THE DYNAMICS OF SUSTAINABILITY:

A Primer for Rural 

Health Organizations

U.S. Department of Health and Human Services

Health Resources and Services Administration

February 2012
This document was developed for the U.S. Department of Health and Human Services, 

Health Resources and Services Administration’s Office of Rural Health Policy by the Georgia Health 

Policy Center, Andrew Young School of Policy Studies, Georgia State University 

under contract HHSH250H8042.
INTRODUCTION

Embarking on new health projects and network building activities can be 

exciting, hopeful and perhaps a bit hectic. Your team is likely focused on 

establishing your work plan and preparing for initial activities. 

In the early phase of your program, it may be challenging to envision what 

your situation will look like in the longer term. Perhaps you have been funded 

to implement a public health demonstration program in your community or 

have a grant to build a more efficient way to deliver services in a rural area. 

Whatever the circumstances, the experiences of other rural communities 

demonstrate that valuable programs and collaborations can be sustained 

long-term with foresight and effective planning.

The goal of this primer is to provide a head start on planning for sustainability 

for organizations and collaborations that are starting a new program. 

The primer contains information and opportunities for reflection and 

discussion appropriate for consideration at the initial stage of program 

implementation. It is not a complete, comprehensive to-do manual for 

sustainability planning; rather this is a “starter guide” to use on your own 

or with your partners as part of your initial project planning activities.

The Development of this Primer

The information about sustainability and the case studies included here were 

collected through a study of rural health organizations that received funding 

from the Health Resources and Services Administration’s (HRSA) Office of 

Rural Health Policy (ORHP) to implement new programs or build new 

collaborations in their communities. This historical analysis, conducted 

under contract by the Georgia Health Policy Center, was completed in 2010 

and consisted of in-depth interviews with 102 Rural Health Care Services 

Outreach (Outreach) and Rural Health Network Development (Network 

Development) grantees funded in 2000, 2002 and 2004. The study sought 

to explore why some communities were able to achieve sustainable impact 

and others were not. 

In addition to the findings from the historical analysis, a cross section of more 

recently funded ORHP grantees were asked to reflect on their experiences in 

starting up new programs and collaborations in their rural communities. 

These individuals discussed their understanding of sustainability and how 

organizations and collaborations similar to their own might be motivated to 

focus on sustainability as part of their work plans. Their input guided the 

format and content of this primer. 
Table of Contents

Why Plan for Sustainability?............................................................................... 1

Stories of Sustainability...................................................................................... 9

Story 1: Training Medical Directors of Emergency Medical Services.................. 11

Story 2: Network of Health and Human Services.............................................. 13

Story 3: Health Care Services in a Remote Community........................................ 16

Story 4: Referral System to Improve Access....................................................... 18

Story 5: Health Care to the Uninsured/Underinsured......................................... 20

Story 6: Rural Health Services to Children........................................................... 22

The Dynamics of Sustainability........................................................................... 24

The WHO Dynamic.......................................................................................... 24

The WHAT Dynamic........................................................................................ 27

The WHY Dynamic.......................................................................................... 30

The HOW Dynamic......................................................................................... 33 

An Initial Assessment of Your Potential for Sustainability.................................. 36
 WHY PLAN FOR 

 SUSTAINABILITY?

The best evidence to demonstrate 

the need to plan for sustainability 

comes from the advice of organizations and collaborations that have 

received grants from the Health Resources and Services Administration’s 

(HRSA) Office of Rural Health Policy 

(ORHP). The following are responses 

from grantees from across the U.S. 

when posed the question, “Why 

should newly funded ORHP grantees, 

or any organization beginning a new 

health program or collaboration, start 

planning for sustainability now?”

u “The 3-year grant period is over before you know it.”

u	“The first year is so focused on getting the project started, but you can’t

	 wait until the last year, or even the second year of the project funding

	 period to start thinking about the “picture of success” or who are

	 potential funders/sustainers.”

u	“If the reason/mission is important, then you will still have the need/desire

	 to see it continued.”

u	“You need to prove value while funded.”

u	“You don’t want to lose the momentum you’ve gained.”

u	“The purpose of a non-profit is to solve a problem...ultimately putting

	 yourself out of business; however, that rarely happens in 3 years or less.”

u	“Without sustainability: access to services ends; collaboration in the

	 community ends; money, resources, and time are wasted; your reputation

	 can be damaged. With sustainability: project continues; change is ongoing;

	 agency reputation improves; collaboration grows; other funding

	 opportunities emerge.”

In short, these grantees remind us that sustainability is essential to the 

continuation of an organization’s mission and purpose and that sustainability 

is neither accidental nor last-minute. Sustainability requires thoughtful, 

purposeful and timely planning. 

1
The 2010 study of past ORHP grantees provided numerous insights into how 

grantees are able to sustain their grant-funded programs and collaborations. 

Their experiences also demonstrate that the impact of the programs funded 

by ORHP at times went beyond the services that were funded. In these 

communities, even in cases where the grant-funded services or activities did 

not continue beyond the grant period, there were still long-term effects of 

those funded initiatives that were positive and impactful. 

The Sustainability of Programs and Services

Over the past decade, sustainability has been a focus for many government 

agencies and foundations that fund community-based programs and nonprofit organizations. Increasingly, funders want to know how organizations and 

collaborations plan to sustain programs or services beyond the grant period. 

There are multiple definitions of sustainability used by funders, researchers 

and community-based organizations. For the purposes of this primer, 

sustainability is defined as:

Programs or services continue because they are valued

and draw support and resources.

Sustainability does not necessarily mean that the activities or program continue in the same form as originally conceived, funded or implemented. 

Programs often evolve over time to adjust to the changing levels of support 

and needs of the community. Organizations may start with one approach, 

but end up sustaining a different model of service provision after testing it 

in the community. For example:

u	 A grant may provide “start-up” funds to establish services that are

	 expanded post-grant period;

A community in the Pacific Northwest used a 3-year grant to expand 

access to primary care services while they worked with community partners 

to become a designated Federally Qualified Health Center (FQHC) with 

long-term funding dedicated to sustaining increased access to health care.

2
u	 An initial investment may fund a model or pilot program from which

	 a new program approach evolves;

A non-profit agency in the Midwest used grant funding to develop and test 

a new community health worker model that eventually evolved into the 

centerpiece strategy for the organization’s community outreach work. 

During the grant period, the community health worker program focused on 

diabetes, providing education and referrals to treatment. During this time, 

the program staff recognized that most of their clients did not know how to 

access the health care system or understand what resources were available 

to them to help manage and treat their diabetes. Following the grant, 

the non-profit changed its community health worker program to focus 

on patient navigation for people with chronic disease.

u	 Some grant-funded programs may be sustained, but the services provided

	 or the coverage area are scaled back to reflect a reduction in resources

	 to support the program.

