Health for All: Making Community Collaboration Work

Health for All Making Community Collaboration Work

Health for All Making Community Collaboration Work

Howard P. Greenwald and William L. Beery Health Administration Press, Chicago

Your board, staff, or clients may also benefit from this book’s insight. For more information on quantity discounts, contact the Health Administration Press Marketing Manager at (312) 424-9470. This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The statements and opinions contained in this book are strictly those of the author(s) and do not represent the official positions of the American College of Healthcare Executives or of the Foundation of the American College of Healthcare Executives. Copyright © 2002 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher. 06

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Library of Congress Cataloging-in-Publication Data Greenwald, Howard P. Health for all, making community collaboration work / Howard P. Greenwald and William L. Beery. p. cm. Includes bibiographical references and index. isbn 1-56793-180-4 (alk. paper) 1. Community health services. 2. Medical cooperation. I. Beery, William, 1994- II. Title. ra445 .g744 2002 362.1'2—dc21 2002020502 The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ansi z39.48-1984. ™ Acquisitions editor: Marcy McKay; Project manager: Joyce Sherman; Text design: Matt Avery; Cover design: Anne Locascio Health Administration Press A division of the Foundation of the American College of Healthcare Executives 1 North Franklin Street, Suite 1700 Chicago, il 60606-3491 (312) 424-2800

To Romalee and Madeline

Table of Contents Foreword

ix

Preface

xi

Acknowledgments

xiii

Part I: Coll aboration Past and Present 1

The Promise of Collaboration

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2

Health Systems and Community Health: Tradition and Innovation

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3

Partnership Challenges

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Part II: A Case Study: The Mutual Partnerships Coalition 4

An Ambitious Partnership: The Mutual Partnerships Coalition

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A Case Study in Conflict

115

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Project Outcomes

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Part III: Lessons Learned

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Assessing Accomplishments: Traditional and Nontraditional Approaches to Evaluation

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Collaboration Intervention: Challenges and Triumphs

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Appendix A: Resources to Help Implement Community Partnerships

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Appendix B: Other Resources for Community Collaboration

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Appendix C: Key Foundations Involved with Community Collaboration

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Appendix D: Further Reading for Chapter 2

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About the Authors

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Foreword

In Health for All: Making Collaboration Work, Howard Greenwald and William Beery have extended their past years of highly productive personal collaboration to delineate the social context, promises, and processes of community coalitions for health. Although health service institutions in the United States such as hospitals, health departments, and universities have long recognized the need for “outreach” to their communities and undertaken efforts in that direction, something new has emerged in recent years. The health service institutions, in approaching communities, have begun to encounter more fully than previously—and sometimes partner with—two types of agencies. One consists of longestablished organizations such as churches and schools that are indicating considerable interest in what they can do for the public’s health as well as that of their own constituents. The other is composed of organizations, often informal at first, that are arising in communities for a variety of social purposes, for example, to safeguard neighborhoods and combat crime, improve education, and serve seniors or children and families. Often these groups include activists who are passionate about social betterment and have a knack for leadership. This grass-roots movement seems to be advancing across the country, possibly in substitution for declining ix

confidence in the traditional agencies presumed to attend to such matters. The book analyzes experience in developing collaboration between the “two sides,” major health services organizations on the one hand, and on the other, community groups and agencies that are interested, or can be interested, in health. Their coming together involves some shift in authority toward the community forces, often called “empowerment” by the traditional institutions. Greenwald and Beery describe in considerable detail this shift, which occurs in varying degrees. The spectrum ranges from the previous efforts by the major health services organizations to community groups to genuine delegation of power and what the authors consider the ideal: citizen power. Their book focuses on what is highly important in this dynamic situation, namely, “how to” advance health. They draw on their own extensive experience in the movement and evaluation of similar work by others. Substantial attention is given to a case study of the Mutual Partnership Coalition in Seattle, Washington. This organization brought into play such diverse groups as an inner-city educational and cultural organization, the local housing authority, a senior services agency, a faith-based organization, and Group Health Cooperative of Puget Sound (the convener). The account deals with, among other issues, the challenge (not pretty) that a serious conflict within the organization posed. The authors also describe other episodes in the movement such as Project Immunization Virginia. Two particularly valuable aspects of the work are the explicit statement of lessons learned and the appendices that list the extensive resources available to help community coalitions for health, including foundations that are interested, and strategies for evaluation. Lester Breslow, M.D., M.P.H., Sc.D. Professor Emeritus, Health Services ucla School of Public Health

