An Assessment of the Sustainability and Impact of Community Coalitions once Federal Funding has Expired. Coalition Impacts

06/01/2012

Systems Impact: Coordination among Hospitals, Clinics and Providers in the Community
A sustained coalition created a streamlined eligibility intake system that provides a one-stop shop to determine the client’s eligibility for federal, state, and local coverage as well as social service and pharmacy programs. The coalition also focused on helping patients to find coverage for their care through enrollment into entitlement programs. The eligibility intake system not only helped the physicians and hospitals, but provided access to coordinated care for patients. The coalition’s activities have resulted in three different kinds of impacts.

First, the enrollment system enabled the hospitals and providers to bill for services that would otherwise be written off as charity. Second, the program provided important wrap-around services to patients that needed them. Third, the eligibility system ensured that providers have access to patients’ previous encounter information in order to provide coordinated care.

Through the literature review, broad searches for community coalition activities in public health reveal that a range of issues are being addressed (from safe streets initiatives to access for the uninsured and underinsured to diabetes management), using a range of intervention methods designed to affect change at multiple levels (e.g., individual, systems, and policy). To capture the array of accomplishments of the former HCAP coalitions, this section discusses impacts in three areas: individual impacts, systems impacts, and policy impacts. Individual impacts are changes in health or behavior at the person level (e.g. increasing screening rates in a particular population). Systems impacts are changes in infrastructure or capacity in the community (e.g. creating a county-wide case management system used by all social services agencies). Community coalitions have also achieved policy impacts at the local, state and federal levels (e.g. changing the county’s policies surrounding alcohol and tobacco billboards and storefront advertising).

Types of impacts. The coalitions were asked to provide information about the types of impacts they have realized since the end of the HCAP grant period. First, as shown in Exhibit 33, the coalitions were asked how successful they have been in achieving individual health and behavior outcomes, systems-level outcomes, and policy change outcomes since the end of the HCAP grant period. Overall, the coalitions reported fairly widespread success for all types of impacts. Sustained coalitions did differ significantly (p<.05) from not sustained coalitions as they were more likely to say individual health and behavior outcomes were not applicable (16% compared to 6%) and less likely to report unsuccessful or very unsuccessful outcomes (10% compared to 24%). Forty percent of sustained coalitions and 47 percent of not sustained coalitions reported that policy outcomes were not applicable for their coalition. One sustained coalition said that "policy work is not easy to track…we talk about tracking that, but don’t know for sure," possibly explaining the high percent of coalitions thinking that policy outcomes were not applicable to their coalition.

Exhibit 33: Impacts since Conclusion of the HCAP Grant
  Very Unsuccessful Unsuccessful Successful Very Successful Not Applicable
**p<.05, Fisher’s Exact Test
Individual Health and Behavior Outcomes**
% Sustained (n=112) 7 3 54 21 16
% Not Sustained (n=50) 10 14 48 22 6
Systems-Level Outcomes
% Sustained (n=112) 7 5 54 16 18
% Not Sustained (n=49) 10 14 43 10 22
Changing Policies
% Sustained (n=112) 4 18 29 8 40
% Not Sustained (n=49) 6 18 18 10 47

Although the survey did not provide an opportunity for the coalitions to discuss their impacts in detail, the key informant interviews and site visits allowed for more in-depth discussions. A key informant from one of the sustained coalitions reported that their program resulted in an array of impacts:

"I want people to understand that it’s the small groups that make the change in the communities. People need to redefine what sustains health care. The HCAP grant has had a huge impact. It had an impact on the residents that might not have had care prior to this, [and] had an impact in the community [which] saw this as a very good program."

Several of the sustained coalitions that participated in the site visits provided program data and evaluation reports. The coalitions frequently noted the importance of being able to demonstrate impacts, in terms of health outcomes and return on investment, as key to sustainability. Specific examples of the coalitions’ impacts discussed in the interviews and site visits are provided in Exhibit 34, and ranged from improving access and integration of health care services to new programs and initiatives.

