Applying Theory to Partnership Building

1. Applying Theory to Partnership Building All coalitions are different This was/is the Texas experienceAll coalitions are different This was/is the Texas experience

2. Context Coalitions are affected by the context in which they operate. To understand the context in Texas: 254 counties Extensive border with Mexico Many rural/ frontier counties Coalitions are affected by the context in which they operate. To understand the context in Texas: 254 counties Extensive border with Mexico Many rural/ frontier counties

3. Context > 24.8 million residents 46% White 38% Hispanic 11.6% African American Highest rate of uninsured residents Large population Highest rate of uninsured Almost 25 million residents Large population Highest rate of uninsured Almost 25 million residents

4. Context Many medically underserved areasMany medically underserved areas

5. Heart Disease and Stroke Burden BRFSS 2009 Prevalence Slightly better off than the US – most likely due to our demographics (young population, large Hispanic population)BRFSS 2009 Prevalence Slightly better off than the US – most likely due to our demographics (young population, large Hispanic population)

6. Texas Council on CVD and Stroke 15 Member legislatively mandated council Most are health care professionals Non voting reps from state agencies Created in 1999 11 Members appointed by the Governor Most are health care professionals, 3 are members of the public 4 are non voting agency representatives: DARS, DADS, TEA, DSHSCreated in 1999 11 Members appointed by the Governor Most are health care professionals, 3 are members of the public 4 are non voting agency representatives: DARS, DADS, TEA, DSHS

7. Council’s Legislative Charges Developing an effective and resource-efficient plan Conducting health education, public awareness, and community outreach Improving access to treatment Coordinating activities among agencies within the state Developing a database of recommendations for treatment and care Collecting and analyzing information related to CVD Charged with having a state plan Loose reference to collection of data but no mandate for either a heart or stroke registry Coordination and education No funding until 2009-2011 biennium $1 million (recently reduced to accommodate state deficit reduction) Staff support has come from Branch Manager (serves as ED) and CDC program staff when there is overlap in objectives Charged with having a state plan Loose reference to collection of data but no mandate for either a heart or stroke registry Coordination and education No funding until 2009-2011 biennium $1 million (recently reduced to accommodate state deficit reduction) Staff support has come from Branch Manager (serves as ED) and CDC program staff when there is overlap in objectives

8. Statewide Partnership “Partnership” developed over several years of semiannual conferences Mostly local public health stakeholders Working meetings to educate, share information, and brainstorm Needs Assessment 10 Essential Public Health Services Training needs Loosely defined partnership – in reality it was an extensive e-mail list of folks the program had worked with and whom had attended our meetings Mostly state chronic disease program staff, local public health staff, some non-profit and health care professional representatives Core group of key organizations These were not the power brokers, these were the worker beesLoosely defined partnership – in reality it was an extensive e-mail list of folks the program had worked with and whom had attended our meetings Mostly state chronic disease program staff, local public health staff, some non-profit and health care professional representatives Core group of key organizations These were not the power brokers, these were the worker bees

9. Who We Were Texas Cardiovascular Disease and Stroke Prevention System Partnership (2006-2008) Given this name by the program in reference to the list of people we had been working with over the yearsGiven this name by the program in reference to the list of people we had been working with over the years

10. May 2008 Partnership Survey Results High degree of satisfaction with the partnership and a desire to move the partnership from planning to action. Agreement that the Department of State Health Services was an appropriate lead agency for the partnership. Conducted a survey of meeting attendees in May 2008Conducted a survey of meeting attendees in May 2008

11. We Decided to Get Organized In favor of creating a structure and processes that would enhance the group’s ability to move into implementation activities. Consensus for creating a Steering Committee that would propose a structure and processes. First formal meeting in October 2008.

