LOS ANGELES HEALTH COLLABORATIVE EVALUATION

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					         LOS ANGELES HEALTH COLLABORATIVE
                    EVALUATION




                              FINAL REPORT
                                  April 2007*




                                 Prepared by:



                       Steven P. Wallace, Ph.D.
                           Joshua Yang, Ph.D.
                          Mona Jhawar, M.P.H.




                                Sponsored by:




*
    Updated May 2007
                                                                           LOS ANGELES HEALTH COLLABORATIVE EVALUATION



                                                   TABLE OF CONTENTS

EXECUTIVE SUMMARY .......................................................................................................... 1

BACKGROUND ........................................................................................................................... 3

HISTORY OF THE LA HEALTH COLLABORATIVE......................................................... 5
  PRECURSORS TO THE LA HEALTH COLLABORATIVE ............................................................... 5
  INTERNAL PLANNING FOR THE LA HEALTH COLLABORATIVE .............................................. 7
  LA HEALTH COLLABORATIVE LOGIC MODEL ......................................................................... 8
  Figure 1. Logic Model............................................................................................................ 10
  EARLY MEETINGS .................................................................................................................... 11
  EARLY ACTION AND INFORMATION SHARING ........................................................................ 14

CURRENT STRUCTURE OF THE LA HEALTH COLLABORATIVE............................ 15
 Figure 2. Model of Action....................................................................................................... 15
 OVERALL COLLABORATIVE STRUCTURE ................................................................................ 16
 PARTICIPATION ........................................................................................................................ 21
 ACTIVITIES ............................................................................................................................... 21
 ACCOMPLISHMENTS ................................................................................................................. 22

BENEFITS AND CHALLENGES ............................................................................................ 25
 BENEFITS .................................................................................................................................. 25
 CHALLENGES ............................................................................................................................ 28

RECOMMENDATIONS............................................................................................................ 31
 DEVELOP A DIRECTIVE LEADERSHIP PRESENCE .................................................................... 31
 EXPAND PURPOSE INTO STRATEGIES ...................................................................................... 32
 STRUCTURE THE LA HEALTH COLLABORATIVE FOR EFFECTIVENESS .................................. 33
 REVIEW OF LITERATURE ......................................................................................................... 34

CASE STUDIES.......................................................................................................................... 36
 PROPOSITION 63 SIGNATURE GATHERING – LOS ANGELES COUNTY .................................... 36
 CHILDREN’S HEALTH INITIATIVE OF GREATER LOS ANGELES ............................................. 37
 ALAMEDA ACCESS TO CARE COLLABORATIVE ...................................................................... 38
 DENTAL HEALTH COALITION FOR NEEDY CHILDREN ........................................................... 40
 LESSONS LEARNED FROM CASE STUDIES ............................................................................... 41

COVERAGE INITIATIVE CASE STUDY ............................................................................. 44
 WORKGROUP FORMATION....................................................................................................... 45
 WORKGROUP PARTICIPATION AND ACTIVITIES ..................................................................... 45
 RESPONSE TO AND INFLUENCE OF WORKGROUP INPUT .......................................................... 47
 ACCOMPLISHMENTS AND CONTRIBUTIONS OVERALL ............................................................. 48
 COVERAGE INITIATIVE CONCLUSION...................................................................................... 49

LOS ANGELES HEALTH COLLABORATIVE CONCLUSION........................................ 50


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REFERENCES............................................................................................................................ 52

APPENDICES............................................................................................................................. 54

   APPENDIX A: STAKEHOLDER SURVEY ...................................................................... 55
   Table 1. Organizational affiliation of survey respondents. ................................................. 56
   Table 2. Key health policy issues in LA County since 2000. ............................................... 56
   Table 3. Primary stakeholders of key health policy issues in LA County since 2000. *... 57
   Table 4. LA County health policy stakeholders and their frequency of involvement in
   health policy issues.................................................................................................................. 58
   Table 5. Role of leaders of stakeholder organizations in LA Health Collaborative. ........ 59
   Table 6. Positions held in home organizations by survey respondents. ............................. 59
   Table 7. Level of involvement of LA Health Collaborative of survey respondents .......... 59

   APPENDIX B: Steering Committee Members, 2006........................................................... 60

   APPENDIX C: Activities of LA Health Collaborative........................................................ 62

   APPENDIX D: LA Health Action Web Site Statistics Dec 2005 to Feb 2007* ................. 67

   APPENDIX E: Key Accomplishments of the LA Health Collaborative............................ 68

   APPENDIX F: Activities of Coverage Initiative Workgroup............................................. 69

   APPENDIX G: Methodology ................................................................................................. 70

   APPENDIX H: The California Endowment Staff Interview Protocol .............................. 73

   APPENDIX I: LA Health Collaborative Participants Interview Protocol........................ 75

   APPENDIX J: LA Health Collaborative Non-Participants Interview Protocol............... 78

   APPENDIX K: Stakeholders Interview Protocol ................................................................ 80

   APPENDIX L: LA Health Collaborative Case Site Comparison Study Interview
   Protocol .................................................................................................................................. 82

   APPENDIX M: Coverage Initiative Workgroup Case Study Interview Protocol............ 85

   APPENDIX N: Host Organizations of Evaluation Participants......................................... 87

   APPENDIX O: LA County Safety Net Issues and Actors Survey...................................... 88




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                                  EXECUTIVE SUMMARY

       The turmoil surrounding safety net financing that led to the Section 1115 waivers in Los
Angeles in 1995 and 2000 prompted The California Endowment and others to establish a forum
where stakeholders could work to avert or better respond to future financial crises. In June 2003,
the LA Health Collaborative was first convened as a common planning table where key
stakeholders in the Los Angeles County health care safety net system could gather and
proactively create a new vision of health care for low income residents of LA County and be
more effective in future crises.

         The LA Health Collaborative continues to work towards the initial goal for which it was
formed. Although the LA Health Collaborative has not created a new common vision of the
safety net, nor is it the type of planning table as originally conceived, it has successfully
facilitated a number of workgroups, promotes information sharing among members and with
outside organizations, and facilitates contact between individuals.

         The two main benefits of participation in the LA Health Collaborative identified by
participants are the networking opportunities and access to important, timely, and high quality
information. LA Health Collaborative meetings provide opportunities for stakeholders to engage
with each other and, at the same time, have access to key local and state officials. Networking
among stakeholders has occasionally led to spin-off initiatives such as Health-e LA, which had
its origins in an informal discussion among stakeholders at an LA Health Collaborative meeting.

         The second benefit of the LA Health Collaborative is the information provided to the
collaborative members through its listserv and meeting presentations. Even though it was
considered a major benefit of collaborative participation, we were unable to measure how or to
what degree the information accessed through the LA Health Collaborative is directly beneficial
to member organizations. The Collaborative also serves to communicate member perspectives
and concerns to the LA County Health Department and other officials. Documenting the impact
of this is also a challenge. A supplemental case study of the 2006-07 state Coverage Initiative
provides insights into the impact of the input of the LA Health Collaborative on county and state
policy.

        A key obstacle facing the LA Health Collaborative is rooted in its conceptualization: it
was convened around the idea of bringing together a diverse set of members without a concrete
action agenda. The first order of business was to identify issues to work on. Interorganizational
relations theory and practice, however, show that the purpose of a collaborative shapes is
membership. By trying to create a diverse membership that determines its purpose, rather than
the other way around, the LA Health Collaborative has been hindered by trying to develop a
focus that can impact LA County’s enormous and diverse populace, fragmented interest groups
and stakeholders, complex health system, and tightly wed relationship between the county health
care safety net and local political structure.

        A second obstacle to the initial goals of the LA Health Collaborative has been an absence
of clear, directive leadership structure. With no preexisting leadership structure in place at the
formation of the LA Health Collaborative, participants looked, by default, to LA Health Action


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staff for leadership and direction. The California Endowment, on the other hand, wanted a
leadership presence to emerge organically. A lack of a strong, directive leadership from either
The California Endowment or a core group of members within the LA Health Collaborative
hindered the early development of the collaborative. More recently, the stability of LA Health
Collaborative staff leadership and the establishment of an executive committee have created a
clear leadership structure. The staff-led structure is not what was initially envisioned, but it is a
viable means for a degree of organizational success and continued operation.

        Participants agree unanimously that the LA Health Collaborative has utility and should
continue to convene. It is seen as a unique forum that needs time to work through the inherent
difficulties of collaborative efforts. Overall, participants are in favor of continuing the LA Health
Collaborative with changes either in operation or expectation.

In light of these findings, we suggest the following recommendations:

   Outcome
   • For the long term: Encourage the steering committee to keep the renewed purpose and
      goals of the LA Health Collaborative in the forefront as the guiding principle for decision
      making and action.
   • For the medium term: Identify issues with an existing degree of momentum behind them
      and engage collaborative members in concrete projects around those issues.
   • For the short term: Select at least one issue that has a degree of urgency associated with
      it, i.e., funding cuts, funding opportunities, reduction of services, etc.
   • Communicate the short-, medium-, and long-term goals and accomplishments of the LA
      Health Collaborative regularly to its members.

   Process
   • Urge the steering committee members to work quickly and decisively in the difficult
      process of its own consensus building to select a focus area or areas and a strategic plan
      to address key issues for the LA Health Collaborative to work on.
   • Review updated collaborative logic model to be provided by the evaluation team and
      decide if the process goals identified are sufficient for the Collaborative.
   • Shorten agendas to allow time for in-depth discussion and creation of action items into
      both executive committee and general group meetings.
   • Collect evaluation information at each quarterly meeting about the content and process of
      the collaborative. The evaluation team will provide a draft form.
   • Provide tasks for members to do as part of a larger plan, creating additional buy-in by
      member organizations to the LA Health Collaborative.
   • Do not avoid difficult discussions and disagreement.
   • Formalize decision making processes.
   • Continue to foster personal relationships among LA Health Collaborative participants.

In light of the findings from our evaluation and the recommendations provided, we anticipate
that the LA Health Collaborative will likely continued to benefit its members and the LA safety
net, though the type and degree of benefit will depend on the nature of any changes made to the
LA Health Collaborative.

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                                        BACKGROUND

        The LA Health Collaborative has its origins in a county health system fiscal crisis that
started in the mid-1990s. The budget deficit for the LA County Department of Health Services
projected in 1995 by the county Chief Administrative Officer, and recommended facility
closures marked the beginning of a prolonged period of budget crisis within the LA County
health care safety net system. Through a federal waiver, waiver extension and realignment of
county health services, major reductions in service have been averted. The constant threat of
fiscal crisis, however, prompted The California Endowment to set in motion a series of activities
that would lead to the formation of the LA Health Collaborative.

        In 1995, the Chief Administrative Officer (CAO) of Los Angeles County projected a
budget deficit of $655 million for Los Angeles County Department of Health Services (DHS),
nearly half of the projected budget deficit of $1.3 billion for the entire county (Zuckerman and
Lutzky, 2001). The projected deficit for the Department of Health Services represented over 28%
of its operating budget and prompted Sally Reed, then-CAO of Los Angeles County, to suggest
cuts in DHS to the LA County Board of Supervisors. Leading health officials in the county met
with the CAO in attempts to dissuade her from suggesting severe cuts to the health care safety
net of the County to the Board of Supervisors. Ultimately, she made two suggestions for
reductions in health services. The first was to close Los Angeles County+USC Medical Center
(the largest county hospital), four of six county comprehensive health centers and 25 health
centers. The second was to close four county hospitals, keep Los Angeles County+USC Medical
Center open, and cut six comprehensive health centers and 19 health centers.

        The Board of Supervisors appointed a Health Crisis Task Force to further examine the
two options presented by the CAO and propose alternative solutions. The Task Force identified a
third option: to close all six comprehensive health centers, 29 health centers, and reducing
hospital outpatient services by 75 percent. Along with this third recommendation, however, the
Task Force requested a delay in cuts to allow time to identify additional revenue streams to avoid
a reduction of health services.

        The State of California and Los Angeles County sought additional funding for the county
health system from the federal government through a Section 1115 Medicaid Research and
Demonstration Project waiver. The County submitted a proposal to the Centers for Medicare and
Medicaid Services (CMS) in February 1996 to use Section 1115 monies to restructure the
Department of Health Services and the delivery of indigent care. Fundamentally, the plan was
intended to steer the County away from a reliance on emergency room and inpatient care and
integrate a system of public and private clinics to provide community-based primary, specialty,
and preventive care. The plan would do this by increasing access to ambulatory care services and
reducing the number of inpatient beds in County hospitals. Los Angeles County’s proposal was
approved on April 15, 1996 and covered the period from July 1, 1995 through June 30, 2000.
The fiscal package provided by the Section 1115 waiver provided Los Angeles County with
approximately $1.2 billion in federal Medicaid funding.

       A critical group in the process of shaping the Section 1115 waiver proposal was the
Health and Mental Health Coalition (HMHC). The HMHC began as a loosely related group of


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individuals who corporately resisted the attempts by Richard Dixon, Los Angeles County CAO
prior to Sally Reed, to redirect money from the budgets of health services and mental health to
other areas of the county. The HMHC met informally to discuss on-going policy issues in Los
Angeles County. It did not take a position on policy issues as a group. Instead, discussions within
the group resulted in each member returning to his or her organization and attempting to position
their home organization on particular issues based on discussions that occurred within the
HMHC meetings.

        The budgetary crisis of 1995 provided the impetus for the group to coalesce to further.
The HMHC advocated against the suggestions of CAO Reed to significantly reduce the services
offered by the Department of Health Services. It acted as a forum where key stakeholders could
refine each others’ strategies for survival and coordinate positions and activities with respect to
reductions in health services. When the County sought additional funding through the Section
1115 waiver, the HMHC played a critical role in bringing together divergent viewpoints and
interests, finding agreement on the final Section 1115 proposal, and working toward its approval
by the federal government.

        By 1999, it became apparent to the County the restructuring goals it had set forth in the
Section 1115 waiver plan would not be achieved by 2000, nor would it be able to operate without
additional support from the federal government. In order to avoid a reversion to budgetary crisis
for the County Department of Health Services, the HMHC began to resume meeting again in
1999. It had become less active in light of the establishment of the Oversight Committee for the
implementation of waiver restructuring plan. Playing a similar role in 1999 as it did in 1995, the
HMHC worked to prevent a collapse of the health care safety net and assure the interests of a
diverse group of stakeholders were met. An agreement was reached between the County and
CMS in January 2001 to extend the waiver until June 30, 2005.




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                  HISTORY OF THE LA HEALTH COLLABORATIVE

        The Section 1115 waiver and extension provided a temporary stream of federal money to
brace the county health care system. As only a temporary solution, however, stakeholders
throughout the county recognized that more fundamental, structural changes needed to be made
to the health delivery system as a whole to ensure sustained, high quality health care for low-
income residents. The California Endowment launched the LA Access Plan in an effort to
identify ways to increase access to care in LA County, while other stakeholders worked with the
LA County Department of Health Services within the framework of the waiver to improve the
functioning of the health care safety net. There was no single, neutral venue, however, where all
key stakeholders could come together and jointly plan a more effective, coordinated system of
health care for the county. Activities of the LA Access Plan were consonant with a petition by
the Health and Mental Health Coalition to TCE to host a planning forum for the county, leading
to internal discussions for what would become the LA Health Collaborative. The discussions
resulted in a plan to host a neutral forum for stakeholders to gather, build trust and improve
working relationships to a degree where a common planning table would develop and ultimately
implement a new vision for health care in LA County would emerge. Early meetings were
limited to abstract discussions regarding the LA County health system, with a concrete set of
projects or activities for the LA Health Collaborative emerging one year after the first meeting.


PRECURSORS TO THE LA HEALTH COLLABORATIVE

         Three independent streams of activity occurring within The California Endowment
sparked the formation of the LA Health Collaborative:
         •  Informal dinners to introduce the new director of LA County DHS, Dr. Tom
            Garthwaite, to key LA County health care stakeholders
         •  Community forums to discuss the budgetary crisis of the county Department of
            Health Services
         •  And an appeal by the Health and Mental Health Coalition to TCE to host a
            collaborative forum for proactive planning to improve the county health care safety
            net system.
The activities, initiated by TCE in a top-down fashion combined with bottom-up grassroots
efforts, converged within TCE in a unique county health context to create the LA Health
Collaborative.

       The two top-down activities initiated by TCE were in response to the pattern of reactive
responses within LA County represented by the two earlier waiver initiatives. As a part of its LA
Access Plan, a place-based approach to increasing health care access in Los Angeles, informal
dinners with the new director of Los Angeles County Department of Health Services and
community forums to discuss the county-wide health care financial shortages were held to
increase the quality of organizational relationships among health stakeholders in the county.

        Soon after the Board of Supervisors voted to bring in Dr. Tom Garthwaite as the new
director of LAC DHS in December 2001, TCE hosted a set of small, informal dinners to allow
county health care stakeholders to meet and begin building relationships with the Dr. Garthwaite.


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Out of these dinners emerged conversations between Dr. Garthwaite and TCE about creating a
place where he could have similar dialogues on key issues outside of the politically charged
atmospheres of formal meetings. Instead of attending numerous meetings with various
stakeholders on essentially similar issues, Dr. Garthwaite had thought to convene forums for
groups to gather and discuss issues in the same setting. He faced pressure from within the
Department of Health Services not to convene forums with stakeholders himself, however, and
TCE appeared to be a good partner to convene these periodic forums on his behalf.

        In response to the anticipated budgetary deficit faced by the LA County Department of
Health Services, the county Board of Supervisor’s decided in 2002 to close 11 health clinics and
two county hospitals. In September of that year, TCE hosted three public forums intended to be a
place where state and county officials, local stakeholders, experts, and the public could engage in
a discussion about the health care crisis, begin discussing ways to restructure the county health
system, and develop a framework for the county to discuss financing with the federal
government. Each of the three meetings addressed a specific area of concern: outpatient care,
inpatient care and emergency room use, and public health. The forums did not result in direct
outcomes, but were helpful in reopening channels of communication between state and local
officials on how to negotiate with federal officials on funding for the county. It also created a
sense among participants that similar broad-based forums to discuss the condition of the county
health system did not exist but needed to be established.

         As TCE was increasing its activity level around the health care safety net in LA County,
individual members of the Health and Mental Health Coalition (HMHC) approached TCE as
concerned individuals about convening a collaborative to extend the work that the HMHC had
been doing. Instead of being reactive to the crises the waivers had presented, a proactive
planning table for the county appeared to be a more worthwhile effort. There was agreement
among its members that the HMHC could not build a broad based planning collaborative to
discuss how to solve the health system crisis in the county. Because of its past activity, it would
be seen as an interest group when what was needed was a neutral convener. It also lacked the
staff, funding, and formality to become more active. Their proposal was to ask TCE to convene a
collaborative effort to bring stakeholders together to discuss how to restructure the county health
system. As a TCE initiated forum, the hope was that it would be seen as a neutral setting and that
the cache of TCE would attract a broader based of participants.

