Blog: Is Your Connected Community of Care Making a Difference?

By Keith Kosel, Executive Advisor at Parkland Center for Clinical Innovation

We ask this type of question every day. For example, we may ask― “Is this product that I purchased making a difference?” or “Is this advanced training that I completed making a difference?” Implicit in this common question is the expectation that because we have made an investment in something to achieve a result, the result should be better or more improved than the pre-investment state. So too with a Connected Community of Care (CCC). As I have discussed in previous blogs, establishing a CCC requires a substantial investment in both time and money. Therefore, it is only natural to ask― “Is this CCC making a difference, and how would I know?” Unfortunately, most CCCs are established with very little forethought given to this exact question. While we expect the CCC will help community residents improve their health and well-being, how will we know conclusively that this has happened? How will we demonstrate its impact to a potential partner or― more importantly― a funder? This is where data, measurement, and evaluation come into play. For most people, these three words cause anxiety levels to immediately rise. But this doesn’t need to be the case; a little planning and forethought can go a long way to assuaging one’ anxiety when asked the question, “Is your CCC making a difference?”

Before we think about what data we will need to answer this question or how we will collect it, we first need to establish what we mean by “making a difference”. Understand, there is no one correct answer to this question. What may constitute a positive difference or impact for one organization may be much different for another, even similar organization. Many factors contribute to the final answer and each are usually organization-, ecosystem- and situation-specific.

In practice, there are many ways to define making a difference. First, we can look at quantitative or numeric information to make this determination. Are we providing more nutritious meals to indigent residents? Is the number of inappropriate Emergency Department visits declining or, conversely, is the number of residents having visits with a primary care provider increasing? All of these effects can be counted and judged against some predefined goal (more on this later). Second, we can assess making a difference by asking the people that are being touched by the CCC. Through surveys or brief interviews, community residents can tell you in their own words what impact, if any, the CCC has on their lives. While this qualitative (non-numeric) information can often be more informative than simple quantitative information because it represents the voice of the individual, to answer the question of whether your CCC is making a difference, you will also still likely need to establish numeric goals. A third way to assess whether your CCC is making a difference is indirectly via the financial and non-financial opportunities that arise as a result of having a CCC versus not having one. For example, having a CCC may make it much easier to perform contact tracing among vulnerable populations during a pandemic like COVID-19.

Having a CCC may also enable a healthcare system or a community-based organization (CBO) to apply for a grant that it otherwise might not be competitively positioned to do if it did not have an integrated system of healthcare and social service providers such as a CCC.

Regardless of the approach to define making a difference, the importance of planning for 1) what things will be measured to generate the necessary data, 2) how and when that measurement will take place, and 3) how the resulting data will be analyzed and evaluated, cannot be underestimated.

Similarly, these decisions cannot be put off until a later date as is often seen with start-ups, including CCCs. While it is natural to want to focus on the more immediate needs associated with launching a CCC, deferring the question of how we will know if the entity is making a difference can prove costly, both from an operational and financial perspective. At the Parkland Center for Clinical Innovation (PCCI) we encourage those planning a CCC to devote the necessary time early on to setting performance goals and objectives and determining how and when they will be measured and evaluated. While it is important to explicitly build this step into your CCC planning phase, the scope and scale of the work does not have to be extensive. In fact, at PCCI we strongly encourage CCCs to start small with a limited set of goals, objectives, and requisite measures and then scale up as the CCC grows and matures. This approach has the dual benefit of providing essential core information early on while also not overwhelming the CCC staff with data collection activities that may be a distraction from more pressing, day-to-day activities.

Based on this author’s work with literally hundreds of healthcare and social service provider organizations, experience suggests that most entities (both new and established organizations) do best if they initially establish 1) a limited number of goals― one or two at most, 2) a similar number of objectives to achieve each goal, and 3) no more than three to four performance measures to support each goal. While this may seem like an insufficient number of performance elements in today’s data-obsessed world, remember that you can always add additional goals, objectives, and measures as your expertise and comfort levels allow and as your CCC evolves.

Even more important than the numbers, however, it is essential to get the selection of the goals, objectives, and performance measures correct. Each of these three performance elements plays an essential role in helping you answer the question “Is my CCC making a difference?” Your goals focus on the long-term― what do you ultimately want to happen, while your objectives are the short-term accomplishments that help you achieve your goals. In both cases, you must be sure that what you are expecting is both realistic and appropriate for your CCC’s stage of development. For example, assuming a newly established CCC will reduce ED utilization in its first year or two may not be reasonable and may lead to frustration and disillusionment if the goal is not achieved. If you select a BHAG (Big Harry Audacious Goal), you must allow sufficient time (and then some) for all the necessary pieces to come together. The rule of thumb for large-scale demonstration projects such as launching a CCC is that they 1) take (much) longer than expected, 2) cost more than budgeted, and 3) generally initially deliver less than expected. These facts should not dissuade you from your journey, but rather help you keep things in perspective as the project evolves to one that in the long-term is viewed as valuable in achieving your goals.

