**FTS-HRSA-OA**

**July 28, 2004**

**1:30 p.m. CDT**

Coordinator This is the operator. I'd like to inform all participants
that this call is going to be recorded. If you have any objections,
please disconnect at this time. Thank you, ma'am, you may begin.

Pat Welcome everyone to our July 28^th^ Special Technical Assistance
call. Welcome to all of the people who went ahead and purchased the
books. We know of 14 networks that bought the ROCI book after we made
this announcement, and certainly there were more than that that already
had the book from the conference in March.

> What I'd like to do right now is introduce Michele Prey, who is
> representing HRSA. Michele?

Michele Hi, this is Michele of the Office of Rural Health Policy. I'm
just going to go over a couple of quick announcements and turn it back
over to Pat. As some of you may know, we currently have another
conference call going on at the same time as this one, it's the 340B
Drug Pricing program conference call. If you want to hear the replay of
that call, you can call 1-866-417-5767. That call will play through
August 25^th^. We'll also have a transcript of the call up on the Web
site within the next week or two.

On July 29^th^ at two o'clock we're going to have the Technical
Assistance conference call outreach grant programs, and you have until
noon tomorrow to sign up for that call. On August 5^th^ at two o'clock
eastern time we will have the TA call for Network Development Planning
Grant program, and on August 10^th^ at two o'clock as well we will have
the TA call for the Network Development Grant Program.

> If you want to sign up for any of these calls just e-mail Mary Collier
> in interoffice, the address is mcollier@hrsa.gov. Just e-mail her and
> tell her what conference call you want to sign up for and leave your
> name and a phone number or an e-mail address that where can contact
> you.

Pat Is that about it, Michele?

Michele Yes.

Pat I would like to let all of you know that this call is also being
recorded and the same guidelines are in place. You can listen to the
call again if you've missed anything, that call-in number is
1-800-238-0563. Or, you can go to the Web site and there will be a
transcript, also, of the call.

With all of that housekeeping in order, I'm really excited that we have
Eric Baumgartner and Kristen West on the line. Eric, would you like to
take over?

Eric Thanks, Pat. Can you all hear me okay?

W Yes.

Eric I'd like to add to the welcome and I'm looking forward to this
conversation with you. As I work with ... across the country,
sustainability is among the top priorities for everyone, and I know
HRSA, for its part, has said, and the Office of Rural Health Policy has
said, that in its grant-making programs it was not simply interested in
funding projects, but really wanted to help capitalize on the formation
of standing community networks that could serve the community over the
long run and be part of the local solution for affordable, quality
healthcare. Securing the partnerships and sustaining them is at the core
of that, so we're very pleased to be able to present this conversation
this afternoon.

> I wanted to mention that what we'll share today is the benefit of a
> lot of thoughtful work and experience from leaders like yourself
> across the country that has been put together into, I believe you'll
> find, a helpful and easy to apply collection by Kristen West, and
> others, with Communities Joined in Action. I will tell you, I am a
> founding member of Communities Joined in Action, and if you're not
> familiar with it, it is a national learning community of communities
> organizing around health. It is of, by and for communities and
> community leaders for health. If you would like to learn more about
> CJA, Communities Joined in Action, please visit the Web site,
> CJAonline.net.
>
> CJA is a relatively new organization, and as I said, is of, by and for
> organizing communities. So it continues to develop its products and
> services as best meets our collective needs. Today's presentation of
> the return of community investment workbook is, in fact, a
> presentation of a product created by CJA for communities across the
> country. Kristen has been kind enough, not only to put a lot of her
> own personal equity, sweat equity into this and thoughtfulness, but
> also as part of a team and today to volunteer more of her time to help
> those who have not been introduced to ROCI to get that introduction,
> to see how to use this thoughtful program text. For those of you all
> who were at the Intensive in Chicago a couple of months ago, that
> in-service did at length, you'll have a chance today to join in and
> let us know what you can affirm about the helpfulness of this, or just
> as importantly, help in conversation, perhaps add some value or
> clarify how to use some aspects of this. Kristen will also let us know
> about some updates that are already coming up. As you can imagine,
> this is an organic process, as we get more clever ways to make these
> value propositions.
>
> ROCI, in its essence, is not just something to help a mid-term or
> mature organization try to find its longer term sustainability, but as
> Kristen will, I'm sure, make clear to you, ROCI is a way that at the
> initiation of coalition building, or anywhere in the life cycle, a
> coalition can have an objective business-like organized set of prompts
> and processes by which to develop that value proposition to hold out
> to each member or potential member that bit of value that comes out of
> the collaborative work that accrues back to them, so that we can get
> partners to run on enlightened self-interest. ROCI is not just one way
> to do that evaluation, it's not just one line of conversation, but
> actually ...
>
> So with that, I would like to introduce Kristen West, who will guide
> us through this conversation this afternoon. Feel free to ask
> questions, and we certainly want to get the dialogue in the balance of
> the 75 minutes or so that we have. Kristen, if you don't already know
> Kristen, although many of you, no doubt do, is executive director of
> Choice Regional Health Network, which is a non-profit organization
> working with five counties, and Kristen, I don't know if it's grown to
> be more than that, but five counties in western Washington state.
>
> Kristen herself is a veteran of state healthcare reform work,
> legislative relations, public healthcare purchasing, and now, Choice
> Regional Network, if you go to their Web site or hear Kristen speak,
> has quite an impressive portfolio of community strategies and regional
> strategies running off of very smart collaborative work. She brings
> all of that and her background in public administration and political
> science in today's Technical Assistance conference call. Kristen.

Kristen Thanks. I'm a little anxious about walking you guys through this
workbook, because this is the first time that I've done this, walked
people through the workbook, because it was much more interactive in
Chicago, it was more of a curriculum that focused specifically on the
workbook. Doing it over a telephone seems even more challenging, so I'd
like to give people permission to just stop and ask me questions, or if
something is unclear for us to navigate this call together.

I just wanted to let you know that I feel like we're in the very early
stages, as a movement of communities, to develop the entrepreneurial
discipline to take our community collaboratives to scale and to be
sustainable. My organization has been around, Choice has been around for
about ten years, and so we're often considered to be sustainable, but
probably like all of you, I spend way too much of my time just trying to
keep core funding for our infrastructure in place. I think that in order
for us to attract the kind of capital and resources for us to have
staying power, I think we're going to have to figure out how to be seen
as less shaky ventures by the private sector.

