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


In addition to discussing their membership, the coalitions answered several questions in the survey about their structure, including the formality of the leadership structure and relationships with members. This section discusses findings related to coalition lead organizations, leadership committees, membership structures, coalition leader experience, and coalition strength.

Lead organization. Seventy three percent of sustained coalitions reported having a lead organization, which is significantly less than the 92 percent of not sustained coalitions. This difference is not surprising as some of the sustained coalitions have likely moved away from the lead organization requirement under HCAP or may not think of the coalition structure in those terms anymore. As shown in Exhibit 10, not sustained coalitions were more likely to have a Federally Qualified Health Center (FQHC) as the lead organization, while sustained coalitions were more likely to be led by a community based organization, government agency, or other type of health sector organization including public hospitals, private hospitals, and other coverage programs. Only 12 (15%) of sustained coalitions with a lead organization have changed lead organizations since the end of the HCAP grant.

Exhibit 10: Type of Lead Organization

Exhibit 10: Type of Lead Organization


Exhibit 10: Type of Lead Organization
Type of Lead Organization % Sustained with a Lead Organization (n=82) % Not Sustained with a Lead Organization (n=46)
Academic medical centers 6 7
Community-based organizations 13 9
Federally Qualified Health Centers 10 30
Government (e.g., local health department) 17 13
Foundations 2 4
Free clinics/other community health centers 2 0
Hospitals (low-income utilization > 25%) 5 9
Medical Associations (Primary Care, Dental, Other) 5 2
Non-Health Sector (Business, Education, Faith) 4 2
Other Health 35 24

Leadership committees. Coalitions were asked to provide information on the types of leadership committees established as part of their coalition operations. The coalitions could select any or all of the following: (1) Steering Committee (a committee made up of representatives from member organizations that works with the consortia leadership); (2) Board of Directors (a group of individuals external to the consortia that provides input and/or oversight to the consortia leadership); (3) Executive Committee (a small group of consortia leadership responsible for consortia operations); and (4) Community Advisory Board (a group of lay-persons from the community that provides input on consortia activities and direction). Sustained coalitions were more likely than not sustained coalitions to have a board of directors (60% compared to 26%, p<.01) or Executive Committee (59% compared to 43%, p<.10). Conversely, not sustained coalitions were significantly more likely than sustained coalitions to have a Steering Committee (65% compared to 41%, p<.01). One-third of sustained coalitions (33%) and less than one-third of not sustained coalitions (30%) reported having a Community Advisory Board.

The findings from the key informant interviews also validated the survey responses. Sustained coalitions discussed the importance of having a board of directors. One coalition said we "have doctors, universities, hospitals, etc. on the Board [of Directors]; that has been key to our sustainability." This coalition created an online system that reports hospital utilization information across the state for health planning councils, providers and policy makers. The providers on their Board recognize the importance of the information and therefore have been active in support the sustainability of this activity.

Another sustained coalition says that the coalition needs a "strong Board to help provide vision and qualified and competent staff; [and] establish key partnerships and involve key leadership in order to be successful." A sustained coalition with a Community Advisory Board referred to the Board [of Directors] as its "touchstone," and indicated that it "do[es] not start something new without getting permission from the Board;" it believes that the Board has had a real role in "grounding" the coalition.

Membership organization and structures. There was no significant difference in the proportion of sustained coalitions (57%) and not sustained coalitions (48%) reporting a formal membership structure (e.g., legally incorporated or Memoranda of Understanding (MOU)). Of those sustained coalitions with a formal membership structure (n=71), 92 percent had MOUs or inter-agency agreements (IAA) with at least some of their members. Similarly, of those not sustained coalitions with a formal membership structure (n=27), 89 percent had MOUs or IAAs with at least some of their members.

In addition to the formality of member relationships with the coalition, a common type of organizational structure was discovered during the site visits. Four of the six site visited coalitions were organized in a "hub and spoke model." In this model, the core coalition staff serve as the hub coordinating all operational activities for the coalition as opposed to a more traditional model. As the hub, they disseminate information out to the members, as well as receive information, and coordinate and manage the day-to-day operational, programmatic, and service delivery activities and decisions. These four coalitions had varying levels of direct, member-to-member activity, though at the minimum all four had mechanisms in place for periodic inter-member discussions and any major opportunities and challenges were discussed and resolved as a group. One coalition with this "hub and spoke model" considered the structure a key to their sustainability because it contributes to efficient, effective, and sustainable operations. Program staff noted that the coalition’s hub and spoke structure was a very purposeful design intended to keep the operations centralized and efficient. Furthermore, the members who are primarily partner and referral organizations clearly valued the centralized nature of the operations and appreciated the efficiency and effectiveness of direct communication with the core coalition staff. During a discussion of how members connect their patients and clients to coalition services, one representative from a member organization noted, "From my end, it’s pretty seamless; I just make a phone call."

