Partnership synergy: a practical framework for studying and strengthening the collaborative advantage

Patient benefits from participating in an integrated delivery system: impact on coordination of care

BACKGROUND

Although the presumption in health services literature has been that integrated delivery systems (IDSs) should improve the coordination of care, the benefits have not yet been well established through empirical research.

PURPOSES

This study assesses whether receiving care from providers who belong to the same IDS improves patient-perceived coordination of care; concurrently, we develop a new approach for assessing the performance of IDS.

METHODOLOGY/APPROACH

A study was conducted of 222 patients who received primary unilateral total knee arthroplasty at a large IDS' acute care hospital. To isolate the effects of provider membership, we enrolled patients who received surgery from the same surgical department in the same acute care hospital in the IDS. We used baseline and 6-week postoperation patient surveys to assess the impact of the participation of the patients' providers in the IDS on patient-perceived coordination of care.

FINDINGS

We found no consistent effects of IDS membership on patient-perceived coordination of care. Patients with in-network rehabilitation care experienced fewer problems than patients with out-of-network rehabilitation care did, while patients with in-network home care experienced more problems than patients with out-of-network home care did. Membership of a patient's primary care physician had no observed effects.

PRACTICE IMPLICATIONS

Health care managers and administrators need to undertake a realistic examination of the care-coordinating mechanisms that exist in their IDS. This study has shown that the integration of financial, contractual, and administrative processes is not enough to improve care from the patient's perspective; to improve care, it is advised that an IDS take a patient-centered approach in its design and implementation. We discuss potential reasons for uneven integration of IDS, particularly with respect to the lack of coordinating mechanisms, and argue for the usefulness of the approach developed here for assessing IDS performance over time.

Partnership selection and formation: a case study of developing adolescent health community-researcher partnerships in fifteen U.S. communities

PURPOSE

This study describes the partner selection process in 15 U.S. communities developing community-researcher partnerships for the Connect to Protect (C2P): Partnerships for Youth Prevention Interventions, an initiative of the Adolescent Trials Network for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) Interventions.

METHODS

Each site generated an epidemiological profile of urban youth in their community, selected a focus population and geographic area of youth at risk for HIV, conducted a series of successive structured interviews, and engaged in a process of relationship-building efforts culminating in a collaborative network of community agencies.

RESULTS

Sites chose as their primary target population young women who have sex with men (n = 8 sites), young men who have sex with men (n = 6), and intravenous drug users (n = 1). Of 1162 agencies initially interviewed, 281 of 335 approached (84%) agreed to join the partnership (average 19/site). A diverse array of community agencies were represented in the final collaborative network; specific characteristics included: 93% served the sites' target population, 54% were predominantly youth oriented, 59% were located in the geographical area of focus, and 39% reported provision of HIV/STI (sexually transmitted infection) prevention services. Relationship-building activities, development of collaborative relationships, and lessons learned, including barriers and facilitators to partnership, are also described.

CONCLUSIONS

Study findings address a major gap in the community partner research literature. Health researchers and policymakers need an effective partner selection framework whereby community-researcher partnerships can develop a solid foundation to address public health concerns.

Lessons learned in systems change initiatives: benchmarks and indicators

Measuring progress toward systems change, sustainable efforts that address root causes of an issue by changing policies and practices, is a difficult task for communities, evaluators, and foundations. Tracking and documenting changes in resources, power, policy, sustainable funding, structured relationships and roles, and underlying values require multi-level analyses. Systems change analysts must consider at least four "strata" at once: (1) events and trends, (2) patterns of interaction, (3) context and cultural or social models, and (4) the systems themselves. In this paper we provide a brief overview of systems change; a discussion of collaboratives as one "engine" of social change; a discussion of benchmarks and indicators of collaboratives focused on systems change; and suggestions for further research. The analysis draws upon several analytic frameworks described in the literature. We illustrate these concepts with examples from six systems change initiatives funded by The California Endowment. The need for further research is outlined.

Strengthening community leadership: evaluation findings from the california healthy cities and communities program

Collaborative approaches to community health improvement such as healthy cities and communities have the potential to strengthen community capacity through leadership development. The healthy cities and communities process orients existing local leadership to new community problem-solving strategies and draws out leadership abilities among residents not previously engaged in civic life. In an evaluation of the California Healthy Cities and Communities (CHCC) Program, leadership development was one of several outcomes assessed at the civic-participation level of the social ecology. Data collection methods included focus groups and surveys, semistructured interviews with coordinators and community leaders, and review of program documents. Findings suggest that the CHCC program enhanced capacity by expanding new leadership opportunities through coalition participation, program implementation, and civic leadership roles related to spin-off organizations and broader collaborative structures. Communities in rural regions were particularly successful in achieving significant leadership outcomes.