> Having said that, I think this workbook is the very first attempt at
> something that needs to be much more sophisticated and helpful to
> people. I'm personally committed, because I think community
> collaboratives hold the best hope for the future of healthcare, and I
> would like to see as many of us hit the ground running and have
> success and learn from each other as possible. It's a bit of a passion
> of mine, which is why I participate in Communities Joined in Action.
> I've already been working, in my brain, on how to make this workbook,
> take it to the next stage, so, working from the first version I'm
> already aware of a lot of limitations. I would be interested in
> getting all of your reactions, too, about how to make this better.
>
> I'm going to start on page 51, if you want to turn to 51 of the
> workbook. In the next version I plan to put the definitions at the
> beginning of the workbook, because one of the things that I think
> needs to happen is that we all need to start to develop a common
> vocabulary, and I'm not as concerned about whether these are the right
> definitions for these words, but more that over time all of us start
> to use common terms to mean common things.
>
> A couple that are used purposely throughout the workbook, one is
> return on investments, which in my mind is how you go to a particular
> investor, whether it be a hospital or a physician practice or public
> health department, and you're able to make a business case or a return
> for their particular organization, the kind of deals that we all
> probably informally broker all the time, and it's just a process of
> being more formal about that and being more accountable over time to
> show what those returns are. I think any community in any level of
> sophistication can begin to apply return on investment principles and
> probably should start, even if they're in the early stages of
> development.
>
> The second term here is return on community investment, which I think
> is a much more sophisticated analysis process and communication
> process. I think there are probably only a handful of communities that
> have really figured out how to do this well. I think it's something
> that evolves over time and you get better at doing. So one of the
> things that I always get worried about is that communities look at
> something as daunting as some of these examples in this workbook and
> think, we could never collect that data, or we could never be able to
> do something that rigorous, and I think that no matter where you start
> that there are some very simple things that you can do that start to
> apply this discipline.
>
> Return on community investment is sort of a combined value
> proposition, so it could be multiple investors, it could be multiple
> stakeholders, but your geographic area is what defines it. You look at
> what is the return for the entire community as a result of our
> collaborative efforts. There will be different value equations for
> different investors and different stakeholders. They will view similar
> outcomes differently, in terms of their own bottom lines, but it's how
> you begin to capture that and talk about that on a community level.
>
> Any questions? I'm not going to go through all the definitions, but if
> you're curious about how a term is being used, feel free to stop and
> ask me.
>
> I'm assuming silence means there are no questions, so if we turn to
> page four of the workbook, the way that we tried to design the
> workbook was to start out with a case that outlined a lesson learned,
> or something that when we would---when I started ten years ago with my
> community collaborative, HRSA, through their network grants, outreach
> grants, were investing in the concept of these community
> collaboratives, but there were a lot of them that folded in the early
> years, and so now that there's a number of us that have been around
> for a while and there's a growing body of evidence, there are some
> best practices or some lessons learned that are sort of evolving out
> of these community practices. One of the first ones that we sort of
> take a look at is community collaboratives that tend to be successful
> are those that reach out to other communities that have done something
> similar to what they want to do and build off of that as a best
> practice. So we're calling those benchmark communities. We sort of ran
> through, in a ... fashion, an example of one community that went
> around---actually this is my community---and looked at what were the
> sort of critical activities at the community level that needed to be
> in place in order for us to improve access and reduce disparities.
>
> There were eight critical activities that started to develop.
> Communities may start in very different places, but within about three
> years they end up looking very similar to each other in terms of
> performing these critical activities. There's usually outreach to the
> uninsured and support services to help them navigate healthcare and
> oftentimes human services. There are attempts to create common
> registration and enrollment among human service providers. There are
> programs to facilitate enrollment in public and private insurance
> programs like Medicaid. There are efforts to stabilize primary care
> capacity and increase primary care and preventive services, especially
> for safety net services. There are activities to reduce inappropriate
> emergency room use. There are activities to organize volunteer
> physician networks that are coordinated with specialty referrals. Then
> there are activities to pave the way or broker access to affordable
> pharmaceuticals.
>
> If you look at those eight critical activities, there are communities
> across the U.S. that are best practices that have done this and that
> communities can learn from. One of the things that we're starting to
> see that's powerful is that rather than just start with one initiative
> and then build off of that, we're seeing communities that are able to
> put together what we call a portfolio of these best practices, to find
> local champions to implement them simultaneously.
>
> So in walking through the workbook, we also tried to identify ...
> because rural areas tend to be different from urban areas, and remote
> rural areas are even different from semi-rural areas, because
> sometimes it's more difficult to get information or data in rural
> areas, we tried to identify ideas about how you can move forward on
> doing return on community investment. So in Case A the exercise is to
> really start to analyze, for your particular community, kind of doing
> a mapping process of do you have those critical activities in place
> already and what stage of development are they in? Are there
> conversations where partners are exploring it? Have you already moved
> into the planning phase? Have you moved beyond planning and you're in
> the process of development? Are you in the early operational phase,
> meaning you've been operating it on a pilot scale or for a period of
> time that you don't have outcome data yet? Or, are you a fully
> operational activity that can just be in the document outcomes and
> return on investment? So there was just a workbook activity on page
> six that helps you begin to map the stages that you're in and then to,
> based on your knowledge, or conversations with others, what are
> potential best practices for areas where you're not fully operational
> that you want to talk to.
>
> On page seven, once you start to begin to write down those best
> practices, who do you know in your national networking to call and
> what excited you about that best practice and what kind of outcomes
> would you like to see replicated in your community. So that when you
> call that person you're able to have a more targeted conversation. All
> of us, I'm sure, provide a lot of peer technical assistance, and to
> the extent that that time can be well organized, it makes the time
> that we can make available to each other do more of it than if we have
> to spend a lot of time helping people organize what their questions
> are.
>
> Any questions about the eight critical activities and the replicating
> best practices?