        With the two waiver initiatives in Los Angeles County as the backdrop, three factors
directly converged to provide the impetus and the momentum to begin discussion around TCE
convening a collaborative planning effort in Los Angeles to impact the health care safety net.
The introductory dinners for Dr. Thomas Garthwaite, the broad-based public forums, and the
desire among former HMHC members to have TCE extend what it started, intersected in 2002
to create a critical mass of discussion in TCE about convening a collaborative effort in Los
Angeles.




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INTERNAL PLANNING FOR THE LA HEALTH COLLABORATIVE

        A subset of the health advocates who participated in the HMHC approached a staff
member at The California Endowment who had been part of the HMHC in her prior position
with LAC DHS about their idea. This staff member worked with the Program Officer for the LA
Access Plan and began the discussions that would have the LA Health Collaborative be a part of
the LA Access plan. The TCE staff member was the point person for the early thinking and
planning about the assumptions a collaborative forum might be based on, its purpose, and its
structure.

        Planning for what would become the LA Health Collaborative happened within TCE’s
development of the LA Access Plan, a place-based strategy through the Access to Care program
area of TCE. The decision to focus on Los Angeles was based on the sheer number of uninsured
in Los Angeles and the fact that Los Angeles has the highest uninsured rate of any county in the
state. The LA Access Plan was a commitment to focus resources on strategies to increase access
to care. Given TCE’s focus on Los Angeles and access to health care, the idea of convening a
collaborative forum worked well.

        In the fall of 2002, a consultant was hired to help refine the approach that would be
adopted for a collaborative forum around safety net issues that TCE could convene. Two basic
premises for initiating a collaborative forum emerged. The first premise was that there was a
small window of opportunity before the second waiver ended in 2005, at which point the county
would likely find itself in another financial crisis. This small window of time provided a unique
opportunity to take a step back, think, and come up with thoughtful, proactive solutions to
stabilize the safety net. A second premise was that a single organization or even a small number
of organizations could not adequately address the complexity of circumstances that led to
previous financial crises. Effective solutions would need the input and buy-in from a wide range
of stakeholders. With the context of a potential financial crisis looming in the distance, a set of
principles for a collaborative forum were developed:

           •   There is no single cause of the crisis or a single solution
           •   There are insufficient resources from the local, state, and federal government
           •   There is a lack of system integration within the public safety net and between the
               public and private sector
           •   The highly politicized environment for making health care policy and resource
               allocation contributes to the recurring crisises
           •   The crisises, which had the same root cause as the crisis in 1995 and 2000, cannot
               be solved by doing the same thing again. That is, obtaining an infusion of reward
               money without a real reform agenda.

The key conclusion of the early thinking that went into the planning for a collaborative forum
was that

                   What is needed is a mechanism to find multiple solutions
                     from multiple sectors that support a single vision



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        The California Endowment and the consultant envisioned a technical work group that
would create a vision of health care in Los Angeles, discuss it and simultaneously elicit expert
input and analysis and engage stakeholders about the plan to build community support to
implement it. The goal of the group would be to develop principles for restructuring where
agreement could be formed and joint action facilitated.

        Working concept papers were developed by November 2002 and in December 2002 a
meeting was arranged between Robert Ross, Thomas Garthwaite, Howard Kahn, Grantlin
Johnson, Ray Baxter, Burt Margolin, and Bruce Vladic, facilitated by Robert Mittman, to discuss
whether or not there was any interest in a collaborative forum. The facilitator was delayed in
arriving at the meeting because of travel problems, and, while waiting, one member of the
meeting insisted that a collaborative take on a specific policy agenda. These two dynamics of the
meeting contributed to the overall lack of interest in the idea of a collaborative by participants in
the meeting.

        The lack of interest from the December 2002 meeting initiated a review of the concept
paper that had been developed for a collaborative. The proposal was reexamined resulting in a
revised concept paper that was fundamentally the same as the one they had developed for the
December 2002 meeting. The thought was that the lack of support from participants in the
meeting derived more from the dynamics of the meeting than the merits of the proposal.

        The first meeting to discuss the formation of a collaborative was scheduled for June 30,
2003, six months after the December 2002 meeting. A TCE staff member and hired consultant
refined the concept for the collaborative and created a list of organizations and individuals to
attend the first meeting. The first meeting was by invitation only to assure a manageable group
size and meaningful discussion. However, the goal of the invitation list was to enlist broad based
support from a range of stakeholders including public and private interests, community groups,
payers, other foundations, the business community, and researchers. And though it was intended
to be an invitation only meeting, when other parties asked to attend, they were not turned away.
After nine months of planning, the LA Health Collaborative would hold its first meeting.


LA HEALTH COLLABORATIVE LOGIC MODEL

        There was no clearly articulated logic model that the LA Health Collaborative was
supposed to follow. TCE did not have particular expectations or outcomes for the LA Health
Collaborative beyond strengthening the stakeholder network in support of the safety net. They
hoped it would follow an organic process that would result in participant ownership and a self-
defined set of processes and goals. A combination of the early thoughts put in place by TCE staff
and the external consultant, combined with comments at the early organizer’s meetings of the
LA Health Collaborative, has been analyzed to deduce a logic model of the LA Health
Collaborative’s goals and how they would be achieved. The logic model represents the essential
melding of ideas from TCE of what the LA Health Collaborative could be and what early
participants of the LA Health Collaborative thought it should be.



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        Figure 1 is a graphical depiction of the logic model behind the LA Health Collaborative.
It begins with basic assumptions about the health care safety net in Los Angeles. It is viewed as:

   •   Ineffective: far too many residents in LA County do not have access to high quality
       medical care.
   •   Fragmented: the components of the health care safety net are not integrated into a true
       system.
   •   Having a high level of distrust: component organizations of the health care safety net are
       viewed as not trusting each other.
   •   Lacking communication: fragmentation is a result of organizations failing to
       communicate effectively with each other.
   •   Underresourced and overutilized: the number of people who seek services from the health
       care safety net outweigh available resources to serve them.

        With this assessment of the county’s health care safety net as the backdrop, the intended
aim of the LA Health Collaborative was to create a common planning table where a broad base
of stakeholders could come together, discuss the issues before them, and develop a new vision of
health care for low-income residents of LA County. In order to accomplish this, however, a
collaborative effort would have to go through a growth process. This first component to the
growth of the LA Health Collaborative according to this model is “active content facilitation.”
This type of facilitation engages the group members, integrates their comments, and moves it
forward. Active facilitation of content helps to synthesize the multitude of ideas that are
discussed in a collaborative effort and prevents the group from getting stuck on topics as it
attempts to reach agreement. Hiring a facilitator for active content facilitation was seen as a first
and critical step to forming a collaborative that would truly be a planning table.

       A series of principles and ideas were also outlined regarding the nature of the group’s
gatherings. It would require:

   •   Neutral convening: to avoid the perception that one person or group’s agenda was being
       prioritized, a neutral convener was deemed necessary for the LA Health Collaborative.
   •   Inclusivity: the best solutions to problems were assumed to come from a wide range of
       participants. Participation was solicited from a broad range of stakeholders and all other
       interested groups were also allowed to participate.
   •   Regular communication: one barrier to relationship building is a lack of communication
       across organizations.
   •   Information sharing: groups needed to freely offer important information to the LA
       Health Collaborative so diverse perspectives could be integrated and informed decisions
       made, both with LADHS and between stakeholders.
   •   Relationship building: because of the distrust that exists among stakeholders, they must
       begin to build relationships across organizational lines.
   •   Power rebalancing: select organizations in the health care safety net had greater decision-
       making power and influence over decision makers such as LADHS. The LA Health
       Collaborative would be a place where equal voice is given to each participant and
       decision-making would follow a consensus as much as possible.


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    Upholding these qualities within the LA Health Collaborative’s meetings and activities were
believed to lead to a collaborative that would act as a common planning table for the health care
safety net of Los Angeles County. Activities of the LA Health Collaborative would then be joint
efforts with joint ownership among participants.

   This common planning table would be a place of:

   •    Trust: groups must trust each other in order to work toward a common vision that
        required each organization to give and take.

Figure 1. Logic Model


                                                Safety Net in LA County
       LA Collaborative                          -Ineffective
                                                                                          [reduces]
                                                 -Fragmented
                                                 -Distrust
                                                 -Lack of Communication
          “Active Content                        -Underresourced, overutilized
            Facilitation”


                                                                                 Greater
                                               Common                        “Effectiveness”
                                            Planning Table                      in Crises
                                             -Trust
                                             -Safe
           Neutral convening                 -Open
           Inclusive                         -Collective Leadership
           Regular communication
           Information sharing
           Relationship building                                                 New Vision of
           Power rebalancing with LADHS                                          Health Care for
                                                                                  Low Income
                                                 Shared planning
                                                                                  Residents of
                                                 Joint action
                                                                                   LA County
                                                 Small scale
                                                  collaborative projects



   •    Safety: people must feel safe that the resources they brought to the planning table would
        not be misused.
   •    Openness: people must be open about their concerns, perspective, and opinions.
   •    Honesty: the group should foster honest expression and prevent misleading information
        or activity for personal gain.



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   •   Collective leadership: no single group or person would monopolize leadership, but it
       would be shared among collaborative members.

    A common planning table with these characteristics was viewed as the forum in which
stakeholders could identify barriers to reform, engage in shared planning, and enter into joint
action to materialize a new vision of health care for low income residents of Los Angels County.
A common planning table would also assure greater effectiveness during the type of crises that
precipitated the Section 1115 waiver and its extension.


EARLY MEETINGS

       The first meeting of the LA Health Collaborative was held on June 30, 2003 from 1:00
p.m. until 4:00 p.m. at the Wilshire Grand Hotel in Los Angeles. The meeting was opened by
Robert Ross to introduce TCE’s rationale for convening the meeting: to gauge interest among
stakeholders about building a shared vision of how to improve access to care and, possible,
reforming financing and service delivery in the county.

       Robert Mittman facilitated the meeting, and the group of 45 participants identified
desired outcomes that could be divided into four categories:

           •   improving LA’s economic climate
           •   improving LA’s health outcomes
           •   improving LA’s health delivery system
           •   improving access and coverage


       The possible strategies the group identified for approaching these outcomes were:

           •   to build a health planning and action collaborative,
           •   reach agreement on the scope and scale of problem,
           •   and develop options for demonstration projects.

       The group began discussion of two other key areas during the meeting: guiding principles
for how the collaborative should accomplish its goals, whatever they may be, and identification
of possible processes that the collaborative would engage in to accomplish its goals.

        Three action items remained from this first meeting: TCE to reaffirm its commitment to
the collaborative through allocation of resources, formation of a smaller group to frame
following meetings, and compilation and distribution of a list of the meeting participants to all
attendees. The group also agreed that projects should begin sooner rather than later.

       Irene Ibarra who was brought into TCE to lead LA Health Action in May 2003, along
with Barbara Masters and Robert Mittman, shaped the structure and direction of the LA Health
Collaborative.


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                                                     LOS ANGELES HEALTH COLLABORATIVE EVALUATION



        During the second meeting in October, stakeholders agreed that the idea of a
collaborative for the county was worth pursuing, the agenda for the second meeting looked to
move the group toward a clearer purpose and a set of ground rules. Five objectives had been
identified for the meeting:

           •   to reach an agreement on objectives and endpoints of the collaborative,
           •   understand lessons from similar collaboratives,
           •   explore cherished assumptions,
           •   clarify on-going roles of group members, and
           •   identify next steps.

        The group engaged in a discussion about whether the focus of the group would be health,
health care, or access to health care services with no agreement except that whatever the
endpoint, an inclusive approach that acknowledges multiple determinants of health was
necessary.

       The meeting then moved toward exploring and categorizing “cherished assumptions”;
nine assumptions were identified. The group proceeded to create a five point charter for the
collaborative to include:

       •   a focus on improving health,
       •   an emphasis on collective leadership,
       •   acknowledgement of the broad range of factors that impact community health,
       •   an expressed desire to make systemic change in health care, and
       •   a recognition that solutions would require connection to issues beyond health care
           that affect community health.

       Other discussions involved identifying lessons from the past collaboratives as well as
potential structure and format of future meetings.

        The first two meetings were not able to reach the level of a consensus on purpose and
structure that the facilitator had hoped for. The large number of participants at the meetings, the
diversity of opinions, and the number of items on each agenda prevented the group from
identifying issues it would address. In response to the difficulties faced in the first two meetings,
two smaller group discussions were held to explicitly identify issues the LA Health Collaborative
could take on as well as potential decision making processes the LA Health Collaborative could
adopt. Meetings were held on November 13th and 17th and the following issues were identified:

       •   Population health, encompassing a broad public health view
       •   Improvement of health care institutions
       •   Addressing the financing of health care
       •   Improving health care for vulnerable populations
       •   Creating a health care policy and planning table

        In addition to identifying issues to address, factors in selecting an issue were identified.
Participants in the small group discussion also expressed interest in consensus being the basic

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                                                   LOS ANGELES HEALTH COLLABORATIVE EVALUATION



decision making criteria for the LA Health Collaborative and the formation of a steering
committee to guide agenda setting.

        Even with the smaller groups meeting in November, the larger group was unable to settle
on the issues the LA Health Collaborative would tackle and the approach it would take in
addressing them during the third meeting on December 2. Break-out groups were created to
discuss the merits of three foci – policy, geographic demonstration projects, and vulnerable
populations – yet no decision was made. At an impasse, the group decided to appoint a Steering
Committee to decide what issues the Collaborative would tackle. The appointment of a steering
committee coincided with the transition of Irene Ibarra from director LA Health Action to an
internal position at The California Endowment in December 2003. The steering committee
would meet twice before the next LA Health Collaborative meeting in March 2004.

        During a January 12, 2004 meeting, the steering committee decided to focus on adult
health and the misalignment between services provided and the needs of the population with
limited access. They set out to conduct a rapid assessment of adult health issues around that
theme and meet again on March 2, 2005 to make concrete recommendations and present their
recommendations to the large group on March 15, 2004. The steering committee included:

       Lark Galloway Gilliam
       Howard Kahn
       John Kotick
       Mandy Johnson
       Lia Margolis
       Carol Roeloffs
       Paul Simon
       Richard Van Horn
       Mark Windisch
       Tom Garthwaite (did not attend)
       Kathy Ochoa (did not attend)
       Rob Simpson (did not attend)

        During its March 2, 2004 meeting, the steering committee decided on three potential
activities for the Collaborative to pursue:

           1. Create a knowledge resource on adult health and related activity in LA County. It
              would be a shared resource as a launching point for other efforts

           2. Identify and promote technological solutions to improve adult access to and
              quality of care

           3. Create a pilot or demonstration project in a geographically defined area based on
              collaboration and partnership.




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EARLY ACTION AND INFORMATION SHARING

       During the following two meetings on March 15 and April 6, 2004, the collaborative
decided to pursue geographically focused demonstration projects. Although establishing a
medical home was the initially discussed, chronic conditions became the focus of these projects.
The priority health areas identified were obesity, diabetes, and heart disease. From these
meetings, the group began to think about which communities to have the demonstration projects
in as well as how to gain entrée into various communities. At the next meeting on May 26th, five
potential communities for demonstration projects were presented:

       •   Long Beach
       •   Bellflower/Paramount/Lynwood/Southgate
       •   Southeast LA
       •   North Valley
       •   Pomona/Claremont/San Dimas

        After this meeting, the geographical focus demonstration project went from being the
focus of the entire group to an activity of a subcommittee. From this point forward, the LA
Health Collaborative became an educational forum on critical and timely topics. It moved away
from a discussion oriented agenda to a presentation based agenda. The core topics since the
Summer of 2004 have been health care financing, the King-Drew crisis, and, to a lesser degree,
exploring alternative governance structures for the county health system. Collaborative related
activities such as Health-e-LA, the geographic focus projects, and the development of the LA
Health Action webpage were placed under the supervision of Collaborative workgroups. Other
topics received attention on the agenda including federal activities and legislative updated. The
three core topics, however, held dominant positions on the agenda and became the focus of the
Collaborative through the end of 2005.

         The county financial deficit which helped precipitate the formation of the LA Health
Collaborative has stabilized and the continued crisis that some foresaw at the end of the waiver
extension in 2005 has not come to pass. Never the less, the county health care safety net stands to
benefit from the articulation and implementation of system restructuring. In an effort to be the
body that provides the guidance for such restructuring, the LA Health Collaborative spent much
of its early meetings discussing abstract aspects of health care in the county, missing the
opportunity to engage key stakeholders in concrete, achievable efforts that would allow it to
develop the momentum to address its broader vision. Misalignment of the current activities of
the LA Health Collaborative to its original intent is in many ways rooted in the inability in early
meetings to move in the desired direction. The LA Health Collaborative does, however, in its
current form provide a perceived benefit to participants, and redirection toward the original
intent can still be made.




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          CURRENT STRUCTURE OF THE LA HEALTH COLLABORATIVE

        The basic structure of the LA Health Collaborative has been quarterly meetings organized
and hosted by LA Health Action staff with periodic topic-specific workgroups meeting as needed
to respond to emerging health issues affecting the county. More recently, a Steering Committee
has been reestablished, which has begun to take on a larger role in the planning of quarterly
meetings and creation of meeting agendas. New workgroups have been formed as well to work
on long-term issues in addition to emergent issues. The following section provides greater detail
about the overall structure of the LA Health Collaborative and three specific areas of the
collaborative: participation, activities, and accomplishments.
        Figure 2 shows the current model of action for the LA Health Collaborative. LA Health
Action identifies issues for the LA Collaborative to discuss, sets meeting agendas, and brings
together the information provided at meetings. The Steering Committee provides consultation to
L.A. Health Action on which issues to bring before the larger collaborative memberships and
suggests speakers for meetings, ensuring alignment with the mission statement of the LA
Collaborative. The mission, crafted by the Steering Committee over several meetings, is:

   “Our mission and vision is to serve as a health planning forum that fosters policy
   action plans and frames pilot projects toward a seamless, coordinated system
   combining safety net and public health services in support of the region's vulnerable
   populations.”

