Networks, such as cross-sector partnerships, have been shown to have advantages over single organizations including more efficient use of resources, greater opportunities for learning, and improved capacity to address complex problems.1 Sharing resources can generate a versatile response to complex issues, especially when driven by local partnerships and coalitions, which are recommended as a means to improve health status and well-being of individuals and their communities.2
Coordinating across clinical, political, and academic domains creates new ways of working based on collaborative efforts and values.1 To be successful in strengthening health systems, it is important to consider relationships between different disciplines and organizations, including how they are affected by leadership, trust, culture, and shared values. The presence of a partnership champion has been identified as a facilitative factor for enhancing these relationships.3
How well a team functions during formative stages of partnerships is an important predictor for sustainability of an initiative, and in many cases partners function as part of the implementing team.2 Continual involvement of the community is imperative when setting an agenda for change.4 Partnerships have the potential to yield costs and benefits at different stages of their development since they are dynamic.3
Partnerships are critical for maximizing capacity-building efforts, which are viewed as a multiplier effect rendering a community more competent to address a problem in the future.5
The Gulf Region Health Outreach Program (GRHOP) is a series of integrated projects designed to strengthen health care in Gulf Coast communities in Louisiana, Mississippi, Alabama, and the Florida Panhandle. The GRHOP was developed jointly by BP and the Plaintiffs' Steering Committee as part of the Deepwater Horizon Medical Benefits Class Action Settlement, which was approved by the US District Court in New Orleans on January 11, 2013, and became effective on February 12, 2014. The GRHOP is supervised by the court and is funded with $105 million from the medical settlement.6 Each of the GRHOP projects is directed by separate organizations, including academic institutions and nonprofit organizations, that work collectively under the advisement of a coordinating committee.
The Louisiana Public Health Institute (LPHI) designed and implemented 1 of the 5 GRHOP projects called the Primary Care Capacity Project (PCCP) with the purpose of expanding access to high-quality, integrated, and sustainable community-based primary care, including linkages to behavioral health services, as well as environmental and occupational health services.6 The 3 main PCCP objectives were (1) to enhance capacity of communities to improve health, (2) to build primary care capacity and increase access to high-quality care, and (3) to support population health management through advancements in health information technology and connectivity (see the Figure).
With a primary focus to invest in community health centers across 17 Gulf Coast counties and parishes, PCCP also engaged stakeholders, including 4 primary care organizations, over 20 federally qualified health centers (FQHCs), public health institutes, health information exchanges, national experts, academic organizations, and health departments along with their relevant community partners. To have a positive impact on population health and health equity, LPHI's priority was to invest in projects or infrastructure that resulted in high-quality, sustainable primary care for the communities served.
This article describes how the PCCP team engaged stakeholders and partners throughout the project from design to planning, implementation, and evaluation to support the strengthening of sustainable primary care systems.
During the initial stage of PCCP, the team focused on learning the new geographic footprint of the approved GRHOP jurisdiction. The team explored and assessed the coastal communities, community health centers (specifically FQHCs and FQHC Look-Alikes), current health systems, key stakeholders, and potential local partners in the 17 counties and parishes included in the settlement. The PCCP team specifically identified FQHCs as key stakeholders, given the health centers' mission to serve vulnerable populations and their commitment to sustain services through federal funding support.
Building on an initial list of contacts, the PCCP team identified and engaged stakeholders from a variety of organizations and sectors, including health care, the interfaith community, schools, social services, business, and local government, to contribute to the design of project planning and investments, and tailored capacity-building activities to maximize sustainability of quality health services. Identifying stakeholders was the first step of the team's engagement process (see the Figure).
Considering the ambitious scope of work, the PCCP team strived to better understand the authentic community voice to help shape the project's design, investment and capacity-building strategies, and sustainability plan. Primary Care Capacity Project's approach was dynamic in nature to ensure responsiveness to community needs. Shared and agreed-upon guiding principles for decision making were established such as utilizing data-informed processes and leveraging existing resources (see the Table). The PCCP team developed these principles to provide a backbone for decision making and assist the team in adhering to the mission of the project.
To ensure stakeholder input into the PCCP design, the project team conducted comprehensive regional assessments of community health needs in each state at the beginning of the project. Community prioritization meetings were held in Mississippi, Alabama, and Florida in December of 2012, and 2 community prioritization meetings were held in Louisiana in November of 2013. The community prioritization meetings brought together a diverse group of stakeholders from state, regional, and local community organizations and nonprofits, as well as local leaders from the health and education sectors. At the start of the meetings, LPHI provided an overview of state, county, and subcounty data as a baseline assessment of demographics, health status, health care access, and barriers to care. These data indicators were chosen on the basis of best practices put forth by the Catholic Health Association and the National Association of County & City Health Officials' Mobilizing for Action through Planning and Partnerships processes for selecting measurements that summarize the state of health and quality of life in a community.7,8 Following the data review, the stakeholders were broken into small groups for facilitated discussions on community health needs and barriers to care. Finally, stakeholders reconvened for prioritizing community needs through real-time polling (see Qualitative Methods as an Intervention: Beyond Program Planning and Implementation in this special issue for more details on this process).
Following the meetings, LPHI provided community stakeholders with comprehensive regional community health assessment reports. Based on the priorities identified during the meetings, additional health and quality-of-life factors were included in the reports, such as data related to veteran and military communities and data related to health disparities by ethnicity.
Data collected through this prioritization process contributed a community perspective that informed PCCP investment and capacity-building strategies for each coastal community. For example, a common priority identified in almost all of the meetings was the lack of access to primary care and dental services. The PCCP team utilized these data when developing scopes of work with the community health centers in the impacted areas.
