Complex social issues demand emergent processes and creative solutions.1 On April 20, 2010, the Deepwater Horizon (DWH) oil rig exploded, releasing millions of gallons of oil into the Gulf of Mexico2 and sparking ongoing worries about the health, economy, and environment along the Gulf Coast.3 In addition to problems related to disaster exposure, the Gulf Region had preexisting vulnerabilities for poor health including poverty, unemployment, health inequities, and prevalent chronic health conditions.4,5 Given the complexity of issues facing the Gulf Coast, a sustained and coordinated approach was necessary to improve the health of the region.
In 2012, the US District Court in New Orleans, Louisiana, finalized a class-action settlement for DWH oil spill–associated medical damages. Within the settlement was the Gulf Region Health Outreach Program (GRHOP). The mission of the GRHOP was to proactively strengthen health care in designated Gulf Coast communities in Louisiana, Mississippi, Alabama, and the Florida Panhandle. The GRHOP consists of 5 projects: Primary Care Capacity Project, Mental and Behavioral Health Capacity Project (MBHCP), Community Health Workers Training Project, Environmental Health Capacity and Literacy Project, and the Community Involvement Project. These 5 had overlapping goals maintained through a Coordinating Committee (CC). Unlike the other projects, the Quad-State MBHCP was carved into 4 state-specific projects: MBHCP-Louisiana, MBCHP-Mississippi, MBHCP-Alabama, and MBHCP-Florida. Each was headed by a different leader(s) embedded in a local academic institution and already part of local, regional, and national mental health fields. Among these leaders, 3 different mental health specialties were represented (ie, psychiatry, clinical psychology, and social work). As such, the 4 state-specific MBHCPs were further colored by their multidisciplinary nature in addition to preexisting similarities and differences in geography, populations, resources, and health care infrastructures.6
All 4 state-specific MBHCPs shared a common mission to support and promote a sustainable increase in mental and behavioral health (MBH) capacity along the Gulf Coast. The MBHCPs were designed to utilize a flexible, community-based, capacity-building approach that was consonant with the national reality of a rapidly changing health care world, as well as with a variety of state-specific health care policies including professional practice limitations, Medicaid reimbursement policies, and acceptance/rejection of Medicaid expansion. By naming state-specific stewards of the Quad-State MBHCP money with “boots on the ground,” as well as with solid academic credentials, the GRHOP explicitly supported the need for local-level and evidence-based decision making about resource allocation and project implementation. As expected, each leader also functioned as a state-specific champion and key informant for the overall GRHOP CC meetings, as well as an informed voice at state, regional, and national scientific meetings.
Recently, multistate collaboratives have been used to advance new initiatives in public health.7 Models to promote the broad effectiveness of collaboratives comprising different types of participants working at different levels have been proposed. One such model is the Collective Impact (CI) model, which postulates that large-scale social change requires coordination among existing organizations, stakeholders, change agents, and the public. Kania and Kramer8 articulate 5 conditions for collective success: (i) common agenda, (ii) mutually reinforcing activities, (iii) continuous communication, (iv) shared measurement strategies, and (v) a backbone support organization. Full and successful enactment of the CI model involves different sectors working at different levels that are sharing data collection and measurement in pursuit of a shared mission. To date, the specific strategies by which the 5 CI conditions are enacted are less well delineated. Moreover, few have considered how an adapted version of the CI model might provide a guidepost for how an interlocking group of projects might coalesce, particularly when they share a mission but involve different leaders located in distinct geographic areas with divergent initial needs and pre-CI conditions. This article is designed to address that gap.
The article describes the process of linking the 4 state-specific MBHCPs into 1 overall Quad-State MBHCP capacity-building effort along the Gulf Coast in order to advance regional health synergistically. Three specific strategies are described that helped the MBHCPs operationalize the 5 CI conditions. These are (1) reciprocal and directed participation in the backbone organization (GRHOP); (2) creation and ongoing comparison of 4 state-specific MBHCP logic models generated in year 1; and (3) development and utilization of a unified Quad-State MBHCP logic model, which was mapped onto the overall GRHOP objectives and then subsumed into a GRHOP-wide logic model. Lessons learned and recommendations are offered for projects and organizations hoping to use an adapted version of the CI model as a guidepost to address large-scale, complex, population-based public health issues in ways that will leverage resources and generate additional impact.