If getting the goals and objectives correct is important, then selecting the correct performance measures and designing a feasible measurement plan is paramount. Here again, quality is more important than quantity. A few well-chosen performance measures, implemented correctly, will generate far more in the way of actionable data than a plethora of randomly selected measures. To optimize your ability to assess if your CCC is making a difference, your performance measures should be collected at regular intervals following the launch of the CCC. While many established programs collect, analyze, and evaluate performance data on a quarterly basis, for fledgling CCCs, PCCI recommends this data be collected monthly for at least the first one to two years or until the CCC reaches a stable level of operations. While monthly data collection requires a little more work, the more frequent feedback allows you to make necessary program or operational modifications more quickly and with fewer disruptions than that afforded with quarterly feedback. If measurement and evaluation is an area where you don’t have a lot of experience, reach out to others that do, especially individuals and organizations such as PCCI that have experience assessing performance in large-scale, multi-sector collaborative projects.

While we all hope that the answer to the question “Is my CCC making a difference” is yes, the answer may be no early on in the life of a CCC. As disheartening as this news may be, it’s important to not give up, but to look critically at what is working and what is not and make adjustments where necessary. Usually, this examination does not necessitate a complete “reboot” of the CCC initiative, but rather requires making minor changes accompanied by paying closer attention to the CCC’s operations. Seek feedback from your staff and those you serve and be open to change, where change is warranted. As indicated, these types of projects take a lot longer to reach fruition than most people believe, but with a solid plan, patience, and flexibility, you will be able to answer, “Yes, my CCC is definitively making a difference in the lives of the community residents it serves.”

About the author
Dr. Keith Kosel is an Executive Advisor at Parkland Center for Clinical Innovation (PCCI) and is co-author of “Building Connected Communities of Care: The Playbook for Streamlining Effective Coordination Between Medical and Community-Based Organizations,” a guide that brings together communities to support our most vulnerable. At PCCI, Keith is leveraging his passion for – and extensive experience in – patient safety, quality, and population health by focusing on understanding social determinants of health and the impact of community-based interventions in improving the health of vulnerable and underserved populations.

Governance: The Glue That Holds Connected Communities of Care Together

By Keith C. Kosel, PhD, MHSA, MBA

Aligning groups that have very different backgrounds and agendas, for the good of the community, is no easy matter. Whether at the city, state, or federal level, governmental or civic entities are tasked with trying to build consensus among various stakeholder groups to affect an outcome that works for the constituents they represent. It is no different for those tasked with leading a Connected Community of Care (CCC).

The Role of Governance
The premise behind the CCC is that by bringing together healthcare providers, community-based social service organizations (CBOs), faith-based organizations, and various civic entities, a community can establish a network of care providers focused on addressing residents’ social and/or clinical needs. While the premise is straightforward, establishing the governance group and governance structure to set up and manage a CCC is anything but straightforward. Before we look at how we might bring entities with different missions and agendas to the table, let’s understand what we mean by a governance group and a governance structure, and why these are essential to form a successful CCC.

The nucleus of a CCC is its governance group― those organizations that have come together to establish the CCC and to form the rules by which it will operate (the governance structure). As most CCCs form from scratch, the governance group is typically made up of one or two organizations we refer to as Anchor Organizations. These are typically large, well-established, and highly respected organizations within the community. They could include national social service organizations such as the United Way or Salvation Army, or they could be philanthropic funders, faith-based organizations or healthcare systems. What all these organizations have in common is a mission to improve the health and well-being of their community’s residents. As such they lie at the heart of the governance group (Figure 1).

Figure 1. Connected Communities of Care Including Governance Structure

In addition to the Anchor Organizations, the governance group typically consists of four to six additional Partner Organizations. These may be somewhat smaller CBOs (in scale and scope), but they all play a foundational community role in addressing resident’s social and/or clinical needs. Partner Organizations are well-known within the community and historically work closely with the Anchor Organizations. Partners could be regional food banks, housing assistance providers, crisis centers, mental health providers, local school districts, etc.― all defined by the fact they deliver essential social or clinical services within the community.