Moving on to Case B, one of the---I don't know if it's trends or fads,
but if it is I think it's a good one---is around grant programs, for us
to get more purposeful about laying out our measurement strategies. One
of the ways to do that for all of us are the HRSA ... grantees, and RWJ
has moved to this as well, is to begin to lay out logic models for our
particular activities, so that we're able to collect measurement data
from the beginning in a consistent way and track our outcomes.

One of the best examples of a collaborative that's done that---this is
actually in Broward County, Florida, and I think it's a wonderful case
example, and if you guys aren't familiar with them you should talk to
Mike DeLuca and check out their Web site---but they've basically set up
and have consistently, over four years now, been able to collect this
baseline data for a disease management program targeted towards
diabetes, asthma, and HIV/AIDS, which was based on a regional health
status assessment that they did there. Then they've been able to track
what their actual outcomes and cost savings have been over time.

> On page nine of the workbook you actually have a copy of their logic
> model framework, where they identify what resources are input that
> they needed, what activities they would do, what would be the outputs,
> what would be the outcomes that they're trying to achieve, and then
> the ultimate impact. They've been able, on page ten of the ROCI
> workbook, able to show baseline data, they've been able to outline
> their target outcomes and then they've been able to compare that to
> their actual outcome. This has resulted in them being able to increase
> the local financial participation of the hospitals over time, because
> the hospitals have been able to see exactly who benefits.
>
> Then on page eleven of the workbook---some of this will be redundant,
> because you'll know some of these things, and some of these things
> will be new---but for people new to doing logic model activities this
> is just on page eleven of the workbook, a way for you to begin to
> start doing a high level logic model. I want to be honest, that I
> would love to see, over time, that maybe even starting with HRSA
> grantees, outreach network and ...---maybe it would even be broader
> than that, to include all community collaboratives---that we would
> have a common logic model that we would all use to achieve better
> healthcare for more people at less cost. Our resources, activities,
> outputs, might be different, but it would feed into a national logic
> model that we would be able to go to some of the major national
> funders and say, stop putting little drabs of siloed money into these
> and let's really fund some of these community collaboratives to go to
> scale and be able to document consistently over communities the kind
> of stunning outcomes that I think that we would be able to achieve.
> That's my personal vision for why I think it's helpful for communities
> to get more consistent with a logic model approach.
>
> Then, on page 12 of the workbook it's a slightly different way to look
> at it, because each of the activities in the logic model that you
> identified, I was beginning to think about what would it take to
> really go to scale with those activities. Because one of my
> observations about why did so many community operatives fail or get
> stalled is because we're so severely undercapitalized for the kind of
> work that we're doing. So I think we tend to think scarcity mentality,
> because we're non-profits and we have more mission than we do margin.
> But I think until we can start to communicate the scale that we need
> to be operating at and not be afraid to go after those kind of capital
> investments, I think we're never going to realize our full potential
> and too many of us will end up folding before we're able to achieve
> the outcomes that we could achieve. ... a Kristen editorial comment.
>
> Moving on to page 13 of the workbook, one of the things that we
> struggle with as a community collaborative, and I hear others struggle
> with it as well, is what kind of measurements or outcomes do we hold
> ourselves accountable for. We need data from multiple organizations
> and we don't always have access to the data that we need in a timely
> fashion and then, also because a lot of our benefits can't be uniquely
> identified as being something that we achieved, because we achieved it
> collectively among multiple organizations, how do you get clear about
> what you're going to hold yourself accountable for, both as an
> organization and as a community partner. So I find that it takes a
> little bit of time to work that through and to be able to be clear
> about that with community partners and get their buy-in.
>
> We're struggling, right now, as a community collaborative because we
> basically are undertaking a 20-year change process, both in terms of
> consumer behavior change and provider behavior change. So we've gotten
> buy-in from lots of people for the big vision, but how do we show
> traction over that long of a time period, where people feel like
> they're part of something that's moving forward. We're actually going
> back, it's not like we had been pretty sophisticated for quite a while
> in terms of how measured and shown progress for activities, but now
> we're having to go back and start again with defining measurements
> over time.
>
> Moving to KC on page 14 of the workbook, this is actually a case
> example---the lesson learned here is that community collaboratives
> that tend to launch quickly are those that are able to assess the high
> potential benefits and go out and broker the deals at the beginning in
> order to be able to have some kind of a shared equity arrangement for
> those benefits getting reinvested back into the collaborative.
>
> One of the best examples of that is Project Access in Buckham County,
> North Carolina, where they were able to use physician self-interest to
> be able to put together a donated care program. Then they were able to
> collect data from the beginning and they paid for an evaluation,
> which, I know a lot of us don't have the money to do that, but they
> actually did invest in an evaluation that was able to leverage them
> going to scale over time. Alan McKenzie is the leader of that group,
> and it's very interesting to be able to talk to him about what they've
> been able to show, but they've been able to show that---the biggest
> one that I use in my community is that they've been able to show that
> they've been able to reduce the direct cost of care by 33%. So that's
> a pretty dramatic savings that they've been able to show by just
> reducing fragmentation.
>
> The exercise on page 15 of the workbook begins to take the work that
> you did in the previous two cases, where you've mapped your activities
> by stages of development, whether they're fully operational or early
> operational. Then, as you begin walking through a process for
> beginning to define whether the high value benefits that you're going
> to track and begin to document, because that will help you figure out
> what deals do you need to broker on the front end in order to be able
> to get people to reinvest those benefits back into the organization,
> and ... on the workbook is just some examples of the kind of benefits
> that you might see from certain types of activity.
>
> Then, one of the things that's helpful is to begin to document what
> are some immediate benefits, what are the low-hanging fruit that you
> can show your investors or your partner organizations in the next
> three months, in the next six months, and then what are going to be
> the benefits that are longer term that's going to require a period of
> time for the program to be operational before you can start to show
> those...
>
> Moving on to page 17, this was actually a script that was used in the
> Chicago Learning Institute to begin to take the case examples and the
> exercises in the first three cases and begin to put them into a
> succinct script that you as a leader can begin to use to go out and
> talk to community partners about return on community investment, so
> how are you going to talk about the best practice community you want
> to replicate, how are you going to talk about how you're going to
> adapt them for your particular community to maximize the potential
> benefits, and whether the logic and the measurement strategies that
> you're going to hold yourself accountable for communicate to investors
> and community stakeholders over time.
>
> So that's the end of part one, which is sort of figuring out what best
> practices and what your measurement strategy is going to be. I'm not
> sure, we have these laid out as part one, part two and part three, and
> I've never been clear that they're actually linear, but that could
> just be because I'm not a linear, logical person. They're sort of, in
> my mind, depending on the activity that you're undertaking and the
> magnitude of it, you sort of move back and forth between figuring out
> what are the activities or the enterprise you're going to manage, what
> are the deals you need to make, how do you get your community ready
> for those deals, and then how are you going to hold yourself
> accountable for performance, so to move in and out of that in more of
> a dance than it's laid out in the logical workbook.
>
> Part two---does somebody have a question?

