Finally, results from this study provide an understanding of the extent to which former HCAP coalitions have evolved to address the needs of their communities, and the impacts and outcomes they have achieved post-federal funding. The discussions below explore the changes in coalitions’ activities, and the individual-, system-, and policy-level impacts that they achieved.
Coalition Activities. HCAP coalitions were brought together initially to undertake a particular set of activities, and activities are still a core part of what coalitions are doing. The most common types of activities conducted by the coalitions initially included programs and services (e.g., eligibility and enrollment or patient navigation) and systems change (e.g., integrated data systems or coordinating pro bono care). Capacity building activities (e.g., providing TA to member organizations) were also prevalent among sustained and not sustained during the HCAP period.
Sustained coalitions did adapt their activities over time. Half of the sustained coalitions conducted capacity building activities during the HCAP grant, but significantly fewer (41%) did so at the time of the survey. This suggests that the need for capacity building may lesson as the coalition matures, but does not diminish completely. This may be related to mature coalitions’ continued adaptation to new issues or activities and the incorporation of new partners over time as the coalition evolves to address the changing needs of the community. As the proportion of effort spent on capacity building activities decreased, the percentage of sustained coalitions conducting policy activities (e.g., working with local officials) increased significantly. The increase may be a function of coalition evolution or may in fact be related to the increasing trend of greater emphasis on policy activities and broader attempts to make more "upstream" impacts.
A final point about the HCAP coalitions’ activities relates to the not sustained coalitions. Even among the 32 percent of coalitions that were not sustained, the majority reported that at least one of the activities they undertook as part of HCAP was still being conducted at the time of the survey. If the activity initiated under HCAP fulfilled an existing community need this significantly contributes to the positive impacts of the HCAP program.
Coalition Impacts. Overall, coalitions reported that they have continued to make individual, systems, and policy level impacts since the end of the HCAP grant. This was especially true for individual and systems level outcomes which were perceived as being part of their core functions. The coalitions were far more likely to say that impacting the policy-level was not applicable to them compared to individual and systems level impacts. This perspective may reflect the influence of the health care and human service provider sectors on the coalition. While HCAP coalitions recognized the increasing emphasis on promoting policy change as a way to promote health, most do not yet understand how to make a direct impact in the policy sphere or how to measure and track those impacts.
Sustained coalitions participating in interviews and site visits provided more specific examples and evidence of these impacts through program reports and internal statistics. In the post-HCAP period, the coalitions have achieved many different types of outcomes yielding significant improvements for the uninsured and underinsured populations and safety net system in their communities. Additionally, the majority of sustained coalitions believed that they have made impacts at a steady pace throughout the coalition’s lifespan (from pre-HCAP to the time of survey). Less than a quarter of sustained coalitions thought that their greatest impact occurred during the HCAP period.
Coalitions generally felt that they needed to sustain the coalition itself in order for their work to continue improving their communities. Fewer than half of sustained coalitions believed that all or most of their individual health and behavior outcomes would continue to benefit the community if the coalition had to disband or dissolve. Just over half said the same about systems-level outcomes and just under half about policy level outcomes. Coalitions serve to bring organizations together, to leverage and coordinate disparate resources in the community, and to fill a gap in the local health and social service system. Without the actual coalition structure in place, it is not surprising that people anticipate significant reductions in perceived benefits.