Using GIS to facilitate community-based public health planning of diabetes intervention efforts

Data from a community survey were analyzed geographically to help facilitate local diabetes prevention efforts. Data were available from the Speak to Your Health! Community Survey, designed and implemented by The Prevention Research Center of Michigan (PRC/MI), whose central mission is to strengthen community capacity to improve health. This survey was developed collaboratively by the university and community partners that comprise the PRC/MI and focuses on health and social issues at the heart of the community of Genesee County, Michigan. Survey data were used to calculate and geographically map diabetes-risk scores and mapped diabetes-screening rates. These maps indicated that those areas where the estimated risk of diabetes was the highest had only moderate rates of diabetes screening relative to other areas. It is hoped that these results will reach those involved in local diabetes-intervention programs with the intent that the data will be used in planning local prevention and intervention efforts.

The right tool for the task: 'boundary spanners' in a partnership approach to tackle fuel poverty in rural Northern Ireland

To date, research on fuel poverty has largely focused on the outcomes of interventions, with little attention being accorded to intervention processes. In reporting on an evaluation of a fuel poverty intervention in rural Northern Ireland, the present authors explore some of the mechanisms that secured the project's perceived success. Specifically, they focus on the role of the 'boundary spanner', a concept that is increasingly applied to the analysis of local health partnerships. Initiated by a health action zone (HAZ), the project was implemented by a partnership of 21 organisations from the statutory, community and voluntary sectors. The role of the HAZ manager was described as ensuring that partners stayed engaged, that the project secured support from organisations and that it impacted on policy-makers. A full-time community energy advisor carried responsibility for the partnership's communication with the recipient communities. She worked closely with community associations and project recipients. The project was consistently described by stakeholders as community-led and as having been very successful. The authors suggest that this was because of the roles of two individuals who, at different levels, communicated and negotiated with partners and recipients, maintained momentum, and facilitated the ongoing involvement of the communities. The literature on boundary spanners usually focuses on how the role enables organisations from a range of sectors to participate in partnerships and tackle issues outside the remit of single organisations. As such, it usually describes spanning boundaries 'across and upwards'. While such insight is important and valuable, this study shows that a fuller understanding of the success or failure of local partnership interventions can be gained by also exploring the process of spanning 'downwards'. The authors conclude that, by extending the concept of the boundary spanner to include spanning 'downwards', the concept's explanatory power is enhanced.

Building strengths through practice-research-policy collaborations

Solving long-standing, sensitive social problems through community-based, collaborative partnerships requires more than rushed policies and program efforts that react to sudden crises. Efforts to support resilient trajectories in children dealing with adversities like peer victimization or adolescents' searching for engagements and identities in communities struggling with a dramatic change in its economic base requires a sustained and coordinated effort based on the best knowledge that we have. But action must not only be knowledge based, it must also be relevant, and the "buy-in" of or "pull from" those who are affected by the action as recipients or as implementers needs to be secured. Collaboration of policy makers, practitioners, and researchers can advance this agenda. Involving decision-makers and knowledge users in the formulation of knowledge has been highlighted as the best predictor for the application of research knowledge. Community-based research can ensure that research results are relevant to a wider audience and thus hasten adoption beyond the immediate communities.

Management academy for public health: creating entrepreneurial managers

The Management Academy for Public Health develops public health managers' management skills. Ultimately, the program aims to develop civic entrepreneurs who can improve the efficiency and the effectiveness of their organizations. With help from a coach, teams write public health business plans to meet needs in their communities. An external evaluation found that 119 teams trained during the first 3 years of the program generated more than $6 million in enhanced revenue-including grants, contracts, and fees through their business plans--from $2 million in program funding. Approximately 38% of the teams expected to generate revenue from an academy business plan or a spin-off plan. Action-learning methods can help midcareer managers transfer their training to the workplace and build entrepreneurial skills.

Partnership as a means for reaching special populations: evaluating the NCI's CIS Partnership Program

BACKGROUND

The National Cancer Institute's (NCI's) Cancer Information Service (CIS) Partnership Program involves collaboration with over 900 organizations and coalitions serving minority and medically underserved populations. Cancer Information Service collaborations are categorized into three types: networking, educational program, and program development partnerships.

METHODS

A survey of CIS partnership organizations (n = 288).

RESULTS

Most respondents reported that partnerships with CIS are collaborative and make good use of their organization's skills and resources, and most perceive that the benefits of partnership outweigh any drawbacks. More than one-quarter say partnerships have not done a good job evaluating collaborative activities. Results vary among three types of partnerships.

CONCLUSIONS

Evaluation of the CIS Partnership Program presents an opportunity to examine how a large-scale and multi-faceted partnership effort has been implemented, how it is evaluated, and initial indicators of program success. Organizations, health professionals, and community leaders interested in effective partnerships can use these findings to strengthen collaborations and maximize outcomes.