Figure 2. Model of Action


                       LA Health
                      Collaborative
                        Steering                       Identify issues
                       Committee                     Set meeting agenda
                                                     Provide information

               Consultation

                                                                LA Health
                  LA Health Action                             Collaborative
                   •Access to consultants                     •Information sharing
                   •Access to top officials                        •Networking
                       •Staff expertise
           •Relations with safety-net stakeholders
                      •Web resources
                         •E-mail list


                                               Information
                                               Perspective             Work
                                                  Advice               group
                                                                         Work
                                                Legitimacy               group
                                                                           Work
                                                                           group
                                                                              Work
                       Safety-net
                                                                              group
                        Issues




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                                                    LOS ANGELES HEALTH COLLABORATIVE EVALUATION



        LA Health Action uses a wide variety of resources at its disposal to coordinate and
inform meetings including access to expert consultants and top state and local health officials,
staff expertise, relationships with stakeholder groups, and electronic resources. Quarterly LA
Health Collaborative gatherings consist of presentations and other forms of information sharing
typically followed by a few questions, and the opportunity at the beginning and end of gatherings
to network with new and old colleagues. Workgroups are the action component of the LA Health
Collaborative. Workgroups of LA Health Collaborative members interested in topics addressed
during LA Health Collaborative meetings convene outside of quarterly meetings to discuss
further planning and action. The workgroups are hosted by LA Health Action and engage in joint
action with LA Health Action, providing diversity in perspective, advice, and legitimacy to LA
Health Action’s work on safety-net issues.


OVERALL COLLABORATIVE STRUCTURE

Membership
        The LA Health Collaborative is comprised of representatives from approximately 70
professional organizations including the medical services, public health, business, faith-based
and philanthropic sectors. There are no official requirements for membership or organizational
participation in the large group meetings. As a result, the number of participating organizations
has waxed and waned depending on the particular issue the collaborative focused on. Long-
standing participants include Community Health Council, Inc., Hospital Association of Southern
California, LA Care Health Plan, LA County Department of Health Services, Community Clinic
Association of LA County, USC Keck School of Medicine, Los Angeles Area Chamber of
Commerce, Mental Health Association of Los Angeles, SIEU International Local 660, UCLA
Center for Health Policy Research and the Los Angeles County Medical Association.

Leadership
         LA Health Action functions as the convener of the LA Health Collaborative. This role
involves providing administrative support for the collaborative including setting agendas,
arranging speakers, convening meetings, and meeting facilitation. As the convening agency, LA
Health Action assumes primary administrative responsibilities to ensure forward movement of
the collaborative while also participating in the collaborative as a member. Yolanda Vera is the
most visible individual administrator of the LA Health Collaborative providing meeting
facilitatation, while also providing direction, guidance and resources to the LA Health
Collaborative with the assistance of Neelam Gupta. Approximately 35% of LA Health Action
staff time is allocated to the LA Health Collaborative.

         The early development of the LA Health Collaborative was marked by leadership
transitions that stabilized once Yolanda Vera came on board in 2004, managing the collaborative
as one of several projects within LA Health Action. As part of the Collaborative she acts as the
facilitator and is perceived by participants as the person taking primary leadership responsibility.
She is viewed as having essential leadership qualities, though there are perceptions that suggest
she could be more assertive when conflicts or decision-making needs arise. Neelam Gupta also
plays a role in the LA Health Collaborative as moderating the collaborative list serve and leading
workgroups as needed, such as the Geographic Focus Workgroup. Members perceive her role as


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a conduit to otherwise inaccessible information on health care delivery issues impacting Los
Angeles County. Veronica Calderon, a part-time graduate intern since the middle of 2006,
provides administrative support for LA Health Action. LA Health Action has also hired
numerous consultants to provide expertise on key issues such as homeless health care and
Medicaid citizenship requirements.

         An initial, temporary Steering Committee was appointed in January 2004 to assist with
collaborative decision-making and goal setting. They proposed three directions for the LA
Health Collaborative to move toward: build a shared information and analytic capacity about the
health, health needs, and health resources of low-income adults; build on existing technology
solutions to enhance the quality of care for low-income adults; and to bring a full spectrum of
resources – public, private, and community – to bear on a health issue in a specific geographic
region in LA County. The collaborative eventually adopted place-based demonstration projects
as its first project. After presenting the three directions, the Steering Committee never met again.

          In April 2006, a subsequent Steering Committee with a two-year commitment was
formalized. The role of the new Steering Committee, made up of different members from the
first, is to establish a structure for leadership, guide the collaborative’s work, set priorities,
articulate positions and provide direction to the LA Health Collaborative (see appendix A for list
of Steering Committee members). After their initial meeting the Committee decided to reshape
proposed strategic priority areas by surveying emergent issues among community groups,
seeking out other collaborative organizations to inform their structure, revise the collaborative’s
mission statement and recruit additional members.

         When asked about what the function of the Steering Committee was when they were
initially asked to serve, a sub-sample of current members interviewed in early 2007 consistently
replied that the purpose of the Steering Committee was to discuss emergent issues in the county,
identify those issues that should be brought before the broader Collaborative, and set the agenda
for meetings. They also agreed that the Steering Committee does in fact serve this function.
Members interviewed also remarked that they enjoyed participating in the Steering Committee
because it brought together key stakeholders with the express purpose of exchanging ideas,
finding common ground, and enacting collaborative solutions. While many of the Steering
Committee members interact on a weekly if not daily basis on critical health care issues, they
stated the tenor and goals of the Steering Committee meetings facilitated joint solutions over
organizational self interest. They all felt that projects of the Collaborative, including the work
being done on the nursing workforce, homelessness, and the coverage initiative, were directly
attributable to the actions of the Steering Committee. Minority dissenting opinions, however, felt
that the Steering Committee was oriented toward addressing issues that would affect the
financial interests of the organizations represented at the meeting. In attempt to act equitably, the
Steering Committee moves in the most conservative directions. One respondent felt that this
tendency toward addressing the underlying financial stake for member organizations might be
addressed by changing the composition of the Steering Committee by including more community
representatives.




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Workgroups
         Following the first Steering Committee’s recommendation to develop an adult health
initiative, the collaborative focused its efforts on designing geographically based projects. The
subsequent work then fell to the purview of the first three work groups formed within the LA
Health Collaborative.

Group 1: Data Workgroup
        The purpose of this workgroup was to build a shared information base and analytic
capacity about the health, health needs, and health resources for low-income adults to the LA
Health Collaborative. The workgroup met four times to identify existing data resource and how
best to make health information widely available to Collaborative members. The Data
Workgroup gathered input from Collaborative members about their data needs through
administration of a Health Information Resource Survey. The information from the survey
helped to shape the dissemination of resources through the LA Health Collaborative section of
the LA Health Action website. Aside from gathering input used to develop LA Health
Collaborative web resources, the data workgroup provided the information that was the basis for
selecting the sites for the geographic demonstration projects.

Group 2: Technology Workgroup
        The purpose of this group was to identify and promote technology solutions to improve
access to and quality of care for low-income adults. The group was given the charge to identify a
particular health issue that could demonstrate the improvements in health that could result from
expansion of existing technology solutions. The group met once to brainstorm the scope of their
work and determine next steps. With the emergence and momentum gained by the Health-e LA
Coalition working toward a coordinated electronic health care information exchange system in
Los Angeles County, the technology workgroup focused its activity on implementing the
recommendations the Data Workgroup on the health information web portal. The website
occupies the first entry on a Google search for “LA Health Action” as of May 2007, and has had
over 28,000 unique visitors since its launch in December 2005. However, “LA Health
Collaborative” does not appear in the first three pages of a Google search. For more detailed
information about LA Health Action website usage please see appendix C.

Group 3: Geographic Focus Workgroup
        The purpose of this group is to build a full spectrum of resources– public, private, and
community– to bear on a health issue in a specific geographic region in LA County. The
workgroup met at least five times to articulate guiding principles on how geographic areas,
health issues and projects would be selected. On April 6, 2004 the workgroup decided that the
health issues focus would be heart disease, diabetes and obesity. At their subsequent meeting on
April 13, 2004 potential geographic areas of interest were identified and then decided upon at the
fifth Collaborative meeting in May 2004.

       Long Beach and the Northeast San Fernando Valley were selected as implementation
areas. The workgroup led the work of conducting a detailed needs and resource assessment of
each community including identifying community leaders with whom to discuss project goals
and population needs. The workgroup was interested in funding projects at organizations that


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already demonstrated collaborative success that could integrate health care systems work and
primary chronic disease prevention.

Coalitions from Long Beach and San Fernando Valley submitted proposals to The California
Endowment in response to the prompting of the Geographic Focus Workgroup. Proposal review
followed The California Endowment protocol, with input from three members of the workgroup.
The California Endowment approved one grant to the Long Beach DHHS Long Beach Diabetes
Collaborative and another to the Valley Care Community Consortium Pacoima Diabetes
Collaborative totaling $862,000. Both projects have been transitioned to oversight and
supervision by The California Endowment program staff. LA Health Action staff, however,
continues to maintain linkages with The California Endowment staff involved with the projects,
monitoring and evaluating the projects and providing time at quarterly Collaborative meetings
for updates. The Valley Care Community Consortium Pacoima Diabetes Collaborative recently
presented its success, lessons learned, and future plans to the LA Health Collaborative in April
2007. The Long Beach DHH led collaborative is scheduled to present its experiences at the July
2007 LA Health Collaborative quarterly meeting.

       Since the formation of the three workgroups dedicated to the establishment of regional
demonstration projects, additional workgroups have been created to address emergent as well as
long-term issues affecting LA County.

Group 4: Governance Committee
       This committee was formed to respond to growing concerns over the administration and
management of the LA County health care system. The purpose of the committee is make
recommendations on how to make administrative improvements to the LA County health care
system. The committee met for the first time in January 2006. It has sponsored forums and
information sessions related to separating public health from LA County DHS and other
governance issues, including a review of a memorandum of understanding between the LA
County DHS Personal Health and Public Health.

Group 5: Post-waiver Expiration Strategy Committee
        This group was formed to advocate on behalf of LA County safety net providers to
ensure an adequate amount of funding from state and federal sources is directed to the county. It
has worked mainly on two issues: hospital financing and Medi-Cal redesign. It is no longer
actively meeting, with many of its members contributing to the work of the Steering Committee.

Group 6: Homeless Initiative
        In response to countywide movement to better deal with homelessness in LA County and
especially in downtown LA, the LA Health Collaborative first began a discussion on how to
become involved in the larger effort in the county at its December 2005 meeting. At that
meeting, a workgroup was formed to examine in greater detail how the LA Health Collaborative
could become involved in the homeless initiative. LA Health Action took first steps by taking an
inventory of current efforts around homelessness and by becoming an active participant in
multiple collaborative efforts to address homelessness. The LA Health Collaborative hosted a
discussion panel at its April 2006 meeting and continues to update members on developments in
the area of homelessness prevention. There is no formal workgroup addressing the homeless


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issue. The county Department of Health Services, however, has asked if the LA Health
Collaborative would adopt its current homelessness collaborative as one of its workgroups.
Because there is no criteria for adopting outside groups as collaborative workgroups, the Steering
Committee has decided to wait on accepting the request from DHS.

Group 7: Nursing Shortage
         The nursing workforce shortage was first addressed at the April 2006 meeting in a
presentation by consultant Peter Harbage. The presentation was followed up with workgroup
meetings on May 15, June 15, and August 8 as well as a panel discussion at the larger LA Health
Collaborative meeting in July 2006. The workgroup continued to meet through the summer and
the fall of 2006 to discuss data, best practices, and the development of a career ladder program
for nursing education. The Career Ladders Subcommittee has been particularly active in its work
to improve the access to careers in nursing and other allied health professions. It hosted a county-
wide Strategic Discussion on April 4, 2007, to begin the development of a joint plan to alleviate
the shortage by addressing academic preparation and career counseling, lack of capacity in
coursework and education programs, and support for training completion.

Group 8: Coverage Initiative Workgroup
       This workgroup formed in response to the statewide request for proposals that established
a competitive funding process through the Coverage Initiative, a provision of the 2005 hospital
financing waiver. The workgroup ultimately came together to influence and shape the LADHS
proposal submitted to the state. The Coverage Initiative workgroup is highlighted as a case study
and a detailed list of activities can be found in Appendix F.

Member Perceptions of Structure and Function
        Yolanda Vera is viewed as an effective leader and the workgroups are recognized as
useful vehicles to execute Collaborative decision-making. Besides identifying Yolanda as the de
facto leader and the existence of workgroups, there is no clearly perceived organizational
structure. One respondent described the structure as “very loose, coordinated by Endowment
staff.”

        Participants expressed awareness of difficulties that are common to working within a
collaborative process, including designating criteria for membership, lack of clarity regarding
processes to setting the agenda or organizational priorities and the tension between managing a
collective process and moving decision-making forward. One respondent summarized this point,
saying

       “I had understood at times that the goal was to try to figure out some way to, for
       multiple parties to collaborate on a broader policy, financing, operational
       agenda. That all sounds nice, but when everyone goes home, they all got their
       own institutional demands.”




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PARTICIPATION

        There are various opportunities for member participation in the LA Health Collaborative
ranging from general meeting attendance to taking an active role in workgroups. Because
membership to the LA Health Collaborative requires no formal commitment, participation varies
from meeting to meeting. Meeting attendance was initially marked by participation of
organizational leaders and shifted to lower level staff representatives as the collaborative faced
difficulty identifying its purpose and accomplishing tangible victories. Organizational leaders
engaged in the work of the workgroups, however, tend to remain active Collaborative
participants.

        Members identified several tangible benefits regarding LA Health Collaborative
participation. Attending meetings is an easy way to stay in touch with organizational leaders.
Members also view the Collaborative as an effective platform to exchange information and an
informational source about current issues that impact county public health and service delivery.
One respondent added of the Collaborative,

       “I think it has… certainly improved the quality of the dialogue.” As a result, members
       find it helpful to be plugged in to what is going on in various LA communities. Attending
       meetings raises organizational visibility, including the work of Los Angeles County DHS.
       It allows for cross talk between organizations regarding their work, provides a place to
       rally support, and serves as a communication vehicle and tool for “soft marketing.”

       Members experience various challenges to participation. Conflicting priorities and
schedules often make meeting attendance difficult. The structure and leadership of the
Collaborative is sometimes unclear to participants, hindering involvement and taking initiative to
assume active roles. A lack of an eminent or looming crisis is also viewed as making organizing,
member participation, and delineating roles difficult. Finally, there is little information flow
between staff within participating organizations regarding meeting content.

        Members suggest that participation is influenced by how directly connected collaborative
efforts are to the work of their home organizations. Greater participation may occur if the
collaborative engages in active policy making, builds a broader base of organizational support,
develops a separate identity from LA Health Action, and expands their work beyond information
sharing.


ACTIVITIES

        Collaborative activities revolve primarily around convening and information
dissemination functions, though it has also engaged in legislative testimony, letter writing
campaigns, and commissioned reports and studies. All member meetings are held quarterly while
workgroups meet as needed. The Steering Committee has started monthly phone meetings and
quarterly in person meetings. These various meetings sometimes generate additional activities
and tasks that are executed by one of the existing work groups or will spur the formation of a
new work group. Information is disseminated through the LA Health Collaborative presentations


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at meetings, special workshops, a listserv with 213 subscribed members as of March 2007, and
the website.

       The activities that members have found particularly useful include networking among
organizational representatives and leaders who would otherwise remain inaccessible to members,
and hearing presentations from high level state officials including former and current LA County
Medical Officers Tom Garthwaite and Bruce Chernoff, respectively, Kim Belshé and Jeff Flick.

   Other activities include:
   •  Expanding Collaborative membership to the business and faith-based community
   •  Recommending regional geographic-focused demonstration projects
   •  Medi-Cal redesign debate activity
   •  Joint letters regarding Medi-Cal redesign
   •  Series of meetings around how to bolster the health care safety net after the expiration of
      the 2000 waiver extension
   • Mark up of an MOU on creating the separate public health department
   • Meetings to discuss county governance and the separation between health authority from
      board of supervisors
   • Launching the LA Health Action website highlighting the work of the Collaborative and
      providing an information and resource portal
   • Working closely with the Steering Committee on the Future of King-Drew Medical
      Center. The King-Drew Medical Center closure threat was a primary topic of focus
      during many meetings in an effort to provide solutions to the King-Drew crisis.

A summary and detailed list of activities is available in Appendix B.

ACCOMPLISHMENTS

       The LA Health Collaborative has created a forum for timely information dissemination in
the form of their website, list serve, and presentations from local, county and state
representatives. These same forums also provide an opportunity to meet other stakeholders and
network across organizational lines. In addition to these functions, however, the LA Health
Collaborative has had other accomplishments stemming from a diverse range of activities.

        One of the important accomplishments of the LA Health Collaborative has been to open
opportunities for and rally members to provide testimony to legislative bodies. LA Health
Collaborative members have worked through the collaborative to provide legislative testimony to
the Assembly Select Committee on the LA County Health Care Crisis and Assembly Health and
Select Committee Hearings on the Pricewaterhouse Coopers audit of the Section 1115 waiver. At
a local level, the LA Health Collaborative worked closely with the Steering Committee on the
Future of King/Drew Medical Center through difficult times and consulted with the LA County
Board of Supervisors on issues related to county health care governance.

        The LA Health Collaborative has also supported the production reports, studies, and
policy briefs by LA Health Action that address health care safety net issues for public
dissemination. Through LA Health Action, the collaborative funded a report on the LA County


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safety net financing and a study on the service implications of downgrading of King/Drew
Medical Center to a community hospital. It has also produced policy papers and briefs on the
economic and health impacts of the Section 1115 waiver and the implications of the proposed
separation of Public Health from LADHS.

         The LA Health Collaborative provided consultation to The California Endowment
in its funding activities, suggesting and reviewing two adult chronic disease projects
focusing on diabetes and obesity. The collaborative also informed a community
mobilization effort in South Los Angeles.

        Though difficult to measure, the policy activity and products stemming from the LA
Health Collaborative has had an impact on member organizations. Evaluation respondents report
that these accomplishments have had an affect on the activities of their home organization. None,
however, could make a direct association between the work of the LA Health Collaborative and a
concrete program or position of their organization. The following quote typifies how respondents
see the impact of the LA Health Collaborative’s activities:

       “And since then, though, [my organization has] taken some health care positions
       that were strongly influenced by the Collaborative’s perspective. The two major
       ones are first, supporting the separation of the county personal and public health
       departments and the second being supporting an independent health authority.
       And both of those were strongly influenced by Collaborative members who spoke
       before our health care committee meetings”.

A comprehensive list of LA Health Collaborative accomplishments can be found in
Appendix D.

Intangible Success
        Much of what the LA Health Collaborative has accomplished – increasing
familiarity and trust among stakeholders, creating an environment for an open exchange
of ideas – is intangible and difficult to measure. Evaluation respondents describe the LA
Health Collaborative as a neutral, non-threatening venue conducive to frankly and openly
discussing opposing opinions regarding health care delivery issues. In an ever-changing
policy landscape it is critical to not only share information but also constructively share
opinions regarding policy implications.