Sustained coalitions were significantly more likely to have formal processes in place for managing conflict between members and coalition leadership than not sustained coalitions (42% compared to 23%, p<.05). One not sustained coalition subsequently instituted a more formal structure during the post-HCAP period because of the lessons learned from the HCAP grant: "The alliance is comprised of lots of the same partners from HCAP and many others, [but] the alliance is more formal, it has by-laws." However, 75 percent of sustained coalitions and 75 percent of not sustained coalitions reported the use of formal decision making processes for the coalition. As shown in Exhibit 11, not sustained coalitions were slightly more likely to hold more frequent member meetings (p<.10).

Exhibit 11: Frequency of Formal Coalition Meetings
Frequency of Formal Member Meetings Every Month or More Every 1-3 Months Every 4-6 Months Once a year or less Never
% Sustained (n=112) 38 34 11 13 4
% Not Sustained (n=51) 55 35 6 2 2

In key informant interviews, both sustained and not sustained coalitions acknowledged that making coalition meetings worthwhile and valuable—not the quantity of meetings—contributes to sustainability. For example, a key informant from a sustained coalition shared the importance of using members’ time wisely in preventing member attrition:

I…needed to make sure at every Board meeting I had the data that the city and the county wanted, the anecdotal information that the other organizations [wanted]...if I left that out they were less likely to come back.

A representative from a member organization that participates in a sustained coalition attributed members’ continued commitment to the high quality of the coalition meetings. The key informant from the member organization explained that the coalition meetings are "very well-run," "organized," and that the "presentations are informational," which engages participants. The opposite is true as well, as a key informant from a not sustained coalition indicated that their meetings were cumbersome, and that "reducing meeting time so it’s not too labor intensive" would have helped the coalition to sustain itself.

Coalition leader experience. Sustained and not sustained coalitions provided information on the years of experience of the coalition leader in directing/managing the coalition, working in the field of health care delivery or health care administration, and living or working in the community served by the coalition. Sustained coalitions were asked, "How long has the coalition leader or director…" and not sustained coalitions were asked, "How long had the coalition leader or director…" Therefore, by definition, sustained coalitions, on average, report leaders with greater years’ experience and the data should not be compared without controlling for the years of coalition operation from the baseline of the receiving the HCAP grant. As can be seen in Exhibit 12, sustained coalitions’ leaders had more experience than not sustained coalitions’ leaders. For example, 54% of sustained coalitions reported their leader having 5 or more years of experience directing or managing the coalition; whereas only 14% of not sustained coalitions reported that length of experience.

Exhibit 12: Coalition Leadership Experience
  % Sustained Coalitions % Not Sustained Coalitions
How long has the coalition leader or director: 1 year or less Between 1 year and 3 years 3-5 years 5-10 years More than 10 years No Opinion/Not Applicable 1 year or less Between 1 year and 3 years 3-5 years 5-10 years More than 10 years No Opinion/
directed or managed the coalition? 8 16 16 39 15 5 10 45 29 10 4 2
worked in the field of health care delivery or health care administration? 1 2 5 15 68 9 6 12 8 24 47 4
lived or worked in the community served by the coalition? 3 0 4 14 71 8 6 14 12 14 53 2

Coalition strength. The coalitions responded to a series of agree or disagree statements about the strength of the coalition structure using a four point scale ranging from (1) strongly disagree to (4) strongly agree, with a fifth no opinion/not applicable option. An exploratory factor analysis revealed three underlying concepts: the strength of the coalition structure, the level of member organization involvement, and the strength of the coalition’s leadership. No statistically significant differences exist between sustained and not sustained coalitions for these three concepts using either an additive scale or the mean for each concept.

In addition to these survey questions, key informants from the interviews and site visits discussed the importance of coalition strength for being able to absorb the influence of contextual factors beyond the control of the coalition. The sustained coalitions provided information on the key contextual factors that affected their coalitions in both positive and negative ways during the post-HCAP period. With the exception of a ubiquitous impact of the economic downturn, which has increased demand for their services but reduced resources like funding donated supplies and services, the contextual factors mentioned were idiosyncratic across sites (e.g., particular changes to Medicaid eligibility in the state, or, mergers between two local hospitals). One theme that emerged across these particular contextual factors is that sustained coalitions are resilient and are able to absorb these exogenous events. To the extent possible, sustained coalitions planned for these events. For example, the two major hospitals, both coalition members, in one coalition’s community were going through a merger and the coalition took a very proactive position in advocating for the coalition to ensure a continued home for the coalition after restructuring. Additionally, sustained coalitions did their best to capitalize on positive contextual factors. For example, one coalition was positioning itself within their state’s discussion of Primary Care Medical Home models and programs established through ACA. The coalition was using its experiences with medical homes to contribute to the discussion, as well as looking for new opportunities for the coalition to engage in future programs.

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