Using principles of community participatory research Groundwork for a collaboration in Brazil

English

This article presents a five-step model for establishing participatory research reflecting the principles of collaboration between researchers and community partners. Theoretical discussion is illustrated from experience gained in the preliminary phases of an international research project on HIV/AIDS work in Brazil. The congruence with social work values is noted.

French

Cet article présente un modèle en cinque étapes d'établissement d'une recherche participative. Ce modèle reflète des principes de collaboration entre chercheurs et partenaires communautaires. L'expérience de la phase préparatoire d'un projet de recherche internationale en lien avec le travail se le VIH/SIDA au Brésil en illustre les fondements théoriques. La congruence avec le travail social est notée.

Spanish

Se presenta un modelo de cinco fases para establecer investigación participativa, modelo que refleja los principios de colaboración entre los investigardores y los miembros de la comunidad. La teoría se ilustra con la experiencia derivada de las fases preparatorias de un proyecto de investigación internacional sobre el VIH/SIDA en el Brasil. Se destaca la congruencia de tal proyecto con los valores éticos del trabajo social.

Determinants of integrated health care development: chains of care in Sweden

Local health care in Sweden is an emerging form of integrated care, linked together by chains of care. Experiences show, however, that the development of chains of care is making slow progress. In order to study the factors behind this development, an embedded multiple-case study design was chosen. The study compared six health authorities in Sweden, three with successful and three with unsuccessful chain of care development. Three major determinants of integrated health care development were identified: professional dedication, legitimacy and confidence. In more detail, space for prime movers and trust between participants were crucial success factors, while top-down approaches targeting at the same time a change of management systems were negative for the development of chains of care. Resistance from the body of physicians was a serious obstacle to such a development. Local health care depends on developed chains of care, but it seems that health care managers do not have the management systems necessary to run these clinical networks, mainly due to a lack of acceptance from the medical profession. This is an impossible situation in the long run, since the number of chains of care is likely to increase as a result of the emerging local health care.

State diabetes prevention and control program participation in the Health Disparities Collaborative: evaluating the first 5 years

BACKGROUND

Approximately 20.8 million people in the United States, or 7% of the population, have diabetes mellitus. Treatment for this disease costs Americans more than 130 billion dollars yearly, and it is the sixth leading cause of death. The prevalence of diabetes has grown substantially in recent decades and is expected to continue to rise.

CONTEXT

The medically underserved and poor are at greater risk of developing diabetes and its complications than are other members of the U.S. population. The Health Resources and Services Administration makes health care resources and services available to economically disadvantaged populations through the Health Disparities Collaborative (HDC), a consortium formed to pool resources and services from state- and community-level donors. Since 1999, many of the Centers for Disease Control and Prevention's Division of Diabetes Translation State Diabetes Prevention and Control Programs (DPCPs) have joined the HDC to leverage resources and services.

METHODS

The purpose of a 2004 evaluation was to examine the impact that DPCP involvement with the Collaborative had on aspects of diabetes care at Federally Qualified Health Centers (FQHCs). An electronic survey was administered to DPCP coordinators. They were asked about 1) their roles and experience as participants in the Collaborative; 2) the skills and expertise most useful in developing and maintaining an effective collaboration for improved health care for diabetes; 3) which DPCP contributions were viewed as being routine and which were perceived to be essential; 4) the effects of DPCP contributions on the use of the chronic care model under which FQHCs operate; and 5) which health systems improvements played the greatest role in enhancing components of the chronic care model.

CONSEQUENCES

Most respondents identified themselves as DPCP coordinators with 3 years of experience in that position. Organizational skills, such as communication, leadership, conflict resolution, negotiation, and meeting management, were cited as necessary to develop and maintain collaborative partnerships. DPCP contributions to FQHCs were perceived to be training, technical assistance with clinical care and patient education, financial resources, linkages to other diabetes partners, educational materials, and improved linkages with community resources.

INTERPRETATION

DPCPs contribute resources, skills, knowledge, and varied perspectives to the Collaborative that FQHCs may not have otherwise.

Research-practice partnership in mental health: lessons from participants

Despite pervasive calls for increased collaboration between researchers and practitioners, there has been limited research on research-practice partnership in mental health. This qualitative study describes one research-practice partnership that supports a study of community-based psychotherapy for children and families. Semi-structured interviews were conducted with all 12 participants (six Researchers and six Practitioners) to elicit perceptions of the collaborative process, including (a) attitudes and experiences entering into the collaboration, (b) perceived challenges and benefits, and (c) suggestions for improvements in future efforts. The findings reinforce the central role of communication and trust-building in developing effective collaborations and exchanging knowledge.

Hospital visiting in obstetrics and gynecology: a tool for the advancement of training

OBJECTIVE

To assess the improvement of obstetric and gynecologic training brought about by peer influence in Europe.

METHODS

In 1996, the European Board and College of Obstetrics and Gynecology (EBCOG) initiated a visiting process by international and local peers to improve training and decrease differences in health care standards.