        “It’s become a place where tough issues get presented in a forthright way. And
       that, you know, people stand up and agree to disagree in that forum but
       respectfully present their points of view”.

        The intangible accomplishments of the LA Health Collaborative, and the difficulty
measuring them, are not lost on collaborative members. Several members acknowledged the
unique purpose of the LA Health Collaborative and the atypical nature of the defining “success”
in a process-oriented initiative.




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        “I value what the Collaborative is trying to do. It’s not an easy task. But I think
       the county is better of for having an organization attempt to do what they’re
       doing. Whether they have any success that they can measure and put out on a,
       broadcast out there, I don’t know. But I think some of their successes are
       unquantifiable”.

        The LA Health Collaborative is a loosely organized, broad-based collaborative
made up of over 70 organizations. It is led by a Steering Committee though LA Health
Action is charged with a large proportion of the work that goes into planning and
organizing quarterly meetings. Workgroups are the substantive action groups of the LA
Health Collaborative, working on both emergent and long-term issues affecting the LA
County safety net. Participation waxes and wanes based on a member organization’s
interest in a particular topic, though most organizations find the educational products
delivered by the LA Health Collaborative to be useful when accessed. Quarterly meetings
also provide an opportunity for networking. Through its wide-ranging activities, the LA
Health Collaborative has achieved many accomplishments and is a useful forum for
participants even if it has not yet achieved its intended purpose. Respondents are
indirectly aware of this, remarking that, in addition to the benefits of participating in the
collaborative, it has unmet potential as well as improvements that can be made to make it
more effective in its current activities.




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                               BENEFITS AND CHALLENGES

        As demonstrated earlier, the LA Health Collaborative has engaged in a wide range of
activities from providing the spark for regional demonstration projects to holding educational
meetings and workshops. The degree to which these activities have benefited member
organizations varies based on relevance to any one organization’s mission, though organizations
continue to participate in quarterly and workgroup meetings because there is some added benefit.
The stated benefits for participation are generally process-oriented, based in opportunities for
education, dialogue, and networking. In addition to benefits, participants also stated clear
challenges facing the collaborative. Lack of a clear, overarching purpose and decisive leadership
as well as internal differences of self-interest are the three major challenges the LA Health
Collaborative must address for greater effectiveness.

BENEFITS

Information
         LA Health Collaborative participants state two benefits to meeting attendance and being
on the LA Health Collaborative listserv: access to current information and networking. The
Collaborative website, list serve and meetings provide access to information and analysis of
current policy issues facing safety net providers. Members viewed information dissemination as
a significant accomplishment of the Collaborative and repeatedly expressed its importance and
utility:

       “… I think the information dissemination is critical”.

       “So, you know, I think it plays an important role of focusing and highlighting
       changes that are going on and getting information out to people so they can
       participate and be knowledgeable about what’s going on”.

        Collaborative meetings were often referred to as a “one stop shop” for those interested in
discussing safety net health care issues. Conversations regularly involved a wider group of
interested individuals and organizations thereby improving the quality of the dialogue as this
participant suggested:

       “… A fair amount of useful conversation happened and involvement of a broader
       set of constituents in the conversation about King Drew happened as a result of
       the Collaborative”.

        Presentations and products sponsored by the LA Health Collaborative are viewed as
highly informative. Because of the broad range of topics covered in meetings, presentations are
not always directly relevant to an organization. When they are relevant, however, they are not
only informative, but judged to be of high quality. Said one respondent:

       “I think [the Collaborative has] really done an outstanding job identifying
       important issues and working them, analyzing them, you know, highly, highly
       professional and credible.”


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        Presentations at meetings by well respected health policy leaders and consultants
provided the basis for communication and dialogue that was highly regarded by Collaborative
participants. These opportunities often provide a foundation for understanding new and evolving
policy issues. For example, one member noted the importance of the dialogue around creating a
health authority:

       “…It’s right now working on getting people involved in the discussions around
       the separation of public health from the health department. I think that’s a really
       important thing. If the Collaborative wasn’t doing that, I’m not sure anybody else
       would be”.

        In addition to meeting presentations, participants gave favorable remarks about the
documents disseminated through the LA Health Collaborative listserv. Similar to presentations,
documents are not always considered directly relevant to an organization. Listserv recipients find
it helpful to have access to up-to-date information that many say would be hard to locate if not
distributed through the LA Health Collaborative. For example, one respondent said of the LA
Health Collaborative,

       “I think it’s good at getting information out although it’s sometimes, you know,
       endless. It could probably be packaged and done a little bit better. I think it’s,
       they try and make it timely so I can appreciate that.”

        The impact of the information provided to LA Collaborate participants is difficult to
assess. No respondents identified specific organizational actions that arose from information
received through the LA Health Collaborative, but active participants stated finding the
information useful.

Networking
        In addition to acting as a conduit for information, the LA Health Collaborative is
seen as a useful forum for networking. Building and nurturing relationships is a key
component of developing a coalition that is related to member satisfaction and
participation within a collaborative environment (Kegler et al, 1998; Rogers et al, 1993;
Wolff, 2001). This is echoed as Collaborative members expressed the important role the
Collaborative plays in fostering, deepening, and maintaining relationships among safety
net stakeholders:

       “Well, I think, you know, for me personally when I was able to be active, you
       know, just going to one meeting, I would see five or six people that I could touch
       base with and maintain relationships and have discussions and that was
       extremely valuable. You know, walk into a meeting where I can talk to Tom
       Garthwaite and Howard Kahn, and John Fielding and Jon Freedman and, you
       know, people from agency heads all in one place. So [I]think the meetings have
       served a good networking function in that respect”.




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        Participants find it helpful to be able to attend a meeting where multiple key stakeholders
are available for networking in one place at the same time. As one respondent said,

       “I think the advantages are getting to network with other stakeholders who
       typically wouldn’t be in a room together. If we are, it’s over at the Board of
       Supervisors generally and it’s not often on the same side of an issue. So it gives us
       an opportunity to network.”

       The opportunity to discuss current and upcoming policy issues at Collaborative
meetings has allowed for the genesis of spin-off projects stakeholders can engage in
outside of the LA Health Collaborative. One prominent example is that of a joint venture
to improve local area health information systems:

       “And I think, if I’m not mistaken, Health-e-LA, which is the e-health, electronic
       health records, had its birth at the Collaborative. I think that’s been very
       beneficial. And so yes, but I did not start that. I came in at the infancy stage. But
       that was [three members of the LA Health Collaborative]. And I believe they had
       their first initial conversation and meeting at the Collaborative”.

        Respondents also attended meetings to be able to hear presentations directly from and
potentially meet key stakeholders whose attention is otherwise difficult to get a hold of including
the director of LADHS and state-level officials. One respondent, referring to the LA Health
Collaborative, remarked,

       “[I]t is a place where we hear from the head of DHS. Or different health plans or
       the head of the associations for those health plans and hospitals. So it does bring
       together stakeholders very effectively.”

        The LA Health Collaborative has also been a place where like-minded individuals and
organizations have met to discuss collaboration on projects outside of the LA Health
Collaborative. For example, discussions around Health-e-LA, an initiative working toward
creating an electronic medical records system for Los Angels County, began with three
participants at an LA Health Collaborative meeting.

        There is consensus among not only LA Health Collaborative participants but non-
participants as well that a forum like the LA Health Collaborative does not exist elsewhere in
Los Angeles County. Its function as a forum where multiple stakeholders can convene to discuss
issues related to the county health system is seen as invaluable. The following comments
summarize this sentiment well:

       “[W]e have to keep it going because we have no other place to provide that sort
       of foundation. We need to have a place to anchor this thing, issues.”

       “I think it does have tremendous potential.”




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        Respondents cite the potential impact of the idea behind the LA Health Collaborative as
reason enough to continue convening in hopes that it will work through the challenges
confronting it to become more effective. Presentations given by Medical Officer Bruce Chernoff
and CEO of King/Drew Medical Center Antoinette Smith Epps at meetings show the continue
recognition and support the LA Health Collaborative receives from key stakeholders.
Respondents agree that an endeavor like the LA Health Collaborative requires patience on the
part of its conveners and an adequate amount of time to fully develop.


CHALLENGES

        While its merits as an information conduit and a forum for networking are clear, the LA
Health Collaborative also faces challenges as it moves forward and reaches its potential as a
significant voice on safety net issues in Los Angeles County. Three interlinked issues present
themselves in 2006 as major challenges for the LA Health Collaborative:

   •   Diffuse purpose
   •   Lack of directive leadership
   •   Internal conflicts of interest
   •   Defining membership

Lack of focus
        The early meetings of the LA Health Collaborative were process oriented and designed to
define the purpose of the LA Health Collaborative. Yet those meetings did not yield a definitive
mission statement or overarching sense of why the LA Health Collaborative existed. Though the
LA Health Collaborative adopted the Steering Committee’s recommendation to support
geographic pilot projects, it was not a part of a coherent LA Health Collaborative vision. Since
that time, the purpose of the LA Health Collaborative has been unclear and evaluation
respondents were quick to point this out. The following comment from an early meeting
attendant sums up the LA Health Collaborative’s purpose this way:

       “Well, it wasn’t clear at first at all. And I’d say it stayed, it remained unclear…”

Or, as another respondent said,

       “There’s been no specific goals and objectives other than to have a convening
       focus.”

The LA Health Collaborative is seen as not having a clear direction or issue which it is devoted
to. Respondents add that the Collaborative addresses issues as they arise without any clear
consistency as to why it chooses to address particular issues in its meetings. In October 2006 the
Steering Committee addressed this issue partially by approving a set of simple criteria to use in
considering new issues for the LA Health Collaborative. It is unclear if those criteria have been
formally implemented.




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Lack of directive leadership
       Respondents spoke highly of Yolanda Vera, finding her to be knowledgeable, open,
welcoming, and personable. They felt, however, the LA Health Collaborative as a whole lacked
an assertive and decisive leadership presence to move it toward a particular direction, set
agendas, make decisions, and give it the sense of purpose.

       “I think that, I really can’t point out anybody who I’d say are the major leaders of
       this thing.”


       As the quote below conveys, there is a feeling among participants that the LA Health
Collaborative is a project of The California Endowment and thus indirectly its guiding force:

       “There’s not any defined formal structure of decision making that I know of
       outside of the staff… It’s sort of a LA focused set of projects by TCE.”

        On the part of The California Endowment, associates would like to see the non-TCE
members of the LA Health Collaborative take ownership of the collaborative and move it in a
direction the group decides on without heavy influence from The California Endowment. This
desired outcome, however, would require an individual, organization, or group of individuals
and/organizations to step forward into a leadership position, moving away from the neutral
convening function that The California Endowment is uniquely positioned to serve. These
contradictory expectations continue to be a major difficulty for the LA Health Collaborative. In
between these competing perceptions and expectations, no individual or group has organically
become the recognized leader of the LA Health Collaborative thus far. The current Steering
Committee will need to fill that void and do so by deciding on a reshaped and realistic set of
concrete activities and strategies that provide a clear direction for the collaborative to move in.

Internal differences in self-interest
       The LA Health Collaborative was conceived as a broad based collaborative convened to
improve the safety-net health care system in Los Angeles County. With such an immense and
vague purpose for convening and a diverse group of stakeholders at meetings, conflicting
opinions over the direction of the LA Health Collaborative are inevitable. As one respondent
remarked,

       “Cause it’s very hard to get health care stakeholders to work together in
       communities because of competing interests and history and turf issues. And I do
       think that, you know, health care is so fractioned.”

       “And there’s kind of different factions, different impulses, conflicting impulses
       about what to do, safety net, Medi-Cal, providers, the county, advocacy groups,
       clinics, hospitals, all kinds of issues going on…”

       The depth and complexity surrounding the safety net health care system and the diversity
of constituents who have a stake in its evolution result in an equally wide range of opinions
about the issues and strategies the LA Health Collaborative should adopt. The advantage of


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diversity within the LA Health Collaborative is having multiple voices informing action items.
The drawback, more relevant to the LA Health Collaborative’s current situation, is an inability to
find enough agreement to move the LA Health Collaborative forward in any one direction. In
combination with a lack of purpose and strong leadership, the diversity of perspectives has
stalled the LA Health Collaborative at its current stage of development.

         The LA Health Collaborative has not achieved its planning table goal, and the challenges
it faces suggest that there are inherent contradictions in what the collaborative was supposed to
achieve and how it was set up to achieve them. The LA Health Collaborative was formed around
an amorphous purpose without clear leadership with the expectation that a naturally formed
purpose and leadership structure from within the broad-based membership would emerge. The
idea of an organically led and self-directed planning table to address the highly complex safety
net health care system in LA County with a large, self-interested and diverse group of
stakeholders which TCE envisioned, while an ideal type, may have held too many contradictions
to be tractable in its very design. The tensions within this vision for the LA Health Collaborative
indicate that either the structure of the LA Health Collaborative or the expectation of what it
should achieve need to be altered.




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                                    RECOMMENDATIONS

    Given the challenges faced by the LA Health Collaborative, either the expectation of what it
should become or its functional structure must be adapted in order to reach the potential
expressed by participants. Decisions regarding a readjustment of the expectations of the LA
Health Collaborative are beyond the purview of this evaluation. The Collaborative clearly serves
a unique and important role as a source of timely and unbiased information and place for
networking. If the goal of the LA Health Collaborative continues to be a planning table for the
county health care safety net, the current challenges the LA Health Collaborative faces are not
insurmountable Respondents expressed confidence that with the appropriate adjustments, the LA
Health Collaborative would be able to reach its potential. The following recommendations
synthesize comments from respondents in 2005-2006 three areas of modification for the LA
Health Collaborative:

   •   Develop a directive leadership group
   •   Identify and communicate a clear purpose
   •   Structure the LA Health Collaborative for effectiveness


DEVELOP A DIRECTIVE LEADERSHIP PRESENCE

       “[The LA Health Collaborative] needs a spark and it needs leadership.”

       “I think [the LA Health Collaborative is] going to need some strong leadership. I
       don’t think the bottom up thing works that well, not with something that is this
       polarizing.”

        Speaking mostly in general terms, respondents in 2005-06 felt that the LA Health
Collaborative needed a source of leadership that solidifies its identity and guides it towards a
clear purpose. LA Health Action has taken steps in this direction by forming the current Steering
Committee. As the Steering Committee moves forward setting the overall direction of the LA
Health Collaborative, it must maintain the goals and purpose stated in the mission statement at
the forefront of its decision making and action. One of its first activities should be to compare the
logic model presented in Figure 1 to the model of action in Figure 2 to decide if the current
functioning of the LA Health Collaborative is desirable or whether it should try and move back
toward the original intent behind the collaborative.

         In order for this to occur, the Steering Committee must continue to meet and develop
relationships among members that facilitate open, honest discussion. With consensus as the de
facto decision making principle for the Steering Committee, the relationships among members
must be strong enough to work through disagreements, find areas of common interest, and agree
on strategies of joint action. In selecting issues for joint action, the Steering Committee should
select issues with an existing degree of momentum and engage collaborative members in
concrete projects around those issues. The Steering Committee must not be afraid to lead the
broader collaborative with ideas and strategies, allowing for the larger group to have input and
modify recommendations from the Steering Committee.


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        Another consideration for leadership is to develop an Executive Committee made up of
chief executives of key health organizations in Los Angeles County to complement the work of
the Steering Committee. An Executive Committee would be made up of a small group of leaders
in the health care community who represent greater decision making authority than members of
the Steering Committee. While the Steering Committee would continue to bring issues before the
Collaborative and shape its direction, the Executive Committee would decide on and move issues
that the Steering Committee is too large and too divisive to agree on. The Executive Committee
would initiate plans of action and contribute organizational legitimacy and resources to specific
proposals coming out of the LA Health Collaborative. It would be particularly important for this
group to have very specific tasks, and perhaps meet only as needed, in order to sustain their
active engagement and buy-in.


EXPAND PURPOSE INTO STRATEGIES

       “I think there ought to be some thought given to… what [the LA Health
       Collaborative] is trying to accomplish at its meetings. Because certainly, you
       know, there’s value for agency heads to get, you know, simply to get together, but
       they’re not going to get together unless there’s a strong reason to do so.”

       Since its formation, a key accomplishment of the Steering Committee was the finalization
of an updated mission statement for the LA Health Collaborative:

       The LA Health Collaborative is a coalition of public and private organizations
       dedicated to preserving and improving the health care safety net and public health
       services in Los Angeles County. Our mission and vision is to serve as a health
       planning forum that fosters policy action plans and frames pilot projects toward a
       seamless, coordinated system combining safety net and public health services in
       support of the region's vulnerable populations.

Other than announcing the mission statement to the broader collaborative, the mission statement
has not explicitly informed the activities of the LA Health Collaborative. The Steering
Committee should take the mission statement and develop it into a series of strategies and
actionable steps for the collaborative to engage in. Instead of responding to emergent issues, the
collaborative should consider proactively addressing issues. The Steering Committee is primarily
responsible for developing appropriate strategies for the collaborative and should select at least
one issue that has a degree of urgency associated with it to launch the collaborative into action.
The Steering Committee developed criteria for selecting issues to engage and ought to utilize
them to form a strategic plan. Issue selection, strategic planning, and the accomplishments of the
LA Collaborative should be clearly and regularly communicated to the collaborative to maintain
interest and encourage broad based participation.

Issue selection must also be specific. Broadly focused efforts do not work to initiate change. In
order to move a group on an issue, it must be specific, even at risk of losing the support of some
members. An inverse relationship exists between the specificity of an issue and the breadth of


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support it will elicit. Instead of working on issues with the breadth to gain support from a vast
majority of Collaborative members, specific issues that can be acted on should be selected for
joint action even at the risk of losing support from some members.


STRUCTURE THE LA HEALTH COLLABORATIVE FOR EFFECTIVENESS

       “And we’re not in the format, in which we come together doesn’t lend itself to
       [open and honest discussion].”

       “In the organizations or stakeholders that are represented, it’s not clear to me,
       because I don’t know, whether it has any recognition from the County, which
       would be I think an extremely useful thing.”

        The LA Health Collaborative would benefit from structural adjustments to facilitate an
action agenda. First, personal relationships are the foundation for effective professional and
working relationships. Establishing personal relationships within the LA Health Collaborative
should become a higher priority. Personal relationships should be fostered in meetings by
providing for more interaction and by the leadership group through small, one-on-one meetings
to “sell” the vision of the LA Health Collaborative and frame its activities to incentivize
participation. Larger group gatherings that are more interactive should also be hosted by the LA
Health Collaborative for participants to become better acquainted with one another. The higher
level of comfort participants feel with each other will facilitate engaging in honest discussion in
the large LA Health Collaborative meetings and working together on projects.

