It is becoming common for foundations  to serve an important function in the communities they operate.  That function is convening “stakeholders” or “community leaders” to discuss issues and in particular  – thorny issues.  They can do this for several reasons.  As funders of nonprofits, they have an interest in collaborating with colleagues who may need an audience to advocate with government officials and other stakeholders for the populations they serve.  The nonprofits typically are recipents of government funds and, as such, are players in a larger network of fiscal exchange that include private and “public” dollars.  (I define public dollars as those raised through taxes).  City and/or state agencies distribute these tax dollars to nonprofit collaborators tying them to the cohort involved.

The “thorniness” arise when discussion opens to critique the way in which the various iterations of public dollars flow and exchange among the entities.  Too often critique is mistaken for criticism and agency directors can revert to defensive postures.   This is particularly true when entrenched entities and the ways  they doing business are suddenly open to public scrutiny.

Business leaders  have an interest in the communities served by nonprofits by dint of living in the same community but also having a direct or indirect financial investment in that community.  The private sector may sneer at the way government entities function.  We suggest that it is healthier for the community to bring that critique to a common ground rather than lob salvos at an agency that might raise and individuals ire.

Foundations play a unique role in this civic environment.  If they call the meeting most people will come.  There is the power of money and the high probability that good food will be part of the deal  inevitably an incentive for people to attend the meetings.  If the meetings are choreographed carefully ahead of time it is very likely that the intellectual discussion will provide enough nourishment to sustain the conversations.

I propose that family foundation’s might have the advantage over community foundations and corporate foundations in this arena since they are inurred from “interests.” Community Foundations must raise money from the community and therefore must be careful not appear endorsing a position that could alienate a (funding) constituency.  Similarly corporations must be somewhat risk averse to issues that could result in a public relations (PR) controversy.  Of course there are exceptions to my broad comments.  Community foundations can and have taken a lead role in conferences that are meant to be conciliatory. Case in point – the Cincinnati Community Foundation’s initiative to address racial tensions in that city a few years ago was a national model and the Pittsburg Foundation‘s efforts (in collaboration with the Heniz Endowment) to address thorny issues in the public schools.  The Columbus Medical Association and Foundation is a national model for convening stakeholders around the crisis of health care in that city.  The Cincinnati Health Foundation is another standard for how to engage a community around this critical issue.  With far fewer resources than our colleagues in Columbus or Cincinnati, we explored their methods as we embarked on our own response.

At the February 2008 Board meeting The Nord Family Foundation made a grant of $100,000  to the Community Foundation of Lorain County to initiate a community engagement and planning process to improve access to health care for the uninsured and under insured. (A great snapshot of the Lorain County Health statistics are found at the Public Service Institute) The initiative was a response to several critical factors.  The two charity hospitals Community Health Partners of Lorain and the Elyria Memorial Hospital are reporting approximately $20 million and $12 million in uncompensated care each year.  In addition to the two charity hospitals, the Lorain County Health and Dentistry is a beacon of hope for the scores of  medically uninsured and under insured in Lorain County.  LCHD had applied several times to receive funds from the Federal government to receive support as a Federally Qualified Health Care Center (FQHC).  Unfortunately it is considered a FQHC look alike because it has all of the services but does not get the Federal Funds.  The requests were turned down several times because demand exceeds supply of federal funds.  Equally disturbing was the increased pressure from the charitable group Lorain Free Clinic (headed by a remarkably talented and passionate executive director Paul Baumgartner)  to meet the increased demands of serving the rising number of medically indigent people in a county with staggering job loss and poverty.

Adding to the complexity is the aggressive move of the Cleveland Clinic Family Health satellite offices in Lorain and Elyria which is perceived as skimming the full-pay insured patients from the other two hospitals and FQHC.

So, when LCHD received a turn down of a $700,000 federal grant we sensed the community needed help.  A convening was in order!

We knew the task was enormous, but the urgency of the situation demanded a response.  Funds were used to support the work of the Altarum Institute of Ann Arbor, Michigan, in partnership with the local Public  Services Institute of Lorain County Community College. The overall project is currently referred to as Health Care Lorain County.

