Prepared by Annette L. Gardner, PhD, MPH, Sara Geierstanger, MPH and Claire Brindis, Dr PH

1. Expanding Advocacy Capacity: Findings from the Evaluation of The California Endowment Clinic Consortia Policy and Advocacy Program Prepared by Annette L. Gardner, PhD, MPH, Sara Geierstanger, MPH and Claire Brindis, Dr PH The Philip R. Lee Institute for Health Policy Studies University of California, San Francisco October 28, 2008

2. Workshop Objectives Describe approaches to assessing policy and advocacy activities funded under TCE Program Share findings for 4 of 6 Program outcomes Discuss theoretical and practical challenges to assessing policy and advocacy

3. Background:Clinic Consortia Policy and Advocacy Program Launched in 2001 and refunded two more times in 2004 and 2007 ($9M per Round) 14 local/regional clinic consortia and 4 statewide clinic associations representing 700+ primary care clinics funded by The California Endowment Goals: Increase services to underserved populations through consortia-initiated policy and advocacy activities Increase access through improved efficiencies within clinic organizations

4. Program Logic Model Increased grantee capacity in policy advocacy Increased policymaker awareness of safety net and clinic policy issues Increased policymaker support for clinic funding Strengthened clinic operations Increased services for the underserved and uninsured Improved health outcomes for targeted communities and populations

5. Evaluation Data Collection Activities: 2002-2009

6. Evaluation Data Collection Activities by Outcome

7. Outcome 1: Expanded Grantee Advocacy Capacity

8. Data Collection Activity: Annual Advocacy Activities Worksheet Grantee self-report (n=15 grantees) Previous year’s activities and their outcomes (n=13) Source: Scholzman and Tierney (1986)

9. Results: Expanding and Innovating Grantees engaged in more grant-funded activities over time--increase from 73% to 86% of surveyed activities, between 2002 and 2006. Grantees consistently targeted most activities (80%) at the local and state levels and less (60%) at the federal level. Grantees perceived some activities to be more effective than others, e.g., helping draft rules, regulations and guidelines Newer (post-1990) grantees were equally effective in achieving advocacy goals by 2006.

10. Increase in Number of Grantee Advocacy Activities, by Level of Membership Focus, 2002-2006

11. Changes in Perceived Effectiveness of Key Activities Since 2002 (4=“very effective”)

12. Percent of Activities That Resulted in a Policy Change, 2002-2006

13. Percent of Grantee Advocacy Activities That Achieved 3 Desired Outcomes, 2002-2006

14. Outcome 2:Increased policymaker awareness of safety net and clinic policy issues

15. Data Collection Activities:2003 Policymaker and 2004 Stakeholder Surveys 2003 Policymaker Survey N = 86 decision makers familiar with consortia and their activities and policy issues 2004 Stakeholder Survey N = 43 stakeholders less familiar with consortia and their activities

16. Results:Policymaker/Stakeholder Awareness 2003 policymakers well-known to grantees considered policy events “very effective” (74%) compared to 2004 stakeholders less known to grantees (61%) Consortia media events rated “very effective” in increasing 2003 policymaker (60%) and 2004 stakeholder awareness (42%) Grantees reported that nearly all advocacy activities (95%) contributed to high policymaker awareness

17. Outcome 3:Increased Policymaker Support for Clinic Funding

18. Data Collection Activity: Funding Secured Worksheet Grantee self-report (n=16-18 grantees) Requires written instructions and follow-up phone calls Previous year’s funding secured attributable to TCE grant Staff time (%) used to determine esimate Use calendar year

19. Results:Increased Clinic Financial Stability, 2001-2007 Total funding secured was $2.9B, with $979M(35%) attributable to grant Funding due to TCE grant increased from $104M in 2001 to $226M in 2007 Modest increase in “new” funding (29% in 2007), e.g., Information technology Public funding dominates: Federal:$344M County:$324M State:$263M Private:$45M

20. Total Funds Attributed to Grant-funded Advocacy Activities, 2001-2007

21. Annual Funding Secured by Type, 2001-2007

22. Total Funding by Type, 2001-2007

23. Data Collection Activity: Policy Outcomes Worksheet Grantee self-report (n=18 grantees) Previous year’s activities

24. Results:Legislation Passed, 2001-2006 Grantees achieved fewer wins but were involved with more legislation over time: 2001-2003: Involved in 58 pieces of legislation. Five (30%) federal policies passed and 26 (60%) state bills passed 2004-2006: Involved in 72 pieces of legislation. Six (18%) federal policies passed and 20 (55%) state bills passed.