Background and Context
Project leaders from the 4 state-specific MBHCPs were responsible for the implementation of their program in counties/parishes named in the GRHOP settlement. In Louisiana, the MBHCP was led by Drs Howard Osofsky and Joy Osofsky from Louisiana State University Health Science Center (LSUHSC). MBHCP-Louisiana served the following parishes: Orleans, Jefferson, St Bernard, Plaquemines, Lafourche, Terrebonne, and Cameron. There were 3 named counties in Mississippi (Hancock, Harrison, and Jackson) with the MBHCP-Mississippi project led by Dr Tim Rehner at the University of Southern Mississippi (USM). Dr Jennifer Langhinrichsen-Rohling, from the University of South Alabama (USA), led the MBHCP-Alabama project,9 which focused on 2 counties in Alabama (Mobile and Baldwin). MBHCP-Florida was tasked with implementing the project in 5 counties (Escambia, Santa Rosa, Walton, Okaloosa, and Bay) and was led by Dr Glenn Rohrer from the University of West Florida (UWF). Each of these project leaders hired and managed a state-specific leadership team, as well as a group of behavioral health providers tasked with clinical service provision. All 4 projects included system-level stakeholders, community leaders, and target beneficiaries. Each project leader also interacted with a university-based training program, which facilitated the inclusion of developing professionals into each MBHCP effort (ie, the Clinical Predoctoral Internship and Postdoctoral Fellowship program and the General and Child Psychiatry Residency program at LSUHSC; Clinical and Counseling Psychology Doctorate program and the Child Psychiatry Residency program at USA; and Masters in Social Work programs at USM and UWF).
Because of the sensitive nature of the DWH Medical Settlement Agreement, all parties signed confidentiality agreements prior to the initial allocation of funds. The leadership of the projects had not necessarily worked with each other previously. Efforts to enhance collective impact, facilitate synergy, and develop cross-state and cross-project initiatives all occurred postaward. In many ways, the situation facing GRHOP was analogous to those facing most grant awardees such that the nature of the funding did not allow preaward coordination or planning across projects. However, postaward, funders, grant recipients, communities in which the work was to take place, and impacted citizens would benefit from collaboration and synergistic efforts to collectively enhance impacts derived from the funding.
To orient readers to the project landscape, existing archival data were compiled to compare the demographics of each GRHOP-targeted county/parish within the 4 states (see Supplemental Digital Content Appendix A, available at http://links.lww.com/JPHMP/A375). At the outset, health care similarities existed across the 4 states. Of note, all 4 states had rejected Medicaid expansion and each county/parish was designated a Mental Health Provider shortage area.10 All MBHCPs agreed to target Federally Qualified Health Centers (FQHCs) in their efforts to increase MBH access for impoverished and underresourced individuals. However, the number of existing FQHCs and clinics progressing toward FQHC status differed substantially across regions and also varied across the life of the project (ie, Louisiana = 4 FQHCs [11 sites]; Mississippi = 1 FQHC [9 sites]; Alabama = 4 FQHCs [27 sites]; Florida = 4 FQHCs [13 sites] as of 2016). Across the 4 states, FQHCs also differed in management structure, as well as electronic health record existence, vendor selection, and utilization. FQHCs varied in the degree to which there were existing on-site behavioral health services (eg, some sites had substance abuse services or behavioral health services through their Infectious Disease Clinics; others had no on-site MBH services). FQHC sites were also of varying geographical distance from the project leader's home institution, complicating travel, integration oversight, and student involvement in the Quad-State MBHCP efforts.
Process Strategies and Results
Strategy 1: Reciprocal participation in the backbone organization (GRHOP)
The Settlement Agreement established a formal CC for GRHOP. As noted on the GRHOP Web site, 12 members are associated with particular GRHOP projects (ie, 2 from the Primary Care Capacity Project, 2 from the Environmental Health Capacity and Literacy Project, 2 from the Community Health Workers Training Project, 1 from the Community Involvement Project, and 5 from the MBHCPs—with 3 of these 5 being voting members). Three CC members were external to the named projects (nonaffiliated). One of the nonaffiliated members functioned as the CC Chair. Per Section IX.G.6 of the Medical Settlement Agreement, Medical Benefits Class Counsel and BP representatives were invited, at their own expense, to attend these meetings as observers. Thus, the CC was the officially designated backbone support organization of GRHOP (satisfying CI condition v).
