The Pennsylvania Rural Health Model: Hospitals' Early Experiences With Global Payment for Rural Communities.

GOAL: In January 2019, the first cohort of rural hospitals began to operate under the Pennsylvania Rural Health Model for all-payer prospective global budget reimbursement as part of a demonstration funded by the Center for Medicare and Medicaid Innovation. Using information from primary source documents and interviews with key stakeholders, we sought to identify challenges and lessons learned throughout the design, development, and early implementation stages of the model. METHODS: We relied on two qualitative research approaches: (1) review of primary source documents such as peer-reviewed publications and news accounts related to the model and (2) semistructured interviews with key staff and stakeholders, including current and former members of the Pennsylvania Department of Health, first-year applicant hospitals, technical assistance providers, and members of state and federal organizations and agencies familiar with the Pennsylvania and Maryland payment reform efforts for rural health and rural hospitals (N = 20). PRINCIPAL FINDINGS: We identified four primary attributes that innovative projects such as the model need: (1) a champion at the state and hospital level, significant cooperation across state agencies and between federal and state agencies, and support from nongovernment stakeholders; (2) ongoing engagement and education of all stakeholders, particularly related to rural health disparities, the challenges faced by rural hospitals (especially resource limitations), and the differences between rural and urban health and health service delivery; (3) realistic time lines, noting that stakeholder relationships with hospital leadership develop over many months; and (4) multistakeholder collaboration, because participating hospitals must have ongoing engagement with community members (i.e., consumers of healthcare), nonacute community partners, and other rural hospitals to foster a "rural health movement." APPLICATIONS TO PRACTICE: A successful Pennsylvania model holds promise for other states seeking to address the needs of rural populations and the hospitals that are vital to those communities. The lessons in this article can assist others in making the transition from volume to value in rural healthcare.

Member engagement in multi-sector health care alliances.

Many communities are developing innovative forms of collaborative organizations such as multi-sector health care alliances (MHCAs) to address problems of misaligned incentives among providers, payers, and community stakeholders and improve health and health care. Member engagement is essential to the success of these organizations due to their dependence on volunteer members to develop and implement strategy and provide material and in-kind support for alliance efforts, yet relatively little research has examined how alliances can foster engagement. This study examined behavioral indicators of member engagement (e.g., recruitment and retention of organizational and individual members) and how they are related to two foundational dimensions of alliance functioning - alliance leadership and community centrality. Using three rounds of an internet-based survey of alliance members from 14 alliances, the study found that organizational recruitment and retention increased over time, from 26.6% to 41.5% and 56.0% to 65.2%, respectively. Recruitment of individuals increased over the study period (38.3% to 47.2%, while retention of individual members declined over the study period (61.0% to 53.2%). Alliance leadership was associated with lower levels of recruitment (both organizational and individual members) but higher levels of organizational retention (both organizational and individual members). Collectively, our findings suggest that behavioral aspects of alliances are more effective at retaining members than relatively stable characteristics such as size and positioning in the community. Contrasting relationships between recruitment and retention, however, suggest that different forms of leadership may be required to simultaneously attract new members while retaining existing ones.

Understanding Nutritional Problems of Metastatic Breast Cancer Patients: Opportunities for Supportive Care Through eHealth.

BACKGROUND: Metastatic breast cancer patients are now living longer but cope with potential symptoms of metastatic disease and prolonged cancer treatment. Nutrition can play a vital role in managing these sequelae, and eHealth tools are emerging as promising delivery options for nutrition interventions. OBJECTIVE: To qualitatively assess nutritional problems and concerns of women with metastatic breast cancer and to explore how to address these problems within an existing eHealth platform. METHODS: Semistructured interviews were conducted with 21 women with metastatic breast cancer participating in an ongoing eHealth study. Interviews were audiotaped, transcribed verbatim, and analyzed using a team-based content analysis approach. RESULTS: Most respondents reported currently or previously experiencing nutritional problems due to adverse effects of cancer treatment or the disease itself; these were rarely addressed during routine clinical care. Five major themes emerged: (1) knowledge about nutrition, (2) nutrition information-seeking, (3) social aspects of nutrition, (4) nutrition interest, and (5) how to address nutrition with an eHealth platform. The respondents reported diverse experiences and perspectives regarding nutrition and diet in the context of metastatic breast cancer within each theme. CONCLUSION: Findings indicate the importance of providing women with metastatic breast cancer with information about nutrition that is tailored to their specific disease, as these patients report both nutritional problems and uncertainty regarding nutritional strategies. IMPLICATIONS FOR PRACTICE: These findings are a first step toward designing supportive care interventions that could fill the gap related to nutritional concerns not addressed during routine clinical care.