        Additional opportunity for discussion must be built in to all meeting agendas. Meetings,
especially the large general meetings, should be simplified, reducing the number of informational
activities and allotting more time to discussion and debate over issues presented. A greater
emphasis on discussion will rely on building interpersonal relationships as well as raising the
level of comfort and expectation among participants with respect to their investment of time and
dialogue. Difficult, potentially contentious, discussion and disagreement among meeting
participants should not be avoided but encouraged and facilitated to reach mutual understanding
and areas of common interest. Discussions should have as their intended endpoint action items
for the collaborative to move on, even if action items cannot be agreed on.

        LA Health Collaborative meetings should incorporate regular evaluative measures to
continually assess the utility and direction of meetings. Multiple evaluation measures, including
evaluation sheets at meetings, online surveys, and periodic conversations with collaborative
participants, can be implemented to provide on-going feedback to the Steering Committee. The
LA Health Collaborative should also obtain additional sources of funding to diversify its funding
base. This will allow the collaborative to engage in a broader range of activities and adopt
stronger positions on critical health issues. With the ability to adopt positions in its advocacy, the
LA Health Collaborative would have greater freedom to engage in activities that will engage
collaborative participants.




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         Collaborative work is time and labor intensive. A broad based effort like the LA Health
Collaborative requires sustained and committed staff to develop the relationships that provide the
foundation for joint action. It requires more than the current level of LA Health Action staff time
(approximately 1 FTE spread across three persons) to be devoted specifically to the
Collaborative, especially if there is an effort to move it forward in a different direction.
Nurturing existing and making new relationships, maintaining subject matter expertise, keeping
abreast of opportunities for joint action, and overseeing tasks to completion are all part of the
staff work of the Collaborative. Staff committed to the LA Health Collaborative should include
at least one FTE high level FTE dedicated to the project, along with a comparable level of
support staff and budget for irregular peak staffing needs in order to command the attention and
commitment of members to the work of the Collaborative.


REVIEW OF LITERATURE

        The recommendations provided above are consonant with findings from other research
on collaboratives. Effective leadership and a clear mission are the two most frequently cited
characteristics of successful collaborative initiatives (Butterfoss and Francisco, 2004; Fawcett et
al, 2000; Roussos and Fawcett, 2000; Wolff, 2001; Kegler et al, 1998). Leadership is the most
often reported internal factor needed for successful collaborative initiatives. Key competencies
include communication, negotiation, and networking. Framing and communicating the vision of
the partnership is also a key function. Leadership research has identified five leadership elements
in successful collaboratives: systems thinking to create a framework for action, vision-based
leadership, having a group outside of the formal leadership assume key responsibilities, sharing
power with constituents, and operating under a process-based leadership model which
emphasizes communication and interpersonal skills (Alexander et al, 2001).

         A clear focus is also one of the most significant contributors to successful collaborative
efforts. While most collaboratives form around a specific vision or purpose, some never develop
one (Roussos and Fawcett, 2000). The focus must be clear in order for people to understand what
they are or are not becoming involved with. It must be developed with influential leaders and
those experiencing the issue or concern in question. The vision and mission of an organization
must also be revisited and revised periodically.

        Creating an action plan (Roussos and Fawcett, 2000), identifying clear opportunities for
partnership, and having members understand their roles (Chervin et al, 2005; Wolff, 2001) are
also important elements of successful collaboratives. Action plans are a blue print for the
collaborative to follow, setting the course to achieve the mission. They include the actions that
will bring about the desired change, who will take those actions, when they will be done, and
what resources will be necessary to get the job done (Fawcett et al, 2000). Without an action
plan, collaboratives lack direction and have a lower likelihood of affecting change. Chervin et al
(2005) have shown that a benefit to collaborative success is helping participants identify
opportunities for partnership and to encourage partnerships. Chervin et al. also found that unclear
role designation for collaborative participants leads to attrition from a collaborative. Getting
organizations and agencies involved in activities relevant to the collaborative’s purpose in a
meaningful way is a crucial element of success.


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        Twenty years of coalition practice and research is synthesized within Community
Coalition Action Theory (CCAT) and provides a useful framework for current coalition work
including that of the LA Health Collaborative. CCAT suggests that coalitions evolve through a
series of stages that influence its ability to attain coalition goals. Each stage is related to tasks
and functions that are often used as markers of effectiveness (Butterfoss et al, 1996; Goodman,
1998).

        CCAT posits that formation, maintenance, and institutionalization are key developmental
stages. The theory also asserts that the lead agency influences coalition membership, which
develops coalition operations, leadership, and structures. And, that increased pooled resources
and member engagement lead to increased assessment and planning. Together these factors
positively influence implementation of coalition strategies (Butterfoss and Kegler, 2002).

         The formation stage is concerned with establishing a core group that will recruit partners
(including staff) and develop processes to guide coalition work (Butterfoss and Kegler, 2002).
Important characteristics at this stage include coalition member satisfaction, member
participation and commitment and the quality of action planning. Member satisfaction is
correlated with increased commitment that contributes to the longevity and capacity of a
coalition. Studies have shown that competent leadership and shared decision-making are also
critical factors that influence member satisfaction and participation. In addition, linkages with
other organizations, a supportive group environment, communication, and benefits of
membership outweighing costs are related to satisfaction and participation among coalition
members (Kegler et al 1998).

         The maintenance stage of coalition development is concerned with sustaining member
involvement and moving from assessing community needs to implementing coalition strategies
to address identified needs. Mobilizing and pooling resources are critical to success at this stage.
Other important characteristics that positively impact this stage include strong leadership to form
an independent coalition vision and effectively deal with conflict, skillful staff with devoted
work time and access to technical assistance, frequent and productive communication, clearly
defined roles and procedures and coalition complexity (as defined as the number of functioning
committees and task forces). Barriers to this stage include lack of community organizational
skills, turnover of staff, and over dependence on technical assistance (Kegler et al 1998).

        As the review of the literature shows, the obstacles currently facing the LA Health
Collaborative are consistent with those faced by other collaboratives. The suggestions made by
collaborative participants are consistent with characteristics seen in other collaborative efforts.
The first two recommendations – developing directive leadership and identifying and
communicating a clear purpose – are needed to establish the direction of the collaborative. The
second two – articulating a decision making process and structuring the collaborative for
effectiveness – will help the LA Health Collaborative move in that established direction. With all
four recommendations, a significant amount of time and energy are needed to develop the inertia
necessary to redirect the collaborative and to begin moving it towards its newly articulated
purpose. All four are crucial modifications to the underlying assumptions behind the LA Health
Collaborative’s original design needed to move it in its original direction.


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                                         CASE STUDIES

        In addition to the professional literature on collaboratives, case study comparisons were
conducted to glean “real world” lessons from currently active collaboratives and coalitions in
California. The case studies identify how key challenges faced by the LA Health Collaborative
have been dealt with by other collaboratives. Four collaboratives/coalitions were selected as case
studies: the Proposition 63 signature gathering effort in Los Angeles County, the Children’s
Health Initiative of Los Angeles County, the Alameda Access to Care Collaborative, and the
Dental Health Coalition for Needy Children. The case studies were selected because they
represent a range of geographic areas, convening foci, and size. A short description of each is
presented below followed by unifying themes across the case studies that shed light on how the
LA Health Collaborative might be reconfigured for the future.


PROPOSITION 63 SIGNATURE GATHERING – LOS ANGELES COUNTY

        Proposition 134, a tax on liquor to fund mental health services as well as other social
services in California, was soundly defeated by a ratio of approximately 2 to 1 in 1990. Despite
efforts by the mental health community to increase their funding base, the liquor industry spent
millions of dollars to oppose the proposition, making it the most costly initiative on the 1990
ballot. Despite the defeat of Proposition 134, the state legislature allotted $10 million dollars to
provide services to homeless mentally ill and mentally ill individuals at risk of incarceration in
Los Angeles, Sacramento and Stanislaus counties California Assembly Bill 34 (Steinberg) in
1999.

         Though AB34 provided a much needed financial boost for mental health services in
California, it was dependent on state budgetary constraints. Following increases in funding in
1999 and 2000, it became apparent in successive years that additional funding for mental health
services in the state budget would not continue. In response, discussions between Assemblyman
Darryl Steinberg and the California Council of Community Mental Health Agencies began to
revisit the idea of a statewide proposition to fund mental health services.

         The California Council of Community Mental Health Agencies allotted money from its
reserves and urged its member organizations to put in money to pay for a consultant and early
polling to examine the viability of a proposition. Through polling and focus groups, it became
clear that there was broad based support for the idea of increased funds for mental health
programs. The next step in shaping the proposition identified a tax on the wealthy as the funding
source. By the summer of 2003, stakeholders began engaging in a process of refining the details
and language of the ballot initiative. Assemblyman Steinberg’s staff worked with the California
Council of Mental Health Agencies to write draft versions of the legislation which was then sent
on to key stakeholders in the mental health community. Stakeholders engaged in a process of
negotiating the details of the proposition and its language, redrafting, and continued negotiation
until a final version was agreed upon by all major constituencies.

        When the wording was finalized, the LA County Department of Mental Health formed a
core planning group to coordinate the signature gathering of mental health agencies in the


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county. Chaired by Areta Crowell, former director of LA County Department of Mental Health,
the core planning group created a forum for agencies to come together, share strategies, and learn
of other agencies’ signature gathering activities. The Mental Health Association of Los Angeles
played a primary leadership role in the signature gathering effort. It devoted staff time to support
the core planning group and played a major role in challenging and encouraging other agencies
to get involved. Pacific Clinics, SEIU Local 660, and local NAMI chapters were highly involved
in gathering volunteer signatures and donating money for paid signatures.

        The signature gathering process proceeded as a loosely coordinated effort by each agency
doing what it could to gather as many signatures as possible, be it through sending out
volunteers, hosting events, or donating money for signature gathering. Level of involvement in
the signature gathering process among agencies in the county varied. Those who were more
involved were attributed as having leadership that understood the broader vision Proposition 63,
was more aligned with the concept of wrap-around mental health services, and saw the benefit of
the funds that might come from the proposition. With the necessary signatures, an ad campaign
was created under the supervision of a consultant and Proposition 63 passed, providing a stable
and increasing large pool of funding for mental health services in California.


CHILDREN’S HEALTH INITIATIVE OF GREATER LOS ANGELES

        With funding from Proposition 10 available to address a wide range of activity in early
childhood development, First 5 LA sought a partnership with LA Care to increase health care
coverage for children ages zero to 5 as a part of strengthening the safety net. Following the
models to increase health care coverage for children in other counties in the state and a desire on
the part of First 5 LA to see increased access to care for 6 to 18 year olds, LA Care initiated
discussions with The California Endowment and the Los Angeles County Department of Health
to convene a coalition of key stakeholders in Los Angeles County Department of Health Services
(LADHS) to work towards increasing access to health care for older children.

        As the co-conveners of what would become the Children’s Health Initiative, head
executives at LA Care, The California Endowment, and Los Angeles County DHS committed
their own time and organizational resources to lay a foundation for the coalition to be formed.
LA Care and LADHS provided critical staff support, The California Endowment and LA Care
provided significant funding for start up and maintenance of the coalition and its activities, and
the head executives at each of the three organizations were personally involved in the coalition.
Providing early leadership, LA Care, The California Endowment, and LADHS outlined the
overall goal of the coalition: to expand health care coverage to children without health insurance,
with the long term goal of 100 percent coverage for all children.

        With this overarching goal, the Children’s Health Initiative held its first meeting in June
2004 with the co-conveners and nearly 50 other local agencies. In early meetings, the coalition
worked to refine the group’s overall purpose and to identify a series of strategies to accomplish
its purpose. Numerous issues, such as what types of coverage packages to offer, how many
children to aim to cover, where to look to secure funds, what programmatic components would
be needed, and what the resultant long range policy action would be were discussed. The


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coalition also addressed the issue of organizational structure, deciding not to incorporate into an
independent non-profit and choosing to exist instead as a loose coalition. Working on a decision
making principle of consensus, three workgroups were formed around policy, program
integration, and fundraising. Workgroups met approximately twice per month on their specific
issues and presented their recommendations to the larger coalition at monthly large group
meetings. Recommendations were discussed in the meetings until consensus was reached on how
to proceed. Meetings were chaired by the CEO of LA Care, who acted as the de facto leader and
facilitator of the coalition meetings.

       In order to facilitate on-going activity of workgroups and coalition meeting decision-
making, a steering committee was formed as a sounding board for workgroup recommendations,
for workgroups to report on their progress, and in order to make decision between coalition
meetings as needed. The steering committee is made up of the chairs of the workgroup, head
executives at LA Care and The California Endowment, and 2-3 other key coalition members.

        The work of the Children’s Health Initiative has been extremely successful. They have
enrolled 42,000 children, demonstrated increases in utilization and declines in barriers. With
regard to the coalition itself, participation in monthly meetings continues to be high, and
organizations continue to send top-level executives to meetings instead of staff members.
Workgroups remain active as the coalition enters its third and final year of its initial plan. The
high level of participation and commitment, both now and early on, has been attributed to the
clarity of its goal, early progress of the coalition toward its stated goal, availability of early funds
for the initiative, visible success, and the alignment of member organizations’ philosophy to that
of the coalition. With its success however, it will need to engage in a discussion of how to
reshape its purpose and reorganize its membership accordingly, as well as find early success in
its reshaped purpose.


ALAMEDA ACCESS TO CARE COLLABORATIVE

        Asian Health Services and La Clinica de la Raza were recipients of the Community
Voices grant from the Kellogg Foundation to strengthen community support services and the
local health care safety net. The five-year, multi-million dollar grant was focused specifically on
community-based solutions to increase access to care for immigrant families. Part of the grant
was an attempt at creating a broad partnership between the two grantees, the Alameda Health
Consortium, and the local health department to address safety net issues. Early work in this
broad partnership raised an awareness of the need to include other stakeholders that made up the
broader county health system into a forum to think strategically about how to impact the county
system as a whole. With additional funding from a Communities in Charge grant through the
Robert Wood Johnson, the Alameda Access to Care Collaborative brought together Asian Health
Services, La Clinica de la Raza, Alameda Health Consortium, Alameda Alliance for Health,
Highland Hospital, and the Alameda County Health Care Services Agency.

       The Alameda Access to Care Collaborative was formed as a table where top executives
could convene and think strategically about how to increase access to care for low-income
residents in Alameda County. The Alameda Collaborative adopted a structural perspective,


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trying to identify innovative solutions to systemic problems. The Alameda Collaborative has a
rotating chair with a one-year term that works with program staff (funded through external
sources) to form the agenda and move the group forward. Instead of formal work groups,
Alameda Collaborative participants volunteer to take the lead on different activities with the
assistance of Alameda Collaborative staff and another Alameda Collaborative participant as
needed. Group action occurred after dialogue during meetings and side conversations between
meetings resulted in agreement about the appropriateness and feasibility of an idea. Under this
structure, the Alameda Collaborative accomplished a number of objectives, including:

           •   Establishing Family Care, a health plan targeted to the families of low-income
               children
           •   County of Alameda Uninsured Survey 2000
           •   Frequent Users of Health Services Project
           •   No Wrong Door Project
           •   Bringing county health care stakeholders to take unified positions on health care
               policy

        The Alameda Collaborative was also critical in equalizing the power relationships among
participant organization. With its early success and turnover in leadership of member
organizations, the Alameda Access to Care Collaborative meetings moved away from their
strategic thinking and planning purpose to program administration and updating beginning in
about 2004. This led to the replacement of organizational executives by staff members at
Alameda Collaborative meetings and a less strategic focus to the Alameda Collaborative as a
whole. With the CEO of Asian Health Services assuming the chair position, the Alameda
Collaborative held a retreat in October 2005 to reestablish its strategic focus and elicit the
commitment from the heads of key organizations that make up the county health system. Coming
out of the retreat, the Alameda Collaborative decided to narrow its membership back to
organizational executives and reshaped its purpose to focus on improved system integration and
coordination of care within the county.

        The success of the Alameda Collaborative has been attributed to a number of different
factors. One, Alameda County is of a size that is manageable with distinct group of key
stakeholders. Two, there has been a history of funder-mandated collaboratives which provided
this collaborative with prior experiences of collaboration to build on. Three, the county as a
whole is a more progressive and liberal environment to push reform. Four, many of the leaders
have been working in the county for a long time and have established working and personal
relationships for Alameda Collaborative relationships to build on. The Alameda Collaborative
has been able to engage key stakeholders by being the only forum for leaders to think
strategically about the county system at large. Participants find it a welcome opportunity to
escape the present-focused, programmatic activities of their home organization or the crisis
orientation of other workgroups. The Alameda Collaborative also makes an effort to reach out to
and engage incoming leaders of key organizations to familiarize them with the Alameda
Collaborative and ask for their participation.

       As the Alameda Collaborative moves forward, it faces a number of challenges. First is
the changing state financial condition and willingness to increase funding for health care access.


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Declining state funds and the instability of foundation funding are a barrier to sustained
programming. The second is maintaining a high level of commitment from participants. The
knowledge and decision-making ability of key executives is critical to the strategic planning
purpose of the Alameda Collaborative. The third challenge is reaching a level of trust and
cooperation among Alameda Collaborative participants where people begin to sacrifice some
organizational self interest for the greater good. With a temporary loss of focus and turnover of
key positions at participant organizations, the Alameda Collaborative has to work toward
regaining the collaboration that led to earlier, tangible successes.


DENTAL HEALTH COALITION FOR NEEDY CHILDREN

         In 1992, a Los Angeles County health educator working in the Child Health and
Disability Prevention Program began to pull together county employees, including social
workers and health professionals, to address the pressing need of children’s oral health. The goal
of the health educator was to create a forum to discuss how the county might improve their
efforts at increasing the oral health status of children in Los Angeles County. As a part of the
effort, the health educator reached outside of the county system to create a broad base of support
from dental schools, private dentists, and grassroots organizations. Through networking and
personal relationships, he identified stakeholders from the wider dental community to form an
advisory group to shape the collaborative effort. Early efforts of the informal collaborative group
were aimed at a fluoridation campaign for the county. As the efforts of this informal group
focused on the county waned, the advisory group that had been formed continued its convening
function as the Dental Coalition for Needy Children.

