Moving beyond the basic identification of sustained coalitions, this study added to the knowledge base by identifying coalition characteristics associated with sustainability and the factors that promote or hinder community coalition sustainability. Several factors explored in the survey, key informant interviews, and case studies appear to be related to sustainability, including coalition leadership, membership diversity, coalition structure, vision guiding action, and resources.
Leadership. Good organizational leadership is often correlated with good management and successful organizational outcomes. Based on our review of the literature many aspects of leadership were explored in the survey, and several factors were found to be independently correlated with sustainability. Perhaps not surprisingly, the results of this study are consistent with others indicating that strong leadership has a direct and positive influence on the sustainability of coalitions. The regression model demonstrates that leadership experience, measured in terms of coalition management, years of experience in the field, and experience working or living in the community, increases the likelihood of sustainability even when controlling for other key predictors of coalition strength and sustainability, such as membership, funding, and coalition structure variables.
The findings from the key informant interviews and site visits also underscored the importance of good leadership on the potential for continued organizational growth and success. Coalitions with strong leaders were able to overcome many of the challenges facing coalitions as they transitioned out of the core HCAP funding and into a self-sustaining mode. For example, experienced and high quality leaders were able to communicate effectively and manage conflict at multiple levels (key executives, partner organizations, and coalition staff), which enabled the coalitions to survive challenging periods. Strong leaders were also able to help partner organizations and staff stay committed and motivated during more difficult periods.
In addition to the important role of the coalition director or manager as a leader and advocate for the coalition, coalition staff frequently discussed the value of having a champion at senior levels of the lead organization and/or partner organizations. In these cases, the coalition champions had the ear of key executives responsible for priority setting and budgetary decisions and helped ensure that continued support for the coalition, its staff, and its activities were integrated into those discussions.
Beyond leadership from individuals, the survey results revealed the importance of having governing bodies comprised of high level leaders from the membership organizations or external organizations. Coalitions with Boards of Directors or Executive Committees were more likely to be sustained. The Board of Directors and Executive Committees are defined in terms of having high level leaders from the membership organizations and/or external organizations. This type of high level or external oversight was positively associated with sustainability in the HCAP coalition population.
Coalition Membership. As with the leadership aspects, both survey and qualitative data collected in this study confirm the literature that various aspects of coalition membership are associated with coalition sustainability. Although survey results showed no significant differences in the size of sustained and not sustained coalitions, the proportion of active members was a significant predictor of sustainability controlling for other coalition characteristics. This point was echoed in the qualitative findings where a key theme emerged that it was the quality of the members’ participation that mattered far more than absolute quantity of members.
Perhaps surprisingly, high membership turnover was not a significant, negative predictor of sustainability in the model. Comparing sustained and not sustained coalitions, the findings suggest that it may be beneficial to have some churning of the membership. Additionally, the turnover among sustained coalitions tended to be driven by issues or changes at the member organization level and not due to constraints at the coalition level. The loss of a member organization that may have been distracted or distracting to the coalition’s efforts may ultimately strengthen the commitment of the remaining organizations.
The survey results also showed that sustained coalitions were significantly more likely to have diversity in the types of members involved, both within the health sector and across sectors (e.g., social service representation). The qualitative results reveal that different types of members bring different perspectives and types of resources, financial and in-kind, to the coalition. Engaging partners across diverse sectors was also noted as a source of new ideas and new perspectives in addressing problems.
Structure. Results of the influence of coalition structure on sustainability were a departure from expectations. Findings from the 2006 national HCAP evaluation suggested that the coalitions with more formal mechanisms in place to maintain a coalition structure would be a significant predictor of sustainability. However, sustained and not sustained coalitions had equal rates of formal membership structures and the vast majority with formal structures (92% and 89%, respectively) had MOAs, MOUs, or IAAs in place with members. Survey results indicated that not sustained coalitions were significantly more likely to hold more frequent meetings compared to sustained coalitions. Qualitative findings support that sentiment with several sustained coalitions discussing the need to reduce the frequency of meetings and increase the quality of meetings. Not sustained coalitions mentioned that the number of meetings and operational requirements for members may have been too burdensome to sustain.
Although not a facet of structure included in the survey component, we did observe that four of the six coalition case study sites, which represented sustained and high performing coalitions, had a hub and spoke organizational model. In these models, the core coalition staff served as the hub, coordinating all operational activities for the coalition. These coalitions had varying levels of inter-member activity, though at the minimum all have mechanisms in place for periodic inter-member discussions and any major decisions were discussed and resolved as a group. Interviews with member organizations of these hub and spoke coalitions suggest that the model provides an efficient and effective organizational structure that contributes to the coalition’s success and sustainability.