The exercise in all chemotherapy trial.

BACKGROUND: Multiple international organizations have called for exercise to become standard practice in the setting of oncology care. The feasibility of integrating exercise within systemic chemotherapy has not been investigated. METHODS: Patients slated to receive infusion therapy between April 2017 and October 2018 were screened for possible inclusion. The study goal was to establish the acceptability and feasibility of embedding an exercise professional into the chemotherapy infusion suite as a method of making exercise a standard part of cancer care. The exercise prescriptions provided to patients were individualized according to results of brief baseline functional testing. RESULTS: In all, 544 patients were screened, and their respective treating oncologists deemed 83% of them to be medically eligible to participate. After further eligibility screening, 226 patients were approached. Nearly 71% of these patients (n = 160) accepted the invitation to participate in the Exercise in All Chemotherapy trial. Feasibility was established because 71%, 55%, 69%, and 63% of the aerobic, resistance, balance, and flexibility exercises prescribed to patients were completed. Qualitative data also supported the acceptability and feasibility of the intervention from the perspective of patients and clinicians. The per-patient cost of the intervention was $190.68 to $382.40. CONCLUSIONS: Embedding an exercise professional into the chemotherapy infusion suite is an acceptable and feasible approach to making exercise standard practice. Moreover, the cost of the intervention is lower than the cost of other common community programs. Future studies should test whether colocating an exercise professional with infusion therapy could reach more patients in comparison with not colocating. LAY SUMMARY: Few studies have tested the implementation of exercise for patients with cancer by embedding an exercise professional directly into the chemotherapy infusion suite. The Exercise in All Chemotherapy trial shows that this approach is both acceptable and feasible from the perspective of clinicians and patients.

Are health systems redesigning how health care is delivered?

OBJECTIVE: To explore why and how health systems are engaging in care delivery redesign (CDR)-defined as the variety of tools and organizational change processes health systems use to pursue the Triple Aim. STUDY SETTING: A purposive sample of 24 health systems across 4 states as part of the Agency for Healthcare Research and Quality's Comparative Health System Performance Initiative. STUDY DESIGN: An exploratory qualitative study design to gain an "on the ground" understanding of health systems' motivations for, and approaches to, CDR, with the goals of identifying key dimensions of CDR, and gauging the depth of change that is possible based on the particular approaches to redesign care being adopted by the health systems. DATA COLLECTION: Semi-structured telephone interviews with health system executives and physician organization leaders from 24 health systems (n = 162). PRINCIPAL FINDINGS: We identify and define 13 CDR activities and find that the health systems' efforts are varied in terms of both the combination of activities they are engaging in and the depth of innovation within each activity. Health system executives who report strong internal motivation for their CDR efforts describe more confidence in their approach to CDR than those who report strong external motivation. Health system leaders face uncertainty when implementing CDR due to a limited evidence base and because of the slower than expected pace of payment change. CONCLUSIONS: The ability to validly and reliably measure CDR activities-particularly across varying organizational contexts and markets-is currently limited but is key to better understanding CDR's impact on intended outcomes, which is important for guiding both health system decision making and policy making.

The importance of understanding and measuring health system structural, functional, and clinical integration.