        The Dental Coalition for Needy Children was established in 1994 to increase access to
dental care for children in Los Angeles. It was founded as a project of Community Partners
where it continues to be housed. It is a loose network of stakeholders concerned with the oral
health of children in Los Angeles County. Its members come from a range of organizations
including dental school, grassroots organizations, community dental clinics, and schools. An
advisory of approximately 5 people shape the overall direction of the coalition, deciding which
issues to take up, members to engage, and strategies to employ. The activities of the coalition
have expanded from its early advisory role to convening meetings for information exchange and
networking, disseminating up-to-date information among members through the internet,
providing support to member activities such as health fairs, holding continuing education
trainings, maintaining a current database of dental clinics, and taking positions on oral health-
related legislation. It has been successful in its current activities through the reputation of its
advisory committee members. The advisory committee is made up of long-standing, well
respected oral health activists who, when they ask, are able to garner the support of coalition
members out of respect. The coalition is also careful not to overburden its member organizations,
selectively engaging members on an issue by issue basis. In general, the coalition can best be
described as a reactive group, responding to oral health issues under the direction of the advisory
committee as they arise but not proactively engaging stakeholders to further an agenda.

       The coalition has recently been trying to move from a reactive to proactive mode of
operation. Since the February 2006 report on children’s oral in California issued by the Dental


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Health Foundation, the coalition has been attempting to become more engaged in finding issues
to improve access to oral health care, discussing approaches to such as promatoras, increasing
the scope of work of dental hygienists and dental assistants, tax deductions for dentists to see
Denti-care patients, and increasing funding by introducing a ballot measure to enact a soft drink
tax. The challenges the coalition faces lay in the inability to secure funding for a full time
employee to coordinate the coalition’s activities. The current administration and maintenance of
the coalition is done strictly on volunteer time, as is member participation. Thus, the coalition
has no resources to commit to staffing or other activities. Another challenge the Dental Coalition
faces is the inherent divide within the dental community regarding the appropriate ways to
address children’s oral health needs. Established dental organizations exist primarily to protect
the interests of dentists and address oral health problems upholding that priority. In contrast,
members of the Dental Health Coalition are in the minority group, seeking to meet the needs of
children as their highest priority. Major foundations and other funding sources have not
committed major funds to improving oral health, limiting the financial resources available to
address children’s oral health. Thus, the coalition faces limits in power and funding to progress
towards its goal. It also has had a difficult time identifying a particular issue to address. The
coalition members are numerous and diverse, making it difficult to proactively select an issue
through consensus.


LESSONS LEARNED FROM CASE STUDIES

       Consistent themes emerged across all of the case studies that are informative for the LA
Health Collaborative. Though there are differences in purpose, composition, and structure,
commonalities exist among all of the case studies. Both contextual and structural factors allowed
each of the case studies to achieve their goals.

Contextual and structural factors
   Three contextual factors allowed each of the case study collaboratives to achieve their goal:

   •   Pre-existing relationships: The members that eventually made up each of the
       collaboratives had either personal or working relationships that helped to undergird the
       group effort. Collaboratives and coalition in many ways arranged and crystallized
       existing relationships in ways that met a particular need. As one respondent said of the
       role of personal relationships to collaborative efforts, “It’s essential. The personal
       relationships are essential.”
   •   Momentum: Each of the collaborative efforts built on an early momentum of other
       related activities, identifying and seizing an opportunity to work together for a larger
       purpose. Discussions for Proposition 63 emerged from the failed Nickel-A-Drink
       campaign in 1990 and more recent legislation, AB 54 and AB 2032. With fluctuation in
       funding opportunities, the mental health community seized on the public willingness to
       fund a mental health initiative to get Proposition 63 to the ballot and ensure its eventual
       passage.
   •   Funding opportunities: Each of the case studies has been successful because there was a
       commitment of funds to support the administration of the collaborative or coalition as
       well as a large potential source of funding for the initiatives the collaborative eventually


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       advanced. LA Care committed staff time for administrative support of the Children’s
       Health Initiative which was bolstered by early commitment to funding from First 5 LA as
       well as The California Endowment. Early potential dollars to support the Children’s
       Health Initiative gave the work of the coalition a greater sense of urgency.

In addition to the three contextual factors identified above, the case studies also shared three
similar structural arrangements that facilitated their development.

   •   Leadership: Leaders in each of the case studies were recognizable, clearly identifiable,
       respected in the local health care community, high level executives in their organizations,
       and had a proven track record of success. The Alameda Access to Care collaborative, for
       example, was led by executives of two long standing community clinics and the new
       Medi-Cal managed care organization. No more than three leaders were identified in any
       of the case studies, and their function was to set out the early vision for the group. It was
       collaborative and coalition leaders that identified a need and/or opportunity and
       developed the overarching purpose and vision of the collaborative. Small groups of
       leaders were responsible for setting the group in its long-term direction. In order for the
       LA Health Collaborative to move forward, the leadership group should take ownership of
       the overall direction of the LA Health Collaborative and guide it toward identifying a
       purpose and developing an action plan. Previous facilitators and consultative groups
       shied away from choosing a concrete direction, assuming the LA Health Collaborative
       would come up with a direction through consensus building. That assumption has been
       shown to be wrong, and leadership now must be directive of the larger group.
   •   Core support group: Once a small group of leaders defined the purpose for the group, it
       was refined and operationalized into a strategic plan for the collaborative or coalition to
       follow. In the case of the Dental Health Coalition, an advisory group made up of dental
       school faculty, education officials, and staff of community-based organizations select
       which issue the coalition will take on, which members to engage, and what strategies to
       use in addressing emerging oral health issues. In other groups, the core support group
       emerged informally from the larger collaborative membership, taking greater initiative in
       moving the coalition forward. The core support groups are larger than the number of
       leaders, yet small enough that agreement through consensus can be achieved. It is in this
       environment, as well as among the leaders, that the hard work of decision-making is
       done. Strategic plans are often formulated at this level of decision-making.
   •   Broad membership: After leaders decide on an overarching purpose and a strategic plan
       is discussed and agreed upon with the help of a core support group, the activities of the
       coalition are spread among the wider collaborative or coalition membership. This is often
       done in the form of workgroups but can also be arranged in ways that best fits the needs
       of the group. The Proposition 63 signature gathering in Los Angeles County, for
       example, was a loosely coordinated effort driven mainly by interested organizations.
       Once the legislation was written and the goals for signature gathering were identified,
       individual groups within the mental health community decided individually how much
       effort they would put into signature gathering and commit organizational resources
       accordingly. It is at this level that the legwork of collaborative and coalitions are done.




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In each of the case studies, collaborative or coalition efforts were derived from the desire on
member individuals and organizations to engage in initiative that extended beyond the limited
activities and goals of their own organizations. With unique opportunities for action and potential
available funding, existing relationships are leveraged for group action. With tiered levels of
function and responsibility, effective collaboratives have a clear purpose, strategy to achieve
their objectives, and the membership based to implement their plans.

Other considerations
        Incentives: For any voluntary effort, individuals and organizations have to decide that
their participation in a collaborative or coalition is worth the trade off in time and resources
committed to participation. Incentives play a role in increasing the number of members and their
level of participation. From the case studies, we identified financial returns on investment, peer
pressure, the furtherance of organizational goals, satisfaction, and the ability to shape a
successful initiative as incentive for participation. It is important to frame the issue and shape the
purpose of the group with these incentives in mind.
        Challenges: All of the case studies reported having challenges to their development, the
foremost being having adequate funding to accomplish their goals. Other challenges include
members being pulled in different directions by the needs of their home institutions and the
efforts of the collaborative or coalition, and securing the support of stakeholders outside of the
collaborative, especially political actors. These challenges, especially in funding and member
conflict, show that coalitions and collaborative are not yet an institutional component of the
broader health care system. They continue to be efforts above and beyond the status quo, making
their viability an ongoing challenge.

Summary
         The case studies show that collaborative efforts are inherently tenuous efforts because
they are not institutionalized approaches to reaching the goals of organizations. The difficulties
faced by the LA Health Collaborative should be seen, then, as a natural part of all collaborative
efforts. There are steps the LA Health Collaborative can take, however, to improve its
effectiveness. On a contextual level, the collaborative should consider existing relationships
within the group and how to solidify them around leadership and workgroup activities. It should
also consider other, on-going activities that have existing funding sources when selecting
activities to work on. Organizationally, the case studies all shared a structure of having a small
leadership team, a core support group, and a broad membership that may be useful for the LA
Health Collaborative as well.




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                          COVERAGE INITIATIVE CASE STUDY

        This case study was undertaken to identify policy changes attributable to LA Health
Collaborative efforts. It was chosen because it was a discreet policy issue with limited input by
other stakeholders.

BACKGROUND

        Financial and political crises have continuously marked the history of the Los Angeles
County public health care system (Cousineau and Tranquada, 2007). During times of financial
instability the County has often looked to the state and federal government to help stabilize
otherwise precarious funding streams and revenue. Federal 1115 Medicaid demonstration
project waivers twice served as federal bailouts for an ailing county health care system. A recent
change in the federal approach to a third five-year waiver opened a policy window within which
the LA Health Collaborative could exercise influence.

        The first 1115 waiver was negotiated during the health care crisis that faced Los Angeles
County in 1995. It allocated 1.2 billion federal dollars over five years to alleviate the financial
crisis and to try to restructure the LA County health care system from having an inpatient
hospital based focus to an outpatient, community clinic focus. The waiver was renewed in 2000
and subsequently renegotiated by then LA Department of Health Services Director Thomas
Garthwaite to secure additional funding over the next five years (Cousineau and Tranquada,
2007).

        On September 1, 2005, the federal government approved the third and most recent
iteration of the hospital-financing waiver. However, instead of earmarking funds specifically for
Los Angeles County, it allocated funding for the entire state. Provisions of the waiver
fundamentally change the payment structure for inpatient services through Medi-Cal and require
state health insurance expansion to the uninsured through the development of the Health Care
Coverage Initiative (Harbage and Ryan, 2006). In order to meet waiver requirements, the
Governor signed Senate Bill 1448 on July 18, 2006 to establish the Coverage Initiative
specifying how the California Department of Health Services would award funds from the $540
million waiver allotment over three years (Harbage and Ryan, 2006). This in effect established a
competitive process for federal funding among cities, counties or groups of counties or a health
authority (State of California, 2006).

         The purpose of the Coverage Initiative is to increase health care coverage among the
uninsured, to improve local health care safety nets and enhance access to health care, while
deceasing health care costs by creating program efficiencies (Wulsin, 2006). For each of three
years, $180 million will be allocated across the state to expand health insurance coverage for
residents who are not eligible through existing programs (Harbage, 2006). This case study
highlights the involvement and contributions of the LA Health Collaborative in shaping the Los
Angeles County Department of Health Services (LADHS) proposal to access this Coverage
Initiative funding. The following analysis is based on a document review of relevant materials
from the LA Health Collaborative and interviews with five Collaborative members during
February 2007.


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WORKGROUP FORMATION

         Limited discussion about the statewide Coverage Initiative occurred between
stakeholders prior to the formation of the LA Health Collaborative Coverage Initiative
workgroup. Conversations occurred within organizations, including LADHS, and informally by
phone between organizations to discuss the initiative. LA Health Collaborative leadership
recognized this as an opportunity to help bring in additional funding to secure the County’s
health care safety net and worked to bring together stakeholders in May 2006, eight months after
the signing of the waiver and four months after CDHS released the framework for proposals (For
a list of detailed activities see Appendix E). To maintain a functional and structured workgroup,
executive leadership of the Collaborative decided to limit the number of members. Invitees
included LADHS, the Community Clinic Association of Los Angeles County, Community
Health Councils, LA Care, Neighborhood Legal Services, the Los Angeles Chamber of
Commerce, Insure the Uninsured Project, and a few health care policy consultants. Although
LADHS had discussed the possibility of stakeholder involvement before the workgroup’s
formation, the Collaborative took the early initiative to meet and craft a strategy for the Coverage
Initiative. Member involvement with either the Collaborative or LA Health Action and
associated resources facilitated the formation of an active workgroup quickly.

       “…I know we were discussing it with our group and I’m sure others were as well.
       But the Collaborative really did allow us to come together and bounce off each
       others thinking in identifying ways that we had some shared vision on how to
       utilize those shared dollars.”

WORKGROUP PARTICIPATION AND ACTIVITIES

        Respondents identified several goals of the Coverage Initiative workgroup. Goals
included initiating the process of formulating a proposal for the County, bringing together
different stakeholders allowing input into the proposal design process, and maximizing resources
and dollars for Los Angeles County to serve the uninsured population. The roles of individual
workgroup members varied and included writing up potential proposal approaches, researching
target populations, providing input based on their organizational perspective, and bringing past
waiver experiences to the table. The resources of the LA Health Collaborative proved crucial
and valuable to the workgroup’s functioning. Staff provided skillful facilitation in identifying
the issues and concerns of workgroup members, follow up research on recommendations,
meeting summaries and materials, and steering follow-through.

        Workgroup activities revolved around understanding Coverage Initiative proposal
requirements, brainstorming, formulating ideas and suggestions for a potential proposal and
providing information to help craft a strategy (See Appendix F for a detailed list of activities).
The process began with a member developing a concept paper that served as a menu of ideas that
could be developed into a proposal. This served as a starting point for the workgroup to throw
out and bounce ideas off each other. Workgroup members discussed initiative constraints, asked
questions of each other, reviewed relevant data, and shared successful program strategies and
lessons learned from other projects with a similar focus such as VIDA, a TCE funded project
delivered through Valley Care. Specific key issues addressed through the workgroup processes


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included understanding funding criteria and requirements around setting up or using existing
enrollment processes for service expansion to the uninsured. Members also spent significant
time identifying a target population. Target populations discussed included homeless patients
and frequent users of the County system who have to deal with multiple agencies such as triple
diagnosed patients, i.e. with a chronic condition, mental health and substance abuse issues.

       “As we all came together and talked about these different strategies and different
       issues we also identified major gaps in knowledge and information. So the
       collaborative brought different speakers to the table to address different aspects.
       If people thought that a certain model worked very well in a certain region that
       we could duplicate county wide, they brought a speaker who could talk about that
       model to the group.”

       Although the Collaborative convened the Coverage Initiative workgroup, LADHS was
responsible for submitting a proposal. When the County started formulating a more concrete
proposal the workgroup evolved to function as a sounding board for LADHS to hear critiques,
questions, and suggestions for change. Although the workgroup did not make formal
recommendations, the workgroup proved useful to LADHS in the process of drafting their
proposal ultimately integrating suggestions from the workgroup and others organizations
influencing the process (see below).

        One respondent mentioned that learning about and educating the workgroup around the
limitations of Coverage Initiative funding was half of their work. For example, one consultant
helped elucidate that using CPEs (used to cover the uninsured or Medicaid clients) ultimately
implied that LA County would have to spend existing funds and then receive a 50%
reimbursement for services provided through waiver funding (Harbage and Ryan, 2006). This
brought to light that receiving Coverage Initiative funds would not be a standard granting
process.

        In addition to working to understand the intricacies of the initiative, members kept
abreast of the state issued request for proposals, which was a moving target due to changing
requirements, and state and federal laws and issues related to the funding as they developed. As
a result, members attended state DHS meetings to ask questions clarifying funding parameters
that sometimes resulted in keeping the County accountable to stakeholder interests. For
example, members asked whether Coverage Initiative dollars could be used to replace funds for
existing services:

       “One thing that started happening for example is there was this issue, where
       there’s always this balance with the County where you want them to always do
       something more that what they’re currently doing. It was starting to look like this
       proposal was going to supplant their existing efforts and not really do anything
       more. So on the stakeholder call we could ask with all the other counties present,
       “so could you explain the requirement of what requirement ‘not supplant’
       means”? And I know my county would never have asked it. And then they
       answered it, and our county had just planned to maintain their effort. And so
       that’s one thing that changed. Because the state said oh you can’t, no, no, you


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       can’t, you have to supplement your efforts not supplant them. Because the clinics
       were also concerned about that too.”

        After the state announced that federal funds could not be used to cover undocumented
residents as a result of the 2005 Deficit Reduction Act (DRA), the workgroup raised issues
regarding this requirement. A letter was crafted to Kim Belshé urging clarification that the DRA
did not preclude non-citizens from accessing coverage through the initiative and that citizen
verification only applied to those deemed eligible and who apply for Medi-Cal (Vera et al,
2006).

       “…The workgroup also prepared letters to the state asking for clarification and
       many of the discussion points that were brought up at the meetings were shared
       with the state in terms of the possible impact of the policy decisions and
       recommended changes or requirements…that was very valuable. The state given
       their response, took those concerns and issues seriously and appreciated the
       input.”

        Organizational workgroup participation remained consistent through meetings. Several
respondents did note however that Community Health Council representation shifted from
executive leadership to other staff. Another individual member’s involvement dropped off not
necessarily due to a lack of interest but moving on to another position. And although the Los
Angeles Chamber of Commerce was invited, it did not participate in the workgroup. Most
respondents agreed that the relevant actors missing from the workgroup were SEIU, the Hospital
Association of Southern California, and comprehensive health center leadership. However,
health care service providers did influence the LADHS Coverage Initiative proposal outside of
the Coverage Initiative workgroup.

        LADHS consulted internally with a twenty-person LADHS steering committee and also
with various public-private partnership (PPP) clinics connected with the Community Clinics
Association of Los Angeles County (CCALAC) to help shape the proposal. Initially, LADHS
worked with CCALAC hoping the information and work on the Coverage Initiative would
circulate among their numerous contracted clinics. When this did not occur, LADHS held
meetings with opinion leaders among the PPP clinics, comprehensive health center directors, and
an existing CCALAC compensated care workgroup. These groups provided feedback on the
proposal direction and operational input on enrollment and reimbursement structures. Ultimately
the proposal was a melding of opinions and ideas from the LADHS steering committee, these
health care providers, and the Coverage Initiative workgroup.

RESPONSE TO AND INFLUENCE OF WORKGROUP INPUT

        The LA Health Collaborative Coverage Initiative workgroup engaged in an iterative
process with LADHS to influence the proposal. The workgroup documented proposal ideas and
provided them to the LADHS workgroup member who would in turn discuss them with LADHS
executive leadership. The LADHS workgroup member would often return to meetings with
other concepts or ideas and ask for further input. Given the need to develop a cohesive proposal
in a short time frame, LADHS responses included whether suggestions were out of the County’s


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scope, cost, or direction. Although the process was at times challenging for both the workgroup
and LADHS, according to the LADHS respondent the submitted proposal reflects the
workgroup’s input.

       “Those issues that did surface from the health collaborative I think they [LADHS]
       listened to and attempted to integrate them and fold them into their plan to the
       best of their ability.”

ACCOMPLISHMENTS AND CONTRIBUTIONS OVERALL

        In the absence of another group external to LADHS taking a leadership role, the LA
Health Collaborative recognized that there existed an opportunity to exercise leadership and
influence to secure available funding for the County’s health care needs. The Collaborative
catalyzed the issue of the Coverage Initiative with key stakeholders and brought them together to
have input on the Coverage Initiative proposal that may not have happened otherwise. In this
way the Collaborative facilitated broader community input to the planning process. This process
brought a diversity of perspectives to the table from that of community health providers to
seasoned experts on past waivers. It was one of few stakeholder groups that the County went to
for input.