The collective impact of GRHOP was enhanced through the CC structure and leadership. Quarterly in-person meetings reinforced the common agenda of the project (CI condition i), ensured ongoing cross-project communication (CI condition iii), and created a space for developing and implementing shared measurement strategies (CI condition iv). For example, each quarterly in-person CC meeting had designated activities that were designed to facilitate communication across projects. One activity, “speed dating,” consisted of each project rotating to share current activities and updates with every other project in the GRHOP portfolio. Projects shared successes, current endeavors, and next steps. Many of the brief shares led to extended off-site cross-project meetings to solve overlapping concerns or to further coordinate efforts in a particular location. Continuous communication was further enhanced with monthly calls and e-mail exchanges facilitated by the CC. Several concrete outcomes attest to the success of this strategy. One was the development of a newsletter publication committee. Newsletters created by this committee were distributed widely to internal and external partners and community stakeholders. Second was the establishment of an evaluation subcommittee tasked with the creation of a shared measurement strategy. Third was the creation of a publication subcommittee to facilitate and promote dissemination of project outcomes and lessons learned.
Using the CC structure as a guidepost and recognizing the value of continuous interproject communication, the Quad-State MBHCPs chose to initiate separate quarterly work group meetings, which helped facilitate reciprocal and directed exchanges between the MBHCP and the GRHOP backbone. A review of MBHCP quarterly reports and Quad-State meeting minutes indicates that each MBHCP was represented at every GRHOP-wide and Quad-State meeting (ie, consistent participation across 5 years). As a measure of Quad-State MBHCP success, increasing numbers of mutually reinforcing MBHCP activities took place (CI condition ii). For example, a shared focus on infant mental health developed and associated activities began (MBHCP-Louisiana and MBHCP-Florida). An annual regional conference, the Generational Resiliency Conference, emerged, expanding the capacity-building mission to the elderly (MBHCP-Florida and MBHCP-Alabama). Ongoing collaborations between MBHCP-Alabama and MBHCP-Mississippi resulted in the submission of a shared grant to increase resiliency in communities vulnerable to environmental disasters.
Strategy 2: Creation and comparison of project-specific logic models
Through the leadership of the GRHOP CC, each Quad-State MBHCP developed a state-specific logic model during year 1 of the project. Logic models are a graphical tool used to specify the inputs, activities, outputs, and expected impacts of a project. Although traditional logic models tend to be prescriptive in nature,1 a visual display of activities and outcomes can be instrumental in the development, evaluation, and maintenance of a program.11 Logic models help programs establish clear goals, track progress, and identify areas of need.12 They may be particularly helpful when addressing complex public health issues.13 Per the GRHOP CC, all the logic models shared the same simple structure (ie, objectives, activities, and outcomes); they were designed to serve as flexible roadmaps for accomplishing the overall mission of each of the 4 Quad-State MBHCPs. Across the life of the GRHOP, the 4 Quad-State MBHCP logic models were compared and contrasted to identify common missions (ie, common agenda), brainstorm reporting metrics (ie, shared measurement strategies), disseminate state-specific activities more widely across the region (ie, continuous communication), and ensure fidelity to the overall MBHCP mission (ie, common meta-agenda). As noted previously, there were many differences in how MBHCP plans were enacted. These were primarily to maximize local conditions and expeditiously face challenges (ie, 4 states, 4 projects). However, several points of logic model intersection were evident (ie, common agenda). See Figure 1.
Specifically, all 4 MBHCP logic models shared an outcome of increased access to, and provision of, MBH services within primary care settings (namely, FQHCs). Although immediate service provision was a universal initial activity, all sought to provide services in sustainable, capacity-building ways and embraced a commitment to not supplant any existing services, especially those already funded. The second shared logic model outcome was to increase the capacity, knowledge, and skills of clinicians, developing professionals, and community members. The drive to bring MBH trainings to relevant stakeholders, existing providers, and developing mental health professionals/graduate students was an important universal objective. All projects also shared a commitment to furthering the GRHOP and to conducting ongoing, recursive project evaluations, which is noteworthy in that evaluation resources were not directly allocated initially. Shared focus on assessment was a benefit that likely materialized out of the decision to choose project leader(s) already embedded within local universities. The outcome was also clearly supported and facilitated by our backbone organization: the GRHOP CC.