Upon approval of the grant, a Steering Committee was formed to provide community leadership for what became known as Health Care Lorain County. This ten-member committee has been chaired by the Executive Director of the Lorain County United Way and includes high-level representatives from the two main hospital systems, a local health departments, the Lorain County Medical Society, a local business leader, two nonprofit healthcare providers, a Lorain County Commissioner, and the President & CEO of the Community Foundation of Lorain County. This committee came together for a strategic planning retreat facilitated by staff of the Altarum Institute.

In preparation for the retreat, the Public Services Institute (PSI) conducted a basic environmental scan using existing data sources, to help define the prevalence and nature of the problem and to identify unanswered questions to inform future data needs. PSI and later United Way of Lorain County and Community Foundation staff also conducted one-on-one interviews with all members of the Working Group (key stakeholders, including members of the Steering Committee) to garner their expertise on the issue and input into the planning process. This compiled information was then presented at the retreat, to assist the Steering Committee in determining a shared understanding of the problem to be addressed, and to begin identifying project objectives and benchmarks for success. The Steering Committee developed into a highly dedicated group of community leaders with expertise and interest in the topic at hand and a commitment to serve the health care needs of the community. Meetings continued throughout the year, and included large stake-holder meetings  to continue data analysis, fine-tune the project direction, and determine the best steps for action.

After more than a year of meetings, the following conclusions were made:

1. There is a need to continue exploring this very complex issue of providing quality health-care to medically uninsured and under insured people in the county.
2. There must be a new technology infrastructure put in place to facilitate data sharing.
3. There is a desire to provide every citizen a sense of a medical home.  People desire a relationship with a personal health care provider rather than an impersonal institution.
4. The community needs to explore open-source charts so every patient can have an online chart that will follow him or her to their port to the health care system. The Cleveland Clinic’s remarkable on-line health record called My Chart is a great example of what an electronic health portfolio for medically under insured and uninsured could look like.
5. There is a need to examine how health dollars currently flow into the county.  There are tremendous inefficiencies and possible duplication of effort among  three distinct health departments (Elyria, Lorain City and Lorain County Health) which draw most of their funding from federal and state programs.  These departments which were established initially to address infectious disease in the earlier decades of the 20th Century, are not equipped to handle comprehensive chronic care that the majority of the population needs.  Competition from for-profit clinics such as Walgreens raise questions about the place of these health departments in a 21st century health care model.
6. The economic pressure necessiate collaboration between the two charitable hospitals and the Cleveland Clinic.

I am pleased to report that the undertaking has the active engagement of Senator Sherrod Brown and House Representatives, the Honorable Marcie Kaptur and Honorable Betty Sutton. The project has taken on a life of its own and stakeholders who would have otherwise had no incentive to come to the table have and continue to do so.  Their is consensus among the stakeholders that the large number of medically uninsured and under insured is a case of tragedy of the commons.  The response requires a willingness of leaders to listen, learn and possibly give up power in the years ahead.  That is a threatening prospect, but and genuine possibility.  It is a conversation that would not have taken place were it not for the foundation’s willingness and financial commitment to step in and assume a leadership role.

We do not know at this point where the effort will end up.  We do know that others have agreed to chip in to pay the costs to continue the facilitation.  It is our sincere belief that this effort will have positive impact on the access to health care that every family in this country deserves.  If nothing else in a age of disease resistant microbes, increased mental illness and poverty access quality health care and drugs is a public health issue that should concern all citizens.

So the challenge for any foundation deciding to take on a major effort in convening, you must determine{

• what role you want to  take
• have flexibility built into the expectations you have for the outcome
• know the level of risk you  will tolerate (the outcome could result in stakeholders walking away from the table) and
• be honest about much staff time and money you are willing to put into the effort
• look for innovation outside the conversations so to better inform the conversations
• be willing to stick with it – conversations of this magnitude can take year

We are making good progress with our effort. I admit to frustration about the ponderous pace the effort can take. It is my sincere hope that our stakeholders will embrace innovation in thought to explore interactive maps such as those developed by the Cincinnati Health Foundation, as well as virtual environments like those featured below that become places to test their theories.

Doing so will encourage even wider and broader horizions of possiblities.

Should the project work well, there can be nothing more rewarding than knowing you have created a space where citizens can leave their official interests at the door and collaborate as colleagues challenged with solving an enormous social problem.