       “And then there was an opportunity to have specific issues and specific portions
       of it earmarked and addressed…And I also think we gave a gateway for different
       groups that otherwise wouldn’t have had input into the process.”

        The County also benefited from the Coverage Initiative workgroup. The workgroup
acted as a neutral party from which to raise issues at state held meetings among other
competitors that would have been difficult for the County the address, such as the implications of
the DRA. The Coverage Initiative workgroup was a resource to the County for both ideas and
labor. In addition to providing guidance to the County with the direction of their proposal, the
workgroup offered resources for analyzing the waiver. Finally, the formation of this workgroup
by the LA Health Collaborative permitted the construction of a small, productive workgroup.
The external nature of this workgroup allowed LADHS to still benefit from stakeholder
involvement without having to be concerned with exclusivity. In contrast to past waiver
experiences when the County had unorganized community involvement, the limited number of
workgroup members helped focus the input, making it more useful to LADHS. This contributed
to a more fully developed county proposal.

       “I do think that the workgroup brainstormed potential visions of what the County
       could potentially do. And among what we would do is we would update them on
       federal laws and state law developments. And I think we initiated the process for
       them because they were clearly not going to do it on their own and they weren’t
       going to do a public process in any way. And I think we were a sounding board
       for various issues and things that came up and concerns about them. I think we
       provided some cover for initiating and engaging with stakeholders that were
       going to be impacted by it.”



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        Outcomes of the Coverage Initiative workgroup included clarifying funding
requirements, providing visions for a Coverage Initiative proposal, engaging in the process to
provide feedback to the County, pushing the County to produce a better proposal, and helping to
produce a letter to the state regarding the implications of the DRA. Without the involvement of
the Coverage Initiative workgroup respondents expressed doubt as to whether the County would
have submitted as competitive a Coverage Initiative proposal as it did. Given the level of
discussion around proposal concepts, suggestions, and realistic implementation strategies, the
shape of the resulting proposal would have undoubtedly been different and not as developed
without their involvement. Finally, without the efforts of the Coverage Initiative workgroup,
interested community stakeholders would have been hard pressed for the broader understanding
of the Coverage Initiative requirements and parameters for funding that the workgroup provided.

COVERAGE INITIATIVE CONCLUSION

         Once the LA Health Collaborative recognized the opportunity to influence the creation of
a Los Angeles County Coverage Initiative proposal it mobilized a workgroup to address how to
utilize available funds to fill health care coverage gaps. The existing relationships among
workgroup members and their current involvement with the LA Health Collaborative facilitated
its formation. The limited number of participants allowed for focused input and suggestions for
what the Coverage Initiative proposal could look like. This input had to be provided in a time
sensitive manner given the impending deadline for the proposal submission. Given that the
Coverage Initiative workgroup came together due to a timely funding opportunity to assess the
needs of the County, brainstorm program ideas, and suggest program alternatives, it has helped
move the LA Health Collaborative towards the planning table it was initially intended to be.
Although part of their work involved envisioning how to fill the health care needs for LA County
residents, the Coverage Initiative workgroup was limited in realizing this planning table potential
given that its input was restricted to influencing the Coverage Initiative proposal submitted by
LADHS to the state.




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              LOS ANGELES HEALTH COLLABORATIVE CONCLUSION

         There is a consensus among participants that having a forum like the LA Health
Collaborative is a positive, even a critical, step toward stabilizing the county health care safety
net. It is currently operating as a vehicle for information dissemination and education, serving a
useful function within the county. It can be considered unsubstantial only in comparison to the
initial vision of what the LA Health Collaborative was designed to be. The LA Health
Collaborative has not become a planning table to develop a new vision of health care for low
income residents of LA County; but it is worth asking whether or not that was a reasonable
expectation to have in the first place.

        Figure 1 shows the logic model that drove the thinking behind the LA Health
Collaborative. Evaluating it now in light of the current challenges and lessons learned over the
past three years, the assumptions regarding the safety net in LA County as being ineffective,
fragmented, and under resourced continue to ring true. Communication may have improved
among stakeholders, but a level of distrust still exists that prevents collegial relationships from
becoming working partnerships. In light of the continued challenges facing the county safety net
system, the goal of creating a new vision for safety net health care system continues to be a
necessary one.

        However, it is less certain whether the process by which the LA Health Collaborative was
supposed to be formed and become the planning table to provide a new vision of health care for
the county was appropriate. The LA Health Collaborative is not a planning table where shared
planning and joint action for the county health care system occurs. Its activities are unrelated to
each other, typically responding to emerging issues and not proactively addressing systemic
issues in a coordinated way. Some participants have reported the LA Health Collaborative to be a
safe place for discussion and where open conversation can occur. In quarterly meetings however,
there is little opportunity for attendees to process the information presented in way that allows
for meaningful, in-depth discussion. There is also little time allotted for discussion in quarterly
meetings. Levels of trust continue to remain low as indicated by the difficulty getting people to
work together and that collective leadership has not emerged from among the group.

        Active content facilitation has not been an effective approach to realize the intermediate
steps needed to create a common planning table. The early meetings of the LA Health
Collaborative where active content facilitation was used initiated meaningful but abstract
discussions about the status of the county safety net health care system and potential solutions.
Without a concrete purpose for convening or actions to take, the intermediate steps to becoming
a planning table were never taken.

        Though the meetings and activities of the LA Health Collaborative are perceived as
neutral and inclusive, regular meaningful dialogue, relationship building, and power rebalancing
have not occurred. LA Health Action disseminates information to LA Health Collaborative
members, but information sharing among LA Health Collaborative members outside of the
Steering Committee is rare. While an organic, inclusive process of group development may be an
ideal way of achieving the intermediate steps to establishing a planning table, it also relies on
people’s good will which, if not met with immediate and tangible results, is diverted to other


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directions. There were and continue to be too many diverse stakeholders with different views and
opinions and the issues facing the county are too multifactorial and complex to be able to
identify ways to develop the planning table through consensus. What is needed instead is
leadership that is visible, firm, and directive while appreciating inclusivity and is responsive to
incorporating input from collaborative members. The logic model underlying the LA Health
Collaborative outlined an organic process when more of an action-oriented structure was needed.

        In order for the LA Health Collaborative to reach its original purpose, a process of
rethinking how best to structure and conduct the LA Health Collaborative ought to be advanced
to have impact beyond the information dissemination and networking roles in currently plays.
The LA Health Collaborative has three overarching objectives it must address to return to the
original intent of its convening: establishing a clear, directive leadership presence that balances
the need for action with inclusivity; defining a clear purpose, which includes a strategic, stepwise
plan to achieve a new vision of health care; and developing the personal and working
relationships needed to produce and execute that plan. Proceeding with these parallel objectives,
the LA Health Collaborative can move toward making the impact stakeholders hope to achieve.
Another option for the collaborative is to readjust the expectations of what is intended to
accomplish. The power dynamics and organizational histories of tense relationships in the Los
Angeles County health care community provide a difficult context for organizations to take part
in a prolonged collaborative effort where organizational interests are subsumed to the greater
good. This context is something that the LA Health Collaborative alone cannot change, and may
make becoming a common planning table impossible to achieve without altering other external
factors over which the Collaborative has no control. Recasting the expectations of what the LA
Health Collaborative can and should accomplish may ease discussions in the Steering Committee
about how to proceed and make the LA Health Collaborative an important vehicle to
restructuring the safety net health care system.




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                                        REFERENCES


JA Alexander, ME Comfort, BJ Weiner, R Bogue (2001) “Leadership in Collaborative
Community Health Partnerships,” Non-profit Management and Leadership,12(2):159-175.

FD Butterfoss and VT Francisco (2004) “Evaluating community partnerships and coalitions with
practitioners in mind,” Health Promotion Practice, 5(2):108-114.

FD Butterfoss, RM Goodman, A Wandersman (1996) “Community coalitions for prevention and
health promotion: Factors predicting satisfaction, participation, and planning”, Health Education
Quarterly, 23:65-79

FD Butterfoss, MC Kegler (2002) “Toward a comprehensive understanding of community
coalitions: Moving from practice to theory” in: Emerging Theories in Health Promotion Practice
and Research: Strategies for Improving Public Health. RJ DiClemente, R Crobsy and MC
Kegler (eds), San Francisco: Jossey-Bass Press.

DD Chervin et al (2005) “Community capacity building in CDC’s Community Coalition
Partnership Programs for the Prevention of Teen Pregnancy,” Journal of Adolescent Health,
37:S11-S9.

MR Cousineau, RE Tranquada (2007) “Crisis and Commitment: 150 Year of Service by Los
Angeles County Public Hospitals,” American Journal of Public Health, 97(4) 606-615.

SB Fawcett et al (2000) “Building Healthy Communities” in The Society and Population Health
Reader: A State and Community Perspective AB Tarlov and F St. Peter (eds.), New York: The
New Press.

E Feighery, T Rogers (1989) “Building and maintaining effective coalitions” in How to guides
on Community health promotion. Palo Alto: Stanford Health Promotion Resource Center, Guide
12

RM Goodman (1998) “Principles and Tools for Evaluating Community-Based Prevention and
Health Promotion Programs”, Journal of Public Health Management Practice, 4:37-47

P Harbage (2006) “The 2005 Hospital Waiver Coverage Initiative: Discussion and Analysis of
22 Key Questions to Launching the CI”, Los Angeles: The California Endowment.

P Harbage, J Ryan (2006) “Examining the 2005 Medi-Cal Hospital Waiver”, Oakland: California
HealthCare Foundation.

P Harbage, J Ryan (2006) “Questions and Answers about the 2005 Medi-Cal Hospital Waiver”,
Oakland: California HealthCare Foundation.




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MC Kegler, A Steckler, K McLeroy, SH Malek (1998) “Factors that contribute to effective
community health promotion coalitions: A study of 10 Project ASSIST coalitions in North
Carolina”, Health Education and Behavior, 25:338-353.

ST Roussos and SB Fawcett (2000) “A review of collaborative partnerships as a strategy for
improving community health,” Annual Review of Public Health, 21:369-402

State of California (2006) “Health Care Coverage Initiative”, Slides accessed online at
http://www.dhs.ca.gov/mcs/mcod/hcci/PPoint/Coverage%20Initiative%20Overview%2011-
06.ppt

T Wolff (2001) “The future of coalition building”, American Journal of Community Psychology,
29:265-269.

L Wulsin (2006) “Summary of SB 1448 (Kuehl) Signed 7/18/06”, Los Angeles: Insure the
Uninsured Project.

S Zuckerman and A Westpfahl Lutzky (2001) “The Medicaid Demonstration Project in Los
Angeles County, 1995-2000: Progress, But Room for Improvement.” Washington D.C.: Urban
Institute

Y Vera, T Broder, S Ambegaokar (2006) “Letter to CHHS Secretary on Hospital Financing
Coverage Initiative and Deficit Reduction Act”, Los Angeles: LA Health Action and National
Immigration Law Center.




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APPENDICES




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                         APPENDIX A: STAKEHOLDER SURVEY
         To assess how well the LA Health Collaborative has included the major stakeholders and
addressed critical health care issues in the county, a Web survey was conducted among LA
Health Collaborative participants. Table 1 shows the range of respondents’ institutional
affiliations. Responding to an open ended question about the key health policy issues affecting
the LA County safety net over the past five years, survey respondents cited facility closures most
frequently as a key health policy issue, including hospital/emergency room closures and the
elimination of DHS clinics (Table 2). Medi-Cal redesign and management of Medi-Cal managed
care as well as increasing the amount of funding for the health care safety-net were also
frequently cited as major policy issues in the county. The 1115 waiver, improving access and
care for uninsured residents, were cited less frequently. Nursing staffing, the separation of county
personal and public health services, and immigration were also mentioned.
        Asked who the most important stakeholders were in shaping the key health policy issues
affecting LA County, LA County Department of Health Services was by far the most frequently
cited stakeholder (Table 3). The LA County Board of Supervisors was the second most
frequently cited stakeholder followed by the Community Clinic Association of Los Angeles
County, state-level government officials, and the Hospital Association of Southern California.
The only other organization named ten or more times was SEIU Local 660.
        When asked about influential stakeholders in LA County health issues more broadly, the
results of the survey show that LA County DHS is perceived as the stakeholder most frequently
involved in LA County health policy issues; ninety-two percent of respondents indicated that
LAC DHS is always or usually influential in county health issues (Table 4). LAC DHS was
followed by the county Board of Supervisors (86%) and state-level officials (68%). Other less
influential stakeholders include foundations other than The California Endowment (TCE) (68%),
local think tanks and universities (68%), mental health advocates (65%), other community
advocates (65%), LA County Medical Association (59%), and the nurse’s union (53%).
         Respondents cited it was critical for leaders of organizations participating in the LA
Health Collaborative to show public support of the collaborative (46%) and be accessible for
consultation (44%) (Table 5). They ranked working to shape issues addressed (56%), attendance
at quarterly meetings (48%), devoting organizational resources (36%), and taking a leadership
role in the LA Health Collaborative (36%) as non-essential but very important roles for
organizational leaders to assume.
        Three survey respondents were affiliated with LAC DHS and three from health care
advocacy groups. Two were from a community clinic/clinic association and two from The
California Endowment. Other affiliations included local government, LA Care Health Plan, other
foundations, and a university or research center. Seven respondents were from an organization
other than those listed. Most respondents were either organizational executives or in a
management position (Table 1). Two were direct service providers, and two others were lower
level staff. Almost a quarter of respondents reported being high involvement with the LA Health
Collaborative, just over half reporting medium level of involvement, and less than 20% low
involvement (Table 7). One respondent of the survey did not know what the LA Health
Collaborative is. Overall, respondents to the survey are a diverse group, reflecting the broader
collaborative membership.


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Table 1. Organizational affiliation of survey respondents.

Employer                                                  % (n)
LA County Department of Health Services                   14 (3)
Health care advocacy organization                         14 (3)
Community clinic or affiliated professional association   10 (2)
The California Endowment                                  10 (2)
Local government official                                  5 (1)
LA Care Health Plan                                        5 (1)
Other Foundations                                          5 (1)
University or research center                              5 (1)
Kaiser Health Plan                                         0 (0)
Other private health plans and insurers                    0 (0)
Hospital or affiliated professional association            0 (0)
Legal services organization staff                          0 (0)
News media (LA Times, local TV news, etc.)                 0 (0)
Other                                                     33 (7)
Business
Community organization
Health education organization
LA County
Local public health jurisdiction
Retired
Self employed consultant
Total (N)                                                   100 (21)




Table 2. Key health policy issues in LA County since 2000.

Issue                                                          Responses
Health facility closures (including emergency rooms,              19
hospitals, clinics, number of beds, and King-Drew
Medical Center)
Medi-Cal (including Medi-Cal redesign and HMO                      12
management)
Increasing Safety-net Funding                                      12
1115 Waiver                                                        9
Uninsured Residents (including increasing health                   6
insurance coverage and delivering care for the
uninsured)
Nursing staffing                                                   2
Department of Health Services and Public Health split              2
Immigration                                                        2




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Table 3. Primary stakeholders of key health policy issues in LA County since 2000. *
Stakeholder                       Response Number

Advocates                         50
 In general                       7
 Labor in general                 12
    SEIU specifically               9
 LA Care                          8
 MCH/HIV/alcohol drug             8
 CBO’s
 Health Access Collaborative      5
 Community Health Councils        5
 CHI/First 5                      3
 Health Access                    2

State and County DHS              53
  County                          49
  State                           4
 CAO                              2

Board of Supervisors              31

Government Officials              31
 State                            18
 Local                            5
 Federal                          5
 Governor                         3

Community Clinic Association of   21
Los Angeles County

Hospital and physician groups     45
 HASC                             18
 Hospital Council                 5
 General                          4
 LACMA                            4
 Unihealth/LA Health Plan         4
 JCAHO/Hospital Regulatory        4
 Physician CMA                    2
 CMS                              2

Foundations                       8
LA Times                          5
Chamber of Commerce               4

Other                             13
 Drug Companies                   3
 Schools of Public Health         3
 Campaign Finance                 2


*Note: Respondents (22 total) were allowed to list up to three policy issues each.


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Table 4. LA County health policy stakeholders and their frequency of involvement in
health policy issues.

Stakeholders                              Total   Always Usually Sometimes Rarely           Never
                                          N        % (n)       % (n)    % (n)     % (n)     % (n)
LA County Department of Health            34      74 (25)     18 (6)    9 (3)     0 (0)     0 (0)
Services
LA County Board of Supervisors            34      68 (23)     18 (6)    15 (5)     0 (0)     0 (0)
State-level officials (legislative &      34      24 (8)      44 (15)   26 (9)     6 (2)     0 (0)
executive)
Federal-level officials                   34      24 (8)      32 (11)   41 (14)    3 (1)     0 (0)
LA City Council                           34       0 (0)       0 (0)    29 (10)   59 (20)   12 (4)
L.A. Care Health Plan                     33      12 (4)      33 (11)   45 (15)    9 (3)     0 (0)
Kaiser Health Plan                        34       3 (1)      15 (5)    41 (14)   35 (12)    6 (2)
Other private health plans and insurers   34       3 (1)       6 (2)    47 (16)   38 (13)    6 (2)
LA County Medical Association             34       6 (2)       9 (3)    59 (20)   24 (8)     3 (1)
Other physicians’ organizations           33       0 (0)       9 (3)    39 (13)   42 (14)    9 (3)
Nurses’ unions                            34       9 (3)      21 (7)    53 (18)   15 (5)     3 (1)
Other health care worker unions           34      12 (4)      24 (8)    50 (17)   12 (4)     3 (1)
Hospital Association of Southern          33      18 (6)      33 (11)   39 (13)    9 (3)     0 (0)
California
Community Clinic Association of LA        34      21 (7)      29 (10)   47 (16)    3 (1)     0 (0)
County
Health care advocacy organizations        34      15 (5)      24 (8)    59 (20)    3 (1)     0 (0)
Mental health advocacy                    34       6 (2)      15 (5)    65 (22)   12 (4)     3 (1)
Other community advocacy                  34       6 (2)      12 (4)    65 (22)   15 (5)     3 (1)
organizations
The California Endowment                  34       9 (3)      29 (10)   44 (15)   18 (6)     0 (0)
Other Foundations                         34       0 (0)       9 (3)    68 (23)   24 (8)     0 (0)
News media (LA Times, local TV news,      34      18 (6)      29 (10)   44 (15)    9 (3)     0 (0)
etc.)
Local think tanks & universities          34       6 (2)      15 (5)    68 (23)   12 (4)     0 (0)




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Table 5. Role of leaders of stakeholder organizations in LA Health Collaborative.

