The ABC's of Working Together

This section provides “The ABCs of Working Together” in your community to improve health, as well as examples of successful approaches to each step.

The health problems that we share as a society are no different from any other common problem in our society. Whether the topic is AIDS or traffic jams, any public discussion can draw out feelings of anger, frustration, and hopelessness. But tension and conflict are the threads that lead to solutions. Just as parents explain lessons to their children, we as citizens have to come together to learn and grow.

There are lots of ways to describe how to collaborate. This section gives you a simple approach to collaboration without being too simplistic. More details and the sources of information for each step in this process are provided later in the Guide.

Five Basic Steps:

Step 1. Talk about the Problem

Step 2. Agree How It Ought to Be

Step 3. Make a Plan

Step 4. Organize

Step 5. Get Going

 

Step One: Talk about the Problem

Have you ever been in a meeting where people complain, but no one is willing to do anything about it? That’s frustrating, but it’s often the first step towards a solution. Nothing will change unless people see a reason for it. You have to turn whining into winning!

There’s a lot to worry about when it comes to health and health care. How do you know if your concern should be a priority or if there’s anything you can do about it?

One way to find out is to ask others what they think. Talk about the problem. Involve local leaders with diverse areas of expertise such as providers, hospitals, and health plans, industry trade and professional organizations, business, government, and consumer advocacy groups. Ask what do other people think should be the priority?

Align Interests to Promote a Healthy Community

Talking about a problem will go farther if you have some good information about local problems and resources. You really don’t want to pursue an issue where there’s no real need anymore or where you would be duplicating the efforts of others working on the same issues.

There are many sources of information about local health problems and how they compare on a national scale. But you may need to collect more information yourself. Once you know the issue you want to address, you need to consider who might already have a hand in the problem and have information about it. For example, your state or county health department may have staff with many years experience addressing a specific health issues. Many organizations routinely conduct community health assessments. It is useful to approach them with an open attitude of wanting to learn about the work they are already doing. The example below describes how concerned individuals came together to address mental health concerns in San Antonio, Texas:


Case Study Example I: Talk about the Problem

A Community-Based Jail Diversion Program for Persons with Mental Illness
The Center for Health Care Services - San Antonio, Texas

When Leon Evans became the executive director of the Center for Health Care Services (CHCS) in April 2000, t he San Antonio mental health system was struggling to meet consumer demand and law enforcement and hospital emergency rooms were shouldering the extra burden. Law enforcement officers routinely waited an average of 12 hours for an emergency room psychological evaluation of a detainee.

In response, CHCS officials and County Judge John Specia, Jr. convened stakeholders to talk about the problem and develop strategies for serving community members with mental illnesses. The diverse group of stakeholders included representatives from law enforcement and the court system such as the local police chief, the sheriff, probate judges and county clerks, as well as mental health care consumers and their family members. The group’s discussions generated short- and long-term strategies such as crisis intervention training, jail diversion programs and a crisis service “triage” center. The initial model the group developed has expanded and stands as a national model of excellence in the area of community mental health services.

By simply convening a diverse group of stakeholders to “talk about a problem,” the group was able to generate creative and effective solutions.

 

Conduct a Needs Assessment

If your group chooses to conduct a needs assessment, the following section provides step-by-step assistance:

A Checklist for Community Needs Assessments

  • Describe the makeup and history of the community to provide a context within which to collect data on its current concerns.
  • Consider the kind of information that best describes your community (e.g., demographic, historical, political, civic involvement, local leaders, or geography.)
  • Use a variety of methods to collect information (e.g. interviews, observation, or data analysis.)
  • Make a list of questions based on discussions with local leaders and community members.
  • Illustrate the issues of concern to people in the community.
  • Determine priority issues.
  • Identify barriers or resistance to solving the problem.
  • Describe the resources available to problem solving efforts.
  • List solutions and alternatives posted by community members and stakeholders.
  • Identify community level indicators; an incidence of behaviors or events that relate to the issues of concern (e.g. for healthcare access collect information on uninsured rates in different populations and the availability of primary care and specialty services.)
  • Describe the resources available for other community projects that may be underway that help address this issue and how they could be used.