A program that formerly served nine counties may reduce their coverage 

area to two counties. A program that was formerly universally available in 

a community may be limited to those who meet certain risk factors or other 

eligibility criteria. Agencies will often be forced to prioritize which program 

components or activities to continue beyond the grant period, reducing the 

scope of their program to match available resources. 

3
 

The Sustained Impact of Programs

Most definitions of sustainability, 

including the one presented on 

page 2, focus on the continuity of a 

service or program. This perspective, 

focusing solely on the sustainability 

of programs and services, may 

understate the full range of impacts 

that a program may have; and it does 

not explicitly describe the potential 

for lasting effects in the community 

that are distinct from a service 

continuing. There are multiple ways 

that an initiative can impact a 

community long after services have 

been discontinued. You should begin 

thinking about the potential 

sustained impact of your program. 

Sustained impact is defined as those 

long-term effects that may or may 

not be dependent on the continuation of a program.

These long-term effects may go 

beyond the services that are put into 

place. The impacts could include 

changes in the way that agencies 

work together to serve community 

members, cultural shifts and practice 

changes, changes in knowledge, 

attitudes and practices of community 

members and providers, and policy 

changes, as described below.

On-going impacts 

of collaboration

Improved 

service 

models

Increased capacity 

in local systems

New policies 

to sustain impact

Changes in 

knowledge, attitudes 

and behaviors The Sustained 

Impact of 

Programs

4
On-going impacts of collaboration:

Through the implementation of a new 

project, agencies can develop a new way 

of working together to serve community 

members; new lines of communications are 

established, interagency referral mechanisms 

are built and the culture of collaboration in 

communities may be changed. Agencies 

working together on a new initiative may 

move beyond turfism and competition to 

build a strong collaborative based on trust 

and open communication. 

Improved service models:

Agencies may develop and implement new 

practice standards that are institutionalized 

following the end of a grant period. For example, 

new programs may result in a new model for 

caring for those with chronic diseases, or training 

and employing community health workers to help 

patients better navigate services and effectively 

manage their illnesses. The opportunity to test 

a new model with grant funding often lays the 

foundation for long-term strategies to meet the 

health care and educational needs of communities.

On-going impacts 

of collaboration

As a result of a grant to serve 

at-risk families, a community 

action agency built a referral 

process with hospital discharge 

planners that has sustained 

well beyond the grant period. 

One of the staff members said 

“The grant allowed us the 

opportunity to develop such 

a strong partnership with 

the discharge planners at the 

hospital that, even now, if they 

have a child who is leaving the 

hospital and they think that 

the family may need some intervention, they will contact us and we 

will visit with that family.” 

Improved service models

A rural community received grant 

funds to train medical interpreters 

to work in the local hospital. 

Prior to the program, patients 

were using family members, often 

young children, as interpreters, 

which was a significant liability 

issue for the hospital. This program 

coincided with the Joint 

Commission for Accreditation’s 

new attention to cultural 

competency in care provision. 

When the grant ended, the hospital 

administration recognized the i

mportance of the presence of 

trained interpreters. The hospital 

now requires certification of 

medical interpreters and continues 

to fund their positions. 

5
 THE CASE FOR 

Increased capacity in local systems:

Grant funds can be used to build the 

capacity of the local health and human 

service infrastructure (e.g., establishing an 

HIT infrastructure), develop curricula (e.g., 

a diabetes self management training 

program that can be used by nurses or 

community health workers, or a physical 

activity program that can be used by math 

and science teachers in the classroom), 

and purchase equipment (medical and 

screening). These resources, once created 

or purchased, remain in the community 

and have lasting impact.

Changes in knowledge, 

attitudes and behaviors: 

Finally, a community may see impacts that 

are beyond services and infrastructure. 

As a result of an outreach program, public 

awareness of a health issue may increase, 

and cultural attitudes about certain health 

behaviors or illnesses may shift. Providers 

who received training through a program 

may approach their practice in a new way 

and recognize health issues in their patients 

that they were not aware of previously. 

Community outreach programs may begin to 

change the way that a community perceives 

and responds to a particular health issue. 

For example, a program to integrate mental 

health services into the primary care setting 

may help reduce the stigma associated with 

accessing mental health services and may 

change the perceptions and practices 

of primary care doctors as they relate to 

mental illness.

Increased capacity in local systems

One community was funded to start 

a wellness center in a county where 

residents had no place to exercise. 

They used grant funds to purchase 

exercise equipment that was placed 

in a rented space. When the grant 

ended and no new funds were 

identified to keep the wellness 

center open, the hospital agreed 

to house the exercise equipment 

and allow community members 

to use the equipment there.

Changes in knowledge, 

attitudes and behaviors

A consortium worked to raise 

awareness among local primary care 

providers of the high prevalence of 

sleep disorders in the community. 

Providers in this community had 

been largely unaware of the impact 

of sleep disorders on patients’ health 

and wellness. As a result of the education and training funded through 

the initial grant, providers now look 

for, diagnose and treat their patients 

for sleep disorders.

6
New policies to sustain impact: 

An organization or collaboration may engage 

in local- or State-level advocacy to effect 

change in a policy that supports the services 

provided through their programs. Those 

policy changes (e.g., a change in Medicaid 

reimbursement, the establishment of a hospital 

taxing district) have an enduring impact on the 

way that services are delivered and financed.

New policies to sustain impact

A rural health network established

transportation services to take

children from school to medical

appointments. During the first year

of the grant, partners appealed to

the State Medicaid office to change

its policy to provide reimbursement

for transportation services. Within

three years, the necessary changes

had been made to State Medicaid

policy. The network now employs a

van driver and maintains the van

for transporting children to their

medical appointments.

Planning for sustainability requires long-term commitment to a process that 

starts at the beginning of grant funding and continues throughout the life of 

your program and partnerships. The stories presented in this primer will 

highlight some of the ways that rural community-based organizations have 

successfully sustained services and created long-term impact resulting from 

their programs. You will also read some cautionary tales from communities 

that will help you reflect on ways that you can better position your program 

and partnerships to be sustainable and impactful over the long term.

The ORHP-funded rural community-based organizations shared their 

thoughts about sustaining grant-funded programs and creating long-term 

positive impact: 

• Provide a program or collaboration that makes a measurable impact.

Programs or collaborations without evidence of measurable impact are 

very difficult to sustain. One of the best ways to increase likelihood of 

sustainability is to produce positive outcomes (e.g., changes in health 

status, health behaviors, utilization of services), not just outputs (e.g., 

number of classes held, number of pamphlets distributed, number of 

meetings attended). Evidence is key to engaging influential partners, 

communicating your story, and justifying the need to potential 

future funders.

7
• Get past the belief that “more money will come when we need it.”

It is a mistake to assume that some future grant or benefactor will show

	 up at your door in 3 years and want to continue funding your program,

	 even if you do provide an effective program or collaboration. It seldom

	 happens that way. The tasks of finding the right opportunities, building

	 relationships, and communicating the value of your program or

	 collaboration require time, effort and planning.