Eric Kristen, this is Eric. I just wanted to pause and see, are folks
able to follow this okay. Do you have any questions about this? Does
someone want to probe more deeply into something that's been referenced
already?

Pat Eric, this is Pat. I'd just like to jump in and say that what
strikes me about the workbook in this first phase is that it's really an
outline for action and that ... workbook to be used and I would just
encourage everyone to do so.

> Kristen, the other thought that I had, when you were looking at the
> best practices, that it gives the individual executive directors and
> coordinators and so on, the opportunity to develop their list of best
> practices, but it occurs to me that it would be really helpful if we
> did this on a national level, post it on the Web site, and then let
> folks just draw down from that as well.

Kristen Thank you. That's excellent, Pat, because one of the things that
I was going to say and I forgot, is that I don't believe that there's
been any rigorous review of outcomes to identify criteria for best
practices. So I would love to see that happen. I haven't had the time to
do it personally, I don't know if I will have the time, but these are
basically a collection of communities that I just know about because
I've had conversations and I've reviewed some of their information, but
I think it will be important for us to, especially in the next version
of the workbook, to really think through what constitutes a best
practice, what kind of outcomes are we looking for, and to be able to
catalog those in a way that's easy for communities.

Pat That's something that I'd have an interest in too, and maybe we can
talk about that over the coming several months.

Eric This is Eric. I could think of a couple more that I think would
pass whatever is our functioning criteria for best practice in reporting
the value of coalition services that we can add to this, and Pat, you're
among them, in the work you did in your rural network.

> Let me just ask, is there anyone on the call who was at the two-day
> intensive that has any observations about the overview thus far, or
> comments or requests? Is there anyone on the call that was at the
> Chicago two-day intensive?

Randall I was. This is Randall.

Eric Okay, Randall. Feel free to either input or help us understand how
to be more responsive.

Kristen I don't want to spend a lot of time talking at you guys if this
isn't working for you.

Pat Kristen, I think the reality here is that everyone listens very
intently and what's wonderful is that after these conference calls we've
found that the phones start ringing and people really start
collaborating. So I think this is going very well.

Kristen All right, I'll keep plugging along. The second part of the
workbook---I also want to say that I personally struggled for a long
time with using the word "deals" because it sounds slimy to me, but I've
become more comfortable with it over time because I think that really is
the power of these community collaboratives, is that it's somebody's job
to go out there and figure out what's the win-win strategy for the
community and then build those relationships and get those commitments
made in order for collective action to happen, because without community
collaborative, that just doesn't happen in communities. So, figuring out
what's the right deal to make, I think, takes a bit of the right kind of
leader, you have to be sort of a social, entrepreneurial personality, I
think, and if you're not then you need to find somebody on your board
that is, that can go out there and articulate why somebody should agree
to participate.

> In Case D, I think it helps to do a process where you begin to catalog
> some benefits and know who benefits from the equation. This is an
> example of somebody who did it right, this is Tammy Stoltz in Arizona,
> who was able to broker a deal with the state government that very few
> communities have been able to do with their state government, and that
> was to get state government to invest in the technology for there to
> be multiple enrollment sites at the community level and for delegating
> electronic enrollment into Medicaid, and they were able to do it
> because they were able to make a compelling case for administrative
> savings. That compelling case for administrative savings was enough to
> counter people's fears about the increase in Medicaid case load and/or
> the fact that state agencies have more of a fraud and abuse mentality
> than these community enrollment sites would.
>
> To give you an example of my organization, that did it wrong, when we
> first started our outreach and enrollment program we went to the
> hospitals for funding---it was one of the case examples in here, and I
> could tell people more about that because they're usually
> interested---and we sold it to them on a return investment, before
> that was even a term that anybody really used for the kind of work
> that we do. So the hospital, we got a grant and so we had enough money
> to hire some outreach workers and to do what we needed for the first
> couple of years, but we didn't go to everyone in the community that
> was going to benefit from this activity and ask them to financially
> participate, because we didn't think about it.
>
> So when our grant funding ran out and when hospitals started having
> less money they could put into the program, our community ... and
> public health and others had been getting this service in the
> community for free for several years, and so because they were getting
> it for free there wasn't the same sense that they needed to
> financially participate to keep the service locally. So I think it's
> helpful to be thinking, before you ever start a particular activity or
> a program, is to really get a handle on who benefits and at least have
> a conversation, even if they don't have the ability to financially
> participate up front, get them to understand how they benefit from the
> program so that when you need to go back and ask for their help, they
> have that on their radar screen.
>
> The exercise on page 20 is just an example of beginning to get
> purposeful about documenting the benefits. I also would like to say
> that these benefits don't always have to be financial. One of the
> benefits to hospitals for participating in some of our activities is
> that it improves their relationships with physicians. That, in and of
> itself, is enough to have them participate in some of our activities,
> even if it doesn't save the hospital money.
>
> Moving on to Case E, this is how you begin to engage potential
> investors, and I use that term purposefully, because you may have
> multiple partners of your collaborative, you may have lots of
> stakeholders for your activities and initiatives, but these are people
> who you're going to go ask for money, and so begin to think about what
> you need to show to get them to take the leap of faith to invest in
> your program or service and have them present that in a sophisticated
> enough way that you'll be successful.
>
> One of the things that we did, this is actually my organization that
> I'm using as a case example here, is that I'm a social justice
> advocate, so I didn't need any convincing that we should go out and
> make sure that uninsured people, ... people have access to the
> healthcare that they need. But I found that even with public and
> not-for-profit hospitals and others, they have bottom line financial
> considerations that it became a no-brainer for them to participate if
> I could show them a return on investment. But we needed to show them a
> potential return on investment, even though we didn't have the data to
> support it.
>
> What we did is that we came up with a methodology that the hospitals
> agreed on. It happened to be documented in this and so I won't go over
> it in detail, but basically we showed them if the program had been
> operating for 12 months what additional reimbursement the hospital
> would have received as a result, and then did a bit of a sensitivity
> analysis in terms of what additional reimbursement would you have had
> if we enrolled this many people. So they could take the leap of faith
> that it was probably highly likely that even in the first year of
> operation that we would be able to show them a 2:1 return on their
> investment. Then we also sweetened the deal a bit by saying that if we
> didn't show them a 2:1, we would return the money at the end of the
> year in order for them to have a 2:1, we'd give them money at the end
> of the year in order for them to have a 2:1 return on investment. That
> was enough for at least ... of the biggest hospitals to participate,
> and then the others came along and had to phase it in over time.
>
> Anyway, then we were able to compare our prospective return on
> investment methodology with after we had a year, or two years, three
> years worth of actual experience with the program and we were able to
> refine our prospective return on investment model so that it then was
> a compelling case to go to other hospitals and get them to invest in
> the first year. We actually average, this is my case, we actually
> average about a 20:1 return on investment for our participating
> hospitals. The return tends to increase ...
>
> The exercises for this section are on page 24. This begins to get you,
> as a leader, thinking about how you're going to describe the situation
> and the opportunity and bring your potential investors and partners
> together, and what kind of events or forum are you going to do that
> in. I know that sometimes it's easier to meet with a hospital
> administrator and the hospital CFO privately to have these
> conversations, sometimes it's helpful to hold physician forums, where
> physicians are attracting other physicians, whatever, it just kind of
> depends on the value proposition that you have and begin to think
> through what kind of events or forum would serve you best. Then, begin
> to pencil out the math for how you're going to talk to these potential
> investors, to be able to show, if you're going to show return on
> investment for each individual investor or investor organization, be
> able to at least introduce some of the concepts of return on community
> investment by putting those value propositions together in some way so
> that they can see how the whole community benefits, not just their
> organization.

