Understanding the Impact of the Rural Health Network Development and Rural Health Care Services...
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Transcript of Understanding the Impact of the Rural Health Network Development and Rural Health Care Services...
Understanding the Impact of the Rural Health Network Development and
Rural Health Care Services Outreach Grant Programs:
A Sustainability Assessment of Former Grantees
Community Health System Development TeamGeorgia Health Policy Center
August 2, 2010
Today’s Objectives
• Present the goals of the Sustainability Assessment of former ORHP grantees
• Share findings and insights
Sustainability Assessment
• Purposes: – Describe the extent to which ORHP-funded
community-based demonstration programs have been sustained post-funding
– Identify recurrent patterns that influence likelihood of sustainability
Sustainability Assessment
• Population studied:– Rural Health Care Services Outreach and
Rural Health Network Development grantees funded in 2000, 2002 and 2004.
• Telephone interviews completed with 102 of 129 grantees
Sustainability Assessment
• Analysis Approach– Study designed with rural communities in
mind– Findings applicable to a wide audience:
rural communities and funders– Qualitative and quantitative analyses
conducted
Sustainability Assessment
• Summary of conclusion:– No discrete set of best practices. – Each situation has unique context.
Transferability of practices may be limited.– There are dynamics, though, that impact
sustainability.
Findings and Insights
1. Broadening the Concept of Sustainability
2. Selected Quantitative Findings
3. Dynamics that Influence Sustainability
Framing the Sustainability Assessment
• Broadening the concept of sustainability– More than just whether or not the grant-funded
activities and collaboratives have been sustained - such an assessment understates grantees’ long-term impact and misses the opportunity to improve outcomes
– We must look in a more comprehensive way • What has been sustained…for how long?• How it has been sustained?• Why it has been sustained (or not)?
What has been sustained?
What has been sustained?
And:
Community and Population Benefits Sustained
• Culture changes– Relationships, foundation for working
together, trust, resolved conflict• Practice standards• Policy• Public awareness and perceptions• Capacity
Assets Purchased or Created
• Equipment
• Curricula
• HIT capacity
How Have They Been Sustained?Means of Sustaining Activities
• Absorbed by partners• Other grants• In-kind• Third party reimbursement• Client fees• Taken over by newly-formed FQHC
How Have They Been Sustained?Means of Sustaining Coalitions
• Member in-kind contributions/ Volunteerism
• Grants
• Service revenue
• Member financial contributions/ dues
Stories Provide Windows of Understanding
• 102 grantees interviewed
• Each told a story– Insights– Examples– Reality
Grantee Stories
1. Read the story
2. Reflect individually– What was sustained? Why?
3. Discuss in small group
Grantees InterviewedTotal
(n) OutreachNetwork
Development
Grantees to be interviewed
129 100 29
Interviews Completed
79% (102) 78% (78) 83% (24)
Contact made, Confirmed not sustained
3% (4) 3% (3) 3% (1)
Declined participation
6% (6) 6% (6) 0
Not able to locate/ Unresponsive
17% (17) 13% (13) 14% (4)
What was Sustained:Status of Outreach Consortia*
Consortium Currently Sustained Outreach Grantees
Yes, formally 34% (26)
Yes, informally 12% (9)
No 55% (42)
*Based on 77 of the 78 Outreach grantee programs reviewed. One grantee was unable to confirm the current status of the consortium.
What was Sustained:Status of Networks*
Network Sustained Currently Network Development grantees
Yes, formally 61% (14)
Yes, informally 4% (1)
No 35% (8)
*This table presents information from 23 of 24 Network Development grantees interviewed. One informant was unable to confirm the current status of the Network.
The Means of Sustaining Outreach Consortia
Means of Sustaining the Consortium* Outreach grantees that have sustained consortia, formally or
informally (n=35)
Member In-kind contributions/ Volunteerism 71% (25)
Grants 46% (16)
Service revenue 23% (8)
Member financial contributions/dues 11% (4)
Fundraising and Donations 6% (2)
*Grantees may have reported multiple means of sustaining their consortia
The Means of Sustaining Networks
Means of Sustaining the Network* Network Development grantees that sustained Network post grant period,
formally or informally (n=15)
Grants 67% (10)
Member In-kind contributions/ Volunteerism
53% (8)
Service revenue53% (8)
Member financial contributions/dues27% (4)
*Grantees may have reported multiple means of sustaining their Networks
What was Sustained:Activities and Services
All ORHP-funded activities sustained
for any period of time post-funding
Some ORHP-funded activities sustained
for any period of time
None of the ORHP-funded activities following end of
grant period
Network Development
Grantees
63% (15) 25% (6) 13% (3)
Outreach Grantees 60% (47) 36% (28) 4% (3)
Total 61% (62) 33% (34) 6% (6)
What was Sustained:Activities and Services
All grantees All ORHP-funded activities sustained
currently
Some ORHP-funded activities sustained
currently
None of the ORHP-funded activities
sustained currently
2000 Cohort (n=51) 47% (24) 37% (19) 16% (8)
2002 Cohort (n=33) 42% (14) 39% (13) 18% (6)
2004 Cohort (n=18) 61% (11) 33% (6) 6% (1)
Total (n=102) 48% (49) 37% (38) 15% (15)
.
