The study identified a number of findings related to the sustainability of community coalitions post initial federal funding:
More than two-thirds of the HCAP coalitions were sustained, with many pursuing a range of activities in their communities.Even using a fairly rigorous definition of sustainability which required three or more organizations to be collaborating for purposes of one or more of the original HCAP goals, a total of 113 (68%) of the 165 responding coalitions were sustained. The fact that more than two-thirds of the coalitions were sustained is encouraging, particularly given that the HCAP project did not have an explicit emphasis on sustainability. These coalitions are still actively pursuing a range of activities in their communities (continuing existing activities and taking on new ones), and have achieved both individual-level impacts (e.g. increased access to primary and specialty care, increased enrollment into health insurance plans) and other policy and system impacts (e.g. streamlined eligibility systems, new processes for care coordination across community providers). Moreover, even among the 52 (32%) of coalitions classified as not sustained, the majority (80% of not sustained coalitions) report that at least one of the activities they conducted under the HCAP grant was still being conducted at the time of the survey. However, all of the 52 coalitions reported that they were no longer a coalition of three or more organizations, and as such these coalitions were considered to be not sustained. Of the not sustained coalitions, 35 (67%) of the coalitions dissolved due to issues such as funding or organizational problems and 17 (33%) disbanded because the coalition achieved all of its goals or was no longer needed in the community.
When asked to define sustainability in the context of their coalition, many HCAP coalitions described sustainability in terms of the institutionalization of key activities in the community and maintenance of their impacts. Sustainability can be defined in terms of whether organizations are still working together, whether specific activities continue, or some combination of the two. 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 of sustained and not sustained coalitions (84%) included some aspect of institutionalized activities or lasting impacts in their definition of sustainability. Only 16 percent of all coalitions defined sustainability in terms of the coalition membership and structures only. Additionally, a greater proportion of sustained coalitions (40%) defined sustainability in terms of the coalition and its activities compared to the not sustained coalitions (19%). The majority of not sustained coalitions (75%) defined sustainability in terms of either its activities or impacts continuing to benefit the community even if the coalition was no longer operating.
Coalition characteristics associated with sustainability include coalition leadership, membership diversity, coalition structure, vision guiding action, and resources.
- Leadership. The results of this study are consistent with others indicating that strong leadership has a direct and positive influence on the sustainability of coalitions. Survey results showed 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 that 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. 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. 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).
- Coalition Membership. Sustained coalitions are comprised of 40 member organizations, on average, with 79 percent of members considered active. Not sustained coalitions were comprised of 22 member organizations, on average, with 74 percent of members considered active. 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. Additionally, membership turnover was not a significant, predictor of sustainability. Comparing sustained and not sustained coalitions, the findings suggest that it may be beneficial to have some churning of the membership. 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. During the site visits, coalition leaders noted that the loss of a member organization that may have been distracting to the coalition’s efforts may ultimately strengthen the commitment of the remaining organizations.
- Structure. Results of the influence of coalition structure on sustainability were a departure from expectations. Sustained and not sustained coalitions had equal rates of formal membership structures and the vast majority with formal structures (92% and 89%, respectively) had Memoranda of Agreement (MOA), Memoranda of Understanding (MOU), or Interagency Agreements (IAAs) in place with members. There was no association between having formal structure with members (e.g., MOAs or IAAs) and sustainability. Survey results also indicated that not sustained coalitions were significantly more likely than sustained coalitions 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, and could have played a role in the loss of membership organizations in the coalition.
- 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. From the perspective of interviewed and site visited coalitions, these factors are key contributors to sustainability.
- Resources. 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. Also, when controlling for other coalition characteristics, a higher degree of flexibility to use funding for operational or programmatic purposes was a positive predictor of sustainability.
Evaluation was considered an important aspect of coalition work for both sustained and not sustained coalitions; however, sustained coalitions were more likely to use quantitative evaluation methods and to conduct outcomes evaluations than 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. 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 in making the business case for the program as well (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 also important to demonstrate the health and social outcomes of their programs and identify new funding opportunities.
Implementation of sustainability actions mattered more than the type and degree of sustainability planning. Sustained coalitions differed in terms of the sustainability actions they undertook and the findings revealed important predictors of coalitions sustainability including reassessing the coalition’s goals, activities, or priorities and developing an infrastructure in the community to support systems-level activities. 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 Patient Protection and Affordable Care Act of 2010 (Affordable Care Act). While sustainability plans were an important first step, they had no impact on sustainability status. Additionally, establishing a committee for sustainability decreased the likelihood of sustaining the coalition, holding all other variables constant. Findings suggested that the coalitions’ ability to carry out sustainability actions differentiated the sustained from the not sustained coalitions.
Even though many of the HCAP 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 coalitions (68% of HCAP grantees) are confident they will exist in two years, but less than three-quarters of those 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.
Sustained and not sustained coalitions reported success in achieving individual, systems-level, and policy impacts. 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. For individual and behavior outcomes, 75 percent of sustained coalitions and 70 percent of not sustained coailtions reported that they were successful or very successful in achieving individual health and behavior outcomes. For systems-level outcomes, 70 percent of sustained coalitions and 53 percent of not sustained coalitions reported that they were successful or very successful in achieving systems-level outcomes. Thirty seven percent of sustained coalitions and 28 percent of not sustained coalitions reported that they were successful or very successful in changing policies. Sustained and not sustained coalitions had similar perceptions of how many of the coalition’s individual health and behavior outcomes and systems-level outcomes would continue to benefit the community without coalition support. 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 (p<.10).
Sustained and not sustained coalitions reported what they would do differently if they could start their coalition over again. First, coalitions reported they would diversify their membership (e.g. expanding to business, specialty care providers, private primary care providers and medical groups, and engaging all health systems in the community including competitors, consumer groups, and faith-based groups). The overall sentiment was that a more diverse membership would have better represented all perspectives of the community and the target population, as well as provided different types of knowledge, skills, and resources for the coalition. Second, coalitions would establish more formal structures. The most frequently cited example was establishing formal contracts, MOAs, etc. with the member organizations that explicitly state and describe the expectations and responsibilities for the member and the coalition so that both parties share a common understanding of the relationship from the very beginning. Several coalitions also expressed a desire to increase the leadership structure through the executive committee or board of directors, and several regreted that the coalition did not establish as an independent not-for-profit. The third frequently cited lesson learned was to focus the coalition’s mission and activities to concentrate on what the coalition did well and where it could make the greatest impact. Several coalitions stressed the importance of assessing activities regularly and being willing to let go of those that do not work well.