Exhibit 34: Examples of Coalition Impacts since End of HCAP Grant
Type Of Impact Example of Coalition Impact
Individual Impacts
Access to primary care From school-based clinics to full-service primary care, one coalition collectively provided more than 275,000 patient visits to low-income residents in 2010.
Access to primary and specialty care A sustained coalition has provided a full range of medical services, including specialty care, to 45,000 patients post-HCAP, and as of June 2011, had 7,000 enrollees in their insurance program.
Access to insurance and other programs As of 2010, a sustained coalition was able to evaluate 1,714 new patients, enroll 883 into entitlement programs, and 101 into Pharmacy Assistance Programs. In initial and follow-up surveys with their clients conducted in Fall 2010 and Spring 2011, respectively, the percentage of clients having a routine checkup in the past two years, going to a doctor’s office or clinic for medical care, experiencing better health, and having health insurance all increased.
Access to screening and care management services As of October 2011, a sustained coalition had screened over 25,000 people, enrolled roughly 25% of those people in a coverage product, and currently provides care management services for over 1,400 people. This coalition has worked with hospitals and community providers to provide over $49 million of donated medical care to their enrollees. The program has received 98% excellent on satisfaction surveys.
System impacts
Eligibility determination A sustained coalition developed a streamlined eligibility intake system that determines patient eligibility for federal, state, and local entitlement programs, social services, and pharmacy programs.
Continuum of care A sustained coalition created an improved continuum of care for patients by developing and maintaining a system which connects providers at hospitals, clinics, nursing homes and emergency management technicians.
Capacity for collaboration A sustained coalition reported that post-HCAP, they continued to build capacity for community partners to collaborate, and have been successful in identifying new opportunities and expanding needed programs and services.
Health navigation A sustained coalition is participating in the Institute for Healthcare Improvement Triple Aim Protyping Initiative. Through this project, the coalition is developing a health navigator pilot to assist uninsured patients with the transition from the hospital to primary care. The health navigator pilot has been successful in helping low-income, uninsured, recently hospitalized patients by coordinating their medical care, assisting with enrollment and eligibility, assisting with medications, facilitating primary care linkages, and accessing social services.
Care coordination An FQHC of a not sustained coalition reported that third-party payer insurance companies have found that the clinic is saving hospitals money because of its integrated and coordinated primary care and behavioral health model, pioneered through the HCAP grant.
Care coordination One sustained coalition is leading a pilot project for an ACA demonstration program that intends to follow the coalition’s program model in trying to coordinate and connect patients to additional healthcare and community resources.
Care coordination A not sustained coalition reported that their experiences in the HCAP program have positioned their FQHC for meaningful use dollars and helped them to receive patient-centered medical home recognition under the National Committee for Quality Assurance.
Information exchange One sustained coalition is one of the original fifteen Health Information Exchange Organizations serving on the Nationwide Health Information Network Trial Implementation Project supported through the Office of the National Coordinator, and today in one of only a handful of organizations across the country which is an active exchange participant.
Policy impacts
Law on kinship care A subset of one sustained coalition’s member organizations have been instrumental in increasing knowledge and awareness of caregiver families and developing more responsive public policy to address issues for these families. Their efforts contributed to the passage of a bill by the Ohio House of Representatives that became effective July 20, 2004. The law provides a grandparent, with whom a child resides, authority over their care. Other bills related to this topic have been introduced in 2005 and 2007.

Sustainability of program impacts in the absence of a coalition. The coalitions were also asked4 about how many of the coalition impacts would continue to benefit the community without additional coalition support or after the coalition disbanded. As shown in Exhibit 35, sustained and not sustained coalitions were similar in reporting how many of the individual health and behavior outcomes, and systems-level outcomes would continue to benefit the community without coalition support. However, sustained and not sustained coalitions differed significantly (p<.10) in their estimation of how many of the coalitions’ policy impacts would continue to benefit the community. Forty six percent of not sustained coalitions estimated that none or only a few of their policy outcomes would be sustained, compared to 29 percent of sustained coalitions.

Exhibit 35: Continued Impacts without Coalition Support
  All Most Some A Few None
*p<.10, Fisher’s Exact Test
Individual Health and Behavior Outcomes
% Sustained (nExhibit 35: Continued Impacts without Coalition Support=92) 16 28 30 20 5
% Not Sustained (n=44) 16 32 20 18 14
Systems-Level Outcomes
% Sustained (n=91) 21 30 24 15 10
% Not Sustained (n=37) 14 38 19 22 8
Changing Policies*
% Sustained (n=62) 27 21 23 16 13
% Not Sustained (n=26) 8 31 15 15 31

During interviews, several key informants from not sustained coalitions described the impact that their coalitions continue to have despite disbanding. In order for the coalition’s impact to continue, activities once implemented by the coalition were absorbed by other community entities. One key informant from a not sustained coalition described their coalition’s experience. In this case, the coalition’s program staff and activities were absorbed by the hospital, which was the lead organization:

"When the grant ended it didn’t make sense to continue all of the activities and it was difficult to find resources to continue them at that level. We knew the hospital wouldn’t institutionalize all our staff. We had young educated staff and they didn’t wait for the end to come, they saw the writing on the wall. By that point we were bare bones, we got down to the point where the hospital could absorb us. We whittled ourselves down to where they could."

Despite shrinking and disbanding, this coalition’s impact "continued to provide tens of thousands of dollars in free care through systems we built." Another key informant described that a pharmacy integration program launched under HCAP "has developed a life of its own" after being absorbed by the county hospital and health department. In another instance, smaller local coalitions now implement an access to care program that was launched by an HCAP coalition.

Timing of coalition impacts. As shown in Exhibit 36, the coalitions were asked about the timing of their greatest impacts. Sustained and not sustained coalitions differed significantly in their responses (p<.01). The modal category, at 52 percent, for sustained coalitions was impact occurring at a steady pace throughout the history of the coalition. The modal category for not sustained coalitions, at 53 percent, was having the greatest impact during the HCAP funding period.


Exhibit 36: Timing of Greatest Impacts

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