RESULTS

A large number of visits of obstetrics and gynecology departments have been conducted across Europe at teaching hospitals by the Hospital Visiting Committee. Compliance with the structured approach of the visiting policy and problems met during these visits are reported.

CONCLUSION

The program focuses on the continuous improvement of the competencies of all persons trained in the obstetrics and gynecology departments of teaching hospitals throughout Europe. It also increases the understanding of diversity in training methods and can gradually lead to the convergence of training and health care standards in Europe.

Collaborative design and implementation of a multisite community coalition evaluation

Evaluation designs assessing community coalitions must balance measures of how coalitions do their work and evidence that the coalitions are making a difference. The Allies cross-site evaluation attempts to determine the combined effects of the seven coalitions' work at the individual, organizational, and community levels. Principal components considered are (a) contextual factors of the coalition community, (b) coalition processes and structure, (c) planning and planning products, (d) implementation actions, (e) activities and collaborations, (f) anticipated intermediate outcomes, and (g) expected asthma related health outcomes. Measurements are quantitative and qualitative, and data generated by these methods are used as ends in themselves and as a way to confirm or inform other measures. Evaluation has been an integral part of the planning and implementation phases of the Allies coalition work, with a priority of involving all of the partners in conceiving of and deciding upon the elements of assessment.

[Developing public health--primary care interfaces in Quebec: a case study]

Public health agencies (PH) have various functions. One of them is to develop initiatives that will help decrease health inequalities among different groups in the population. To reach vulnerable groups, PHs must establish interfaces with various players, including primary care clinicians (PCC). Through a qualitative analysis, this case study identifies the organizational factors that either help or hinder the establishment of a functional interface in an area of the Quebec City region. Findings indicate that PHs must first undertake specific strategies to implement a new paradigm (such as the population perspective) among clinicians before introducing structural changes for developing and formalizing PH-PCC interfaces.

Process evaluation for community participation

This review provides a synthesis of published public health and social science literature to determine how process evaluation has been used to examine community participation and its intermediary role in health and social change outcomes. Community participation is defined, and its relationship to other community-development principles and evaluation and research methods is described. Then, case studies and research initiatives help answer questions such as who participates and why? What are the benefits and challenges of community participation? What qualitative and quantitative methods are used in process evaluations to measure community participation? What measures are used to help define the influence of community participation in community-based interventions? A better understanding of these issues is needed to ensure that community participation is valued and used effectively to plan and implement health-promotion initiatives and evaluate their processes and outcomes.

Community coalition project directors: what makes them effective leaders?

OBJECTIVE

Effective leaders, both voluntary and paid, facilitate successful coalitions. The attributes that characterize effective project directors, however, are unclear. Our aim was to identify characteristics of effective project directors leading community coalitions.

METHODS

The study examined 13 project directors who led eight community-based coalitions established to combat substance abuse. We inductively identified common characteristics and leadership effectiveness of the project directors by abstracting data from detailed ethnographic studies of these coalitions. We assessed the validity of leadership effectiveness by comparing data abstracted from ethnographic studies with two independent ratings. We then employed a cross-case comparison strategy for analyzing patterns among the common characteristics identified and leadership effectiveness. Six characteristics emerged among the project directors studied: status with community (insider vs outsider); shared leadership; bridge building skills; substance abuse expertise; vision; and management style.

RESULTS AND CONCLUSIONS

Shared leadership, bridge building skills, and insider status were consistently related to leadership effectiveness. Less support was found for substance abuse expertise or vision. When hiring project directors, coalition leaders may consider assessing whether candidates are "insiders" within the community and demonstrate shared leadership and bridge building skills.

Collaborative partnerships for nursing faculties and health service providers: what can nursing learn from business literature?

Collaborative partnerships between nursing faculties and health service providers are the cornerstone of successful clinical experience for nursing students. The challenge of providing an optimal learning environment can be enormous given the turbulent and rapidly changing environment in health. The present study uses the business literature to examine what nursing can learn from business about the development of successful collaborative partnerships. The characteristics of sound partnerships are described and a set of best practice guidelines is developed. The guidelines summarize the factors considered to be essential for the effective development of collaborative partnerships. In these times of nursing shortages and high turnover high quality, collaborative partnerships between nursing faculties and the health care sector are seen as a possible solution to optimize clinical learning and therefore graduate preparedness.

Diffusing a research-based physical activity promotion program for seniors into diverse communities: CHAMPS III

INTRODUCTION

Increasing the physical activity levels of older adults through diffusion of successful research-based programs into community settings is challenging because of differences between research and real-world settings. This project diffused the Community Healthy Activities Model Program for Seniors (CHAMPS) II, an individual-level research-based physical activity promotion program, through three community organizations to reach lower-income and minority (primarily Hispanic or Latino and African American) seniors.