No matter the membership and structural model, coalitions ultimately do require collaboration across organizations. These findings suggest that coalitions must be mindful of a careful balance between establishing and maintaining formal structures that facilitate membership and activity and formal structures that yield too much bureaucracy and hinder member organization participation. Additionally, the type of formal member structure should be tailored to individual coalition needs. As noted in additional detail below, coalitions need resources and personnel to manage these structural and operational issues.
Vision Guiding Action. The ability to stay focused on the overall goals of the coalition while maintaining action steps that are manageable in the day to day was positively associated with sustainability. Survey results showed a high level of agreement among sustained coalitions about the importance of the coalition’s vision and using the vision to focus activities and services. These results are consistent with recent literature and research attention on collective impact organizations like the Strive Partnership, which helps communities build their civic infrastructure to support educational support for children from "cradle to career" based on a shared mission, mutually reinforcing activities, continuous communication, common metrics, and the presence of a core organization dedicated staff and resources (Hanleybrown, Kania, and Kramer, 2012; Strive Network, 2011).
Qualitative data strongly supported two particular aspects of the concept of vision guiding action: shared sense of mission and mission-driven organizations. From the perspective of interviewed and case study coalitions, these factors are key contributors to sustainability. A shared mission among member organizations was responsible for the initiation of several of the case study coalitions and that shared mission was essential in overcoming inter-member obstacles. For example, two competing hospitals were working together on a coalition because they shared the same mission and saw the value of servicing the mission as paramount. Additionally, being mission driven provided some member organizations with the justification they needed to continue providing in-kind support or donated services to the coalition. This concept is described further in the discussion of evaluation below.
Resources. Findings on the role of resources for sustainability are consistent with the literature on coalition effectiveness. Sustained coalitions were significantly more likely to have funding from more diverse sources, including state level agencies and departments (other than the health department), local health departments, foundations, and community-based organizations. Fifty percent of sustained coalitions said they had more diverse funding at the time of the survey than during HCAP. Additionally, on the survey as well as in the telephone interviews and site visits, many sustained coalitions indicated that member organizations contribute funds for coalition operations and programs or services. Some coalitions had this formalized though coalition membership dues and others determined the need and availability of funds from members on an annual or budget cycle basis. Member contributions in some coalitions were relatively large with organizations contributing twenty thousand dollars or more per year.
Perhaps not surprisingly, controlling for other coalition characteristics, the regression model showed that a higher degree of flexibility to use funding for operational or programmatic purposes was a positive predictor of sustainability. Even though greater flexibility was beneficial, 40 percent of sustained coalitions reported less flexibility now than during the HCAP period, suggesting that the sustained coalitions continued to adapt their operational approach to the constraints.
Survey results showed that sustained coalitions received more types of in-kind support and this was a significant predictor in the model even controlling for other characteristics. Additionally, the qualitative data suggested that sustained coalitions have done an excellent job of acquiring in-kind support for specific functions that require a skill-set or specific type of employee the coalition could not support on its own. These services included processing claims data, financial analysis, grant writing, and database and software development.
Although sustained and not sustained coalitions did not vary significantly in terms of the number of full time equivalent staff reported on the survey, sustained coalitions participating in the site visits clearly articulated the importance of having a dedicated position for coalition operations in order to nurture the coalition itself, and maintain and grow it. Serving as an advocate for the coalition among leadership, members, and the community was a large part of these individuals’ responsibilities. Sustained coalitions have struggled to maintain this level of support over time with 58 percent of sustained coalitions reporting that they had less funding for coalition operations at the time of the survey than they did during the HCAP period.
While these specific aspects of funding and resources impacted sustainability, survey and qualitative results suggested that the sustained coalitions have gotten by under resource constrained conditions. Even with a history of sustainability now in place, 62 percent of sustained coalitions reported feeling less certain about future funding at the time of the survey than they did during the HCAP period.
Evaluation. Evaluation was considered an important aspect of coalition work for both sustained and not sustained coalitions. Coalitions noted that evaluation activities were important for fine tuning the coalition’s work and for demonstrating results to funders and key stakeholders. Survey results revealed that sustained coalitions were more likely to use quantitative evaluation methods and to conduct outcomes evaluations than not sustained coalitions. Qualitative data supported this finding with several coalition members from the interviewed and site visited coalitions discussing the importance of having concrete figures to show key stakeholders the impact of the coalition’s work. Further, respondents mentioned the benefits of evaluation in the context of sustainability because they credited the ability to demonstrate health and social outcomes as a powerful tool in seeking additional resources and support both from formal funding opportunities as well as organizational member support and in-kind donations.