12. Who We Are The Texas CVD and Stroke Partnership is a group of individuals and organizations working together to achieve a common goal. We shortened our name. In our case, we did not target specific organizations or high level administrators within organizations. We invited everyone interested and what we got were the folks that are on the ground doing the work. Sent a survey to everyone who had participated in the past 2 years (>200 people)We shortened our name. In our case, we did not target specific organizations or high level administrators within organizations. We invited everyone interested and what we got were the folks that are on the ground doing the work. Sent a survey to everyone who had participated in the past 2 years (>200 people)

13. Our First Meeting Meeting Objectives Gain consensus for implementing the Texas Plan to Reduce Cardiovascular Disease and Stroke 2008 Gain consensus for a partnership building framework – Community Coalition Action Theory (CCAT) Identify Partnership structures and processes that will facilitate Plan implementation

14. Partnership Purpose Our Common Goal To decrease the impact of cardiovascular disease and stroke in Texas by implementing the Texas Plan to Reduce Cardiovascular Disease and Stroke and to continue to assess the burden of disease in Texas and revise the Plan using a system wide approach.

15. Community Coalition Action Theory Developed by Dr. Frances Butterfoss - Coalitions Work Dr. Michelle Kegler - Department of Behavioral Sciences and Health Education at Emory in Atlanta, Georgia. Published in the text Emerging Theories in Health Promotion Practice and Research We adopted the Community Coalition Action Theory as our guiding partnership building frameworkWe adopted the Community Coalition Action Theory as our guiding partnership building framework

16. Community Coalition Action Theory A set of 14 major constructs 21 practice proven propositions (revised from 23) All of the constructs and propositions were derived from extensive analysis of the literature on coalition building the expertise of the authors, both experienced in coalition building This theory is comprised of 14 major constructs 21 propositions. The constructs are major ideas or concepts, like leadership. The propositions are statements about the constructs that are believed to be correct, based on the research. This theory is comprised of 14 major constructs 21 propositions. The constructs are major ideas or concepts, like leadership. The propositions are statements about the constructs that are believed to be correct, based on the research.

17. Community Coalition Action Theory Framework as a diagram. Each boxes represents one of the constructs of the theory. The first construct across bottom Formation – the coalition is just beginning and decisions are being made about what it will look like, how it will operate, and why it exists (mission statement). Maintenance - the group has been together for a while, perhaps a year or more, and is actively doing what it set out to do. This is not a stage for coordinators and leadership to take it easy. There continues to be things that need to be done to keep the coalition vital, keep folks committed, and continue to build the coalitions capacity to do it’s business. Institutionalization means the coalition and its work become a permanent part of the community. The arrows - coalition building is cyclical. For a number of reasons coalitions can move from formation to maintenance and then back to formation again or from institutionalization back to formation. Cycling is, in theory, a natural part of coalition building. It does not necessarily (although it can) mean that the coalition building process has been bad. Community context second construct of the theory Framework as a diagram. Each boxes represents one of the constructs of the theory. The first construct across bottom Formation – the coalition is just beginning and decisions are being made about what it will look like, how it will operate, and why it exists (mission statement). Maintenance - the group has been together for a while, perhaps a year or more, and is actively doing what it set out to do. This is not a stage for coordinators and leadership to take it easy. There continues to be things that need to be done to keep the coalition vital, keep folks committed, and continue to build the coalitions capacity to do it’s business. Institutionalization means the coalition and its work become a permanent part of the community. The arrows - coalition building is cyclical. For a number of reasons coalitions can move from formation to maintenance and then back to formation again or from institutionalization back to formation. Cycling is, in theory, a natural part of coalition building. It does not necessarily (although it can) mean that the coalition building process has been bad. Community context second construct of the theory

18. Partnership Formation We had an opportunity CDC Capacity Building funds We faced threats Poor Health Outcomes There were mandates To have a state plan (Council and CDC) To have strategic partnerships (CDC) To conduct surveillance activities (Council and CDC) Spend first year in Partnership Formation. The model states that coalitions are generally formed because of opportunities, threats, or mandates. In our case, we had all 3 Spend first year in Partnership Formation. The model states that coalitions are generally formed because of opportunities, threats, or mandates. In our case, we had all 3