• Create shared ownership for sustainability.

	 Planning for sustainability is most effective when partners and key

	 stakeholders are engaged early and often. The collective perspective is

	 useful in helping maintain the long-term focus. Additionally, when people

	 participate in the planning and implementation process, they develop

	 a greater level of commitment to the effort.

8
 STORIES OF 

 SUSTAINABILITY

Each story in this section recounts the experiences of an actual ORHP-funded 

grantee. While the outcome of each story is different, this collection of stories 

represents some of the most common experiences of grantees. 

These stories can help you and your partners envision the possible experiences and outcomes for your program or collaboration. Having the ability to 

predict possible outcomes will make it easier to discuss how your actions may 

have a positive or negative impact on your own long-term success.

The communities in these stories may be very different than your own, but 

the situations are relevant, since each describes partners in rural communities 

striving to complete successful and sustainable projects.

How to Use These Stories

Read each of the stories below and as you read, reflect on the following 

three questions as you learn about the communities’ experiences:

u What has been sustained?

u What was not sustained?

u What led to these results?

You will find that the answers to these questions will be different for each 

story. Examine the post-grant status of each program, and consider:

u Was a program or service sustained? If so, in what form? 

	 u Was it sustained at the same level, or was it expanded or 

reduced in scope? 

	 u Did the activity evolve over time?

The long-term impact of rural health programs may be broad. Think about 

the benefits beyond the continuation of programs and services. 

u As a result of these projects were there sustained impacts on the 

local health system that remained even if the grant-funded 

activities did not?

9
u Did a collaboration that was formed to implement a new program 

endure and go on to address other community needs?

u Did the grant facilitate the purchase of equipment or other materials 

that continue to be utilized in the community, or did local providers 

 receive training that increased their capacity to serve their patients?

u Did the organization and their partners work to effect policy changes 

that remain in place? 

u What about changes in knowledge, attitudes or practices of 

community members or health professionals? 

The factors contributing to sustainability are numerous. Look for dynamics 

that might have contributed to the sustainability, or lack thereof, of the 

program, the collaborative, or the sustained impact. 

u Was there something about the environment within which 

the program was implemented?

u Were there issues related to collaboration and partnerships? 

u How did the capacity and influence of program leadership 

impact outcomes?

u Was there something about the program design that might have 

made it more, or less, likely to sustain beyond the ORHP grant period?

Use the stories to reflect on the current situation and the future possibilities 

for your own program or collaboration. Through comparison and reflection, 

you will start your discussions with a greater understanding of sustainability 

and sustained impact. 

10
Story 1: 

Training Medical Directors 

of Emergency Systems

A community non-profit organization in the Mountain West was funded to 

develop a Web-based training program for medical directors of Emergency 

Medical Services (EMS). The training, which is required by the National 

Highway Traffic Safety Administration, had previously only been offered to 

medical directors through courses that required providers to travel outside 

their communities to attend the training. The grant agency and consortium 

partners were focused on building a cost-effective way of training EMS medical 

directors from rural areas. By developing an accredited Web-based training, 

doctors located in rural areas no longer had to leave their jobs and travel long 

distances to complete the course at a training center. 

A consortium was formed, and each partner had a defined role in the 

development and implementation of the program. The grantee agency took 

the lead in developing the training course. Members of the consortium, 

which included national associations for emergency medical services as well as 

local clinical providers, provided technical input on the content of the training, 

as well as guidance on the design of the modules. One partner provided the 

facilities for the hosting of the Web-based training. 

The program has been sustained through course fees paid by individual 

providers or States. The training program is accredited by the National 

Association of Emergency Medical Services Physicians, and physicians can

receive continuing education credits for taking the one-day course. 

The program is offered for both individual EMS Medical Directors as well as for 

States wanting to provide additional training for their EMS Medical Directors. 

The course is currently used by providers in 12 States. In addition, the agency 

has built 2 additional modules into the training program: one for pediatric 

medical directors and the other for geriatric medical directors.

11
Discussion

The grantee agency and the partners began this project with a clear 

understanding of a discrete need and a focused plan to address that need. 

This grantee viewed the ORHP grant funds as “seed money” to fund the 

design and startup of a new program. Such grantees start their new projects 

with a clear idea of how the program would be sustained in the long term. 

This grantee developed the Web-based approach to training as a marketable 

product with an identified consumer base (EMS Medical Directors and States) 

and has been able to sustain the program through user fees. 

For this particular consortium, the partners each provided specific technical 

input into the development and maintenance of the modules. Because the 

scope of this program was narrowly focused, the roles and responsibilities 

of the partners were similarly focused. The partners were engaged in this 

project because of their technical or clinical expertise, and each had a specific 

role to fill and tasks to complete. 

12
Story 2: 

Network of Health and 

Human Service Agencies

A community health center in the Northeast served as the fiscal agent for a 

young rural health network that was seeking to formalize its structure and 

further develop the network’s programs and services. The network was comprised of virtually all of the health and human service agencies in the region, 

with agencies representing 12 municipalities in the State. The partners had 

been meeting as a coalition prior to receiving Network Development 

funding. The grantee described the focus of the Network Development grant 

in this way: “We had been meeting together and were working as a coalition 

but did not have any formal structure at that point. The major thrust of the 

grant was to develop a formal structure and policies and procedures for the 

Board and various subcommittees, and to do the work to have the written 

agreements necessary for the type of data sharing, resource sharing and 

program planning that they were going to be doing together. We needed 

to make things more formal.” 

Grant funds were used to develop three areas of the network: the creation 

of cross- agency teams of care coordinators and case managers to provide 

a venue for data sharing, patient tracking and referral across agencies and 

to provide support for individuals doing case management and care coordination; the development of a standardized format for patient data collection 

and tracking to allow for the sharing of patient information across agencies; 

and the formalization of a process for conducting regular regional needs 

assessments that could be used by all health and human services agencies. 

The network and all of the program components funded through the Network 

Development grant have been sustained and expanded following the end 

of the ORHP grant period. The grantee stated that the cross-agency case 

coordination and case management has become “one of the hallmarks” of 

the network and still works extremely well. The approach to cross-agency 

coordination formalized under the Network Development grant “has changed

13
the way agencies work [in our community] in a dramatic way.” With additional 

Federal funding the patient information-sharing database has been developed 

into a regional system that does one-time benefits eligibility determination 

and patient referral, and permits participating agencies to share information 

on patients. Coordinated needs assessments are conducted every 3 years. 

Agencies in the region went from conducting 17 different needs assessments 

to conducting one comprehensive health/public health assessment for the 

region. There is no outside source of funding to conduct the regional 

assessment; rather, this effort is completed with in-kind participation from 

network member agencies. By using this cooperative method of conducting 

the assessment, networking agencies obtain the data they need to secure 

major grants for the region. 