METHODS

Through an academic-community partnership, university staff worked with each organization to adapt the program to be appealing and effective, enable their staff and volunteers to provide the program, increase participants' physical activity, and leave sustainable programs in place. Evaluation was based on methods recommended by the Centers for Disease Control and Prevention.

RESULTS

The adapted programs, referred to as CHAMPS III, differed from the original program and among organizations. Group-based components and resource guides were included and new features were added; however, individualized components were not offered because of limited resources. A total of 321 people enrolled among three organizations; there was a trend toward increased physical activity at two organizations (an estimated increase of 481 kcal/week [P = .08] and 437 kcal/week [P = .06] expended in physical activity). Evaluation revealed challenges and unexpected community-level benefits. All organizations are continuing efforts to promote physical activity for older adults.

CONCLUSION

This project enabled community organizations to implement physical activity promotion programs. The overarching challenge was to retain original program features within each organization's resources yet be sustainable. Although the programs differed from the original research program, they were a catalyst for numerous community-level changes. Our findings can guide similar projects to reach underserved older adults.

A framework for developing evaluation tools used in Washington State's Healthy Communities projects

Washington State's Healthy Communities pilot projects were developed to test approaches and recommendations of the Washington State Nutrition and Physical Activity Plan and to provide a statewide model for implementation. The Healthy Communities program included plans for ongoing process evaluation to ensure implementation. Two years into the first project, however, the evaluation team recognized that data for evaluation were inadequate to explain the experiences of the pilot community partnership. The team sought a framework through which to better understand how the community partnership functioned, including what worked well and how guidance and technical assistance could best be provided. The evaluation team identified the community health governance model of Lasker and Weiss through a literature search and applied this model to existing Healthy Communities project evaluation data. The team also designed a new survey tool based on the model and used it in the second pilot community. The new tool provides feedback to community partners to help guide project implementation and tests the applicability of a theoretical model to public health practice.

Clinical education delivery – A collaborative, shared governance model provides a framework for planning, implementation and evaluation

Following a scheduled review of a university pre-registration Bachelor of Nursing program, a decision was taken to introduce a new model of clinical education delivery. Principles of collaboration, as used by other university nursing programs, were applied to the change management process. As the process of change progressed, a model incorporating collaboration and shared govemance emerged to address the challenge posed by multiple stakeholders from culturally different organisations and the genuine commitment by those stakeholders to share contol in the planning, implementation, and evaluation of the clinical education delivery model. Using a case study approach, this article demonstrates how the principles of collaboration and shared governance were combined to effectively manage change in the delivery of clinical education across several different organisations, aind provides an extended framework for collabortive change management involving multiple stakeholders.

Factors associated with interorganizational relationships among outpatient drug treatment organizations 1990-2000

OBJECTIVE

To identify the factors associated with drug abuse treatment center participation in interorganizational relationships (IORs).

DATA SOURCES

Three nationally representative samples of outpatient drug abuse treatment units surveyed in 1990, 1995, and 1999/2000 as part of the National Drug Abuse Treatment System Survey (NDATSS), stratified by public/private status, treatment modality (methadone or nonmethadone), and organizational affiliation.

STUDY DESIGN

Probit analyses on 647 lagged treatment center-year observations from the years 1990 to 1995 with outcomes in 1995 and 2000, respectively. Standard errors were adjusted for clustering of center-year observations within centers.

PRINCIPAL FINDINGS

Centers with greater motivation to form IORs (e.g., as a result of client diversity or government revenue) were more likely to do so, as were centers with greater opportunities to form IORs (e.g., centers whose directors participated in policy making).

CONCLUSIONS

Both motivating and enabling factors promoted the formation of IORs by drug abuse treatment centers. Managed care also played a distinct role, in this case appearing to undermine interorganizational cooperation. Because IORs can improve access to care and quality, policy makers should consider using both incentives and support such as management training to promote IOR formation.

Network structure and attitudes toward collaboration in a community partnership for diabetes control on the US‐Mexican border

PURPOSE

This study seeks to provide an examination of a health policy network operating in a single, small community along the US-Mexican border. The purpose of the paper is to discuss why and how this network evolved, and then to present findings on how the network was structured. Analysis will focus especially on agency involvement, or "embeddedness" in the network, and its relationship to attitudes held by network members regarding trust, reputation, and perceived benefit.

DESIGN/METHODOLOGY/APPROACH

Data were collected from 15 public and nonprofit agencies trying to work collaboratively to influence local policy and services regarding the prevention of obesity-related chronic disease, especially diabetes. Embeddedness was measured in three different ways and both confirmed and unconfirmed networks were assessed. Network analysis methods were utilized as well as nonparametric correlation statistics.

FINDINGS

The network was found to be densely connected through unconfirmed linkages, but much less so when these links were confirmed. Strongest findings were found for shared information. Measures of agency embeddedness in the network were strong predictors of agency reputation, but findings for trust and perceived benefit were generally weak.