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Health for All

Preface

Health for All: Making Community Collaboration Work draws together and integrates hitherto scattered ideas and experiences associated with collaborative community interventions. Ubiquitous throughout the United States, the collaborative community intervention brings together diverse forces capable of determining the health of communities. The collaborative community intervention can be viewed as a social movement within the worlds of healthcare, public health, and health policy. It departs from tradition by integrating the interests and efforts of powerful institutions, grass-roots groups, and private citizens. It also breaks new ground by focusing not on treatment of disease but on creating conditions within communities that can prevent illness and promote well-being for residents of every age and economic stratum. Hence, the book’s title: Health for All. The book is at the same time a conceptual and practical guide. It is both a celebration and a critique of the collaborative community intervention. It highlights the contribution community collaboration can make to health in the new century, and it provides concrete information about the factors that can keep this dream from becoming reality. Most important, this book provides practical lessons

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intended to promote fulfillment of the potential of collaborative community interventions. The chapters to follow offer information of particular value to leaders and managers of healthcare organizations who have an interest in launching collaborative efforts with the community. The basic concept of community collaboration is reviewed. This review emphasizes the importance of community collaboration as a means for mobilizing ideas, resources (material and political), and energies from highly diverse quarters. Only through collaboration, it is noted, can the ideal of community health be realized. Alerting leaders, managers, practitioners, and citizen-activists to the power that can be unleashed by coalitions is the book’s principal mission. However, a message presenting only the payoffs of community collaboration would be misleading. Everyone who contemplates a collaborative venture must be aware of the hurdles that can stand in the way of success. Thus, this book pays significant attention to factors that can derail even the most conscientious and well-funded efforts. The chapters include stories about programs initiated with insufficient preparation, collaboratives beset with conflict, and expertly planned evaluation efforts that resulted in negative findings. Many lessons are to be learned from these cases. Over all, the authors wish to convey encouragement: Collaborative interventions represent the best values in the American tradition, and community health reflects the most progressive contributions of the health sciences. We hope the book will inspire creativity and experimentation and endow such efforts with the practical wisdom required for success. Howard P. Greenwald William L. Beery

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Health for All

Acknowledgments

The community health movement involves government agencies, foundations, private organizations providing healthcare, healthcare professionals, scientists, community activists, and many individual private citizens committed to making a difference. This book reflects the ideas and experiences of the full range of organizations and people who have initiated and participated in the movement. The formal acknowledgments that follow can express thanks to only a few of those who have inspired and supported us in writing this book and in founding and developing the movement itself. We first acknowledge Group Health Cooperative of Puget Sound, Washington. “Group Health,” as folks in the Pacific Northwest know it, occupies a venerable place among healthcare institutions in the United States. Founded by visionary consumers and providers in 1947, Group Health Cooperative is today one of the largest healthcare organizations in Washington State. It has maintained its nonprofit status and consumer governance structure even as successive waves of change have altered healthcare throughout the United States. For its entire history, Group Health Cooperative has initiated and sponsored the type of collaborative community intervention that is the focus of this book. It now serves as the parent