When asked to describe the reason that the network has been able to sustain 

and expand following the ORHP grant, the grantee described what was 

crucial to the network’s success: “We established relationships between 

people first. Then we established the relationships between the agencies. 

And that is all about trust and communication . You then formalize that 

[relationship] from one individual to the agency. We all agreed to agree, but 

the way that we got there in the early years was individual to individual at 

the CEO level, then individual to individual at the team level, then we 

formalized it all by putting in inter-agency agreements and having a designated 

representative and their alternate. So now every single agency writes it into 

the job description of the CEO that they represent that agency on the Board 

of the network.”

Discussion

In contrast to the project described in the first story which had a narrow 

focus on the development of a specific product, this network was designed 

to address issues at a community-wide level, and thus, required an active, 

diverse and engaged consortium that was committed to changing the way 

that agencies relate to each other and the way that services are delivered in 

the community. This grantee, and others like it, approached the grant program 

with a long-term strategic vision for their community. They had spent time 

prior to the grant period building a shared vision and assessing the needs in 

their community. The network saw the grant funding as a step in a larger 

process to effect long-term meaningful change in the community.

14
The difference in the scope of the program (narrowly focused in the first story 

versus a more systems-wide approach in this story) is reflected in the roles of 

the consortium partners and the nature of their engagement in the project 

over the longer term. The role of the network partners was not to provide 

focused technical input, but rather to use their position in the community to 

change the way that business was done. As such, this requires the engagement of agency leadership and their willingness to commit their organizations 

to being part of this change process over the long term. Their work is driven 

by regular needs assessments that give them a clear understanding of the 

issues to be addressed. As a result of the energy spent on developing a strong 

and engaged network with a high level of trust among members, the members 

have taken on a significant amount of the work as “in-kind” and made it part 

of their agencies’ standard operations.

15
Story 3: 

Health Care Services in 

a Remote Community

A county fire district located in the Pacific Northwest received a grant to 

expand health care services in an isolated community that had no local 

source of health care. A consortium was formed consisting of the fire district, 

a citizens group formed with the objective of bringing health care to the 

community, and a community health center from the closest city. The impetus 

behind the consortium’s formation was a concern that local residents were 

putting off needed primary care until they became very ill and had to be 

transported 50 miles away by ambulance to the closest city for more 

expensive urgent care. 

During the grant period, the consortium established a primary care clinic in 

the local fire department, where there was a large amount of unused space 

available for rent. Grant funds were used to purchase equipment and 

supplies and hire a nurse practitioner to provide services to community 

members 3 days a week. In addition to primary care services offered 

at the clinic, a behavioral health clinician traveled to the clinic once a month 

to offer mental and behavioral health services.

Two years into the grant period, the citizens’ group formulated a business plan 

for sustaining the clinic beyond the ORHP grant period. They recognized that 

the community was too small to support a clinic through user fees and third 

party reimbursement, and they did not want to continue to depend on grants 

to support the clinic. The group decided to form a taxing hospital district 

for the community, a mechanism through which tax dollars are directed to 

a specific entity in the community. The citizens group took the idea to the 

community and advocated for its approval with voters. The majority of 

residents voted in support of the formation of the hospital taxing district, 

resulting in a portion of the taxes paid by residents being directed to the clinic. 

The clinic is now funded by taxpayer dollars and revenue generated by fees 

for services provided. 

16
Since the end of the ORHP grant period, the clinic has expanded to include a 

registered nurse and a WAVE laboratory with a half-time technician. The clinic 

has also expanded the number of tests offered. The clinic operates 3 days a 

week, providing basic primary care to three-quarters of the residents of 

the town. 

Discussion

This grantee identified a need for local healthcare services in the community 

and by utilizing existing space to open a clinic in the community, was able to 

minimize the overhead costs of the clinic. The consortium engaged in business 

planning relatively early and recognized that, in order to create a sustainable 

solution to this need, they would have to act at the policy level to secure 

sufficient funding for the clinic moving forward. This grantee engaged consortium partners who held influence in the local community and were able to 

advocate effectively for the taxing district with voters. Much like the 

consortium described in the first story (The EMS Training Program in the 

Mountain West), this consortium was brought together for a specific purpose 

and the members were chosen based on their commitment to expanding 

local access to care and their influence in the community. The clinic has been 

sustained because the consortium was strategic both in how they used 

existing resources to minimize overhead costs and in how they engaged key 

leaders in the community to advocate for policy change necessary to sustain 

the clinic over the long term.

17
Story 4: 

Referral System 

to Improve Access

A school district in a Plains State was funded to establish a rural health 

network to implement an identification and referral system among local 

agencies to improve access to health care for school-aged children and their 

families. The ORHP funds were used to conduct an assessment on how 

families in the area access health care services, the types of services families 

seek, barriers to services and unmet service needs. In addition to the needs 

assessment, grant funds were used to create a comprehensive resource library 

that included contacts for local services and educational materials for parents 

to use with their children. 

Following the end of the grant period, the resource library was sustained and 

expanded by one of the partner agencies. The library is supported by other 

grant funding as well as by institutional support of the agency that houses it. 

The needs assessment funded through the Network Development grant has 

not been repeated, but it provided “real data as to what was happening at the 

local level” that has been used to access new funding streams. 

The network itself was not sustained beyond the grant period, so a referral 

system for children and families never materialized. There was a significant 

change in the network partners during the grant period. The original board 

was comprised of agency leaders and decision-makers from each partner 

agency. They played an active role in advising the program staff on the 

direction of the work. Dissatisfaction among board members led to a 

reorganization that resulted in fewer network members with board 

representation from agency staff rather than organizational leadership. 

The board, which had started in a decision-making role that was active in 

directing the implementation of activities, moved more into an advisory role. 

The staff of the grantee agency took on the responsibility of planning for and 

carrying out the grant-funded activities. 

18
The change in the make-up of the board and its transition from a decisionmaking body to a less active advisory role prevented the young network 

from developing as an organization. There was a lack of understanding 

among many of the network partners and staff at the grantee agency about 

the purpose of a Network Development grant. Many did not recognize that 

the grant was about developing a network rather than providing direct 

services. They began to focus more on the project, instead of how to build 

their collaboration. At the end of the grant period the partners did not have 

a commitment to the network because they did not see a lot of value in it and 

could not see where to go next.

Discussion 

The experience of this grantee is not uncommon among groups who are 

seeking to build a new collaboration. There often exists a tension between 

those who are eager to get programs up and running in the community versus 

those who see the need to dedicate significant time and energy to developing 

a shared mission and building a more formal infrastructure to facilitate ongoing collaboration among key stakeholders in the health system. This story 

illustrates the importance of building a shared vision that includes broader 

goals (beyond program implementation) for developing long-term strategic 

partnerships to improve coordination and integration of services. If there is a 

lack of alignment among partners around a clear vision for a collaboration or 

network, the relationships will most likely collapse, even if some of the 

programs are sustained by individual agencies.