The ability to make a business case that shows how resources are leveraged by the coalition and how coalition activities save the lead organization and member organizations money is also important. While some sustained coalitions had sophisticated means for collecting, processing, and analyzing these data (e.g., dummy claims processing through Blue Cross Blue Shield for all enrolled patients), other simple analyses were effective too (e.g., adding the value of all donated pharmaceuticals, lab, and imagery services and dividing by the coalition’s total funding in order to demonstrate that every dollar of funding yields so many more dollars in patient products and services).
While sustained coalitions tended to have more sophisticated evaluation methods and processes, they explained that the anecdotes were important too. Quotes from participating providers and patient success stories provided an important publicity and communication tool for stakeholders focused on the mission but who might skim over tables of outcomes and financial data. Additionally, the anecdotal information combined with evaluation results proved an effective tool for supporting the morale of coalition staff and further strengthening the bonds between individuals working in separate organizations towards a common goal.
Contextual Factors. In qualitative interviews and case studydiscussions, the coalitions provided information on the key contextual factors that affected their coalitions in both positive and negative ways. With the exception of a ubiquitous impact of the economic downturn, which has increased demand for their services, but tightened resources like funding and donated services and products, the contextual factors were unique to the communities being served. However, one theme that emerged across these particular contextual factors is that sustained coalitions possessed a resiliency to handle the external shocks and were able to absorb these exogenous events.
To the extent possible, these coalitions planned for such events. Since planning for and reacting to these contextual factors happened primarily with the coalition director and senior leadership, some of the success in handling these situations was undoubtedly tied to strong leadership. Additionally, the ability of these sustained coalitions to be resilient to these shocks was facilitated by the fact that they have the support for these core personnel, who could focus on the issues rather than being completely dedicated to programmatic and service activities.
Additionally, sustained coalitions did their best to capitalize on positive contextual factors, looking for opportunities to enhance the coalition’s value to the community. For example, one coalition was positioning itself within their state’s discussion of patient centered medical home models and programs under the Affordable Care Act. The coalition was using its experiences with the medical home model for the uninsured to contribute to the discussion, as well as looking for new opportunities for the coalition to expand coalition activities such as participating in the design and implementation of the state’s community care teams.
Sustainability Perceptions, Planning and Actions. As noted above, sustainability can be defined in terms of whether organizations are still working together, whether specific activities continue, or some combination. This study required continued collaboration among organizations in order to be considered sustained, though the survey instrument also sought the perspectives of coalition staff on how they defined sustainability. The vast majority (84%) of responses tended to include some aspect of institutionalized activities or lasting impacts in their definition of sustainability. Only 16 percent of all coalitions defined sustainability only in terms of the coalition membership and structures. Additionally, a greater proportion of sustained coalitions defined sustainability in terms of the coalition and its activities compared to the not sustained coalitions in which the majority defined sustainability in terms of activities or impacts continuing to benefit the community. In qualitative interviews, coalitions discussed both aspects when they talked about their long-term sustainability. While, as one sustained coalition noted, the activities of the coalition are vital, "someone needs to be here to coordinate services."
Interest in sustainability issues is understandably quite high and there is limited data on the practical concerns of maintaining a coalition once initial funding has ceased. Surprisingly, these results indicated that having a sustainability plan had no impact on sustainability status and establishing a sustainability committee actually decreased the likelihood of being sustained. Rather, sustained coalitions differed in terms of the sustainability actions they undertook such as reassessing goals and priorities, developing a strategic plan for resources, and reorganizing coalition membership. The qualitative interviews suggested that sustained coalitions were always thinking about what needed to happen for sustainability, such as obtaining additional types of funding, developing a focus on showing results, getting institutional support for coalition activities, evolving with the community needs, incorporating new partners, as well as strategizing to handle external factors like the Affordable Care Act. While sustainability plans were an important first step, it was coalitions’ ability to carry out sustainability actions that differentiated the sustained from not sustained.
This project examined coalitions that have successfully sustained themselves over several years following the HCAP funding and the case studies explored the experiences of several high functioning coalitions. Even though these coalitions could be considered "successful" in terms of their continued existence, some coalitions remained apprehensive about the long-term stability of their coalition. Two-thirds of the sustained coalitions said they have sufficient funding for the next year, but that proportion drops to only 38 percent when asked to forecast for two years out. Nearly all of the sustained HCAP coalitions (68%) are confident they will exist in two years, but less than three-quarters of the sustained HCAP coalitions believe they will exist in 10 years. Coalition work is a challenging endeavor and even the most successful coalitions face uncertainty which may encourage greater attention to long-term planning and emphasis on action steps.