Each MBHCP state-specific logic model also had unique components. The MBHCP-Louisiana developed a model for in-person and telepsychiatry consultation and treatment services for largely rural clinics within the designated geographic areas. MBHCP-Louisiana also provided professional training and programming in infant mental health. The MBHCP-Mississippi model created a social work–driven care coordination program that integrated behavioral health into the medical treatment plans of patients with chronic health conditions. MBHCP-Mississippi designed and taught university-level courses in Integrated Health and Disaster Preparation. The MBHCP-Alabama model uniquely included activities related to promoting resilience in couples and families. MBHCP-Alabama also focused efforts on first responders, specifically targeting improving the MBH capacity of law enforcement, while seeding the development of Crisis Intervention Teams. MBHCP-Alabama also launched an on-site Coordinated School Care Initiative that partnered school counselors and teachers, child psychiatry residents, and doctoral-level clinicians in psychology to provide integrated mental health care in a high-risk elementary school. To address the MBH needs of children, a pediatric health and school focus was also developed in the MBHCP-Florida and MBHCP-Louisiana models. The MBHCP-Florida model emphasized the importance of tailoring each plan to meet local needs as expressed by community stakeholders; this sentiment was echoed in other logic models. MBHCP-Florida also furthered the life span focus by directing resources toward aging and elderly citizens. In conjunction with MBHCP-Alabama, MBHCP-Florida developed and hosted an annual bistate Generational Resiliency Conference.
Strategy 3: Ongoing utilization of logic model(s)
In keeping with the unique needs of each state and each site, each MBHCP self-determined how to measure state-specific project outcomes related to its logic model. However, through informal and formal MBHCP Quad-State interactions, which often took place during CC meetings and the separate Quad-State working group meetings, a unified Quad-State MBHCP logic model was derived. Simultaneously, the focus of many GRHOP-wide CC meetings was on generating an overall GRHOP-wide logic model; the resulting logic model specified short-, medium-, and long-term goals common among the 5 GRHOP projects. In the overall GRHOP-wide logic model (which subsumed the Quad-State MBHCP logic model), 3 region-wide goals were identified: (1) increased capacity to deliver quality health care; (2) development of a more informed community; and (3) sustainability of project activities. See Figure 2 for how the MBHCP projects fit into the overall GRHOP logic model. After comparing individual MBHCP models per strategy 2, and in conjunction with the development of an overall Quad-State MBHCP model (strategy 3), shared MBHCP measurement strategies were developed to meet the overall GRHOP goals.
Developing a shared measurement strategy postfunding was challenging, particularly given the diversity of activities engaged in by the 4 MBHCPs. However, it is a task that will be faced by any group of stakeholders invested in enhancing their collective impact. We found the comparison of the individual MBHCP logic models particularly useful in discovering shared metrics. Namely, all 4 MBHCPs expected to have data related to promoting integrated health in FQHCs (eg, number of patients seen on-site by MBH providers within primary care pre- and postproject). All 4 MBHCPs were also conducting capacity-building trainings to develop a more informed community. Thus, there were cross-state data on the number of trainings offered, the number and nature of attendees, and pre-/postproject evaluations of learning. We also considered cross-state archival data. An example of an existing cross-state metric is Uniform Data System (UDS) reports (FQHCs regularly submit these reports to the Health Resources & Services Administration). Summaries of these reports are available online to the public and are specific to each FQHC. Thus, we could obtain data related to the specific sites in which each MBHCP was active. Data show, even with significant obstacles to reporting (eg, varying electronic medical records [EMRs] and levels of EMR utilization, diverse codes documented for MBH services), the number of unique mental health patients captured in the EMRs of the GRHOP-relevant FQHCs increased substantially from 2012 to 2015 in all 4 GRHOP states (mean increase of 35%; range, 12%-57%).
Isolated approaches to complex public health issues are often ineffective. In contrast, coordinated approaches with an emphasis on shared goals, activities, and knowledge have been shown to facilitate positive social change.1,8 The CI model has 5 distinct elements: common agenda, mutually reinforcing activities, continuous communication, shared measurement strategies, and a backbone support organization.8 The Quad-State MBHCPs, which consist of 5 projects taking place in 4 different states and led by mental health professionals from different disciplines, provide a real-life example of 3 strategies used to help realize the 5 CI conditions. Use of these strategies accelerated and advanced a regional response to a public health problem: lack of accessible integrated mental and behavioral health care for vulnerable populations. The success of the Quad-State MBHCPs suggests an adapted version of the CI model, which concentrates on different projects and locations rather than on diverse stakeholders at multiple levels in a common location, can be utilized successfully even with projects led by investigators trained to promote individual impacts. Implementation of this adapted CI model would require a paradigm shift for funders, grant recipients, and preexisting “on-the-ground” organizations. Substantial postaward effort is also required. Furthermore, our work indicates that project leaders need management and funding flexibility to find the right people for each job and to take advantage of evolving opportunities within and across states and projects. It is worth noting that project leaders brought collaborative skills and a willingness to spend time communicating and compromising at multiple work group meetings. Sharing complex tasks with multiple leaders with different visions was invigorating and relationship-promoting, even while time-consuming.