19
Story 5: 

Health Care to the 

Uninsured/Underinsured

An Area Health Education Center (AHEC) in the Pacific Northwest received a 

grant with the goal of providing expanded health care services to the uninsured/underinsured in a high poverty, geographically isolated community of 

about 5,000 residents. There is a high level of un-insurance, and most of the 

patients in the community who are insured are covered by Medicaid or 

Medicare. It is challenging for providers in the area to make a living because 

physicians and other clinical providers are reimbursed at levels well below 

what private insurers pay. 

Grant funds were used to provide subsidized primary care for the uninsured. 

Three local providers agreed to see uninsured patients at a reduced rate, and 

the cost of care was shared among patients, providers and the grantee agency. 

Patients seen by participating providers paid one-third of the service cost; 

grant funds covered one-third of the service cost (reimbursed to the provider 

through the grantee agency); and the participating providers donated the 

remaining one-third of the cost through the in-kind provision of care. During 

the grant period, 800 patients received care through the expansion of primary 

care services. 

Consortium partners included three local providers and representatives from 

the community. The AHEC convened the three local providers and their staff 

for monthly meetings to build stronger collaborative relationships among 

them. During the grant period, the practice staff members did establish 

better communication and, as a result, increased the sharing of information 

and transferring of medical records. One of the hoped-for long term 

outcomes of the grant program was that the physicians would come together 

to practice in a clinic setting and achieve efficiencies by sharing staff and 

equipment. This never materialized due to a lack of commitment from the 

providers after the grant funds ended since there was no longer a guarantee 

that they could cover the cost of providing care for the under- and uninsured. 

The program ended as soon as the grant period ended.

20
Discussion 

One of the most common reasons that programs do not sustain beyond the 

3-year ORHP grant period is the selection of a programmatic approach that is 

inherently unsustainable given the context within which it operates. 

In this case, grant funds were the only way to provide payment for services to 

the uninsured in this under-resourced community. This grantee did extremely 

important work during the 3-year grant period, and many people who would 

otherwise not be served received needed access to health care services. 

However, the effort was unsustainable because the participating physicians 

were unwilling or unable to continue to provide charity care after grant funds 

ran out, and there was no strong commitment to building a more permanent 

infrastructure for providing services to the underserved. This grantee and 

others who had similar experiences see grant funding as a way to address an 

acute need that would otherwise go unmet, but they face contextual barriers 

such as inhospitable reimbursement environments, State and local policies or 

cultural/political characteristics of a community that may render a particular 

intervention unsustainable over the long term.

That being said, there were multiple grantees who were able to rise above 

difficult contexts to build a sustainable approach to address an identified 

problem. Such communities demonstrated a clear understanding of the 

contextual barriers (local, State and national) that were at play and designed 

a comprehensive approach involving a series of multiple, integrated strategies 

to address complex problems. These communities almost always engaged in 

some policy-level work and sought to effect change at the systems level.

21
Story 6: 

Rural Health Services 

to Children

A school district in the Midwest received an Outreach grant to provide rural 

health services to children and families in need of basic mental, dental, and 

vision care. The consortium, made up of seven local health and human service 

agencies, did not exist prior to the grant period. ORHP funds were used to 

implement a range of community education and outreach activities as well 

as to support the provision of direct clinical and mental health services in the 

community. Nurses and program coordinators were hired and paid through 

the grant funds to provide health services. Other activities funded through 

the Outreach grant included: the creation of a rural health council, the 

provision of dental care for school children, the establishment of counseling 

services in a school-based setting, an inhaler clinic for middle school students, 

community education on suicide prevention, domestic violence prevention 

education for school children, health screening events in the community, 

and a traumatic head and neck injury program. The consortium partners saw 

multiple unmet needs for health care and prevention education and viewed 

the Outreach grant as a way to address them.

Toward the end of the ORHP funding period, the grant staff began to look for 

additional grant funding to support the various activities funded by the ORHP 

grant. They also briefly explored the possibility of Medicaid reimbursement 

for clinical services, but received no support from administration officials at 

the school district. The consortium had mixed success in sustaining the 

grant-funded activities following the end of the funding period. The dental 

program for school children has been sustained largely through the efforts 

of a dental hygienist who has applied for grants to pay for the program. 

The suicide prevention education program was taken over by a parent 

volunteer who is an expert in the field and offers educational sessions in 

the school system. The domestic violence education program was sustained 

when the local domestic violence coalition agreed to continue to provide

information about domestic violence prevention in the schools. 

22
At the end of the grant period, the employment of nurses and counselors 

hired with grant funds was discontinued due to lack of funding. As a result, 

the school-based counseling services, the head and neck injury program, 

the inhaler clinic and the health screening program were also discontinued. 

No other agencies were able to step in and provide these services. 

The consortium also disbanded at the end of the grant period. The grantee 

attributed the lack of sustainability of the consortium to the fact that they 

were unable to secure additional grant funding to support the programs, 

and the school system was unwilling to dedicate funding to the programs 

or collaborative. 

Discussion 

This consortium used the ORHP grant funds to attempt to address multiple 

needs in the community with interventions that were limited in scope and 

were not integrated across agencies in any way. For this grantee, and others, 

the grant funds were a short term solution that helped local health and 

human service agencies address multiple emergent issues. Little to no 

attention was paid to building a longer-term, more comprehensive approach. 

While it is understandable that a community would want to maximize the

infusion of resources by “spreading the wealth around,” the ultimate impact 

is a superficial approach for the short time of the grant and the inability to 

demonstrate value and impact, which are critical to sustainability.

On a positive note, because so many activities were put in place during the 

grant period, a few did “stick” and were sustained, often because of a personal 

commitment by a passionate individual in the community. The consortium, 

however, disbanded following the end of the grant period. This story 

illustrates the difference between a collaboration that sees a grant as one 

step in a longer term process versus a group that comes together to respond 

to a grant opportunity. The former is guided by a shared vision of community 

change, a strategic multi-pronged process that will unfold over many years. 

The latter is governed by a need to produce outputs that will fulfill 

grant requirements.

23
 THE DYNAMICS OF 

 SUSTAINABILITY

The qualitative analysis of the 

factors influencing the outcomes 

of the 102 former ORHP grantees 

revealed a broad range of influences 

that can be grouped into the following categories: WHO, WHAT, WHY, 

HOW. These are the dynamics over 

which you and your partners have 

influence. A description of each 

dynamic is provided along with 

a list of characteristics that were 

found to correspond with favorable 

outcomes regarding sustainability. 

This is not to indicate that all partners 

must demonstrate all characteristics 

to ensure sustainability. Rather, it appears that when these characteristics 

are present among the partners, the 

likelihood of sustainability increases.