Randall This is Randall. I just had one comment about this section. This
is one of the things at that training in March where we sort of
practiced what you would say to investors to make sure that you properly
pitched what you were saying to the right audience in the right way. I
actually think that in thinking about this, that it's really worth doing
it with some of your board members, practicing with them, because I find
that that actually was very helpful in making me rethink how I was going
to approach some of the potential investors. I think it actually ended
up significantly improving by doing a run-through.

Pat The other comment that I'd like to make, Randall, is that when you
really look at this, what you're doing is you're building the win-win
proposition and the trust, and Kristen, the fact that you're willing to
say to them up front if this doesn't work we'll give you your money
back; wow, that's really powerful.

Kristen They would be business anyway if it didn't work. Yes, I just
want to agree that I struggle with asking people to invest. I'm really
good at asking for help, but to turn those things ... into asking people
to invest in our program just has personally been hard for me and I find
that it helps me to practice. I don't know if other people are in that
same category. I've recently started venturing into the social
entrepreneurial investment world, and I find that it takes an even
greater degree of compelling arguments and sophistication to effectively
communicate ... in a business sense.

I'm going to try to move more quickly through this, because I can tell
this is taking way too long. On page 26 of the workbook I just want to
highlight for you that when I started this workbook I assumed that this
kind of savings calculations existed somewhere, because this was in the
research and we just had to find it. I've been shocked, really, to find
out that it doesn't exist. I think this is data that I wasn't able to
pull but it's pretty anecdotal and it's pretty specific. I think this is
one area where we collectively could develop some greater sophistication
that would help all of our ... . If we had---where it says the formula
for calculating annual savings---if we had good formulas that we really
could take to our communities to quantify these kinds of things, I think
it would help all of us, so that's a place where I would like to see us
spend some time and energy. I found that, I have gone through this
particular sheet, on page 26, I've done this from my collaborative, and
because I'm able to use a combination of research with local data, I
find it to be pretty compelling with potential investors.

Randall This is Randall. I would again agree. We use something like this
in making our case for the investment in the teleradiology project at
each of the hospital sites. The formulas that our consultants came up
were very helpful in showing them sort of over time where they will get.

Kristen Thanks. Moving on to page 27, which is Case G, this is where I
started to think that, at least in terms of my knowledge about return on
community investment, that things to start to get weak. So I think being
brave enough to write things down and get people to talk about it and
think about it is the only way that we're going to improve the logic of
this. The stock flow and analysis is one way of looking at it. I don't
know how compelling it is. Adding up return on investment for each
individual investors and then throwing in some other values that might
not be apparent into kind of a community balance sheet is another
approach. I find that when I use it with my community partners they kind
of go, yeah, yeah, yeah, because it feels like it's just self-promotion,
but I'd be interested in hearing other people's experience. I think
these tools need a lot of work before they really have something that I
would consider as disciplined for return on community investments.

If you look at page 28, it's an example of a balance sheet that we tend
to try to use with our communities, but assigning value to things like
cultural competency, reducing increasing value to life; those kind of
things are still pretty fuzzy to my community partners.

Moving quickly to page 30, I do think there's some potential for a
safety net return on investment, hypothetical value maturation and ...
This is a pretty sophisticated analysis and it requires data that, for
instance, we probably wouldn't have locally. But I think that in order
for us to take this work to the next level, we're going to have to be
able to show when we expect to break-even, because part of what's
happening is we write sustainability strategies because we learn the
latest jargon that the grantors are looking for, but we haven't really
done an analysis about whether we're going to be sustainable at the end
of the two-year grant period or the three-year grant period. This kind
of analysis, I think, is going to be key to these community
collaboratives being sustainable.

Moving on to page 34, which is to make the community deal ready, a lot
of this is figuring out what readiness, how bold is your community ready
to be and how do you move your community to a different level of
readiness, is some of our most challenging work. The piece that I'm
going to highlight is on page 37, which is that I found this mapping
process to be very helpful in moving your community to a different place
of readiness. It's a little Machiavellian, but I find that if we don't
write it down and actually work it, that we can sometimes get stalled.

