Community Efforts to Reduce Racial and Ethnic Health Disparities: Challenges and Facilitators Identified by 16 Multistakeholder Alliances.

The Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program aimed to improve health care quality and reduce racial and ethnic disparities in 16 diverse communities in the United States from 2006 to 2015; yet most communities failed to make substantive progress toward advancing health care equity by the program's end. This qualitative analysis of key stakeholder interviews aims to identify the major contributors to success versus failure in addressing local health disparities during AF4Q and identified five major themes. Three themes highlight challenges related to collecting local data on racial and ethnic health disparities and transitioning from data collection to action. Two themes capture the critical contribution of stakeholder engagement and access to technical expertise to successful efforts. The challenges and facilitators experienced by these 16 AF4Q communities may help inform the disparities reduction efforts of other communities and guide state or federal policies to reduce health disparities.

Lessons learned about advancing healthcare equity from the Aligning Forces for Quality initiative.

OBJECTIVE: The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) initiative aimed to advance healthcare quality and equity in 16 communities across the United States through multi-stakeholder alliances of healthcare payers, providers, and consumers. Our objectives are (1) to summarize the major approaches and activities undertaken by the AF4Q alliances that were most successful in tracking and implementing programs that aimed to reduce local healthcare disparities by race, ethnicity, and primary language spoken (REL), and socioeconomic status (SES); and (2) to identify the major lessons learned from the successes and failures of the AF4Q alliances to inform other equity-focused initiatives. METHODS: We analyzed data from 6 rounds of key informant interviews conducted between 2010 and 2015, and triannual progress reports submitted by the alliances to RWJF between 2008 and 2015. RESULTS: Of the 16 AF4Q alliances, 2 succeeded in developing community wide systems to track local healthcare disparities, 5 alliances implemented substantive programs that aimed to reduce local disparities, and 3 alliances were successful in disparity measurement and program implementation. The alliances that were most active in addressing disparities tended to have long-established relationships with relevant community organizations, focused on improving the quality of care provided by safety-net providers, and shifted quickly toward working to address disparities even if their initial efforts to stratify performance measures by REL failed. CONCLUSION: Few alliances were able to develop community wide systems to track local healthcare disparities or implement large-scale initiatives to reduce disparities during the 7 years that these objectives were advanced by the AF4Q initiative. Establishing robust local disparity-tracking systems and establishing productive relationships with key community stakeholders took substantial time. The AF4Q experience suggests that efforts to reduce disparities should not be held up by disparity measurement challenges.

Investigating a Multistakeholder Alliance Approach to Reducing Hospital Readmissions.

There is growing appreciation that significant improvements in healthcare quality cannot be achieved by organizations working in isolation. To that end, the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) initiative provides multistakeholder alliances-groups of payers, purchasers, providers, and consumers that work together-with funding and technical assistance to improve healthcare community wide. Reducing readmissions was one of the several AF4Q goals. Alliances crafted their own interventions, tailored to address the communities' unique needs, and took advantage of local resources. Our objective was to determine whether readmission rates declined more in AF4Q communities than in non-AF4Q communities by year 7 of the 10-year initiative. We conducted a quasiexperimental study using zip code-level demographics and 30-day readmission rates for all medical and surgical discharges using Medicare claims data for 2008 through 2012. This interim analysis found that AF4Q was not associated with significant reductions in medical or surgical readmissions, suggesting that AF4Q's multistakeholder approach was no more effective at reducing readmissions than other national efforts, such as the Hospital Reduction Program under the Affordable Care Act.

Advancing Payment Reform at the Community Level.

BACKGROUND: Multistakeholder alliances-groups of payers, purchasers, providers, and consumers that voluntarily work together to address local health goals-have increasingly been used to improve health care quality within their communities. Under the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) initiative, 16 multistakeholder alliances were charged with advancing payment reform as part of a larger effort to achieve dramatic and sustainable quality improvement. METHODS: Drawing upon key informant interviews with alliance leaders and document reviews conducted from 2010 to 2014, we describe the payment reform projects undertaken by the AF4Q alliances and the roles that the alliances played to advance them. RESULTS: The most common types of projects pursued by alliances were those that introduced supplemental payments to fee-for-service reimbursement and built upon alliances' ongoing quality improvement initiatives. Alliances advanced payment reform through 4 roles: (1) educating and advocating, (2) designing payment reform projects, (3) recruiting participants, and (4) supporting the operation of projects. However, less than half of alliances' payment reform projects were operational by 2014. CONCLUSIONS: Quality improvement-focused multistakeholder alliances may play meaningful roles to advance payment reform, but they are not a panacea for overcoming well-documented barriers to reform.