ORIGINALITY/VALUE

From a practice perspective, the study points to the problems in building and sustaining community-based chronic disease health networks, especially in a small community with substantial health needs. The research also contributes to theory on embeddedness and to methodology for collecting and analyzing data on community health networks.

Collaborating to Conquer Cancer: A Comprehensive Approach to Cancer Control

Despite substantial contributions on the part of public, non-profit, and private sector organizations, the burden of cancer in the United States remains high. As public health organizations, particularly county, state, tribal, and territorial health departments, try to reduce the significant burden of cancer, they face additional issues that make it difficult to address cancer in a comprehensive way. These challenges along with the need to accelerate progress in reducing the U.S. cancer burden, prompted the Centers for Disease Control and Prevention (CDC) and its national partners to begin to work together to further define and describe comprehensive cancer control (CCC) as an approach to reducing the burden of cancer. CCC is defined as "an integrated and coordinated approach to reducing cancer incidence, morbidity, and mortality through prevention, early detection, treatment, rehabilitation, and palliation." This article describes the national effort to support comprehensive cancer control, outlines national and state level success in comprehensive cancer control, and provides a call to action to public, private, and non-profit organizations, governments of all levels, and individuals to renew their commitments to reducing the burden of cancer.

Mobilizing communities for teen pregnancy prevention: associations between coalition characteristics and perceived accomplishments

PURPOSE

To describe coalition membership, examine associations between coalition processes and short-term coalition outcomes, and assess the relative contribution of key coalition processes to perceived accomplishments in teen pregnancy prevention coalitions.

METHODS

A self-administered survey was distributed to active members of 21 teen pregnancy prevention coalitions in 13 communities. The overall response rate was 67%, with 471 surveys returned. Process measures included staff competence, member influence in decision making, and coalition functioning. Short-term outcome measures included perceived accomplishments, member satisfaction, member participation, and coalition viability.

RESULTS

About 50% of coalition members represented health or teen pregnancy prevention or youth development service organizations, with 13% participating primarily as residents or youth. None of the process measures were associated with coalition viability (defined as active 2 years post-survey). Many bivariate associations between coalition processes and other short-term outcomes were significant at the individual and coalition levels of analysis. In a multivariate random coefficients model, coalition functioning (p <.001) and member influence in decision making (p = .019) were significantly associated with perceived coalition accomplishments.

CONCLUSION

Consistent with research on coalitions that have addressed other health issues, good coalition processes were associated with short-term indicators of effectiveness in these teen pregnancy prevention coalitions. Coalition processes were not associated with coalition viability 2 years post-survey, however, suggesting that other factors influence coalition survival.

Evaluating integrated health care: a model for measurement

Purpose

In the development of integrated care, there is an increasing need for knowledge about the actual degree of integration between different providers of health services. The purpose of this article is to describe the conceptualisation and validation of a practical model for measurement, which can be used by managers to implement and sustain integrated care.

Theory

The model is based on a continuum of integration, extending from full segregation through intermediate forms of linkage, coordination and cooperation to full integration.

Methods

The continuum was operationalised into a ratio scale of functional clinical integration. This scale was used in an explorative study of a local health authority in Sweden. Data on integration were collected in self-assessment forms together with estimated ranks of optimum integration between the different units of the health authority. The data were processed with statistical methods and the results were discussed with the managers concerned.

Results

Judging from this explorative study, it seems that the model of measurement collects reliable and valid data of functional clinical integration in local health care. The model was also regarded as a useful instrument for managers of integrated care.

Discussion

One of the main advantages with the model is that it includes optimum ranks of integration beside actual ranks. The optimum integration rank between two units is depending on the needs of both differentiation and integration.

Community-based research partnerships: challenges and opportunities

The complexity of many urban health problems often makes them ill suited to traditional research approaches and interventions. The resultant frustration, together with community calls for genuine partnership in the research process, has highlighted the importance of an alternative paradigm. Community-based participatory research (CBPR) is presented as a promising collaborative approach that combines systematic inquiry, participation, and action to address urban health problems. Following a brief review of its basic tenets and historical roots, key ways in which CBPR adds value to urban health research are introduced and illustrated. Case study examples from diverse international settings are used to illustrate some of the difficult ethical challenges that may arise in the course of CBPR partnership approaches. The concepts of partnership synergy and cultural humility, together with protocols such as Green et al.'s guidelines for appraising CBPR projects, are highlighted as useful tools for urban health researchers seeking to apply this collaborative approach and to deal effectively with the difficult ethical challenges it can present.

