often ACH organizations, provide governance

services for a region of the state. Better Health Together is the ACH

organization in Eastern Washington, which includes 6 counties and 3

tribal nations in urban and rural areas with a population of about

600,000 people.

HEALTH SYSTEM

564 organizations working to

improve individual and

population health for people in

Eastern Washington

Linkage Type

CONTEXT

Business Sector

Education Sector

Public Sector

Health Sector

Social Sector Figure 1 Eastern Washington’s health

system.

Target counties are highlighted in teal.

Each node represents a geocoded

organization. Nodes are sized by average

weighted in-degree and colored by

sector. Edges are colored to match the

sectors they link and are sized by weight.

Nodes outside the state boundary

represent organizations in other states

(not shown by geocoded location).

Diversity

Equity

Centrality

Nodes sized by betweenness centrality.

BHT = orange node

Multiplex Network Collaboration Network

# Orgs #

Interactions

Graph

Density

Avg.

Degree

A.W.

Degree

Network

Diameter

Avg. Path

Length

Avg.

Clustering

Coefficient

BHT 6-County

Region

564 9,039 0.06 16 30.9 4 2.3 0.39

Social Sector 249 1,926 0.03 7.7 14.6 5 2.2 0.31

Health Sector 108 1,091 0.09 10.1 18.5 4 2.1 0.52

Public Sector 103 170 0.02 1.6 3.7 5 2.3 0.12

Education Sector 78 329 0.06 4.2 12.5 4 2 0.48

Business Sector 27 7 0.01 0.3 0.4 5 2.3 0

Collaboration 412 5,050 0.03 12.3 27.3 5 2.2 0.42

Referral 362 2,726 0.02 7.5 12.8 8 3.2 0.17

Data Exchange 235 517 0.01 2.2 3 13 4.5 0.03

Education 223 473 0.01 2.1 2.4 9 2.6 0.05

Financial Support 228 273 0.01 1.2 1.3 4 1.5 0

Adams & Lincoln

County

57 93 0.03 1.6 3.2 4 2 0.13

Northeast Tri-

County

119 401 0.03 3.4 5 5 2.2 0.39

Spokane County 272 3,555 0.05 13.1 25.2 4 2 0.38

Tribal 21 42 0.1 2 3.4 4 1.9 0.36

Regional 95 50 0.05 4.74 11 3 2.2 0.27

Health systems with a

coordinating entity that have

high centrality are associated

with better outcomes.

(Burt 1982; Provan and Milward 1995;

Mitchell and Shortell 2000)

Ensuring equitable

representation of historically

underrepresented groups is a

vital component of successful

health systems.

(Towe et al. 2016; Emerson and Nabatchi

2015)

Collaborative networks

addressing a broad problem

set should have diverse

member representation.

(Mitchell and Shortell 2000; Towe et al.

2016; Emerson and Nabatchi 2015)