> So if I were to give you a tool to use, I would say that this one has
> been a highly effective one for us, where we start with assessing
> individual people and whether they're key to making something happen,
> whether they're important to making something happen, or whether
> they're just helpful, and then figuring out whether they're a
> supporter or a detractor or fence sitter, and then figuring out how
> you're going to move them, one step at a time, from wherever their
> starting position is to eventually being a champion for the work. I
> just wanted to highlight that, that will help you focus. We all have
> more telephone calls than we can return and e-mails that we can
> answer, and so this helps us focus on what individuals to be really
> spending time in conversation with.
>
> The other piece on page 41, this is my personal pitch. This tends to
> get lost in return on community investment discussions or return on
> investment discussions, but I think that we need to build into our
> performance evaluation systems community leaders delivering return on
> community investments. So, we've attempted to show some ways, at least
> in my organization, that my paycheck and my employee's paycheck is
> tied to us achieving the returns that we promised to the community and
> that we have both our internal data collection processes and our
> external processes aligned with that.
>
> On page 43 is an example of whether my board decides whether I've done
> a good job or not, where we have the goals of organizational
> performance and I'm holding myself accountable for what we're actually
> able to achieve, and my board goes through that with me each year ...
> corrections. So I would like to see more community collaboratives have
> their performance management system tied to return on community
> investments.
>
> I think that's probably---the other exercises, the end of section
> three---just help you think about it in a more promotional type of
> way, how you're going to communicate performance and how you're going
> to communicate it to the media and celebrate your successes and how
> you're going to recognize your partners. So I think that's the end of
> my walking through the workbook. I'd be interested in people's
> questions or comments and suggestions.

Randall This is Randall. I have one. Do you, when you're talking to the
press, talk in terms of return on social investment? Do you use those
phrases with them, or do you not?

Kristen It depends on the reporter, for me, and the newspaper. If it's a
more business-focused newspaper, then I try to use my business terms. If
it's a story showing the great things we've done in the community, I
tend to use more ... human interest angle.

Randall Right. Because I do think it's important to sort of, as you said
earlier, figure out ways to start using this language. I've used it
twice in public meetings, sort of generically, and then when asked tried
to be more specific. But I'm not convinced that, although I think it's
really important and it's the way for agencies to look at it, I'm not
convinced that if you're the only one talking in those terms it's the
way to go, just because they get the message but they think they're
missing something.

Kristen Yes, I would agree with that. I think maybe you're hitting my
point ...when I said about I don't think we've really figured out how to
... return on community investment well enough where it looks like
anything other than promotion for ourselves.

Randall Right. One of the reporters there was for a once a week sort of
advocacy paper, and I think she tried, but I probably won't be using
some of those terms again, just because I did think it---unless, maybe
you're right, maybe the thing to do is just go talk to the reporters.
Anchorage is small enough, there are not that many reporters who cover
these beats, but I could try to do that. Maybe I'll think about that.

Kristen Yes. If you find that you're able to talk about it in a way that
seems like it's starting to resonate, let me know, because I would love
to hear about those.

Randall Okay.

Kathy This is Kathy Yarborough in California. One of the things that
I---I don't necessarily use the words "return on community investment,"
but what I tell them is that what they're doing is investing in the
community and that their activities and their participation is going to
improve, not only the health of the community but the economy of the
community. I tie them both together. So we have business people,
hospital people, the papers at our meetings, and they all need to know
that this one ... will not ... individual ... That's what I do.

Kristen That sounds like a good way to talk about it.

Eric This is Eric. Again, it strikes me the universal need to be able to
capture or describe the value of collaborative workaround health in
order to recruit, retain partners and in order to do that broader
community outreach, like you all were just describing. When I look at
this workbook, I don't see it as something that you need to use the
terms just as they're offered or you have to do the protocols just as
they're presented, but this is a way, as I see it, to put together
examples of real achievements by real peer communities and sort of the
thoughtful formulas or processes or recipes that have been applied in
the real world to help you get to one that works for you and your
partners.

> What we hope is that this will help every one of you all either get
> further in making your own value analyses and securing those stronger
> relationships, and long-term relationships, or if you haven't started
> yet, which I'm afraid is quite often the case, where partners are not
> in the process of actually quantifying and qualifying the value of
> what they're doing or what they could do to get to the next level,
> then hopefully this gives you some landmarks to navigate by, some
> confidence, and some peers that have been named that you can contact
> to get more information or get more encouragement to set about this
> process. So I guess my basic point is, don't see this as immutable,
> just see this as suggestions, guidelines and so forth that have been
> tested in somebody's real world.

Kathy I have a question---this is Kathy in California---Kristen, with
your company that you call Choice, are you selling your services now?

Kristen Well, we're always selling our services, but do you mean do we
have a service line that we charge ...?

Kathy Right, when you go into a community to do your community based
planning, how do you come about charging them?

Kristen Well, we're a membership organization of hospitals, physicians
and public health, and they pay, based on the size of their annual
budget, they pay membership dues to the organization.

Kathy So everything you do is included in those dues?

Kristen Yes. But we also then go out and get grants for---so for
instance, they'll come together and say---this is a recent
example---Kristen, we're having a terrible time with medical
interpreting, can you guys do anything about that? But we obviously
can't do that within our existing services, within the dues that they
paid us, but then we'll say, well, what is it that needs to be done, ...
people, decide on a desired strategy, and then we go out and we find the
funds to develop a language access system.

Kathy What if somebody comes to you that isn't part of your partners and
they want to do something with a partner? That's what I have going. I
have partners within our network, but then I've got other people that
now want to partner with the partners that aren't part of the network,
so we're having problems with how to do that.

Kristen We found that our strength is in our not expanding our
geographic area, it's in the relationships that we have within our
geographic area. So it depends on if my organization needs money or not,
frankly. If it does, which it often does, I will charge a reduced
consulting rate to go out and help that community get started to create
an organization like my organization.

Kathy What do you charge when you do that?

Kristen I charge \$75 an hour.

Kathy All right, so it is reduced. So if you go for a whole day you
charge \$75 for travel, for the hours that you're gone?