Ethical challenges for the "outside" researcher in community-based participatory research

Although community-based participatory research (CBPR) shares many of the core values of health education and related fields, the outside researcher embracing this approach to inquiry frequently is confronted with thorny ethical challenges. Following a brief review of the conceptual and historical roots of CBPR, Kelly's ecological principles for community-based research and Jones's three-tiered framework for understanding racism are introduced as useful frameworks for helping explore several key challenges. These are (a) achieving a true "community-driven" agenda; (b) insider-outsider tensions; (c) real and perceived racism; (d) the limitations of "participation"; and (e) issues involving the sharing, ownership, and use of findings for action. Case studies are used in an initial exploration of these topics. Green et al.'s guidelines for appraising CBPR projects then are highlighted as an important tool for helping CBPR partners better address the challenging ethical issues often inherent in this approach.

Integrating patient safety into the clinical microsystem

Healthcare institutions continue to face challenges in providing safe patient care in increasingly complex organisational and regulatory environments while striving to maintain financial viability. The clinical microsystem provides a conceptual and practical framework for approaching organisational learning and delivery of care. Tensions exist between the conceptual theory and the daily practical applications of providing safe and effective care within healthcare systems. Healthcare organisations are often complex, disorganised, and opaque systems to their users and their patients. This disorganisation may lead to patient discomfort and harm as well as much waste. Healthcare organisations are in some sense conglomerates of smaller systems, not coherent monolithic organisations. The microsystem unit allows organisational leaders to embed quality and safety into a microsystem's developmental journey. Leaders can set the stage for making safety a priority for the organisation while allowing individual microsystems to create innovative strategies for improvement.

Integrating patient safety into the clinical microsystem

Healthcare institutions continue to face challenges in providing safe patient care in increasingly complex organisational and regulatory environments while striving to maintain financial viability. The clinical microsystem provides a conceptual and practical framework for approaching organisational learning and delivery of care. Tensions exist between the conceptual theory and the daily practical applications of providing safe and effective care within healthcare systems. Healthcare organisations are often complex, disorganised, and opaque systems to their users and their patients. This disorganisation may lead to patient discomfort and harm as well as much waste. Healthcare organisations are in some sense conglomerates of smaller systems, not coherent monolithic organisations. The microsystem unit allows organisational leaders to embed quality and safety into a microsystem's developmental journey. Leaders can set the stage for making safety a priority for the organisation while allowing individual microsystems to create innovative strategies for improvement.

The feasibility of government partnerships with NGOs in the reproductive health field in Mexico

In 1995 the Mexican government began to develop policies on establishing collaborative agreements with civil society organisations, and there is currently interest in Mexico in government and NGOs working together. This paper analyses whether the conditions exist in Mexico for successful partnerships between the public sector and NGOs in the reproductive health field. In-depth interviews were carried out with key informants in the public sector at national and state level and the NGO sector in six states in Mexico. Partnerships were found to be an option for the provision of reproductive health services in geographical areas where the population is under-served, and for services the government does not provide. While the contribution of NGOs to the reproductive health field is recognised, at least at federal level, there are still very few public agencies that collaborate with NGOs, and agreements are often limited to short-term financing of projects. The future of NGOs in Mexico will depend largely on their ability to obtain funding from within the country. More effective mechanisms are needed by government to generate resources for health care. Government must recognise the specific contribution of NGOs, including inputs of social capital and creation of community networks, and must share decision-making more equitably with NGO for partnerships to succeed.

Building Legitimacy and the Early Growth of Health Networks for the Uninsured

An integrated system of health care for serving the uninsured population of one community was followed from formation through early growth. Funding was provided through the Health Resources Services Administration's Community Access Program to bring together a diverse set of health care providers to form a collaborative network managed by a central administrative entity. Legitimacy building was critical for explaining how the network evolved and the effectiveness of the network in sustaining itself and building a patient base. Based on the study's results, conclusions are drawn that contribute to theory on network legitimacy in health care. In addition, lessons learned are offered that may help other communities address the health needs of the uninsured through collaborative health care networks.

Building community capacity around chronic disease services through a collaborative interorganizational network

This article presents the findings of a study examining the evolution of a network of health and human service organizations operating in a rural community on the Southwest border. The aim of the network was to build the capacity of the community to provide chronic disease education, prevention, and treatment services by developing collaborative relationships among a broad range of organizations. The impetus for the effort was based on receipt of a Turning Point grant. The findings, based on two waves of data collected 1 year apart, demonstrate how network structure and attitudes toward collaboration evolve as a community attempts to build capacity to address its health needs.

Partnership experiences: involving decision-makers in the research process

OBJECTIVES

To describe researchers' experiences with involving health system managers and public policy-makers (i.e. decision-makers) in the research process, and decision-makers' experiences with the research process, including their assessments of the benefits and costs of the involvement, and their recommendations for facilitating it.

METHODS

We conducted semi-structured interviews with principal investigators and research staff for the seven research programmes funded by the Canadian Health Services Research Foundation in the 1999 and 2000 competition years, and with the decision-makers they involved in the research programmes.