 

The example below describes how a group in Roanoke Valley , Virginia conducted a needs assessment to identify the scope of a problem and help them craft effective solutions:

Case Study Example II: Conducting a Community Needs Assessment

Child Health Investment Partnership (CHIP),
Roanoke Valley, Virginia

The Child Health Investment Partnership (CHIP) of Roanoke Valley is designed to ensure low-income children living in the Roanoke Metropolitan Statistical Area age birth through six have access to comprehensive health care. Pediatrician Douglas Pierce founded the program in 1999 after seeing a growing number of low-income children with severe and untreated health problems in his practice.

Dr. Pierce recognized that he must first understand the needs of his target population before developing a plan of action. Through a community needs assessment analysis, program developers learned that besides health care access, low-income families lacked the resources and education for preventive measures, proper nutrition, transportation to health care centers, follow-up medications, and on-going treatment. Without these supports, otherwise innocuous medical conditions escalated into serious health concerns. This additional information helped program developers establish services to support these families and provide children with the health care they need.

The program has been an overwhelming success and served many low-income children in the Roanoke Valley area.

 

Obtain Community Health Data

Whether you are writing a report, making a speech, or simple trying to assess the situation in your community, the following list of possible sources can help you make your case:

Source: http://ctb.ku.edu/tools/en/sub_section_main_1022.htm

Talking about the problems and assessing needs can have its’ own impact. It can expose problems that people hadn’t been talking about yet. And it can help people bond together around a larger purpose. Here’s what one participant in a community project said: “You begin to see your interests as broadening in relationships with other people, particularly as you begin to have serious conversations and you begin to identify with other people’s experiences.”

Source: www.kettering.org/stream_document.aspx?rID=1146&catID=25&itemID=1144&typeID=8

Step Two: Agree How It Ought to Be

Before you start thinking about how to solve the world’s problems, you need to think about what you want the world to look like. A vision that binds your group together is the real power that will sustain your effort.

Creating a vision can have a big impact all by itself. Why not ask everyone to think positively about change in the community? It can create a new way for people to get involved.

The Visioning Process

Thinking big doesn’t always come easy. Here are some questions to get people thinking:

Community Vision

  • What is your health care dream for our community?
  • What should change?
  • What kind of community (or school, neighborhood, etc.) do we want to create?
  • What health care issues or problems do we share?
  • Why should we address these issues?
  • What are our major strengths and assets?
  • What are our weaknesses?
  • What should our purpose be?
  • What would success look like?

 

The following case study provides an example of how a group in Richland County, South Carolina came together to help parents advocate for their children with asthma.

Case Study Example III: Agree How It Ought To Be

Project Breathe Easy,
Richland County, South Carolina

Family Connection of South Carolina, Inc. initiated Project Breathe Easy (PBE) in 1997 in Richland County. The project provides parents of asthmatic children with parent-to-parent support and empowers them to advocate on behalf of their children. PBE targets, but is not limited to, lower-socioeconomic communities.

Organizers attribute Project Breathe Easy’s early success, in part, to its clearly defined goals established by a project advisory committee. The committee, comprised of a broad group of parents, asthma professionals, state government officials, social services agencies, South Carolina American Lung Association representatives, developed specific program curriculum and participation requirements. All parents must complete extensive initial and annual training and have home visits and monthly telephone contact.

By thinking though programming goals from the outset, project organizers established a successful and replicable program.

Step Three: Make a Plan

After thinking big, you need to start small. Small doesn’t mean accomplishing little or nothing. It means focusing on the details. As baseball legend and folk philosopher Yogi Berra once said: “If you don’t know where you are going, any road will get you there.”