19. Partnership Formation Coalitions are generally started by Lead agency (DSHS) Convener group American Heart Association Texas Medical Association Texas Medical Foundation QIO Texas Association of Local Health Officials The third construct of CCAT says that coalitions are usually started by a lead agency or a convener group. We had worked in the past with AHA, TMA, TMF, TALHO, and some other programs in the agency. This became the convener group. We had one initial meeting to reach consensus on the large issues of Agreement to have a partnership Agreement on leadership structure and to serve as the leadership team until members volunteered from within the partnership Agreement on some of the operating procedures to get started Agreement on using CCAT as our framework The third construct of CCAT says that coalitions are usually started by a lead agency or a convener group. We had worked in the past with AHA, TMA, TMF, TALHO, and some other programs in the agency. This became the convener group. We had one initial meeting to reach consensus on the large issues of Agreement to have a partnership Agreement on leadership structure and to serve as the leadership team until members volunteered from within the partnership Agreement on some of the operating procedures to get started Agreement on using CCAT as our framework

20. Partnership Formation Lead Agency or Convener Group Hosts the initial meeting Recruits partners Enlists community gatekeepers Provides Space and staff Technical assistance Financial and material support Credibility Valuable networks and contacts As the Lead Agency, we conducted these activities. As the Lead Agency, we conducted these activities.

21. Partnership Formation Leaders and staff were identified Staffing tasks were assigned Organizational structures were identified Processes and procedures were developed Discussion regarding leadership, staffing, structure, and processes became our Operating Principles Operating Principles were organized according to the CCAT framework Saves time if you present recommendations that can be responded to by the group Discussion regarding leadership, staffing, structure, and processes became our Operating Principles Operating Principles were organized according to the CCAT framework Saves time if you present recommendations that can be responded to by the group

22. Operating Principles 2 Levels of Members Steering Committee General Partner 2 Co-chairs: 1 from the Steering Committee membership, 1 from DSHS program 1 Chair Elect 2 levels of membership, members self selected based on level of involvement Large SC (>80 members now) INCLUSIVE – commitments involved (travel, meetings, Goal committee work) General partner - > 130, one way communication Co-chair from the SC serves for one year Chair Elect moves into Chair position, serves for one year as Co-Chair DSHS program staff as Co-chair – maintains consistency over time, ensures DSHS/CDC priorities are considered Convener group agreed to this up front SC members agreed because they knew we had the most invested2 levels of membership, members self selected based on level of involvement Large SC (>80 members now) INCLUSIVE – commitments involved (travel, meetings, Goal committee work) General partner - > 130, one way communication Co-chair from the SC serves for one year Chair Elect moves into Chair position, serves for one year as Co-Chair DSHS program staff as Co-chair – maintains consistency over time, ensures DSHS/CDC priorities are considered Convener group agreed to this up front SC members agreed because they knew we had the most invested

23. Operating Principles 4 Goal Committees – each with a Committee Chair Additional Committees Membership Nominations Communications Quality (Evaluation) Members self selected for a committee

24. Operating Principles Partnership meets 3 times per year Spring – Videoconference Summer – Training Conference Fall –Planning Meeting Committees meet as often as needed via conference call and during meetings in Austin

25. Partnership Maintenance Operations and Processes Fair and transparent decision making Effective communication Effective conflict management Frequent contact among members Clear roles and responsibilities Follow-through and follow-up Regular feedback and recognition There are other operational and process related issues that will require attention during Coalition Maintenance. Building trust through transparent processes like decision making will help to ensure your membership is satisfied, motivated, and committed. Good communication is essential for keeping everyone involved, maintaining attendance at meetings, and keeping everyone up to date on coalition progress. Managing conflict is never easy, so be prepared to be professional, fair, and courteous but firm. Leadership needs to be in control of meetings so that overbearing members don’t monopolize or intimidate others and everyone gets heard. Arrange for members to have time together. Networking and relationship building is a value added benefit for participation. Make sure leader, staff, and member roles are clearly defined and communicated. Make sure there is follow through on action items and follow-up after actions have occurred. Provide regular feedback using effectiveness tools and provide plenty of recognition when accomplishments have been achieved. There are other operational and process related issues that will require attention during Coalition Maintenance. Building trust through transparent processes like decision making will help to ensure your membership is satisfied, motivated, and committed. Good communication is essential for keeping everyone involved, maintaining attendance at meetings, and keeping everyone up to date on coalition progress. Managing conflict is never easy, so be prepared to be professional, fair, and courteous but firm. Leadership needs to be in control of meetings so that overbearing members don’t monopolize or intimidate others and everyone gets heard. Arrange for members to have time together. Networking and relationship building is a value added benefit for participation. Make sure leader, staff, and member roles are clearly defined and communicated. Make sure there is follow through on action items and follow-up after actions have occurred. Provide regular feedback using effectiveness tools and provide plenty of recognition when accomplishments have been achieved.