Across the MBHCPs, all 5 CI conditions outlined by Kania and Kramer8 were found to be important for promoting synergy. One of the joint MBHCP missions was to bring integrated health care to primary health care sites. Although this was enacted differently by state, site, and discipline, the MBHCP had a shared agenda that was embedded within the overall GRHOP health capacity mission. Shared activities and continuous communication were achieved through active and reciprocal interaction with the GRHOP CC, the backbone organization. Noteworthy activities supported by the GRHOP CC included the development of logic models (MBHCP project specific, MBHCP Quad-State, and overall GRHOP). Development of these models took effort but provided a shared language (ie, common agenda) and concrete outcomes to move toward (ie, scaffolding for shared measurement). Notably, this exercise also highlighted differences among MBHCPs, revealing unique project-specific dimensions and strengths. Cross-fertilization of activities and objectives graphically exhibited in the logic models fostered creativity and reduced potentially isolating theoretical or professional training differences (eg, psychodynamic vs behavioral; psychiatry vs clinical psychology vs social work).
Stronger in-person relationships among project leaders co-occurred through expanding and more extensive in-person meetings and shared cross-project activities. The relationships built, in addition to the activities already implemented, have an increased likelihood of sustainability due to enhanced group identity. The GRHOP CC structure, which led to an empowered backbone organization, thus built capacity among multiple mental health professors already located in various institutions along the Gulf Coast. Across the life of GRHOP, there have been tornados in all 4 states, as well as the Great Flood of 2016 in Louisiana. Shared Quad-State resources and expertise facilitated an integrated response to MBH needs across the Gulf States, instead of the previous state-specific response and recovery efforts. Most recently, LSUHSC has received a Substance Abuse Mental Health Services Administration grant for a Category II Center within the National Child Traumatic Stress Network—Terrorism and Disaster Coalition for Child and Family Resilience. The Quad-State MBHCP programs have united to support the coalition and build it across the Gulf Coast.
Demonstrating our ability to collectively enhance MBH capacity along the Gulf Coast required identification of shared outcomes and measurement. Developing shared measurement postaward is difficult. Several barriers were apparent from the outset including limited dedicated resources for evaluation in the many of the initial MBHCP budgets; different project leaders' divergent ideas about what, how, and when to measure; and different disciplines with distinct but overlapping preferences on measurement components (client, clinic/system, community). Project leaders also differed in their approaches to dissemination of findings from the projects. Building shared evaluation metrics into projects funded to tackle a shared social problem is best accomplished prefunding or articulated as a condition for receiving funding.
Implications for Policy & Practice
- Funders should consider building in a mission-wide CC or backbone organization to collectively enhance the impact of multiple projects tackling the same mission. The structure of this group is important.
- Realizing all 5 CI conditions is essential for collective success.
- Despite costs, regular mission-wide communication is important to build relationships and recognize points of intersection.
- A similar but flexible logic model structure for individual projects and the mission as a whole is needed to provide a common language among diverse projects.
- Regularly cross-walking-specific logic models can facilitate cross-project endeavors, relationships, and measurement strategies.
- Comparing and contrasting each MBHCP logic model led to greater clarity of shared objectives and clarification of project-specific strengths.
- Development of a mission-wide logic model is labor-intensive but necessary for cross-project synergy. An overall logic model provides the scaffolding for shared measurement and collaborative ventures.
However, the CI strategies described in this article, and the working from project-specific logic models to mission-wide logic models to concrete outcomes, led to 9 shared metrics that are being used to understand the success of the Quad-State MBHCP, as well as the contributions of the GRHOP as a whole. One metric, UDS reports, already shows dramatic increases in the number of unique mental health patients seen in project-identified FQHCs across the region. Gathering, reporting, and disseminating shared metrics are likely to shed additional light on how to collectively impact and further improve MBH capacity across the Gulf Coast.