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organization of the Group Health Community Foundation, under whose auspices this book was written. Few of the ideas in this book can be claimed exclusively by the authors. Many have been developed by the evaluation team of the Group Health Community Foundation, which has been active in advising and evaluating collaborative community interventions for two decades. Particularly worthy of recognition are Dave Pearson, Sandra Senter, and Allen Cheadle. Special thanks are due to Carolyn J. Stemshorn, who played an important role in preparing the manuscript. We wish to express gratitude to several scholars, commentators, and scientists who have been instrumental in developing the conceptual and factual basis of community collaboration as well as providing important critiques: Tom Bruce, Ed Wagner, Marshall Kreuter, Gary Nelson, Alicia Procello, Gary Yates, Tom David, Joe Hafey, and Maria Campbell Casey. Several agencies and foundations deserve special thanks for providing both funding and encouragement for the projects we have been privileged to help launch, advise, and evaluate: the Henry J. Kaiser Family Foundation, the W. K. Kellogg Foundation, The California Wellness Foundation, The California Endowment, the Partnership for the Public’s Health, the federal Centers for Disease Control and Prevention, the American Cancer Society, the Public Health Institute, and the Group Health Community Foundation. A large number of colleagues from public and community agencies in Seattle deserve our gratitude. Of great importance were agency executives Gregory Davis, John Froyd, Margaret Strachan, Marsha Johnson, and Tom Rasmussen. Key staff included Craig Shimabukuro, Joan Greathouse, Katherine Woolverton, Sally Friedman, Paul Howard, Karen Hulbert, Mary Diggs, Helleyne Summerrise, Candice Adudell, Ruth Famm, and Kathy Kelly. Finally, we thank the many public and private agencies and community residents who have participated in the collaborative efforts reported here. Although too numerous to mention individually, all have made invaluable contributions. xiv

Health for All

PART ONE

Collaboration Past and Present

“Coalition” is a concept that is today embraced in an extraordinary range of contexts. World leaders look to coalitions to address the new century’s most critical concerns. In the United States, officials have found coalitions useful in addressing public matters traditionally handled by bureaucrats, financial movers, or technical experts. Responsibilities ranging from keeping a city’s favorite sports team from moving to promoting opportunities for the chronically unemployed are today delegated to coalitions. The coalition concept speaks to the core American value of participation. Of equal importance, it allows individuals from many walks of life and organizations in diverse specialties to contribute their expertise to problem solving. Coalitions promise to promote solutions to problems that are technically optimal and most likely to gain public acceptance. This book addresses coalitions and collaboratives involving organizations concerned with health. Hospitals, health maintenance organizations (hmos), public health departments, community clinics, and numerous additional entities have joined together for common purposes, perhaps most often in prevention of illness. Grass-roots participation has been invited and often emphasized. By joining coalitions, organizations concerned with health have sought not 1

only to reduce illness and injury, but to demonstrate their public citizenship through measurable community benefits. Part I of this book provides a summary of the objectives that have been sought through coalitions. It discusses the components of coalitions, with special emphasis on collaboratives which are (1) closely tied to the local community and (2) aimed not only at promoting physical health but at enhancing the community’s general wellbeing. Part I provides several examples of community coalitions to illustrate the range of objectives pursued by collaboratives and indicates the diverse forms the structures of these entities may take. Finally, part I familiarizes the reader with the challenges collaboratives must meet to become successful.

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Health for All

CHAPTER 1

The Promise of Collaboration

INTERVENING IN COMMUNITIES

The twenty-first century has begun with a fresh-sounding concept in the conversations of people seeking social transformation: the collaborative community intervention. This book addresses the collaborative community intervention as applied to an objective of key importance: improving the health of people in communities throughout the United States. Each element of this concept deserves special attention: • Collaborative. Collaboration signifies association of individuals or organizations with divergent histories, interests, and perspectives working together on projects with a common purpose. According to political scientists, the United States is a pluralistic society. Groups and “interests” in cities and neighborhoods normally compete for political power, business opportunities, public funds, and the attention and support of citizens. When people or groups collaborate, they seek to put aside their differences and concentrate on objectives they all hold in common.