OBJECTIVE: We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance. We sought to collect rich qualitative data to reveal whether and to what extent health systems vary in important ways across dimensions of structural, functional, and clinical integration. DATA SOURCES: Interviews with 162 c-suite executives of 24 health systems in four states conducted through "virtual" site visits between 2017 and 2019. STUDY DESIGN: Exploratory study using thematic comparative analysis to describe factors that may lead to high performance. DATA COLLECTION: We used maximum variation sampling to achieve diversity in size and performance. We conducted, transcribed, coded, and analyzed in-depth, semi-structured interviews with system executives, covering such topics as market context, health system origin, organizational structure, governance features, and relationship of health system to affiliated hospitals and POs. PRINCIPAL FINDINGS: Health systems vary widely in size and ownership type, complexity of organization and governance arrangements, and ability to take on risk. Structural, functional, and clinical integration vary across systems, with considerable activity around centralizing business functions, aligning financial incentives with physicians, establishing enterprise-wide EHR, and moving toward single signatory contracting. Executives describe clinical integration as more difficult to achieve, but essential. Studies that treat "health system" as a binary variable may be inappropriately aggregating for analysis health systems of very different types, at different degrees of maturity, and at different stages of structural, functional, and clinical integration. As a result, a "signal" indicating performance may be distorted by the "noise." CONCLUSIONS: Developing ways to account for the complex structures of today's health systems can enhance future efforts to study systems as complex organizations, to assess their performance, and to better understand the effects of payment innovation, care redesign, and other reforms.

Dissemination of quality improvement innovations by multisector health care alliances.

PURPOSE: Multisector health care alliances (alliances) are increasingly viewed as playing an important role in improving the health and health care of local populations, in part by disseminating innovative practices, yet alliances face a number of challenges to disseminating these practices beyond a limited set of initial participants. The purpose of this paper is to examine how alliances attempt to disseminate innovative practices and the facilitating and inhibiting factors that alliances confront when trying to do so. DESIGN/METHODOLOGY/APPROACH: The authors adopted multiple holistic case study design of eight alliances with a maximum variation case selection strategy to reflect a range of structural and geographic characteristics. Semi-structured interviews with staff, leaders and board members were used. FINDINGS: The findings show that dissemination is a multidirectional process that is closely if not inextricably intertwined with capacity- and context-related factors (of the alliance, partnering organizations and target organizations). Thus, standardized approaches to dissemination are likely the exception and not the rule, and highlight the value of existing frameworks as a starting point for conceptualizing the important aspects of dissemination, but they are incomplete in their description of the "on-the-ground" dissemination processes that occur in the context of collaborative organizational forms such as alliances. ORIGINALITY/VALUE: Despite a rapidly expanding evidence base to guide clinical and managerial decision making, this knowledge often fails to make its way into routine practice. Consequently, the search for effective strategies to reduce this gap has accelerated in the past decade. This study sheds light on those strategies and the challenges to implementing them.

The perceived importance of intersectoral collaboration by health care alliances.

There is growing interest in the use of intersectoral collaboration (e.g., alliances, coalitions, partnerships) to address complex, health-related issues in local communities. Relatively little empirical research, however, has examined how to foster and sustain collaboration across sectors during later stages of development, despite a recognition that the needs and goals for collaboration may change over time. The purpose of this study was to address this gap by examining the perceptions of alliance participants regarding the importance of collaborating with different industry sectors as alliances transitioned from stable, prescriptive foundation support to a more uncertain future. Our findings suggest that, in addition to the contextual characteristics highlighted in previous research, the perceived importance of intersectoral collaboration varies for different types of alliances and participants. Moreover, the salience of these characteristics varied for different types of collaboration, in our case, collaboration with nonmedical health care sectors and nonhealth care sectors. Collectively, our findings point to the importance of thinking more comprehensively, across multiple levels of influence, when considering ways to foster or sustain intersectoral collaboration.

Funding profiles of multisector health care alliances and their positioning for sustainability.