RESULTS

We identify three models of decision-maker involvement--formal supporter, responsive audience, and integral partner--each of which yielded important contributions to the research process. Four factors--the stage of the research process, time commitment required, alignment between decision-maker expertise and programme needs, and an existing relationship between the researcher and decision-maker--influenced the role played by decision-makers.

CONCLUSIONS

While on balance a beneficial experience, the further promotion of decision-maker involvement in the research process should involve helping researchers and decision-makers identify strategic opportunities for decision-maker involvement and support the costs associated with the involvement. Consideration should also be given to undertaking and evaluating interactions between researchers and decision-makers outside of the research process.

Minimizing disincentives for collaborative research

While collaborative research partnerships offer a number of advantages, the disincentives to collaboration which are present in the academic environment can be daunting and can result in failure unless they are explicitly and proactively addressed. Based on successful models of collaboration and a review of the literature, four disincentives to collaboration-increased requirements for time and communication, lack of clarity regarding leadership, need to share resources and revenue, and the problem of partners who do not fulfill their commitments-are discussed and strategies to minimize these disincentives are presented.

Community-based participatory research: implications for public health funding

Community-based participatory research (CBPR) increasingly is being recognized by health scholars and funders as a potent approach to collaboratively studying and acting to address health disparities. Emphasizing action as a critical part of the research process, CBPR is particularly consistent with the goals of "results oriented philanthropy" and of government funders who have become discouraged by the often modest to disappointing results of more traditional research and intervention efforts in many low income communities of color. Supporters of CBPR face challenging issues in the areas of partnership capacity and readiness, time requirements, funding flexibility, and evaluation. The authors suggest strategies for addressing such issues and make a case for increasing support of CBPR as an important tool for action-oriented and community-driven public health research.

Broadening participation in community problem solving: a multidisciplinary model to support collaborative practice and research

Over the last 40 years, thousands of communities-in the United States and internationally-have been working to broaden the involvement of people and organizations in addressing community-level problems related to health and other areas. Yet, in spite of this experience, many communities are having substantial difficulty achieving their collaborative objective, and many funders of community partnerships and participation initiatives are looking for ways to get more out of their investment. One of the reasons we are in this predicament is that the practitioners and researchers who are interested in community collaboration come from a variety of contexts, initiatives, and academic disciplines, and few of them have integrated their work with experiences or literatures beyond their own domain. In this article, we seek to overcome some of this fragmentation of effort by presenting a multidisciplinary model that lays out the pathways by which broadly participatory processes lead to more effective community problem solving and to improvements in community health. The model, which builds on a broad array of practical experience as well as conceptual and empirical work in multiple fields, is an outgrowth of a joint-learning work group that was organized to support nine communities in the Turning Point initiative. Following a detailed explication of the model, the article focuses on the implications of the model for research, practice, and policy. It describes how the model can help researchers answer the fundamental effectiveness and "how-to" questions related to community collaboration. In addition, the article explores differences between the model and current practice, suggesting strategies that can help the participants in, and funders of, community collaborations strengthen their efforts.

Making the most of collaboration: exploring the relationship between partnership synergy and partnership functioning

Considering the challenges inherent to collaboration and the time it takes to achieve measurable outcomes, partnerships need a way to determine, at an early stage, whether they are making the most of collaboration. The authors have developed a new measure, partnership synergy, which assesses the degree to which a partnership's collaborative process successfully combines its participants' perspectives, knowledge, and skills. This article reports the results of a national study designed to examine the relationship between partnership synergy and six dimensions of partnership functioning: leadership, administration and management, partnership efficiency, nonfinancial resources, partner involvement challenges, and community-related challenges. Data were collected from 815 informants in 63 partnerships. Results of regression analysis conducted with partnership-level data indicated that partnership synergy was most closely related to leadership effectiveness and partnership efficiency. Implications of these findings for research and practice are discussed.

Can communities and academia work together on public health research? Evaluation results from a community-based participatory research partnership in Detroit

This article reports the results of a formative evaluation of the first 4 years of the Detroit Community-Academic Urban Research Center (URC), a community-based participatory research partnership that was founded in 1995 with core funding from the Centers for Disease Control and Prevention (CDC). Several organizations are members of this partnership, including a university, six community-based organizations, a city health department, a health care system, and CDC. The Detroit URC is a strong partnership that has accomplished many of its goals, including the receipt of over $11 million in funding for 12 community-based participatory research projects during its initial 4 years. Detroit URC Board members identified a number of facilitating factors for their growth and achievements, such as (1) developing a sound infrastructure and set of processes for making decisions and working together, (2) building trust among partners, (3) garnering committed and active leadership from community partners, and (4) receiving support from CDC. Board members also identified a number of ongoing challenges, including organizational constraints, time pressures, and balancing community interests in interventions and academic research needs. Overall, the Detroit URC represents a partnership approach to identifying community health concerns and implementing potential solutions.