Means of Sustaining Activities and ServicesPercentage of Grantees
Sustaining Activity by mean* (n)N=96
Percentage of ActivitiesSustained by Mean (n)
N=214
Absorbed by partner 57% (55) 42% (89)
Other Grants 46% (44) 31% (67)
In Kind/Volunteerism 46% (44) 31% (67)
Third Party Reimbursement 39% (37) 27% (57)
Client Fees 27% (26) 15% (33)
Government/Public Subsidy 23% (22) 20% (42)
Earned Income 14% (13) 9% (19)
Taken Over by Newly Formed FQHC
11% (11) 10% (21)
Member Fees/Dues 5% (5) 6% (13)
Equipment/Resources still available in the community
4% (4) 2% (5)
* Grantees reported multiple means of sustaining each activity
Insights from the Sustainability Assessment
• Sustainability requires a broader definition– What gets sustained?– How is it sustained?
• For this assessment to be applicable to other rural communities, it must also explain the dynamics that influence sustainability– Why (or not) is it sustained?
Dynamics Influencing Grantee Sustainability
• No set of best practices or criteria that determine level of sustainability success– Context specific– Inter-relatedness of factors
• There are, however, dynamics that seem to influence sustainability– Useful in predicting success– Can impact some factors to favorably, or unfavorably,
change dynamics
Influencing Dynamics
WHO Dynamic
• Primarily about leadership– Ability to engage the “right” people
• Strategic• Influential
– Create shared ownership and commitment– Resolve conflict
WHO Dynamic
Favorable Characteristics Unfavorable Characteristics
Engaged leaders with strategic mindset
Partners sense struggle for control
Widespread sense of trust among partners
Lack of consistent presence by partners
Key decision makers and influencers are involved or easily accessed
Conflict left unresolved
Partners share passion and purpose for the program
Belief that each partner has own agenda first
Vision for program is shared Partners are informed about activities not engaged in leading and planning
Examples
The right people at the table
• A network in the Northeast writes participation in Network into job descriptions of CEOs
• A consortia in the Midwest lost the decision-makers and lost its way.
WHAT Dynamic
• Related to the substance of the intervention– Designed program demonstrates:
• Relevance• Practicality• Value
– Program is aligned to community context
WHAT Dynamic
Favorable Characteristics Unfavorable Characteristics
Solution based on clear assessment of community needs
Solution only addresses symptoms and not root causes
Partners have leverage to address the problem long-term
Solution approach does not match partner and provider culture
Stakeholders benefit directly (Network)
Legal barriers – real or perceived – halt progress
Program or service has a value that others would be willing to reimburse and/or purchase
Stakeholders and potential partners do not perceive recognizable value of solution
The solution evolves and adapts as the environment changes and knowledge is acquired
Solution attempts to solve too many issues with too many small, unrelated efforts
Examples
Aligning approach to context/root cause of issue:
• Training program for EMT Medical Directors in the Mountain West
• Providing primary care to poor, uninsured through a cost sharing model in the Pacific Northwest
WHY Dynamic
• About the motivation for partners to work together– Well-defined vision for working together– Shared vision and understanding of roles– Use HRSA grants as a means to an end
versus being an end unto itself
WHY Dynamic
Favorable Characteristics Unfavorable Characteristics
There is a clear focus to the vision Sense of fear and desperation among partners
Efforts are aligned and prioritized to vision and goals
Many partners believe that others are just “looking for money”
Partners have formed a strong sense of group identity
Partners believe they’ve come together just to deliver on grant
Focused both on system change and meeting partner member needs
All goals and plans are short-term without alignment to a larger vision
Clear understanding of need based on evidence
Partners can not clearly explain why they are at the table
Examples
Shared vision and understanding of project goals
• Network in New England coordinates case management, provider training and a regional needs assessment
• School-based referral network in a Plains state
HOW Dynamic
• Relates to the way programs or networks are operationalized– Effective strategies employed– Adequate capacity built– Impact and value is documented and
communicated
HOW Dynamic
Favorable Characteristics Unfavorable Characteristics
Capable and skilled staff are employed to deliver solution
Sustainability is a topic of discussion late in the grant period
Impact and value is documented and communicated
Organization lacks staff capacity to fully implement solution
Partner assets are utilized to integrate program components into existing infrastructure
Spend resources on unreasonable and unwarranted overhead expenses
Focused both on system change and meeting partner member needs
Value of program is communicated only to partners
Clear understanding of need based on evidence
Coalition fails to begin with the end in mind
Examples
How a plan is put into action - Efficiency and effectiveness:
• Establishing a clinic in the fire department in the Northwest: developing new infrastructure vs. building on existing assets
• Hiring new staff vs. building the capacity of existing staff
WHERE and WHEN Dynamic
• Factors typically beyond the control of grantees– The legal, social, cultural, and economic
environment at the time of program implementation
– Coincidental trends at the time of program delivery
– Makes each situation unique and prevents application of universal best practices
WHERE and WHEN Dynamics
Where Factors When Factors
State policies and mandates Economic pressures
Geography of program location Receipt of multiple grants
Availability of technology Length of planning
Reimbursement climate History of working together & turnover of key staff
Organizational culture – university, FQHC, PH
Idea surfaces before its time – acceptance, technology, etc.
Hostile or competitive environment Ability to collect timely results to demonstrate impact
Examples
Timing and context
• Establishing a program to certify medical interpreters in a hospital in the Southeast
• Building a mental health tele-network in the Mid Atlantic
Review• Communities that receive grant funding have
sustained a broad range of community impacts– From short term outputs to long term community
benefits like changes in policy or practice • Most communities report sustaining activities
through diversified funding streams – Absorption, In-kind, Other grants, Reimbursement
• Sustainability cannot be attributed to any one factor or type of intervention.– The “who, what, why, where, when and how”
factors combine in infinite ways leading to a broad range of outcomes at the community level
Questions?