You need to identify specific goals. They should include what you want to accomplish and when. These goals can focus on changing behavior like smoking by youth. They may be about changing something in the community like access to primary health care. Or the goals might try to create a better way to do something like coordinating health care and social services for people with a disability. Objectives will likely be a combination of different kinds of activities.

Identify Objectives

While objectives will focus on different kinds of results, they all share the same characteristics. They should be S.M.A.R.T. + C as the University of Kansas Community Toolbox recommends:

S.M.A.R.T. + C

  • Specific. That is, they tell how much (e.g., 40 %) of what is to be achieved (e.g., what behavior of whom or what outcome) by when (e.g., by 2010).
  • Measurable. Information concerning the objective can be collected, detected, or obtained from records (at least potentially).
  • Achievable. Not only are the objectives themselves possible, it is likely that your organization will be able to pull them off.
  • Relevant to the mission. Your organization has a clear understanding of how these objectives fit in with the overall vision and mission of the group.
  • Timed. Your organization has developed a timeline (a portion of which is made clear in the objectives) by which they will be achieved.
  • Challenging. They stretch the group to set its aims on significant improvements that are important to members of the community.

 

Create a Strategy

Once you have your objectives, you need to figure out how to accomplish them. You need a strategy. Strategies explain how the initiative will achieve its objectives. Generally, organizations will have a wide variety of strategies that include people from all of the different parts of the community. These strategies range from very broad efforts that involve different parts of and groups in the community to very specific strategies that take place on a much smaller scale.

Examples of broad strategies include:

Five types of specific strategies can help guide most interventions.

Consider what has been proven to work. Nothing succeeds like success. Look at “best practices” and recognize it is not always necessary to start from scratch. The example below points out the value of simply bringing various existing healthcare delivery organizations together under one roof, and involving the local citizens in developing and assessing services.

The following case study in Jackson, Mississippi provides an example of how building on success can help sustain and grow an initiative.

Case Study Example IV: Building on Success:

The Jackson Medical Mall,
Jackson, Mississippi

In 1995, Jackson physician Aaron Shirley, MD, conceived of turning a vacant and dilapidated shopping mall into a comprehensive, multidisciplinary health care complex serving the low-income residents of Jackson.

Dr. Shirley and his friend Reuben V. Anderson, an attorney and former Mississippi Supreme Court justice presented the idea to Dr. Wallace Conerly, vice-chancellor of the University of Mississippi Medical Center (UMC). The Medical Center’s teaching clinics while successful had outgrown their space on the Medical Center campus; however the Center could not afford to build a new, freestanding ambulatory care center. When presented with the idea, the Medical Center moved quickly to help create the Jackson Medical Mall Foundation, which purchased the mall in 1995 for $2.7 million with loans from three prominent banking institutions. Capitalizing on the support of the Medical Center, organizers expanded their coalition to include other health partners such as Tougaloo College and Jackson State University.

Building on the success of established health providers, Dr. Shirley’s vision has become what is now the Jackson Medical Mall – a one-stop, comprehensive health care facility that also offers human services and economic development.

Step Four: Organize

The first step in organizing your effort is to understand the need for leadership. Organize, Organize, Organize “I decided to put myself in charge” reads a t-shirt popular with parents shopping for children’s clothing. Community leaders take responsibility for the well-being and improvement of their communities.

How to Be a Good Leader

If you are a community leader or want to become one, you’re qualified if you answer yes to the following questions:

Don’t wait for someone to appoint you as a community leader. Even people who run for office first make a decision that they want to be a leader. You can probably take as much responsibility for your community as you are willing.

Here are some of the values you want to nurture as you develop your leadership abilities:

The following case study provides an example of how finding common ground among diverse groups – even when the motivations are different – can result in a successful program.

Case Study Example V: Organize

The Ashville Project, Ashville, North Carolina

The Asheville Project, established in 1997, utilizes community pharmacists trained in diabetic education to help diabetic patients adhere to a diabetes control health regimen.