26. Partnership Maintenance Leadership We have a leadership team of committed members Use an empowering leadership style Build leadership capacity through training and mentoring Without good leadership and staffing, coalitions are not likely to move beyond the initial steps in formation. Effective coalition leadership requires qualities and skills that are not often found in one individual. Leadership teams are most effective when comprised of members willing to commit time, with varied skills and experiences, and with a leadership style that empowers others rather than dominates. Leadership training and experience gained by members is a value added benefit for members. Without good leadership and staffing, coalitions are not likely to move beyond the initial steps in formation. Effective coalition leadership requires qualities and skills that are not often found in one individual. Leadership teams are most effective when comprised of members willing to commit time, with varied skills and experiences, and with a leadership style that empowers others rather than dominates. Leadership training and experience gained by members is a value added benefit for members.

27. Partnership Maintenance Staffing Adequate staffing is critical to effectiveness, member satisfaction, and achievement of outcomes. Without paid staff members take on staffing/administrative duties Staff should be competent to conduct the tasks assigned Some coalition research suggests that staff who play a supportive role for the coalition, rather than a visible leadership role, have higher levels of implementation. Adequate staffing is critical Share staffing tasks among members Staff competency is associated with quality outcomes Some coalition research suggests that staff who play a supportive role for the coalition, rather than a visible leadership role, have higher levels of implementation. Adequate staffing is critical Share staffing tasks among members Staff competency is associated with quality outcomes

28. Partnership Maintenance Formalized Rules, Roles, Structures, and Procedures Operating Principles or By Laws Memoranda of Agreement Letters of Commitment or Support Mission statement Written goals and objectives Routinized operations Coalitions are more likely to engage members, pool resources, and assess and plan well when they have formalized structures and processes. Operating Principles are less formal than By Laws and merely put into writing the decisions that have been made about how the coalition will operate. MOA’s or Letters of Commitment formalize member commitments to the coalition. Having a mission statement and written goals and objectives provides a concrete framework for member recruiting, commitment, and action planning. Routinized operations would include things like having set meeting times and dates (Third Thursday of the month), set meeting locations, standard meeting registration processes, and standard evaluation tools. Creating a routine that members can get familiar with and rely on. Coalitions are more likely to engage members, pool resources, and assess and plan well when they have formalized structures and processes. Operating Principles are less formal than By Laws and merely put into writing the decisions that have been made about how the coalition will operate. MOA’s or Letters of Commitment formalize member commitments to the coalition. Having a mission statement and written goals and objectives provides a concrete framework for member recruiting, commitment, and action planning. Routinized operations would include things like having set meeting times and dates (Third Thursday of the month), set meeting locations, standard meeting registration processes, and standard evaluation tools. Creating a routine that members can get familiar with and rely on.

29. Partnership Maintenance Member Engagement Members are empowered Members recognize a sense of belonging High levels of participation Satisfaction with the work being done Benefits of participation outweigh the costs A positive coalition environment Member engagement is the process by which members are empowered and develop a sense of belonging. Engaged members have high levels of participation, are satisfied with the work of the coalition, and experience a positive environment. For member engagement to be consistent and of high quality, the benefits of participating must outweigh the costs. Member engagement is the process by which members are empowered and develop a sense of belonging. Engaged members have high levels of participation, are satisfied with the work of the coalition, and experience a positive environment. For member engagement to be consistent and of high quality, the benefits of participating must outweigh the costs.