 The WHO Dynamic

The WHO dynamic is related primarily to leadership – style, mindset, 

influence, and relationships. Having passionate leaders with a strategic 

mindset appears to have a favorable impact on sustainability. This contributes 

to the ability to get the “right” partners to the table and to establish rapport 

and a shared sense of responsibility among all parties required to implement 

a program effectively. At the most fundamental level, the WHO dynamic 

involves selecting the partners instrumental to program success. In this 

regard, collaborators ideally represent the operative agencies and 

organizations, have leverage to effect the change(s) needed, and are in 

a position to make commitments of time and resources to implement and 

sustain the efforts of the consortium or network over time. Strategic leaders 

appear better able to put day-to-day interactions and decisions into a broader 

context, seeing the relationship between short-term activities and their 

ultimate impact on long-term success. 

24
In other circumstances, however, the WHO dynamic may undermine 

sustainability. In many cases, conflict and/or ineffective communication 

prevent alignment around a common vision and significantly limit the 

likelihood for programmatic or organizational success. Further, a perceived 

need for control may isolate a lead agency, resulting in fewer options for 

sharing the resources as well as the programmatic responsibilities among 

key partners once a grant period has ended. 

Think back to the second case study of the network of health and human 

service agencies in the Northeast. In this community you can see the WHO 

Dynamic at work in a favorable way. The network built participation on the 

Board into the job descriptions of the member agency CEOs, ensuring that 

those who were able to make decisions and commitments of time, energy and 

resources are at the table. In addition, they spent a lot of time building trust 

among network partners and ensuring clear and consistent communication. 

As a result of the attention paid to openness and trust, those partner agencies 

have been willing to commit significant in-kind staff time and resources to the 

work of the network. 

You can also see where the WHO dynamic can create circumstances that may 

undermine a program’s long term sustainability. In Story 4 about the schoolbased referral system in a Plains state, the network members went from being 

a decision-making body to acting in more of an advisory role. They met for no 

other reason than to receive updates on program activities and had little to no 

role in planning for or carrying out activities. Because they were not involved 

in the work in any direct way, the network members did not have a strong 

commitment to the program. There was a lack of clarity about the purpose of 

network development and no shared vision for the collaboration over the long 

term. Because of this lack of shared commitment, the efforts dissolved soon 

after the grant ended. 

25
The assessment of former ORHP grantees provides evidence and examples 

of how this dynamic influences the long-term impact of a program in the 

community. An analysis of the stories from these rural communities offers 

examples of actions that an organization, a partnership or a community can 

take to position a new program for long-term sustainability. Those agencies or 

collaborations for which the WHO dynamic was a positive driving 

force for their programs demonstrated the following characteristics: 

3 They engaged people who are passionate, collaborative, 

and able to inspire and motivate others.

3 They adopted a strategic mindset. They were able to put day-to-day 

interactions and decisions into a broader context and take into account 

the impact of short-term activities and their ultimate impact on long-term 

success. These grantees did not limit their vision to the implementation of 

a three year grant, but rather saw the grant-funded activities as one step in 

a longer-term vision for change in their communities.

3 The partner agencies were represented by individuals who were in a position 

to make commitments of time and resources on behalf of their agencies.

3 They took the time to understand partners’ agendas and concerns on an 

ongoing basis. They were intentional about working through conflict, control, 

and competitive challenges because they recognized that both trust and 

collaboration among partners are critical to long-term success.

3 They were always aware of changing needs and circumstances that impact 

programs and organizations. Programs and relationships evolved to 

remain relevant and viable.

3 There was a culture among partners in which open, honest communication 

with and among partners was encouraged.

3 They worked with partners in a meaningful way, sharing responsibility for 

outcomes. They recognized that simply “reporting out” to collaborators on 

a regular basis was not sufficient to position the program for sustainability, 

because this allowed partners to assume a passive role, not feeling 

accountable for long-term impact.

3 They were proactive in advocating for the community’s needs and in 

communicating the accomplishments of the program and the collaboration.

26
The WHAT Dynamic

The WHAT dynamic is related to the substance of the program — its relevance, 

practicality and value — and the impact of program selection and design on 

sustainability. The relative “favorability” of this influence is determined by 

the extent to which programs or activities are aligned with any or all of the 

following three factors: community need, the partners’ ability to address 

the need over the long term, and the real or perceived value created by the 

program or services. Those who base program design on a deep, shared 

understanding of the problem to be addressed often exhibit a more durable 

commitment to sustaining the intervention. 

It is important to ensure that the WHAT, meaning the program itself, is 

practical. An effective programmatic approach is based on understanding 

the available leverage to create change, the capacity available to implement, 

and the likely result of the improvements sought. Moreover, addressing a 

given problem on a fundamental, rather than a superficial, level appears to 

result in a more sustainable impact over time. For instance, if a community 

is interested in expanding access to primary care and commits to recruiting a 

new physician, the intervention must take into account and attempt to remedy 

the inherent challenges in rural recruitment and retention — otherwise, the 

program will have only a short-term effect, if any at all. Other examples of a 

lack of alignment involve insufficient skill and capacity among partners, a lack 

of reimbursement options for sustaining the program in the long term, and 

legal or cultural barriers that prohibit the program from being continued or 

from being implemented at all. 

In the most favorable circumstances, root causes of a problem are taken into 

account when working to address a given community issue from multiple 

vantage points simultaneously, i.e., working with local providers, the public, 

payors, and/or policy makers. Conversely, those grantees that attempt to 

tackle multiple issues in a limited way — for instance, implementing a 

program that attempts to reduce rates of diabetes, asthma, suicide and 

smoking through health fairs and screening programs only — frequently 

exhibit greater difficulty achieving the outcomes they set forth. 

27
Finally, the WHAT dynamic is related to the extent to which a program and/

or coalition creates real and perceived value. In unfavorable circumstances, 

the programs do not generate the impact hoped for during the grant period 

and are ended; in others, programs may in fact be valuable, but grantees do 

not capture or effectively communicate their impact. In favorable conditions, 

value is documented in order to make a case for continuation after the grant 

funds have been expended. 

When the “what” is a favorable driver in the community, the program is 

matched to the need and is aligned with existing capacity and resources. 

The program approach is also matched in scope to the complexity of 

the program.

This was the case for the program described in Story 1 about the development 

of a Web-based training program for EMS medical directors. In this case, the 

grantee was intentional and strategic in the design and implementation of the 

approach (the “what”), knowing from the start how they intended to sustain 

the program and designing it with that goal in mind. The program was relatively narrow in scale and was not intended to address a highly complex problem- the need (a way for EMS Medical Directors to receive needed continuing 

education without having to leave their practices for days at a time to travel 

to a training center) and the approach (develop a Web-based training for EMS 

medical directors) were matched in scope. The partners in the consortium 

were engaged because of specific technical skills and content-area expertise, 

and they were effective in developing, maintaining and continuing to expand 

the curriculum. 