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• Community. Community reflects a feeling of familiarity, loyalty, and pride among individuals about a place they live, activity they engage in, or value they hold. The term community is most often applied to physical location. People consider their block, neighborhood, or city their community. In addition, communities are formed within professions, among people practicing the same religion, and among devotees to the same sport. In every true community, members are able to define the boundaries of that community. Within community boundaries, members experience a sense of comfort and common interest. • Intervention. Intervention means attempting to take control over something of significance in the environment. Often, the term has a negative connotation, as when police intervene in the trafficking of contraband or military forces invade a neighboring country. In a more positive sense, intervention signifies taking action to reduce threats to a community’s well-being, such as disease, chronic unemployment, or the criminal element. Intervention may also seek to recognize and enhance a community’s capacities, encouraging residents to use their skills to improve the lives of others or mobilizing resources to enable young men and women to achieve their potential. By powerfully combining and directing material and human resources, the collaborative community intervention can become one of the most effective means in the United States today for improving health and promoting well-being. A collaborative community intervention involves making contact with people outside one’s own organization and mounting a combined effort toward a common goal. Participants are likely to retain their differences, but, in effective coalitions, most put them aside long enough to allow the common focus to work.

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Health for All

The hospital in a small western town finds its emergency room extensively used for routine healthcare needs. The cost to the hospital is significant. This takes place despite a state program that provides inexpensive health insurance to low-income families. The hospital seeks the community’s help. A coalition is started to make high-quality, accessible care more readily available. Members of the coalition include the health department, the school district, a large employer, a representative of the Migrant Health Service, and several individuals not a;liated with any agency. Intense exchanges take place within the coalition about why people look to the emergency room for everyday needs. It is apparent that most emergency room users are Hispanic people whose employers do not provide health insurance. The comment is made that these families feel uncomfortable revealing to private doctors that they are beneficiaries of the state program. It is further revealed that the only Spanish-speaking nurse practitioner in town works at the hospital emergency room. Coalition members pool resources to address the problem. The hospital provides o=-site space for a community clinic. The employer donates start-up funds. The health department agrees to recruit Spanish-speaking providers. The community residents provide advice about how to make the facility attractive to the community and how to help users complete forms. Everyone agrees to participate in directing the project and seeking funds to make it self-sustaining.

This book concerns health; many examples with aims similar to the intervention described above will follow. However, the principle of collaborative community intervention has been applied to numerous concerns other than health in areas as distinct from health as law enforcement and natural resource management. For example, “community policing,” a concept of growing importance in law enforcement, makes extensive use of community coalitions:

The Promise of Collaboration

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A city police department finds itself embattled by dissatisfied citizens. Community leaders in several neighborhoods have complained to the city council about police services. These leaders assert that burglary and vandalism are daily occurrences and that drug tra;ckers and prostitutes operate openly at known locations. At the same time, the city’s minorities are angry about alleged “racial profiling.” Blacks, Hispanics, and young Asians argue that police stop them simply because they are minorities. Seeking to avoid reprimands, police o;cers become cautious about stopping members of these groups for investigative purposes. In response to this cross-pressure, the chief of police assembles the Chief’s Advisory Council, which includes community and minority group leaders as well as young people whose age or appearance frequently attracts the attention of police o;cers. The council provides the chief with information regarding where o;cers should be deployed. Police training personnel become better informed about the community and thus are better able to instruct o;cers about who is and is not likely to be involved in crime. Communities throughout the city become better informed about the crime problem in their neighborhoods and receive encouragement to take informed action.

Another example is the management of publicly owned resources, such as rangeland and water, which has become a divisive issue in rural areas. Community coalitions have demonstrated their value in advising government agencies about use of these resources. Actions are taking place in this manner: A valley of streams and rolling hills has been cattle country for generations. Recently, a