30. Partnership Logic Model

31. Partnership Short Term Outcomes Objective By June 30, 2010, achieve greater than 80% agreement from the Steering Committee that the Partnership has achieved a minimum of 8 identified measures of partnership capacity to support and sustain collaborative implementation of the Texas Plan to Reduce Cardiovascular Disease and Stroke.

32. Measures of Partnership Capacity Lead Agency Support Membership Processes Structures Leadership Staffing Synergy – Member Engagement and Pooled Resources Assessment and Planning Implementation Outcomes Measures are derived from the constructs propositionsMeasures are derived from the constructs propositions

33. Partnership Evaluation

34. Partnership Evaluation

35. Partnership Evaluation

36. Partnership Evaluation

37. Partnership Evaluation

38. Partnership Evaluation

39. Partnership Evaluation

40. Partnership Evaluation

41. Partnership Evaluation

42. Partnership Evaluation We conducted a Meeting Effectiveness Survey at every meeting for the first year and a half.We conducted a Meeting Effectiveness Survey at every meeting for the first year and a half.

43. Partnership Letters of Commitment (Feb 2009)

44. Partnership Evaluation

45. Partnership Evaluation

46. Partnership Intermediate Outcomes Objective By June 30, 2010, >50% of Steering Committee members will experience a self reported increase in competency in at least 3 of the 7 competency areas identified by the NACDD for managing, planning, implementing, and evaluating programs.

47. Partnership Evaluation

48. Partnership Evaluation

49. Partnership Intermediate Outcomes Objective By June 30, 2010, increase by 30% the number of partners reporting using the state plan in their organization/program planning.

50. Partnership Use of State Plan

51. Partnership Use of State Plan

52. Partnership Maintenance Short term (6 months) Outcomes Are coalition members satisfied? Are meetings effective? Is membership diverse and representative? Is there a quality Action Plan? Is there a logic model? Has an assessment been conducted? Measuring and reporting outcomes is critical to partnership maintenance. Process outcome measures derived from the CCAT model – several of the propositions that speak to what makes an effective coalitionMeasuring and reporting outcomes is critical to partnership maintenance. Process outcome measures derived from the CCAT model – several of the propositions that speak to what makes an effective coalition

53. Partnership Maintenance Intermediate (1 year) Outcomes Have we achieved synergy? Are members engaged? Have resources been contributed? Have evidence-based strategies been implemented? Have you increased community capacity? Intermediate outcomes derived from propositions related to measures of coalition capacity and effective maintenance efforts. What outputs have been produced along the way? Intermediate outcomes derived from propositions related to measures of coalition capacity and effective maintenance efforts. What outputs have been produced along the way?

54. Partnership Outputs Medicine Assistance Program Guide Stroke Public Education Campaign Toolkit Outlined Systems of Care for Heart Attack and Stroke Developing Website Portal for Heart Attack and Stroke Practice Guidelines Conducted a survey of local health depts

55. Partnership Maintenance Longer term (> 1 year) Outcomes Policy changes Environmental changes System changes Community capacity Longer term outcomes will be seen after interventions have been implemented. These might include community change outcomes such as policy, systems, and environmental changes. Community capacity might also be considered a longer term outcome. Longer term outcomes will be seen after interventions have been implemented. These might include community change outcomes such as policy, systems, and environmental changes. Community capacity might also be considered a longer term outcome.

56. Partnership Maintenance Long Term (5 years) Outcomes Improved community health Reduction in disease Reduction in mortality Reduction in morbidity Health and social outcomes are long term. Collecting this data will require surveillance activities. Health and social outcomes are long term. Collecting this data will require surveillance activities.

57. Applying Theory to Partnership Building Jane Osmond, MPH, RRT Program Specialist V Cardiovascular Disease and Stroke Program Department of State Health Services Jane.osmond@dshs.state.tx.us Any final questions?Any final questions?