On the other hand, the “what” might be a challenge to long term sustainability if the problem to be addressed is highly complex and the funded program 

or solution does not adequately address such complexity by using multiple, 

related strategies (in other words, the problem far out sizes the proposed solution). The WHAT dynamic can exert a negative influence on sustainability when 

the solution (i.e. program or activity) is a stop-gap measure that does not seek 

to address the real root of the problem. Think back to Story 5, the program to 

expand access to health care to the uninsured in the Pacific Northwest. The 

grantee and partners were seeking to expand access to primary care for the

28
uninsured in a very difficult context - in an isolated and high poverty 

community with high rates of uninsured and a large number of patients 

covered by Medicaid or Medicare. In this community, providers struggle to 

make a living, so it is not feasible to expect them to be able to continue to see 

uninsured patients without the reimbursement provided through the grant. 

While the services provided to the uninsured during the 3 years of the grant 

were much needed, the approach was unsustainable. Local providers lacked 

the capacity to continue to provide care for uninsured patients, and there was

no community-wide commitment to explore alternatives to meeting the 

health care needs of the uninsured (e.g. applying for a new start FQHC or 

opening a shared clinic).

Some valuable lessons were learned from the sustainability assessment of 

former ORHP grantees as it relates to the WHAT dynamic. Findings from the 

study pointed to the importance of matching the program approach to 

the need. Those that were able to sustain over the long term exhibited the 

following characteristics as they relate to the WHAT dynamic:

3 They based the program design on a thorough understanding of the needs 

that they were attempting to address. They used needs assessments and 

community studies, their own experiences, and consultations with others 

who were working on the same issues or with the same target 

populations locally.

3 They used multiple, integrated strategies to address complex problems from 

different angles (policy change, coalition building, individual-level 

interventions, etc).

3 They worked to be sure that the strategies “made sense,” that they were 

practical and likely to accomplish the short- and long-term goals. 

3 They considered the context within which they were working - professional, 

cultural, legal, political, economic, geographic, etc. They identified conditions 

or policies that might present challenges or opportunities for sustaining 

their efforts beyond the grant period. 

3 Because they understood the importance of matching the scope of the 

approach to the complexity of the problem, they avoided taking a 

“scatter-shot” approach. Trying to address too many problems at once limits 

the chance of having an impact in any one area.

29
The WHY Dynamic

Perhaps one of the strongest dynamics affecting sustainability and long-term 

impact is the motivation for working together — the WHY. A vision may be 

short- or long-term, broadly or narrowly defined, held by one organization or 

leader or shared among partners, be nebulous or clearly articulated. All of 

these characteristics appear to influence outcomes at the community level, 

including the extent to which programs and coalitions are sustained. 

Programs and coalitions characterized by a clear long-term vision for what 

they hope to accomplish appear most likely to maintain alignment and 

continue working together over time. Viewing grant funds as a means to 

accomplish longer-term goals creates the ability to plan beyond the grant 

period. This approach enables the development of group identity that is not 

tied specifically to the implementation of a short-term program, but rather 

to making a sustainable impact on the community. 

In contrast, focusing on short-term resource needs will impact the design of 

the program and the timeline for planning. In this scenario, the opportunity 

for resources often drives the design of the programmatic approach more 

strongly than the combined aspiration of the partners. This may result in a 

group seeing itself as responsible for implementing a grant program rather 

than a group that is determined to address a problem over time. 

A narrowly defined but long-term vision provides the ability to focus intently 

on solving a particular problem and improves outcomes. In those instances 

in which short-term goals are clearly identified, the program strategies may 

be very effectively implemented during the funding period and discontinued 

when the grant funds are no longer available. When the vision is to change 

the broader system, a more strategic, comprehensive approach aimed at 

impacting the system at multiple levels is required to improve the likelihood 

of sustaining impact.

In the absence of a clearly articulated vision, it is difficult to achieve demonstrable outcomes or sustain partnerships over time. Similarly, when a vision 

is held by only one leader or organization, a lack of alignment and common 

purpose most often results in partners “leaving the table” and, ultimately,

30
insufficient support for continuing programs at the end of the grant period. 

Communities that experience a significant turnover in leadership are 

especially vulnerable when the vision for the future is not understood or 

carried on by other members of the collaborative.

Those ORHP-funded communities in which the WHY dynamic was a positive 

driving force were purposeful in creating a longer-term vision for where they 

wanted their communities to be and saw the grant funding as a step toward 

getting them there, rather than a means to an end. In Story 3 about the 

consortium that established a clinic in a remote community in the Pacific 

Northwest, the consortium came together with a clearly defined vision to 

expand access to primary care in their community. As a consortium they were 

committed to building something that would sustain beyond the grant period. 

They were strategic in their approach, using grant funds to provide start up 

funding to establish the clinic and then using the influence and shared 

commitment of their consortium partners to this clinic to advocate for the 

establishment of the taxing district that would fund the clinic after the grant 

period ended. 

In the absence of a clearly defined vision shared among collaborators, 

programs and partnerships may fall apart once grant funding ends. Think back 

to Story 6, the consortium in the Midwest funded to provide an array of 

services to children in a school district. The partners saw the influx of grant 

funding as a way to address multiple issues in the community. Little or no 

attention was given within the consortium to building a longer-term, more 

comprehensive approach. As a result, there was not a cohesive, shared vision 

for longer-term change in the community. The consortium disbanded when 

the grant period ended because, without the grant funds to support the 

myriad of services they were implementing across multiple agencies, 

there was no clear “why” to keep them collaborating.

31
Those organizations or collaborations that were able to achieve some level of 

sustainable impact demonstrated the following characteristics related to the 

WHY dynamic: 

3 They were clear about their strategic vision and specific about what they 

wanted to be different in the community 5 or 10 years into the future 

as a result of having received the ORHP grant. These communities thought 

beyond the 3-year funding period.

3 They included a broad range of stakeholders in the visioning process 

and the design of the intervention. These communities demonstrated that 

participation breeds buy-in, understanding and support for the future. 

A shared vision is also more durable when there are changes in leadership.

3 They built in a process for revisiting the vision and goals regularly to keep 

the partners engaged and created opportunities for feedback and 

midcourse corrections.

3 They viewed their ORHP grant as a means to an end rather than a mere 

opportunity for funding. The grant-funded program was one piece of a

larger and longer-term effort to solve a problem in the local community. 

32
The HOW Dynamic

The HOW dynamic refers to the ways in which a plan is put into action, 

including the strategies employed, the capacity built, and the documentation 

and communication of impact and value. 

