Coalitions were asked several questions to understand how they defined sustainability, whether and how they planned for it, and who was responsible for sustainability.
Sustainability definition. In the survey, coalitions were asked to complete the following sentence about sustainability—"According to your coalition’s definition, sustainability of your coalition means"—with one of the following options:
- Our coalition has the resources it needs to continue operating with our membership and structures in-tact for the long-term.
- Our coalition’s programs, services, and activities will continue in the long-term even if our coalition is no longer in operation.
- Both our coalition and its activities will continue in the long-term.
- Our coalition has made a lasting impact on our community that will continue regardless of whether our coalition or its activities continue operating.
Overall, coalitions were more likely to include some aspect of sustaining activities or impacts in the definition of sustainability. Across both sustained and not sustained coalitions, only 16 percent selected the definition that framed sustainability only in terms of the membership and structure of the coalition. Sustained and not sustained coalitions differed significantly (p<.01) in terms of how they define sustainability, as shown in Exhibit 24. Sustained coalitions were more likely to define sustainability in terms of the long-term operation of the coalition itself, while not sustained coalitions tended to define sustainability in terms of the coalition’s activities and impacts. Further, twenty percent of sustained coalitions reported that sustainability meant that the coalition had the resources it needed to continue operating with the membership and structures in-tact for the long-term, compared to only six percent of not sustained coalitions.
To provide some context for this finding, some of the key informants from not sustained coalitions commented that they perceived sustainability as the continuation of their work in the community—even if these activities continue through another entity. For example, one key informant from a not sustained coalition noted, "We planned it so that we would make sure that the services would be provided even if we no longer existed—it was by design that we focused on the programs that we were implementing, instead of focusing on sustaining the coalition." In contrast, other respondents from sustained coalitions emphasized that in order to continue to provide services, their coalitions had to sustain. A key informant from a sustained coalition shared, "It is important to sustain the coalition, because the coalition allows us to help our patients to utilize the healthcare system as it should be utilized." Another key informant from a sustained coalition echoed this point, explaining that "someone needs to be here to coordinate services."
Forty percent of sustained coalitions reported that sustainability meant the continued operation of the coalition and activities, compared to 19 percent of not sustained coalitions. Conversely, forty percent of not sustained coalitions reported that sustainability meant that the coalition’s programs, services, and activities would continue in the long-term even if the coalition was no longer in operation, compared to 19 percent of sustained coalitions. Thirty five percent of not sustained coalitions reported that sustainability meant the coalition made a lasting impact on the community that would continue regardless of whether the coalition or its activities continued, compared to 22 percent of sustained coalitions.
Exhibit 24: Definition of Sustainability
Sustainability plan. The literature suggests the importance of developing sustainability goals and objectives in a comprehensive sustainability plan at the outset. The survey explored whether coalitions developed a sustainability plan and when. Only twenty two percent of all responding coalitions had a sustainability plan in place prior to receiving the HCAP grant. Another 34 percent developed a sustainability plan prior to the end of the HCAP grant. Nineteen percent developed a plan after the HCAP grant ended. Fifteen percent of all coalitions did not have a plan at all, but they had plans to develop one. The last 11 percent did not have a plan or intentions to develop one. As shown in Exhibit 25, there were no statistically significant differences between sustained coalitions and not sustained coalitions in terms of developing a sustainability plan.
One sustained coalition implemented a specific plan for sustainability at the outset, but used less formalized sustainability strategies as the coalition evolved. A key informant elaborated on the sustainability plan that the coalition implemented initially:
We wanted to make sure that we had a certain number of grant applications [that] went out the door per month, per year, for at least a 40 percent hit rate, and we got it. We saw it as a good exercise in bringing in resources. That was a clear sustainability plan for us in the beginning. Also, part of the sustainability plan was the processes of keeping elected officials informed, making sure everyone knew what we were doing— newsletters, electronic communication…
However, this coalition has not implemented a formal sustainability plan in the past five years, even though it continues to sustain itself and expand upon its activities. Another key informant from the same coalition explained that, in the beginning, "knowing that you have to sustain [yourself] hangs over your head," but as relationships among member organizations solidify and the coalition becomes more institutionalized within the community, the need for formalized strategies decreases.