Kristen Yes. If a community wants to replicate one of our programs, like
our outreach and enrollment programs, we charge \$80,000 to go into a
community and replicate that.

Kathy Okay. How much?

Kristen It's 80,000.

Kathy That's an interesting number, because that's just about what I
came up with too. I came up with like 65 to replicate our program for
non-members, when you looked at the hours and the time and the mailings.

Kristen Yes.

Kathy Okay.

Kristen I try to not have it be exploited in terms of charging ...

Kathy It's a good price.

Kristen ...charging more, but then also to recoup some of the
development costs of our initial investors.

Kathy Right.

Pat This is Pat. One of the lessons learned in the work that I did as a
network director is the balance between developing a management service
organization and providing out of member services and staying in line
with your network mission. My only, well a very large lesson, I should
say, that I learned, was to make sure that those two were in sync. Every
time that they were, whether it was 80,000 or 800,000, it worked. When
we stepped out of our area and went into another direction just for the
sake of bringing money into the organization, quite frankly, it didn't
work.

Kathy I agree with you, because we're stretched already and we have a
hard time charging, so the services we give away free.

Pat Yes. That's so true.

Kristen Which is why I said that I sell my consulting time, I try not to
bring it into my organization. It's mainly something I'll do on evenings
or weekends or just to bring some extra revenue in. But I've seen a lot
of ... community collaboratives collapse for just the reason that you
talked about, Pat.

Pat Yes. But you know what, it works if you stay true to your mission.
I've seen it over and over again. Do you know what I mean when I say
that?

Kathy Yes.

Pat Okay.

Maureen Kristen, this is Maureen over at Schneider in Minnesota. Thank
you very much for walking us through things. I picked up some good
language and some other thoughts as a result of what you were telling
us.

> One thing that has bothered me consistently is that we have been
> working with some of our collaborative partners for in excess of 12
> years, and they have very often come to rely on us for the technical
> assistance that they couldn't afford and couldn't get anywhere else,
> and so, I too face a question about how do I break the news to them
> that these things will now be charged for. One benefit that we've had
> recently is that a couple of our partners are very active in our
> state's county lobbying association, the Association of Minnesota
> Counties, and next week I will have an opportunity to talk with the
> AMC about our project, and some of the sound bites that I got from
> you, Kristen, today, are definitely going into my remarks, so my time
> on the telephone has been more than worth it. Thank you again.

Kristen Oh, great. I'm glad to hear that, because I wasn't quite sure
how the structure would work with the ...

Maureen It's been very helpful to me. I wrote faster than I could think.

Kathy So how do we order this book now?

Pat I'll jump in there. This is Pat from the Georgia Health Policy
Center. You can actually order the book for \$65 by contacting Tia at
our office. Let me give you her number, it's 404-651-3147. What we do is
we purchase these books from the Communities Joined in Action and then
just charge their printing costs plus shipping and handling, so the
price is really kept low.

Kathy Thanks.

Maureen Pat, you said \$55?

Pat No, \$65.

Maureen I'm sorry. Thank you.

Katherine The phone number was 3137; 3147 is the fax number.

Pat Thank you, Katherine.

Kathy What is the number, 31 what?

Pat It's 404-651-3137 is the phone and 3147 is the fax.

Kathy All right.

Eric Pat, this is Eric. I had a manual and people wanted it and they got
it, so I'm going to order two more from you.

Pat Okay.

Eric So I'll talk with you about that.

Pat Great.

Eric For those of you all on the phone, and we'll have a mix of
community coalition that are earlier in their process and those that are
further along, I hope there's no one there that fails to see the
criticality of planning for sustainability and how the ROCI type
activities can support that. It's for every phase; contemplating a
coalition, consolidating the early stages, and happily ever after work.
What about what you see in this workbook and what it helps prompt you to
do, whether you use it exactly or adapt it, is there anything else that
you're looking for or hoping to get that would help you get down to the
real work of building those value propositions for partners and for the
community? Is there anything else that you see that you, right now,
would like to have as part of what you can run on to work effectively
for building those return on investment statements?

Kathy This is Kathy in California. I know this sounds rather sarcastic,
but better leadership in some of these hospitals. We can go in and work
with a community, but if we don't have the leadership skills as
necessary in the leadership of the hospital, sometimes it's very
difficult to commingle our work. I work on that and try to deal with
that on a regular basis with what I'm doing.

Eric I think that's an excellent point. Towards that end, I will say
that one of the effective adjuncts to this type of dialogue with
hospitals to try to get them to buy in because they see enough value in
it for them to do so, has been to get hospital leadership, CEOs, CFOs,
from another coalition where they've already bought into it and they see
the evidence that it's good business and have them speak to their
colleague in your community, whoever you may be. I think part of what
this technical assistance out of Georgia Health policy, or if you were
to work with the network, say, Communities Joined in Action or whatever,
part of what can be done is to help surface those type of hospital peers
that might be willing to have that conversation should you want to with
your own. That's been famously successful in the physician volunteer
movement across the country, where physician colleagues talk to each
other and can say: we had these same questions and concerns, we're now
two years into it and we can tell you that it can be very good for your
practice. There are a growing number of hospitals among this national
network of communities that are starting to see a favorable experience,
who, I think, would also offer those testimonials. So let us know if you
have a specific request to try to name names.

Kathy That's a good idea. Thank you.

Eric The second thing I wanted to say is that, as you may know,
Communities Joined in Action has an annual meeting in partnership with
an organization called ACHI---what is that now?

Pat The Association for Community Health Improvement, I think.

Eric Because I know there's an ACHI in Arkansas and I always blur the
words together. This is a contemporary iteration of the community care
network out of the American Hospital Association. Are you all familiar
with that?

Pat Yes.

Eric So their ACHI national program is about improving community health
through collaborative work. It's not just about hospitals, but certainly
includes a particular liaison with hospitals. So CJA, in the upcoming
joint annual meeting with ACHI, which will be---Kristen, can you remind
me? It's in 2005.

Kristen I know and I'm forgetting too. I think it's like February, but
anyway.