Peer-to-peer learning through the regional care collaborative
In accordance with the Deepwater Horizon Settlement, LPHI developed a regional network, later called the Regional Care Collaborative (RCC), that supported the organization and facilitation of regular communications among PCCP health centers through the development of communication tools; hosted periodic meetings, joint training, and continuing education sessions; and encouraged other opportunities to interact and collaborate with each other. The goal of the RCC was to advance community health centers in becoming high-performing primary care providers with integration of high-quality services, sustainability of systematic changes, and collaboration among providers as a group.
The RCC provided opportunities for shared learning and peer exchange to a network of Gulf Coast community health centers, state primary care associations (PCAs), public health institutes, GRHOP project partners, and additional strategic health partners and organizations. A variety of learning opportunities was offered to participants that included in-person forums, consultation calls, special interest calls, and webinars designed to maximize collective problem-solving among organizations.
To provide the most relevant and timely learning opportunities for RCC participants, the PCCP team created the RCC steering committee comprised of key stakeholders within the coastal network, including each state PCA, staff members of community health centers, and other LPHI staff. The steering committee created infrastructure to help give the RCC solidarity and power.
During the RCC events, community health center staff were encouraged to sit at roundtables by topic area designed to foster discussion. For example, at a few RCCs, executive directors of community health centers discussed potential transitions of electronic health record (EHR) systems and planned follow-up visits to demo different systems at neighboring sites. This provided organizations with real-time honest feedback when deciding on large investments, such as EHR procurement. This facilitated peer exchange benefited not only community health centers but also other health partners. For example, the 4 PCAs identified emergency management capacity building as a common priority that existed across the region. This resulted in the PCCP Emergency Management Initiative Project, which provides a braided approach of emergency management, with community resilience focused on building capacity of community health centers.
During the 2016 RCC in-person forum, LPHI conducted dyadic or paired interviews of health centers (see Qualitative Methods as an Intervention: Beyond Program Planning and Implementation in this special issue for more details on this process). The dyadic interviews fostered more focused opportunities for peer-to-peer learning as participants shared challenges and lessons learned with one another, guiding the discussion toward topics of utmost importance to them. During an interview on sustainability, the participants steered the conversation toward EHRs, after one of the centers recently made a switch to a new one.
P1: During this year we actually changed our EHR.
P1: Yes, after twelve years.... Over time as our reporting requirements got greater and we just wanted to know simple things, like where are we referring our patients? The whole idea of using this record is to be able to...
P2: Pull data out.
P1: Pull data out, and use it to make decisions.
P2: So when did you go live with it?
P2: Okay. We've met with that EHR company before too.
P1: There are several things I love about it ... [Explains various components of new system].
P2: It would be good for huddles, if you have a schedule you can print everyone for the day. And in the huddle, say what everyone needs and make sure you have what you need.
They discussed the benefits and challenges of the EHR, specifically issues around reporting, training, and billing and finances. The participants exchanged contact information, and 1 center offered to host the other to show them their new EHR and how it was working at their sites.
Collaborative state partnerships
As noted in the Stakeholder Identification section above, the team actively pursued partnerships with multiple sectors at varying levels of leadership roles. The PCCP team developed a stakeholder management plan that prioritized the various groups and identified engagement and communication plans for each one. Flexibility, transparency, use of data, leveraging opportunities, consistent communication, and agreed-upon expectations were principles utilized to guide these plans (see the Table).
As part of the project's engagement strategy, PCCP partnered with state organizations whose mission, competencies, and organizational relationships were aligned with the goals of PCCP. These partnerships allowed for the maximization of investments in the impacted communities, provision of state-level policy education/information for impacted communities and health centers, and provision of sustainable partnerships for communities and their primary care service providers.
Primary Care Capacity Project entered into formal contractual agreements with the 4 state PCAs, health departments, and other public health institutes as part of the state partner engagement strategy. The state partners served as local advocates for the project and provided necessary information and linkages to related efforts statewide. These relationships allowed for the transfer of knowledge, capacity, and resources across all stakeholders. Primary Care Capacity Project was able to use state-specific information from local partners to identify priorities for making investments and monitoring project progress along the way. Establishing formal partnerships with state partners over the entirety of the PCCP project period not only benefited the PCCP communities but also provided an opportunity for future collaborative efforts on a regional level.9
Sustaining a Network
Through PCCP's funding and technical assistance, LPHI was able to advance capacities of community health centers and strategic health partners across the 4 states to better prepare these organizations to operate within the evolving health care environment. The value created by facilitating community prioritization meetings, peer exchange through the RCC, and building relationships with state partners contributed to a post-GRHOP regional collaborative that will continue to serve the community health centers in an ongoing way. In addition, as a result of the RCC peer exchange opportunities, a number of community health centers have formed lasting partnerships across state lines.
Implications for Policy & Practice
- The engagement strategies presented are recommended as useful practices when approaching a similar project over a large geographic area. For PCCP, community prioritization efforts, peer-to-peer learning through the Regional Care Collaborative, and dyadic interviews were instrumental for guiding capacity building and linking critical stakeholders.
- Communication is integral to the success of change management but is often underutilized by organizations.10 Virtual communication is necessary in today's work environment, but the power of meeting face to face strengthens relationships and can add value and bring forth new opportunities.
- Presenting data to a community should be approached carefully, especially at the beginning of partner engagement. While data may not portray a community's entire story, they can assist with initiating discussion on shared priorities.
The PCCP team transferred what may have been challenges into future opportunities. Health partners across the 4 states are now better positioned to collaborate on future regional opportunities such as continued knowledge transfer through special interest groups, ongoing engagement with the annual regional convening, continued efforts to advance emergency management and resiliency, and potential development of group purchasing and other shared services. Sustaining efforts within the network of strengthened and new partnerships has been a critical outcome of engaging the right stakeholders at the right time throughout PCCP.