A key lesson learned that emerged from key informant interviews with not sustained coalitions was the need to plan for sustainability earlier. Several key informants shared: "As soon as the grant was awarded, we should have developed a sustainability plan;" "It is a good idea to start planning for sustainability when you are writing your grant, when you start the project;" "Plan, and develop sustainability on the front-end;" and "Focus on sustainability early and look at the big picture early."
Sustained coalitions also echoed the need to plan for sustainability sooner. A key informant from a sustained coalition that is still conducting many of the same activities that it did during the HCAP program ended said: "We could have kept more people involved if we had planned in advance."
Although there were no differences between sustained and not sustained coalitions in terms of sustainability planning, there were significant differences in terms of the types of actions coalitions took to prepare for sustainability. These findings demonstrate that real actions—not just plans—contribute to coalition sustainability. As shown in Exhibit 26, sustained coalitions were significantly more likely to reassess the coalition’s goals, activities, or priorities; identify the most effective goals and activities to continue; develop a strategic plan for attaining resources; reorganize the coalition’s membership; hire an external consultant to assist with sustainability; and develop an infrastructure in the community to support systems-level activities. Among the sustained coalitions, the most frequent actions reported relate to identifying the most effective goals and activities (77%) and reassessing goals, activities, and priorities (75%). Additionally, a majority of sustained coalitions developed strategic plans for attaining resources (55%) and developed community infrastructure to support systems-level activities (51%).
Not sustained coalitions were significantly more likely than sustained coalitions to reduce the membership to prepare for sustainability, however only 12 percent of not sustained and four percent of sustained coalitions took this action. The only sustainability action adopted by a majority of not sustained coalitions (55%) was identifying the most effective goals and activities to continue. Only four percent of sustained coalitions and eight percent of not sustained coalitions took no sustainability actions at all.
During the key informant interviews and site visits, coalition leaders talked about their sustainability actions. Consistent with the survey findings, representatives from sustained coalitions commented on the importance of reassessing goals, activities, and priorities to meet the changing needs of their community. For example, a key informant from a sustained coalition commented on the need for behavioral health services in their rural community. During the HCAP program, this coalition focused on expanding access to behavioral health services in the community. However, due to a lack of funding, this activity was not sustained post-HCAP. Recognizing the need for this service, the coalition has worked with key entities in the community to identify new funding. Today, behavioral health services are available in the local hospital.
Another key informant for a sustained coalition talked about their sustainability actions at the beginning of the HCAP grant. While the coalition did not develop a formal sustainability plan, a reserve fund was created to support critical operations and activities. The key informant noted that the reserve fund helped the coalition to sustain its activities as the level of HCAP funding decreased each year (a feature of the program). To maximize their resources, the coalition also hired the minimum number of staff necessary conduct the program activities, with the intention of hiring additional staff over time, as needed.
Stakeholders involved in sustainability planning. Coalitions were asked to report on the different types of groups or individuals who were involved in coalition planning. As shown in Exhibit 27, the only significant differences between sustained and not sustained coalitions were for the different types of leadership groups.
As noted in the findings on coalition structure, sustained coalitions were more likely to have a board of directors or executive committee compared to a steering committee. Similarly, sustained coalitions were more likely to have the board of directors or executive committee involved in coalition planning.
Key informants from sustained and not sustained coalitions emphasized the role of stakeholders from individual member organizations in planning for sustainability. In many cases, champions from institutions such as health departments, community development organizations and local government had resources and networks that were important for sustainability. A key informant from a sustained coalition said:
"It is important to get local government involved—local department of health, county executive’s office. There is a real role for sustainability in those entities. If there is a way to have an organization to adopt it, nurture the collaboration—it goes a long way."