Eric It's considering how we can take advantage of that mingling of
hospital representation, who comes in, along with those more like us,
and try to see through the formal agenda or through some adjunctive
dialogue during those couple of days, that we can try to get more of
that sense among the hospital industry that we're not asking them to get
beyond their mission, we're not asking them to get beyond their means,
but we're asking them to open up to finding that relationship and to
surface what sort of value documentation they need for them to invest
their services, broker a connection to their specialist, or offer cash
back to the coalition as a portion of the prevention dividend that they
realized. So Kathy, I think you're right on, and we're trying to find
smart ways to get more of the hospital industry to open up to our
collaborative efforts.

Kristen Do you know what practical thing that I did Kathy in the early
days, because we had some really small rural hospitals and the
leadership is just really not there, is that for a couple of years we'd
bring the CFOs together, and there would be a meeting of the CFOs so
that they could problem solve with each other.

Kathy That's a good idea too.

Kristen And then we did it with the COOs, like right now there's
hospital throughput issues, and we really didn't have to do anything
other than convene the meeting, and the peer support, it looks like they
were kind of looking for sharing ideas with each other.

Kathy That's a great idea. I hadn't thought about that. ... To talk
about a positive, there's one of these community health projects in a
community called ... and it was very successful. They ended up voting a
\$50 million obligation bond in the community by 72%. What the
architectural firm is doing is using our business plans that the
community advisory committee put together in putting to work and putting
to life what the community thought was necessary in a health complex.

Kristen Congratulations!

Pat Yes, that's fantastic.

Kathy It is. People from the community are sitting on the planning
committee as they plan---we don't call it a hospital anymore, we call it
a health complex.

Kristen Wonderful!

Kathy My husband actually works at the architectural firm, and he told
me yesterday they had their very first meeting and it went absolutely
wonderful. He said it probably cut the planning time, he says, probably
in half, because everything is going so well.

Kristen My bet is that there was a lot of communication worked on prior
to that.

Kathy Oh, yes. We met for sixteen months.

Kristen There you go.

Kathy Sixteen months and then they passed this bond, and one of the
things that you spoke to was using individuals in the community to sell
it, that's what we did. This community advisory committee, which is our
community planning committee, has now been made an official planning
committee under the board.

Kristen Fantastic!

Kathy So there have been lots of good things that have come out of it. I
firmly believe in involving the community, and giving the community to
understand the importance of their participation in their health. I
think rural hospitals have a wonderful opportunity to switch from
illness care to wellness care. Most of the sick people don't go to their
hospitals anyway.

Kristen Right. That's a great story. Have you guys written that up?

Kathy No. We just finished it. I just finished it and I've got---it's me
and a half-time secretary---I'm making excuses now, and I've got six of
these projects going right now in California in the rural areas. It
takes me 14 hours to get to one place, just to drive there.

Pat Is that Kathy Yarborough speaking?

Kathy Yes.

Pat Congratulations again!

Kathy Thank you. It's been fun, but it is a lot of work and getting
people to truly understand the importance of participating is a trial.
But it can happen. I should write it up. I should have written up many
things.

Pat I'm sure.

Kathy This has been wonderful. I wish your annual meeting were sooner.

Kristen Eric, any thoughts?

Eric About moving the annual meeting sooner, no.

Kathy No. I was teasing. I was only kidding.

Eric I'm just kidding. My thoughts are simply that I hope everyone
that's on the call is thinking seriously and already has engaged a
process by which to build these value equations, whatever you want to
call it, and run on that. If you're still hesitant or you still don't
feel like you have enough tangible process to go by or you still think
you need other critical ingredients, please talk with your technical
assistance team leader or whoever it is that you have confidence in, and
just see how we can get you going. It's like any other business prospect
or any prevention, I guess, the sooner you start in earnest, the more
time you have to achieve your objective, in this case sustainability
through demonstrating the value of what you do to the point where
partners in the broader community will be sure to keep you viable.

> I think Kristen's methods also are profound among all of her messages,
> where her partners pay each year, year after year, with the
> expectation of a certain scope of benefits, but they also see that
> that's the place to go with some ad hoc sort of opportunities or
> concerns, knowing that the coalition can not only continue to serve in
> its traditional way, but it's seen as a place to come to bring new
> projects or initiatives with the confidence that the coalition can
> work out how to deal with those and if it requires an incremental
> investment that the partners will trust that there will be a
> justification for doing that.
>
> So please engage and make sure that you do something, if it's not ROCI
> by that name, whatever it is that helps you have strong partners,
> continue to grow and be part of your community for the long term.
> Everything that we're doing in this complex issue is a journey. None
> of this is a single project and to really achieve what we want to do
> we have to have the long view.
>
> If any of you all are interested in any of the processes we're talking
> about, if you want to feed back on further enhancements of the ROCI
> workbook, if you'd like to learn more about the planning of the annual
> meeting agenda, or if you have any suggestions for future TA calls,
> and I guess, Pat that's what you're about to say...

Pat Yes.

Eric ... please let us know how we can help you get to the outcome of a
strong, viable sustainable coalition. Pat.

Pat Thank you, Eric. Kristen, once again thank you so much for all the
preparation that you did for this call, I know you were the primary
author on the ROCI workbook. Thank you, Eric, for facilitating this. I
think this was certainly one of the best calls that we've had.

Michele, do you have any closing comments?

Michele No. I don't. ... last year or earlier this year when we had our
grant team meeting ... we had it in conjunction with the ROCI. All the
feedback that I received was just wonderful. Everyone seemed to love the
conference and they really appreciated the fact that they were able to
attend. I'm hoping that we'll be able to do that again next year.

Pat Yes, that sounds wonderful. In closing, thank you all for joining
the call. Again, you can receive the workbook by calling Tia at the
Health Policy Center at 404-651-3137. Our next Technical Assistance call
is October 27^th^ and the team will be getting together to look at
topics. But Kristen, based on some of your comments, I jotted down some
ideas for future topics, and Kathy, I think it was from you, looking at
hospital leadership development common data sources and data sets, a
national directory of best practices, and developing a common logic
model. So I think if we just looked at those we have an agenda, at least
for a year.

W Sounds great.

Pat Okay. Thank you, everyone. Any last thoughts? Okay. We'll talk to
you all in October, if not before. Thank you.

W Bye.