Under the program, the city of Asheville, N.C., offered employees and their family members with diabetes regular consultations – at no cost – with a community-based pharmacist specially trained in diabetic education. During consultations, patients received treatment monitoring, advice on diet, exercise, stress reduction and medications, and home glucose meter training. When necessary, pharmacists referred patients to a physician or to a diabetes education center.

As an incentive for patients to participate, participants received a free home blood glucose monitor and a waiver of co-payments for all diabetes-specific drugs and supplies. To encourage pharmacist participation, program organizers provided pharmacists with training in diabetes management, monetary reimbursement for the additional patient care responsibilities and recognition of their expertise and contribution to patient healthcare.

By obtaining buy-in from the two major stakeholders vital to the program’s success, the City of Asheville succeeded in lowering their health care costs and providing individuals with diabetes more personalized care, education and disease management. The program has been recognized as an innovation in health care provision.

Community Organizing

Leaders of community collaboratives first need to set a direction. Then the process of organizing activities can begin. Below is a checklist for doing basic organizing:

Checklist for Organizing

  • Gain an understanding of the community -- What is the community like, and what is important to its residents.
  • Generate and use power -- There are many types of power; depending on the nature of your organization and your long-term goals, your organization may have or need different types. There is political or legislative power, consumer power, regulatory power, and protest power.
  • Articulate issues -- A crucial part of effective organizing is being very clear about what people find important, and what you feel should be done about it.
  • Plan purposeful action – decisiveness is key to effective community organization.
  • Involve other people -- Simply put, community organizing works in large part because of the strength that exists in numbers. The idea that "what we can't do alone, we can often accomplish together" is what community organization is all about.
  • Generate and use other resources -- While involving many people is at the heart of any community organizing effort, a group will need to obtain other resources as well. These may include cash, gifts in kind, and other forms of donations or support.
  •  Communicate with your community -- There are many ways to effectively get the word out and let the community at large in on what you are doing and about why you are doing it, and why they should be a part of it.

 

 

Work with Community Leaders

Next, you need to work with other leaders and organizations in the community. Consider writing a memo of collaboration to involve others in the community. This memo would show everyone’s roles in tackling the problem and achieving the goals. It would involve walking other organizations through the same kind of leadership steps that you do for your own organization. Specifically, this involves working together on a mission statement, objectives, an action plan, and measuring progress. Since health disparities are such serious problems when it comes to access to quality healthcare, it is a good idea to involve underserved community leaders. Then you need to determine how to share resources and responsibilities for achieving results. Here is an example of a high degree of collaboration in North Carolina.

Step Five: Get Going

Now you are ready to go to work. You have determined the problems you want to solve and agree on their importance. You have created a vision, outlined strategies and are ready to make a plan, organize and execute it. Now you need to consider the importance of measuring your results.

How will you know if you are achieving your goals? You need to be able to see your progress and show everyone else. Sometimes you might even receive the honor of an award. That’s what Premier, Inc., a national coalition of non-profit hospitals, tries to do for notable efforts throughout the country. The following example of a group in Allegany County, Maryland providing health care to low-income, uninsured adults illustrates how successful programs have clear, achievable goals.

Case Study Example VI: Achieving Results

Allegany Community Access Program, Allegany County, Maryland

The Allegany Community Access Program (Allegany CAP) provides improved access to quality health care services for low-income, uninsured adults by coordinating services and decreasing service duplication. Program organizers developed a virtual network and universal intake form to determine eligibility, streamline enrollment, provide referrals, and track utilization.

Over the years, the Program has achieved its goals and demonstrated proven results. Since it’s inception in September 2001, program operators have provided over 5,000 services to uninsured and low-income individuals in the county.

Allegany CAP continues to identify unique and collaborative solutions addressing the needs of the economically depressed region in western Maryland, including development of a community healthcare plan for the working uninsured.

