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Expanding Advocacy Capacity: Findings from the Evaluation of The California Endowment Clinic Consortia Policy and Advocacy Program Prepared by Annette.

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Presentation on theme: "Expanding Advocacy Capacity: Findings from the Evaluation of The California Endowment Clinic Consortia Policy and Advocacy Program Prepared by Annette."— Presentation transcript:

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

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

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

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

5 Evaluation Data Collection Activities: RoundAreas of Investigation Round 1 ( ) Funding secured ( ) Policies targeted ( ) Effectiveness of advocacy activities ( ) Partnerships with clinics and consortia ( ) Activities to strengthen clinic operations (2002, 2003) Media perceptions of media advocacy (2003) Clinic perceptions of consortia activities (2003) Grantee Implementation and Sustainability Survey (2003) Policymaker/Stakeholder awareness of consortia advocacy (2003, 2004) Round 2 ( ) Newspaper coverage secured (2004 and 2005) Individual grantee indicator data (2004 and 2005) Partnerships with non-health partners ( ) Perceptions of consortia policy advocacy by non-member clinics (2005) Media perceptions of media advocacy (2005) Clinic perceptions of grantee advocacy (2005) Three policy advocacy case studies (2006) Grantee Best Practices - achievement of Program outcomes (2006) Round 3 ( ) Tracking policy achievements - comparison of 3 key policies ( ) Case studies to assess longer-term Program outcomes (2009)

6 Evaluation Data Collection Activities by Outcome Outcome 1: Increased grantee advocacy capacity Outcome 2: Increased policymaker awareness Outcome 3: Increased policymaker support for clinic funding Outcome 4 Strengthened clinic operations Grantee Implementation and Sustainability Survey 2003 Policymaker and 2004 Stakeholder Surveys Annual Funding Secured Worksheet 2004 and 2006 Clinic Focus Groups Annual Advocacy Activities Worksheet 2003 and 2005 Interviews with Media and Media Consultants Annual Policy Outcomes Worksheet 16 Grantee Best Practices Partnerships Among Clinics, Among Consortia, and with Non-Health Allies Content Analysis of Newspaper Coverage Secured 3 Policy Case Studies

7 Outcome 1: Expanded Grantee Advocacy Capacity

8 Data Collection Activity: Annual Advocacy Activities Worksheet Grantee self-report (n=15 grantees) Previous years activities and their outcomes (n=13) Source: Scholzman and Tierney (1986) ActivityFede ral (Y/N) State (Y/N) Local (Y/N) Effectivenes s (1 to 4, 4= very effective Outcome 1: Increased clinic funding(Y/N) Outcome 2: Achieve a policy change(Y/N) Outcome 3: Increased policymaker awareness (Y/N) Media advocacy Contact policymakers directly Analysis: 1)Determine percent activities at the federal, state and local levels, and overall 2)Calculate effectiveness overall and by activity 3)Determine percent of activities that achieved each Outcome 4)Sort by grantee age (pre/post 1990 launch) Informal contacts with elected officials Hosting clinic tours for policymakers Helping draft regulations, rules or guidelines

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

10 Increase in Number of Grantee Advocacy Activities, by Level of Membership Focus,

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

12 Percent of Activities That Resulted in a Policy Change,

13 Percent of Grantee Advocacy Activities That Achieved 3 Desired Outcomes,

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

15 Data Collection Activities: 2003 Policymaker and 2004 Stakeholder Surveys 2003 Policymaker Survey –N = 86 decision makers familiar with consortia and their activities and policy issues 2004 Stakeholder Survey –N = 43 stakeholders less familiar with consortia and their activities Not at all familiar A little familiarSomewhat familiar Very familiar How familiar are you with The consortium? Activity 1? YesNoNot sure Since 2001… Has the consortium increased you awareness of… Analysis: 1) Determine percents Do you recall seeing….

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

17 Outcome 3: Increased Policymaker Support for Clinic Funding

18 Data Collection Activity: Funding Secured Worksheet Grantee self-report (n=16-18 grantees) –Requires written instructions and follow-up phone calls Previous years funding secured attributable to TCE grant –Staff time (%) used to determine esimate –Use calendar year Funding Source $ Amount How secured? Write a grant? New or Maintained funding? Estimate the % due to TCE grant How much went to consortium? How much went to clinics? Federal 1. Clinic 330 grants Analysis: 1.Calculate total funding, funding attributable to the grant, funding allocated to consortia and clinics 2.Code and county funding type - federal, state, local, private 3.Code and categorize data on how funding was secured and what funding was spent on by consortium and clinics 4.Determine whether new or maintained (carryover) funding State 1. Tobacco Settlement $ Local 1. County contracts Private

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

20 Total Funds Attributed to Grant-funded Advocacy Activities,

21 Annual Funding Secured by Type,

22 Total Funding by Type,

23 Data Collection Activity: Policy Outcomes Worksheet Grantee self-report (n=18 grantees) Previous years activities Policy targeted Bill Number and/or title? Grant-funded policy advocacy activities undertaken in Choose from list: a) media advocacy; b) in- person meetings with decision makers; c) drafting of rules, regulations; d) materials development; e) grass roots activities; f) Other: list Target populations to be affected by policy. Choose from list: a) clinics; b) uninsured; c) low- income populations; d). clinic consortia; e) other special populations; f) Other: list Outcomes as of 12/07. Choose from list: a) Passed - signed in to law; b) Vetoed; c) Pending - still being considered by decision makers; d) funding secured; e) Other: list. Federal Analysis: 1.Code and categorize all policies 2.Count number of grantees that mentioned each policy 3.Count federal and state legislation 4.Code and categorize advocacy activities, target populations, and outcomes State Local

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

25 Federal and State Legislation Targeted by Grantees: Round 1 ( ) vs. Round 2 ( )

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

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

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

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

30 Outcome 4: Strengthened Clinic Operations

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

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

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

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

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

36 For More Information: Annette Gardner, PhD, MPH Evaluation Director Philip R. Lee Institute for Health Studies University of California, San Francisco 3333 California Street, Suite 265 San Francisco, CA Phone: (415)


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