An important concept related to the “how” dynamic is “beginning with 

the end in mind,” which helps build programs into or as a part of existing 

infrastructure or organizations. The logic and desire to build upon assets 

in the system helps minimize short-term costs and anticipate the need for 

sustaining resources, for personnel and overhead. In addition, building 

additional capacity within partner organizations and sharing responsibility for 

implementation results in increased awareness of the initiative and enhanced 

commitment. Conversely, thinking about “sustainability” near the end of 

the grant program or just before the funds are exhausted is dangerous. 

Merely focusing on implementation and the need to “get things done,” may 

prevent the ability to put day-to-day decisions into a broader strategic context. 

And, when funds are used to develop a new, free-standing infrastructure (staff, 

equipment, overhead), programs are often more costly to maintain which 

can result in reductions in service, or in more extreme cases, a decision to 

discontinue programs.

Often a significant challenge is acquiring and maintaining capable skilled staff 

to “do the work,” since the capacity required may not readily exist in rural 

communities. Without sufficient capacity, it may not be possible to effectively 

implement interventions. However, when capacity is built among existing staff 

and the training is conducted as part of the grant implementation, long-term 

assets are created for the local health system, even if programs or 

collaborations are ultimately reduced in scope or discontinued. 

It is important to view evaluation as a critical dimension of the “how” dynamic 

- an essential element of a sustainability strategy which includes carefully 

monitoring progress, discussing experiences with partners, and refining 

programs to improve efficiency and outcomes. Evidence of impact at 

individual, organizational, and/or population levels is imperative for making 

a case to funders, partners and even policy makers that additional resources 

should be committed to sustain local efforts. In contrast, when evaluation is

33
The HOW Dynamic

seen more as an “extracurricular activity” or a grant requirement, the result is 

greater difficulty demonstrating value and securing the investments needed to 

support efforts at the end of the grant period.

For those organizations and collaborations where the HOW dynamic was 

a positive influence, the planners were strategic from the beginning in the 

way that the program was designed. They were deliberate in designing an 

approach that minimized the need for new resources to sustain the program 

over the long term. This was the case in Story 3 about the establishment of a 

primary care clinic in the Pacific Northwest. The coalition took advantage of 

an existing space in the community rather than building a new structure that 

would have required a significant output of capital and continued funds to 

maintain a separate clinic building. In Story 2 about the regional network of 

health and human service agencies in the Northeast, the HOW dynamic is at 

play in the way that the partners streamlined the needs assessment process. 

The region went from doing 17 different needs assessments to conducting 

one comprehensive regional needs assessment every 3 years. The partner 

agencies now share the work and the expense of the needs assessments 

among all the partners, and everyone can then use the data collected to 

secure grant funds. 

An example of a community where the HOW dynamic was a negative force is 

seen in Story 6 about the school district in the Midwest that received a grant 

to provide health services to children and families. The grantee organizations 

used grant funds to hire program coordinators and nurses, creating significant 

new overhead costs for the school district. The costs could not be absorbed by 

the district or other partner agencies once the grant ended, so those positions 

were eliminated. The work to sustain the activities started through the grant 

was not initiated until the end of the grant period. The consortium began 

looking for other grant funds in the last part of the last year of the funding 

period. They briefly explored the possibility of Medicaid reimbursement 

for some of the clinical services provided by nurses, but this effort was 

unsuccessful because they had not worked to build the support needed 

from the school district administration from the beginning.

34
Valuable lessons were learned from the sustainability assessment of former 

ORHP grantees as it relates to the HOW dynamic. Those that were able to 

sustain impact over the long term exhibited the following 

characteristics as they relate to the HOW dynamic: 

3 They considered sustainability options from the beginning. 

Programs and partnerships were built with an awareness that the needs 

they were addressing were for the long term.

 

3 They recruited or hired capable staff with the necessary skills for 

implementing programs effectively. These groups anticipated the 

organizational capacity and human resources needed, since training, 

recruitment and retention often prove problematic. 

3 They built on local assets rather than creating new ones that would have 

required additional support. They shared staff, equipment, and space 

with partners when possible to maximize resources and minimize 

costs over time.

3 They were strategic in the design and implementation of the program 

evaluation. They included indicators of impact that were of interest to 

partners and potential funders.

3 They consistently communicated the value of their efforts with key 

audiences – internal and external.

35
 AN INITIAL ASSESSMENT 

OF YOUR POTENTIAL FOR

 SUSTAINABILITY

Stories from rural and frontier communities across the country were presented in this primer. Their stories present dynamics that influence the potential 

for long-term impact of programs and partnerships in a community. 

These dynamics, WHO, WHAT, WHY and HOW, can be favorable or 

unfavorable as they relate to a program’s or partnership’s sustainability. 

Perhaps you recognize your community, your partners or even your own 

agency in some of the stories presented in this primer. Now is the time to 

make an inventory of the dynamics at play in your own community and think 

about how to build an impactful program in your community. The inventory 

below is by no means comprehensive, but may help to get you started in 

identifying those areas where some attention and work needs to be focused.

The WHO Dynamic

Look at the other people sitting around the table. 

Are they:

u the people who can make commitments and decisions on behalf 

of their organizations?

u passionate about the work that you are doing, fully committed to 

the vision and able to inspire others?

u have the ability to attract support and financial resources for your efforts?

u able to put aside their personal agendas and work collaboratively?

u clear on their stake in this project and having their organizational 

and individual needs being met?

u engaged in meaningful ways in the planning and implementation 

of the program?

36
The WHAT Dynamic

Think about your program approach, the issue you seek to address, 

and the context within which you are working.

Do you:

u have a clear understanding of the need that you are addressing? 

Is that understanding based on a recent and comprehensive needs 

assessment that included input from your target population?

u have a programmatic approach that “fits” the issue you seek to address? 

Is your approach matched in scope to the complexity of the issue you 

seek to address? 

u have the partners engaged with you demonstrated the power to make 

the change you seek to make?

The WHY Dynamic

Think about the vision for this program and its impact in your community.

Is the vision:

u limited to a grant funding period?

u clear and shared by your partner organizations? Did your partners 

participate in the process of defining setting priorities and 

clarifying goals? 

u Can your partners articulate your vision and describe the ways in which 

they can and will contribute to the success of your initiative, both 

short- and long-term?

37
 AN INITIAL ASSESSMENT 

The HOW Dynamic

Think about your program approach and how your plan will be 

put into action. 

Is your program:

u staffed by people with the necessary skills and expertise to 

effectively implement the program?

u strategic in building on existing resources and infrastructure? 

Are you sharing staff, equipment and space when possible to maximize 

existing resources and minimize overhead costs? 

u being evaluated to document outcomes and demonstrate value?

u guided by a comprehensive communications plan that includes tailored 

messages for key audiences about the value your program creates. 

Are you communicating with both partners internal to the program 

and stakeholders external to the effort?

This primer was designed to help rural health organizations 

and collaborations starting up a new initiative recognize 

the importance of building sustainability planning into your 

project from Day One. 

38
U.S. Department of Health and Human Resources

Health Resources and Services Administration

February 2012