The role of the governance group is to provide structure and guidance for the CCC. By structure we mean things like: (1) how network participants will be identified and approved, and what will be expected of each; (2) what the CCC’s mission and charter will include; (3) how the CCC will be funded; and what type of data must be collected and shared, consistent with HIPAA regulations. While the governance structure deals with establishing the rules and policies that guide the day-to-day workings of the CCC, the governance guidance function focuses on issues like: (1) support for a Readiness Assessment (See previous blog) to determine if the community needs― and is even ready for ―a CCC; (2) how and at what rate the CCC should grow; (3) strategic partnerships; and (4) CCC sustainability. A governance group is essential to establishing and growing the CCC. Moreover, without a strong, representative and resilient governance group, most CCCs will eventually fail.

Act 1 -Forming the Governance Group

While we might think that forming the Governance Group would be a fairly easy task, given that many Anchors and Partners already know one other, in reality the process is far more complicated. While many of the Anchor and Partner Organizations work in parallel, they often have a narrow topical focus, such as providing food, housing, healthcare or after-school programs. These topical focus areas may conflict either with regard to the purpose of the work or the process by which the work takes place. As an outsider looking in, we might think these are minor, easily solved issues when in fact they are anything but. Layer on top of this funding mechanisms that often are not uniform or are based on an organization’s own performance to support its mission within the broader CCC, and simple differences compound quickly. As the number of Anchor and Partner Organizations increases, the complexity of achieving alignment among these entities also increases dramatically. This is the point where the presence of a powerful and commanding Anchor Organization(s) become critical in driving alignment.

Because there are usually only one or two Anchor Organizations, the likelihood of disagreement is minimized, compared to the next governance level down (i.e., Partners). Typically, the Anchor Organizations individually have been contemplating a Connected Community of Care for some time and all it takes is the right “spark” at the right moment to bring them together. Further, Anchor Organizations by their nature are well versed in coalition building and working across multiple sectors, which is a skill set that may be less well-developed in the Partners, especially in smaller or rural communities.

A key function of an Anchor Organization is to bring a handful of Partner Organizations into the governance group. Here the Anchor’s skill in selecting collegial partners or ones that can easily be won over to align with the CCC’s mission and goals is extremely important. Including a Partner that will be disruptive or non-cooperative is a fatal error, regardless of what resources that Partner might control. Even if it means working harder to secure the necessary resources, it is better to include only cooperative and committed partners than to access resources at the cost of major disruption.

Act 2 – Moving the Governance Group Forward
Establishing a highly cohesive and well-functioning governance group is only the first step in an ongoing process to grow a successful CCC. The governance group must continue to evolve along with the CCC network. As the network expands, there may be a need to increase representation within the governance group. While warranted, this process must be handled carefully to avoid the disruption just mentioned. At the same time, the governance group may need to remove some participants from the network for failing to follow the CCC’s charter or for sub-standard performance. Although these are difficult decisions, neglecting to make them can irreparably damage the entire CCC over time.

In wrestling with these decisions, the governance group must always be focused on sustainability – sustainability of the CCC and of the governance group itself. Sustainability of the CCC takes different forms from operational sustainability to financial sustainability, each of which are indispensable to a CCC’s long-term growth and viability. Operational sustainability focuses on the challenges of keeping the CCC network up-to-date with regard to technology, strategic partnerships, growth through additional participants, and ongoing social and health needs assessments (i.e., is the prevalence of obesity increasing silently in the community? Are more people accessing utility assistance in the face of declining employment as businesses relocate to more favorable locations?). It also includes provisions for turnover at both the CCC administrative level and at the level of the CBOs, which historically have high turnover levels due to numbers of volunteer staff, etc.

Achieving financial sustainability is the ultimate challenge facing CCC governance groups. Without sustained funding, whether through internal or external means, a CCC cannot survive long term as an effective functioning network. The real challenge is not only securing funding but doing so in a way that benefits all network participants in some fashion based on need and contribution. When network participants must seek funding on their own, inequities are prone to develop, as participants begin to follow their own interests rather than the collective interest of the CCC. Though a difficult challenge, especially in today’s pandemic environment of scarce funding, CCC governance groups must confront it head-on.

CCC governance is not an easy or straight road. Rather it is strewn with potholes, stop signs and detours- but one that must be followed none the less if a CCC is to achieve its goal of improving the health and well-being of the community and its residents. The time and thought that goes into establishing a cohesive and highly effective governance group and structure will pay dividends to the CCC and those it serves many times over as the CCC grows and matures to become a key fixture within the community.

About the author
Dr. Keith Kosel is a Vice President at Parkland Center for Clinical Innovation (PCCI) and is author of “Building Connected Communities of Care: The Playbook for Streamlining Effective Coordination Between Medical and Community-Based Organizations,” a guide that brings together communities to support our most vulnerable. At PCCI, Keith is leveraging his passion for – and extensive experience in – patient safety, quality, and population health by focusing on understanding social determinants of health and the impact of community-based interventions in improving the health of vulnerable and under-served populations.