There’s an old management saying: “You cannot improve what you cannot measure.” Measuring results means that you can see actual differences in the health and well being of a group of individuals. Here’s how one major institution tracked its results:


Case Study Example VII: Measuring Results

Allegany Community Access Program, Allegany County, Maryland

The Allegany Community Access Program (Allegany CAP) provides improved access to quality health care services for low-income, uninsured adults by coordinating services and decreasing service duplication. Program organizers developed a virtual network and universal intake form to determine eligibility, streamline enrollment, provide referrals, and track utilization.

Over the years, the Program has achieved its goals and demonstrated proven results. Since it’s inception in September 2001, program operators have provided over 5,000 services to uninsured and low-income individuals in the county.

Allegany CAP continues to identify unique and collaborative solutions addressing the needs of the economically depressed region in western Maryland, including development of a community healthcare plan for the working uninsured.

Develop a Business Plan

You will need to consider how your effort will be financially sustainable. Consider drafting a business plan and forming a financial sustainability committee. You can find templates for writing business plans at United States Small Business Administration ( www.sba.gov/smallbusinessplanner/plan/writeabusinessplan/index.html). Not all business plan elements will apply to your objectives in improving the health of a community, as this often involves a heavy dose of social responsibility.

Business Plan Checklist

  1. Describe the venture (new or current organization, product or service), often including its primary features, advantages and benefits
  2. What the organization wants to do with it (buy it, expand it, etc.)
  3. Justification that the plans are credible (e.g., results of research that indicate the need for what the organization wants to do)
  4. Marketing plans, including research results about how the venture will be marketed (e.g., who the customers will be, any specific groups (or targets) of customers, why they need the venture (benefits they seek from the venture), how they will use the venture, what they will be willing to pay, how the venture will be advertised and promoted, etc.)
  5. Staffing plans, including what expertise will be needed to build (sometimes included in business plans) and provide the venture on an ongoing basis
  6. Management plans, including how the expertise will be organized, coordinated and led
  7. Financial plans, including costs to build the venture (sometimes included in business plans), costs to operate the venture, expected revenue, budgets for each of the first several years, identify when the venture might break-even (begin making more money overall than it has cost), etc.
  8. Appendices (there are a wide variety of materials included in appendices, e.g., description of the overall organization, its other products and/or services, its current staff, etc.)

A financial sustainability committee is a group that helps you to raise money or to obtain goods for your project. Generally, such a group is made up of people in your community that have, or can get, money or goods. People who have experience dealing with legal or financial issues, such as lawyers and accountants, may also be members. That's because they can help you with the many legal issues that can affect you financially, such as becoming tax exempt. They can help ease the transition from one source of funding to another, such as at the end of a grant period. They can help find money or goods from many different sources. A financial committee that has members with many connections will help lead to a diverse funding base for your organization, which is one of the most effective ways to ensure sustainability. Sometimes, the existence of a committee for financial sustainability is a requirement for receiving a grant. Too often, members of organization spend so much time trying to find resources for the organization they are unable to spend time doing what they were hired to do. Ideally, the committee should be formed during the first year of your project.

Behind the Scenes of a Successful Meeting

Throughout this entire process and especially at the beginning, running the meetings will require much effort on your part, or the engagement of an outside facilitator. A diverse group of people all with their own time constraints can be a challenge to coordinate. Sometimes it will indeed feel as if you are trying to herd kittens. Figure 4 gives you some practical advice about running a meeting.

Communities that do more of this kind of change, get better at it. They increase their capacity to change because practice does indeed make perfect. But the process is not always linear. You can have a clear vision and objectives at the start only to find out there are large obstacles that cause you to rethink your expectations for success. With practice, you also need patience to be successful over the long term.

1. Set the Stage

2. Help People Talk to Each Other

Conclusion

Communities that do more of this kind of change, get better at it. They increase their capacity to change because practice does indeed make perfect. But the process is not always linear. You can have a clear vision and objectives at the start only to find out there are large obstacles that cause you to rethink your expectations for success. With practice, you also need patience to be successful over the long term.

Next: Assets on Your Side