Purpose The purpose of this paper is to examine the relationship between different aspects of alliance funding profiles (e.g. range of sources, dependence on specific sources) and participant' perceptions of how well the organization is positioned for the future. Design/methodology/approach A mixed method study in the context of eight alliances participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality program. Data collection approaches included surveys of alliance participants and semi-structured interviews with alliance leaders. Findings The findings indicate that dependence on grant revenues, in particular, may be problematic for how well alliances are positioned for sustainability. While a number of approaches were identified to reduce dependence on grants, implementing these strategies presented more of a challenge for alliances due to the contextual demands of their external environment and a need to strike a balance between pursuing alternative revenue sources and fidelity to the mission and identity of the organization. Practical implications Alliance leaders need to have not only a broad and accurate understanding of their external environment, but also an appreciation of the alliance's identity in that environment. Collectively, the findings can help organizational leaders be more informed about their funding choices and the implications those choices have for the future of their organization. Originality/value Collaborative forms of organizations (e.g. alliances, coalitions, networks) are increasingly viewed as an effective means of addressing complex, multifaceted health, and social challenges. For collaborative organizations that depend on the coordinated efforts of volunteers, addressing such complex issues is predicated on sustaining programmatic activities as well as the interest and participation of stakeholders over extended periods of time. This study sheds light on how leaders of these organizations may improve their prospects for sustainability.

Evaluating a complex, multi-site, community-based program to improve healthcare quality: the summative research design for the Aligning Forces for Quality initiative.

OBJECTIVE: The Aligning Forces for Quality (AF4Q) initiative was the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site complex program, RWJF funded an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced during the summative evaluation phase of this near decade-long program are discussed. STUDY DESIGN: A descriptive overview of the summative research design and its development for a multi-site, community-based, healthcare quality improvement initiative is provided. METHODS: The summative research design employed by the evaluation team is discussed. RESULTS: The evaluation team's summative research design involved a data-driven assessment of the effectiveness of the AF4Q program at large, assessments of the impact of AF4Q in the specific programmatic areas, and an assessment of how the AF4Q alliances were positioned for the future at the end of the program. CONCLUSION: The AF4Q initiative was the largest privately funded community-based healthcare improvement initiative in the United States to date and was implemented at a time of rapid change in national healthcare policy. The implementation of large-scale, multi-site initiatives is becoming an increasingly common approach for addressing problems in healthcare. The summative evaluation research design for the AF4Q initiative, and the lessons learned from its approach, may be valuable to others tasked with evaluating similarly complex community-based initiatives.

The Aligning Forces for Quality initiative: background and evolution from 2005 to 2015.

OBJECTIVE: The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) program was the largest privately funded, community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. This article describes the AF4Q initiative's underlying theory of change, its evolution over time, and the key activities undertaken by alliances. STUDY DESIGN: Descriptive overview of a multi-site, community-based quality improvement initiative. METHODS: We summarized information from program documents, program meetings, observation of alliance activities, and interviews with RWJF staff, TA providers, and AF4Q alliance stakeholders. RESULTS: The AF4Q program was a dynamic initiative, expanding and evolving over time. The underlying theory of change was based on the notion that an aligned, multi-stakeholder approach is superior to independent siloed efforts by stakeholders. Participating alliances developed or strengthened programming to varying degrees in 5 main programmatic areas: (1) measurement and public reporting of healthcare quality, patient experience, cost, and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers in health, healthcare, and alliance governance (consumer engagement); (3) adoption and spread of effective strategies to improve care delivery; (4) advancing healthcare equity; and (5) integration of alliance activities with payment reform initiatives. CONCLUSION: The AF4Q initiative was an ambitious program affecting multiple leverage points in the healthcare system. AF4Q alliances were provided a similar set of expectations, and given financial support and access to substantial TA. There was considerable variation in how alliances addressed the AF4Q programmatic areas, given differences in their composition, market structure, and history.

Summative evaluation results and lessons learned from the Aligning Forces for Quality program.