Exhibit 27: Groups Involved in Sustainability Planning
Timing of sustainability planning. There were no significant differences between sustained and not sustained coalitions in terms of when sustainability planning took place, as shown in Exhibit 28. Across sustained and not sustained coalitions, 62 percent reported that sustainability issues were addressed in the course of regular meetings and planning activities, 24 percent reported dealing with sustainability issues toward the end of grant or funding cycles, 10 percent addressed sustainaiblity issues as they became a problem, and only 4 percent addressed them rarely or never.
Exhibit 28: Groups Involved in Sustainability Planning
Sustainability as a function of planning and action. These key sustainability planning and action variables are included in a logistic regression model summarized in Exhibit 29. The full regression results are presented in Appendix C. The results indicate that planning for sustainability does not increase the likelihood of sustainability, but the number of actual sustainable actions undertaken does increase the likelihood of sustaining the coalition. Controlling for the other variables in the model, there is no effect of developing a sustainability plan. Additionally, addressing sustainability issues with coalition members during regular meetings or near the end of funding cycles (compared to addressing sustainability issues through targeted attention), significantly decreases the likelihood of sustaining the coalition. However, the more sustainability actions the coalitions takes, the greater the likelihood of sustainability. Holding the other variables at their mean or modal category, the model predicted that a coalition that takes no sustainability actions had a 35 percent change of being sustained, compared to a coalition that undertook nine sustainability actions and had a 93 percent chance of being sustained.
In a second model, the individual sustainability actions were broken out to examine their individual effects on coalition sustainability. This model is summarized in Exhibit 30 and the full model is included in Appendix C. Again, the model showed no association of having a sustainability plan and a negative association of the coalition addressing sustainability issues during regular meetings or near the end of funding cycles, compared to more targeted attention on sustainability issues. In terms of the specific sustainability actions, establishing a committee for sustainability and reducing the coalition membership decreased the likelihood of sustaining the coalition, holding all other variables constant. The two sustainability actions with positive effects for sustaining the coalition were reassessing the coalition’s goals, activities, or priorities and developing an infrastructure in the community to support systems-level activities. During key informant interviews, key informants from sustained coalitions framed these sustainability actions in terms of the coalition’s natural evolution—coalitions generally moved forward with and expanded the parts of their programs that were most effective, most in-line with current funders’ priorities or most in-demand within the community.
Current perceptions of sustainability. Sustained coalitions were asked to report agreement with a series of statements about the coalition’s sustainability situation at the time of the survey, as shown in Exhibit 31. Eighty six percent of sustained coaltions agreed or strongly agreed that the coalitions identified alternative strategies for project survival and 78 percent agreed or strongly agreed that they have leaders who are continually planning for sustainability. Sixty two percent of sustained coaltions agreed or strongly agreed that the coaltion has sufficient funding for current operations and activities; sixty six percent agreed or strongly agreed that there is sufficient funding for the next year; and only 38 percent say the same for long-term funding. A slim majority, 53 percent, agreed or strongly agreed that they have sufficient resources to hire and retain quality staff.
Perceptions of long-term sustainability. Sustained coalitions were also asked to estimate the likelihood that the coalition will exist at several time points in the future, as shown in Exhibit 32. Only 6 percent thought the coalition was somewhat or very unlikely to exist 2 years from the time of the survey. That number doubles to 13 percent for five year survival and again to 26 percent for ten year survival. Similarly, even among those coalitions who believed it was likely they would survive over the long-term, the level of certainty decreased considerably with 75 percent saying very likely for two years, down to 40 percent for five years, and only 21 percent for ten years. Still, nearly three quarters (74%) of sustained coalitions believed they would still exist ten years out. When key informants were asked about the coalition’s perspective of the health reform changes that will be implemented as a result of the Affordable Care Act (ACA), some expected that while the nature of their activities may shift slightly, an underserved population would continue to exist. One key informant from a sustained coalition mentioned that the coalition was planning to adjust its programs to fill in gaps that would remain despite the ACA: "How do we continue to fill the gaps no matter what they are, so that we can help the community to adjust?" Another sustained coalition plans to explore opportunities for coordinating care, in the event that their safety net program for the uninsured is no longer necessary.