For better or worse, foundations often go it alone in seeking to improve the lives of the people they focus on. Each has its own strategy and ways of working. But when the problem is a big one, philanthropy should be a team sport. A good example: helping community clinics transform themselves as part of health reform.
Over the years, California's clinics have become an integral part of our health care system. In the beginning they were local affairs that often grew out of the identity politics of the 1960s and '70s to serve a particular ethnic group or community.
Today, they care for more than four million mostly uninsured and low-income adults and children each year. And they have become big business, with revenues of $1.8 billion in 2008. These numbers are likely to grow as previously uninsured residents gain coverage under federal health reform.
At the same time, health reform also means that many current community clinic patients will have coverage, giving them more choice about where they can obtain care. Given greater choice, some may seek care at private practices, seeking shorter wait times and better service. Competing for patients will force many clinics to do more to market their services, including focusing on improving the overall patient experience.
Adapting to a New Era
Will health reform change everything for clinics? No. But to thrive in an era of heightened competition, safety-net providers will need to find creative ways to deliver comprehensive, cost-efficient care in the hopes of becoming "providers of choice."
Keenly aware of these challenges, community clinics are moving to adapt. Foundations can support these changes in a number of ways by funding the development of resources and expertise, sharing lessons on how to build technology infrastructure, and encouraging clinics to join forces when appropriate. No single foundation can support all these needs alone.
At CHCF, much of our work over more than a decade has focused on enhancing clinics' capability to collect and analyze data, and then use that data to improve care. This includes the use and reporting of common measures in chronic disease care, such as how well an organization fares at caring for patients with diabetes. Other measures include providing timely access to care, and getting feedback from patients about the care they receive. One of our goals is to get 80% of California's community clinics to use and report these standardized quality measures — a precursor to anticipated requirements under health reform to publicly report clinics' performance on quality and efficiency measures.
We also have sought to help clinics develop mechanisms for sharing knowledge about how to do things better. In this area, our principal strategy has been to fund several consortia — regional groups that support many clinics. These consortia, which are very familiar with the challenges their member clinics face, are now sharing expertise and resources on issues ranging from how to use information technology systems to support better care, to decreasing clinic wait times.
Clinics Working Together
To transform how they work, clinics also need effective models. Through projects like Team Up for Health, CHCF has worked with a number of clinics eager to implement strategies for meaningful patient engagement. The next phase of this work will focus on improving the patient experience.
An analysis of California clinics' financial performance showed great variation among them, with larger clinics generally faring better. Because they rely heavily on state and federal reimbursements, community health centers are especially vulnerable to federal and state budget crises. The prospects for survival among California clinics depend upon their individual ability to compete for resources and their willingness to collaborate with other organizations to shore up reserves and sustain operations.
Strategic restructuring — establishing formal partnerships ranging from administrative consolidation to fully integrated mergers — is one potential solution. This approach, long used in the for-profit sector, is becoming more common among nonprofits. Through case studies and presentations developed by La Piana Consulting, an expert on nonprofit restructuring, CHCF has funded the creation of resources to help clinics jumpstart these necessary conversations.
And Foundations Too
Clinics aren't the only groups who need to work together to succeed in this new world; foundations do, too. As funders, we all need to be clear on how we can help, and that the sum of our work supports the success of these crucial community resources.
In a state the size of California, which has 230 licensed clinic organizations on 740 sites, no single foundation can individually address the needs of them all. The recently concluded California Networks for Electronic Health Record Adoption offers a good example of how foundations can work together. A partnership of three foundations, the project was designed to speed and lower the cost of electronic health records (EHRs) adoption in California community clinics and health centers. Clinic sites not only successfully implemented EHRs as a result of the four-year project, but also were able to share key lessons to help others do the same.
Adoption of health IT tools among community clinics — according to a new CHCF snapshot, nearly half of all California community clinics have implemented an EHR (up from 3%) — is a positive trend that will accelerate and support better clinic operations. It's unlikely the efforts of one foundation would have achieved as much progress.
Another example of the way foundations have joined forces to assist clinics is the Emergency Working Capital Loan Fund. For the past few years, California's chronic budget deficits have threatened the operation of some of the state's safety-net clinics. This low-interest loan pool, funded by CHCF and a number of other foundations and nonprofit organizations, is designed to ensure that clinics are able to provide uninterrupted care. Last year the fund made available a total of $22 million.
In many areas, other California-based foundations have taken the lead in supporting clinics. For example:
- Blue Shield of California Foundation's Clinic Leadership Institute is an innovative program designed to identify and cultivate the next generation of community clinic leaders.
- The California Endowment recently announced its new innovation fund to develop and sustain "health homes" (akin to medical homes) for low-income populations and communities of color in California.
- The California Wellness Foundation provides core support and sabbaticals to help clinic executives recharge and gain fresh perspectives.
- Sierra Health Foundation in Sacramento and Alliance Healthcare Foundation in San Diego are among the many regional foundations that provide important support to clinics in their areas.
- The Tides Foundation has been a longtime supporter of the Community Clinic Voice, a free, online community for health centers and other safety-net professionals. It also has partnered with The California Endowment on the Community Clinics Initiative, which provides resources, evidence-based programming, and evaluation, education, and training to clinics across California.
For CHCF, being a catalyst for positive change in California's health care system means taking the lead when we have the necessary knowledge, experience, and financial capability. It also means acknowledging that following the leadership of others can be a pathway to success.