OBJECTIVE: To report summative evaluation results from the Aligning Forces for Quality (AF4Q) initiative, the Robert Wood Johnson Foundation's (RWJF's) signature effort to improve quality of care from 2005 to 2015. METHODS: This was a longitudinal mixed methods program evaluation (ie, multiphase triangulated evaluation) of 16 grantee "alliances" from across the country, funded by RWJF as part of the AF4Q initiative. Grantees were selected in a nonexperimental manner and were charged with deploying interventions in 5 main programmatic areas to improve health and healthcare in their communities. RESULTS: Except for a small proportion of outcomes, there were no major differences in the rate of longitudinal improvement in AF4Q communities, compared with control communities, on quantitative outcomes related to the Triple Aim. Although the majority of the measures improved in both AF4Q and non-AF4Q communities, there were some exceptions to this improving trend, most noticeably in the cost of care and population health. There was also considerable heterogeneity across communities in terms of programmatic areas and the scale and scope of interventions in these areas. Although a number of AF4Q alliances implemented robust interventions in specific areas, often advancing strategies useful for others in the field, no AF4Q alliance pursued and aligned all 5 AF4Q programmatic areas in a robust way. In addition, whereas all alliances were able to garner the participation of multiple stakeholders initially, sustaining this participation and securing new sources of funding after RWJF support ended proved challenging for many alliances. Conclusion and Policy and Practice Implications: While the AF4Q program did not attain the ambitious community-level changes predicted by its sponsor at the program's outset, it did produce pockets of success on some dimensions for particular alliances. A number of factors explain the less-than-expected impact of the AF4Q initiative on community health and the observed variation in alliance sustainability and intervention strength. These include differing acceptance of the AF4Q initiative's theory of change, variation in the experience and capacity of the alliance communities selected for the program, differences in alliances' local healthcare market context, and the changing programmatic requirements for alliances participating in the AF4Q initiative. The variation in AF4Q program outcomes offers important lessons for those engaged in regional health improvement work.

Aligning Forces for Quality multi-stakeholder healthcare alliances: do they have a sustainable future?

OBJECTIVES: Multi-stakeholder healthcare alliances in the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program brought together diverse stakeholders to work collaboratively to improve healthcare in their local communities. This article evaluates how well the AF4Q alliances were collectively positioned to sustain themselves as AF4Q program support ended. METHODS: This analysis relied on a mixed-methods design using data from a survey of more than 700 participants in 15 of the 16 AF4Q alliances (1 alliance was unable to participate because it was in the process of closing down operations at the time of survey implementation), qualitative interviews with leaders in all 16 of the alliances, and secondary sources. Qualitative analysis of interview data and secondary sources were used to develop a classification of alliance strategic directions after the AF4Q program relative to their strategies during the AF4Q initiative. Descriptive analyses of survey data were conducted in the following areas: (1) alliance priorities for sustainability, (2) alliance positioning for sustainability, and (3) alliance challenges to sustainability. RESULTS: The likelihood of sustainability and the strategic direction of the former AF4Q alliances are both decidedly mixed. A substantial number of alliances are at risk because of an unclear strategic direction following the AF4Q program, poor financial support, and a lack of relevant community leadership. Some have a clear plan to continue on the path they set during the program. Others appear likely to continue to operate, but they plan to do so in a form that differs from the neutral convener multi-stakeholder model emphasized during the AF4Q program as they specialize, make a major shift in focus, develop fee-for-service products, or focus on particular stakeholder groups (ie, employers and providers). In most cases, preserving the organization itself, rather than its programmatic activities from the AF4Q program era, appeared to receive the greatest emphasis in sustainability efforts. CONCLUSION: As their core strategy, most alliances will not perpetuate the original AF4Q program vision of diverse local stakeholders coming together to implement a prescribed set of aligned interventions centered on healthcare improvement.

A Systematic Review of the Literature on the Sustainability of Community Health Collaboratives.

Recent interest in community health collaboratives has been driven by the potential of these types of organizations to solve complex health problems at the local level by bringing together stakeholders that have traditionally operated independently, and often at cross-purposes. Much of the work that is central to the mission of collaboratives can take years to reach fruition, however, and there are a number of challenges to sustaining their activities. In this article, we systematically reviewed the theoretical and empirical literature on health care collaborative sustainability, focusing on definitions and antecedents of sustainability. Given the diversity and fragmentation of this literature, we used this review as a foundation to develop a synthesized definition, conceptual groups of antecedents, and potential research propositions to help guide future research, planning, and practice of sustainable community health collaboratives.