25. Federal and State Legislation Targeted by Grantees: Round 1 (2001-03) vs. Round 2 (2004-06)

26. Major Policy Wins & Losses in 2006 Federal: Wins: HR 5647--Health Center Appropriations Losses: HR 4241--Deficit Reduction Act State: Wins: SB 437--Children’s Health Coverage Expansion Wins: SB 2282--Safe Harbor Losses:SB 1427--Four Walls Losses:Prop 86--Tobacco Initiative Local: Wins: Mental Health Services Act (MHSA) funding, County Contracts

27. Methods:Developing Policy Case Studies Criteria for inclusion: 1 state and 1 local policy Single grantee vs. multiple grantee involvement Policies studied: Measure A (Alameda County) Local sales tax to support health care safety net Mental Health Services Act (MHSA) Local funding secured for clinics in Alameda and San Diego Counties State Prospective Payment System (PPS) legislation Move from cost-based payment to prospective payment of FQHC clinic services

28. Methods:Developing Policy Case Studies (cont.) Data collection, development and analysis: 30-60 minute phone interviews with: Grantee staff 1-2 decision makers per policy 1 clinic staff member per policy UCSF developed 5-7 page description of policy, advocacy activities undertaken and outcomes Grantees reviewed and commented on summary Comparison of 3 policies by advocacy activities

29. Analysis: Comparison of Policy Case Studies Variation among cases: Not all policies are “media-friendly” Challenges vary, e.g., measures requires 2/3 majority Common factors for success: Staff expertise (technical, advocacy, networking) Early and often involvement Mobilizing clinic staff and patients and building coalitions Leveraging partnerships with clinics

30. Outcome 4: Strengthened Clinic Operations

31. Methods:Developing Grantee Best Practices Criteria for inclusion: Exemplary activities funded under TCE Program (2004-2006) Types of practices: A particular bill or measure An advocacy activity or strategy Programs to expand access to health care Data collection, development and analysis: UCSF reviewed background materials and interviewed grantee staff UCSF wrote a 1-2 page description Grantees reviewed and commented on description UCSF mapped Best Practices on Program logic model

32. Community Clinic Association of L.A. County (CCALAC)Preserving Public-Private Partnership (PPP) Program Funding The Challenge: Sustain funding for program that supports links between public and private primary care clinics that serves 1.3M people The Solution: Multi-faceted advocacy campaign to preserve and evaluate Program Success: Preservation of funding - 3 year contract ($51M in 2005) Lessons Learned: Work with local data Partnerships key Garner county support Looking Forward: Focus on maintaining county support

33. Achievement of Program Outcomes:Round 2 Grantee Best Practices Improved health outcomes for targeted communities and populations - TBD • Increased services for the underserved/uninsured • NCCN: Securing Health Professional Shortage Area Designations • RCHC: Expanding Enrollment in Health Care Insurance Programs • Strengthened clinic operations • CPCA: Clinic Emergency Preparedness Project • CHPSCC: Patient Advocacy Training Program • Increased policymaker support for clinic funding • CFHC: Averting Cuts to Title X Funding • CPPEF: Training and Coordinating Affiliates in Grassroots Policy Advocacy • CRIHB: Develop Research Infrastructure to Inform Policymaking • Increased awareness of policymakers of safety net and clinic policy issues • CCC: “What’s Going Around?” on CBS Local Channel 8 • COCCC: 6th Annual Bridges Conference • Increased grantee capacity in policy and advocacy • SCCC: Creating a Voice for Change--Launching a Clinic Consortium • NSRHN: Use of Economic Data to Inform Local Decision Making

34. Summary of Findings Achievement of first 4 Program Outcomes: Sustained advocacy capacity Increased policymaker/stakeholder awareness Increased funding secured Important policy “wins” benefiting clinics Early evidence of longer-term outcomes: Clinic services expansions Increased utilization by uninsured Consortia as agents of systems change in their communities

35. Challenges and Potential Solutions Aggregating diverse grantee achievements Use of longitudinal tools and individual case studies Issue of lobbying Identify what is funded under the grant Analyze legislation as measure of capacity Acknowledge role of lobbying Relying on grantee self-report Interview member/non-member clinics Interview policymakers/stakeholders Interview partner organizations Attribution Focus on what can be identified as attributable

36. For More Information: Annette Gardner, PhD, MPH Evaluation Director Philip R. Lee Institute for Health Studies University of California, San Francisco 3333 California Street, Suite 265 San Francisco, CA 94121 Phone: (415) 514-1543 Email: annette.gardner@ucsf.edu