Type of Involvement from             Total       Critical   Very      Moderately Somewhat Not
Organizational Leaders                                      important important important important
                                     N           % (n)      % (n)     % (n)     % (n)      % (n)
Attend quarterly meetings            25          12 (3)     48 (12)   28 (7)     8 (2)     4 (1)
Participate in subcommittee          25           0 (0)     24 (6)    44 (11)   12 (3)    20 (5)
meetings
Be accessible for consultation       25          44 (11)    36 (9)    12 (3)     8 (2)     0 (0)
Publicly support Collaborative       24          46 (11)    42 (10)   4 (1)      8 (2)     0 (0)
agenda
Devote organizational resources to   25          24 (6)     36 (9)    32 (8)     8 (2)     0 (0)
Collaborative
Take a leadership role in            25          20 (5)     36 (9)    28 (7)     8 (2)     8 (2)
Collaborative
Work to shape the issues             25          24 (6)     56 (14)   12 (3)     8 (2)     0 (0)
addressed




Table 6. Positions held in home organizations by survey respondents.

Survey Member Organizational                 % (n)
Position
Executive                                 45 (9)
Management                                35 (7)
Direct service provider                   10 (2)
Other staff                               10 (2)
Total                                         100(20)




Table 7. Level of involvement of LA Health Collaborative of survey respondents

Survey Member Involvement                        % (n)
High                                            23 (5)
Medium                                          55 (12)
Low                                             18 (4)
None                                             0 (0)
I don’t know what the LA Health Collaborative is 5 (1)
Total                                                100(22)




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                     APPENDIX B: Steering Committee Members, 2006

Irene Dyer
Director, Office of Planning and Analysis
Los Angeles County Department of Health
Services

Jonathan Freedman
Director, Public Health Emergency
Preparedness and Response Program
Los Angeles County Department of Public Health

Lark Galloway-Gilliam
Executive Director
Community Health Councils

Mark Gamble
Vice President, Los Angeles Region
Hospital Association of Southern California

Sam Garrison
Public Policy Manger
Los Angeles Area Chamber of Commerce

Neelam Gupta
Assistant Director
LA Health Action

Lynn Kersey
Executive Director
Maternal and Child Health Access

Kathy Ochoa
Senior Health Policy Analyst
SEIU International, Local 660

Michael Pfeiffer
Executive Director
Los Angeles County Emergency Medical
Directors Association

David Pruitt
Vice President of Government Affairs
Los Angeles County Medical Association




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                                                 LOS ANGELES HEALTH COLLABORATIVE EVALUATION



Gloria Rodriguez
Chief Executive Officer
Community Clinic Association of Los Angeles
County

Wendy Schiffer
Director, Planning, Evaluation and Development
Los Angeles County Department of Public Health

Barbara Siegel
Managing Attorney
Neighborhood Legal Services of Los Angeles
County

Marvin Southard*
Director
Los Angeles County Department of Mental Health

Yolanda Vera
Director
LA Health Action

Mark Windisch
Senior Advisor
L.A. Care Health Plan



*Representative to be appointed




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                   APPENDIX C: Activities of LA Health Collaborative

Summary

2004

   •   Formation and high level activity among 3 workgroups: data, technology, geographic
       demonstration project.
   •   Develop a close working relationship with Steering Committee on the Future of the
       King/Drew Medical Center.
   •   Governance committee is created to develop recommendations to improve the
       administration of the LA County health care system.
   •   Post-waiver expiration strategy committee is created, advocating on behalf of LA County
       safety net providers and patient to ensure they receive a fair share of federal and state
       funding.
   •   LA Action-commissioned report on safety net financing authored by RAND is released.


2005

   •   Kim Belshe, Sandra Shewry, Stan Rosenstein, and Gary Wells provide on-going updated
       on Medi-Cal redesign for LA Health Collaborative members.
   •   Forums addressing CMS and LADHS recommendations regarding King/Drew Medical
       Center are held in co-sponsorship with Community Health Councils and the Hospital
       Association of Southern California.
  •    Governance committee engages LA County CAO on Health Authority Blueprint.
  •    Members of LA Health Collaborative testify before the Select Committee on the Future
       of the Los Angeles County Health Care Crisis.
  •    Joint letters are sent to the State and legislative staff on impact of proposed statewide
       hospital financing waiver to LA County by members of the LA Health Collaborative
  •    Hosts briefing on financing intricacies of the statewide hospital financing waiver.
  •    Releases LA Health Action-commissioned report on the service impact of transition
       King/Drew Medical Center to a non-teaching facility and the Sick System policy brief.
   •   LA Health Action website is launched.
   •   Presentations at meetings include: PPP program, psychiatric ER bed reductions, state of
       LA health care coverage, county hospitals’ self-pay patients, homeless dumping on Skid
       Row.

2006

   •   Host briefing with State DHS Medi-Cal director on statewide hospital financing waiver.
   •   Special workshop on MOU for separation of personal and public health.
   •   The California Endowment funds two adult chronic disease demonstration projects
       stemming from the geographic focus workgroup.



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Detailed


                         Date                       Activity                         Outcome
                   May 2003           Irene Ibarra hired as LA Health
                                      Action Director
                   June 30, 2003      First Collaborative Meeting        Possible outcomes and strategies
                                                                         identified; guiding principles and
                                                                         collaborative functioning
                                                                         discussed
                   September 2003     Data Resources Group formed
                   October 10, 2003   Second Collaborative Meeting       Purpose clarified; multiple
                                                                         determinants approach needed;
                                                                         assumptions and lessons from
                                                                         other collaborative identified
                   November 13 and    Smaller meetings to discuss        Issues to pursue identified;
                   17                 collaborative direction and        consensus as basis for decision
                                      decision making                    making
                   November 2003      Irene Ibarra leaves LA Health
                                      Action
                   December 2, 2003   Third Collaborative Meeting        No agreement on issues and
 Formation Stage




                                                                         strategies to pursue; Break out
                                                                         groups formed for further
                                                                         discussion on focus areas;
                                                                         Decision making difficult so
                                                                         Steering Committee appointed
                   December 2003      Irene Ibarra moves into TCE VP
                                      position
                   January 12, 2004   First Steering Committee meeting   Adult Health Initiative focus;
                                                                         decide to conduct rapid
                                                                         assessment of adult health issues
                   February 9, 2004   Data Workgroup Meeting             Purpose was to identify data
                                                                         sources to illuminate scope/scale
                                                                         of ER problem; discussed reasons
                                                                         for why inappropriate ER use was
                                                                         not a reliable indicator for
                                                                         misalignment of resources for the
                                                                         underserved; added additional
                                                                         indicators to examine including
                                                                         usual source of care,
                                                                         demographics facility use and
                                                                         reason for selecting facility
                   March 2, 2004      Second Steering Committee          Recommendations from Data
                                      meeting                            workgroup presented; Three
                                                                         potential activities articulated



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                                   March 15, 2004     Fourth Collaborative Meeting      Agreement: Geographically
                                                                                        focused demonstration projects
                                                                                        will be pursued; health issue focus
                                                                                        includes obesity, diabetes, and
                                                                                        heart disease; workgroup
                                                                                        meetings
                                   April 6, 2004      Geographic Workgroup Meeting      Selection of health conditions to
                                                      (part 1)                          focus on
                                   April 13, 2004     Geographic Workgroup Meeting      Discussed selection criteria;
                                                      (part 2)                          candidate geographic areas
                                   May 10, 2004       Geographic Workgroup Meeting       Discussed selection criteria;
                                                      (part 3)                          candidate geographic areas
                                   May 26, 2004       Fifth Collaborative Meeting       Potential communities for
                                                                                        demonstration projects identified
                                   June 23, 2004      Geographic Workgroup Meeting      Select geo areas; identified
                                                                                        community leaders to contact
                                   June 29, 2004      Data Workgroup Meeting            Review data supporting geo. focus
                                                                                        site selection, work plan, next
                                                                                        steps
                                   July 2004          Yolanda Vera hired as LA Health
Implementation/Maintenance Stage




                                                      Action Director
                                   July 29, 2004      Sixth Collaborative Meeting       Integration model discussed; team
                                                                                        reports (notes?)
                                   September 29,      Seventh Collaborative Meeting     Financing, delivery, and
                                   2004                                                 information systems trends and
                                                                                        issues; King Drew and workgroup
                                                                                        updates
                                   December 3, 2004   Eighth Collaborative Meeting      Financing , King Drew updates,
                                                                                        and workgroup updates
                                                      Ninth Collaborative Meeting
                                   January 13, 2005   Data Workgroup Meeting            Next steps to create shared data
                                                                                        resource; Group 3 update to be
                                                                                        prepared for future data needs;
                                                                                        reviewed results from Health
                                                                                        Information Resource Survey
                                   March 4, 2005      Tenth Collaborative Meeting       Workgroup updates on San
                                                                                        Fernando Valley and Long Beach
                                                                                        Chronic Conditions projects; King
                                                                                        Drew and Health-e LA update;
                                                                                        Select committee on LA county
                                                                                        health crisis; finance/delivery
                                                                                        developments; governance
                                                                                        discussion




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April 18,2005      Eleventh Collaborative Meeting     CHIS 03 data on employer
                                                      sponsored coverage for LA
                                                      county; Finance/Delivery
                                                      developments re: Medi-Cal,
                                                      hospital financing reform, impact
                                                      of federal proposals on safety net;
                                                      developments re reducing psyche
                                                      beds; LA co DHS update
                                                      (KDMC, DHS budget); Health-e
                                                      LA update
June 16,2005       Twelfth Collaborative Meeting      Workgroup updates; LA co ED
                                                      and trauma services info;
                                                      ambulatory care; finance/delivery
                                                      update: medi-cal and hospital
                                                      financing reform
September 14, 2005 Thirteenth Collaborative Meeting   Governance: Separation of PH
                                                      from LADHS; Legislative wrap
                                                      up and looking forward; F/D
                                                      updates on KDMC and the impact
                                                      of Harris and Rhode lawsuit
                                                      settlement; workgroup updates
November 2005      LA Health Action Launches web      Based on the visioning from the
                   site                               Data Workgroup Committee
December 15,       Fourteenth Collaborative Meeting   Skid Row patient dumping
2005                                                  discussion; Governance of safety
                                                      net hospital disc; DHS update;
                                                      workgroup update;
January 12, 2006   Governance Committee Meeting       MOU review between LA County
                                                      DHS Personal Health and Public
                                                      Health
January 19, 2006   Fifteenth Collaborative Meeting    Conference Call; Update on
                                                      Medi-Cal redesign; Hospital
                                                      financing and state budget
March 16, 2006     Geographic focus grants awarded    Long Beach DHHS: Long Beach
                                                      Diabetes Collaborative; Valley
                                                      Care Community Consortium:
                                                      Pacoima Diabetes Collaborative
April 18, 2006     LA Health Collaborative Steering
                   Committee Kick Off

April 20, 2006     Sixteenth Collaborative Meeting    Collaborative strategic planning;
                                                      County issues re: nursing
                                                      workforce; homeless prevention;
                                                      workgroup updates




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July 20, 2006        Seventeenth Collaborative          Update on King-Drew Medical
                     Meeting                            Center review processes, nursing
                                                        shortage information
                                                        dissemination, tobacco tax and
                                                        DHS/Public Health separation
                                                        discussion
August 8, 2006       Nursing Shortage Subcommittee      Discussion of nursing shortage,
                     Meeting                            options to address shortage and
                                                        viable options to move forward.
                                                        Three areas identified to address:
                                                        capacity, career ladder and
                                                        legislation.
September 26,        Steering Committee Meeting         King-Drew update and discussion
2006


September 27,        Nursing Shortage Workgroup
2006                 report back

October 25, 2006     Nursing Shortage Committee
                     Meeting

November 13,         Health Care Coverage Pre-          For applicants who could not
2006                 Application Teleconference         attend the actual conference

9/10/06, 10/10/06,   Career Ladders Subcommittee        Development of planning issues
11/8/06, 11/29/06,   meetings of the Nursing Shortage   and design of larger April 4
1/26/07,             Committee                          meeting.
2/20/07, 3/2/07,
3/8/07, 2/16/07,
3/22/07, 3/29/07
February 16, 2007    Eighteenth Collaborative Meeting   Statewide health care reform,
                                                        federal policy developments,
                                                        LAC/USC Medical facility, health
                                                        care disparities in LA County
April 4, 2007        Increasing Career Opportunities    Half day meeting to formulate a
                     in Nursing and Allied Health in    collective plan to implement
                     the Los Angeles Area: A            strategies to address the nursing
                     Strategic Discussion               shortage.




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            APPENDIX D: LA Health Action Web Site Statistics Dec 2005 to Feb 2007*


     Month            Unique Visitors      Number of Visits                    Pages                 Hits
    Dec 2005               174                 318                             6,604                 9,846
                                            (1.82 visits/visitor)        (20.76 pages/visit)   (30.96 hits/visitor)
    Mar 2006                140                     347                        5,772                 8,143
                                            (2.74 visits/visitor)        (16.63 pages/visit)   (23.46 hits/visitor)
    Apr 2006                197                     351                        5,596                 8,043
                                            (1.78 visits/visitor)        (15.94 pages/visit)   (22.91 hits/visitor)
    May 2006                473                     718                        7,608                10,883
                                            (1.51 visits/visitor)        (10.59 pages/visit)   (15.15 hits/visitor)
    Jun 2006                563                     882                       11,732                17,156
                                            (1.56 visits/visitor)        (13.30 pages/visit)   (19.45 hits/visitor)
    Jul 2006                515                     796                        8,469                13,007
                                            (1.54 visits/visitor)        (10.63 pages/visit)   (16.34 hits/visitor)
    Aug 2006                448                     748                       10,287                14,097
                                            (1.66 visits/visitor)        (13.75 pages/visit)   (18.82 hits/visitor)
    Sep 2006                431                     685                        6,218                 9,413
                                            (1.58 visits/visitor)         (9.07 pages/visit)    (13.74 hits/visit)
    Oct 2006                512                     798                       12,935                20,844
                                            (1.55 visits/visitor)         (16.2 pages/visit)    (26.12 hits/visit)
   Nov 2006**              6,419                   7,270                      15,870                20,419
                                            (1.13 visits/visitor)         (2.18 pages/visit)     (2.8 hits/visit)
   Dec 2006**             16,955                  19,618                      29,283                32,764
                                            (1.15 visits/visitor)         (1.49 pages/visit)    (1.67 hits/visit)
   Jan 2007**              1,252                   2,007                      12,924                17,496
                                             (1.6 visits/visitor)         (6.43 pages/visit)    (8.71 hits/visit)
    Feb 2007                780                    12,57                      10,064                14,450
                                            (1.61 visits/visitor)          (8 pages/visit)      (11.49 hits/visit)



Data provided by LA Health Action March 2007.
*Due to a change in the web statistics software in March 2006, data from Jan 2006 and Feb 2006 is irretrievable.
** The Nov 2006 and Dec 2006 statistics are falsely inflated, as the LAHA web site had been hacked into and
invisible links were added. The rogue code was deleted in Feb 2007. The activity caused by the hack script seems
to have peaked in Dec 2006 and decreased in Jan 2007.




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           APPENDIX E: Key Accomplishments of the LA Health Collaborative

Identified and recommended project to The California Endowment for funding.

Provide testimony to legislative bodies such as the Assembly Select Committee on the LA
County Health Care Crisis hearings, Assembly Health and Select Committee hearings on
Pricewaterhouse Coopers audit of Section 1115 waiver, and the LA County Board of Supervisors
on issues related to county governance.

Featured presentations from CMS Region IX Director, California CHHS Secretary Kim Belshe,
California DHS Director Sandra Shewry, LADHS Directors Tom Garthwaite, Bruce Chernoff,
and LADHS Public Health Office Jonathan Fielding.

Convened and sponsored forums and meetings on critical LA County safety net issues such as
the emergency services crisis, the hospital financing waiver and the coverage initiative,
alternative models for county governance, and the King/Drew Medical Center crisis.

Funded research and advocacy efforts such as a report on LA county safety net financing and a
study on the service implications of downgrading of King/Drew Medical Center to a community
hospital.

Developed policy papers and briefs to provide information on safety net issues such as a review
of economic and health indicators during the 10-year LA County Section 1115 waiver and the
implications of the proposed separation of Public Health from LADHS.

Created and supported regional technology solutions, such as a county-level web-based health
data resource, an LA Health Collaborative listserv and Health-e-LA.

Formed and convened the Coverage Initiative workgroup to influence LADHS’ Coverage
Initiative proposal to CADHS.




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                  APPENDIX F: Activities of Coverage Initiative Workgroup


              Activity                          Date
Hospital financing waiver briefing at    July 14, 2005
HASC
Hospital financing waiver approved       September 1, 2005
Email to list serve from Pam Swan        October 19, 2005
asking for stakeholder input re:
developing the Healthcare Coverage
Initiative concept
Stakeholder feedback deadline to         November 2005
CDHS regarding hospital financing
waiver/CI
CDHS releases Healthcare Coverage        January 21, 2006
Initiative Proposal (CI framework)
SB 1448 proposed (state coverage         February 2, 2006
initiative response to federal waiver)
CI stakeholder meeting in                February 27, 2006
Sacramento, CDHS
CI stakeholder meeting in                March 10, 2006
Sacramento, CDHS
Workgroup meeting 1 (In-person)          May 5, 2006
Workgroup meeting 2 (Conference          June 7, 2006
call)
Workgroup meeting 3 (In-person)          June 19, 2006
SB 1448 signed                           July 18, 2006
Workgroup meeting 4 (Conference          July 28, 2006
call)
Workgroup meeting 5 (In-person)          August 8, 2006
Workgroup meeting 6 (In-person)          September 6, 2006
CDHS solicits written comments           September 12,
from stakeholders on the RFA draft       2006
State RFA drafted                        September 13,
                                         2006
Final CDHS RFA released                  November 1, 2006
Pre-application conference               November 13, 2006
teleconference
Workgroup meeting 7 (In-person)          November 16, 2006
Workgroup meeting 8 (In-person)          December 1, 2006
Letter to Kim Belshé regarding DRA       December 4, 2006
changes to RFA
Voluntary Letter of Intent to CDHS       December 15, 2006
due
Application due                          January 5, 2007
Workgroup meeting 9 (Conference          January 17, 2007
call)




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                                 APPENDIX G: Methodology


DATA SOURCES

Semi-structured interviews, organizational documents, a web-based survey, and participant
observations were used as sources of data for the evaluation. Semi-structured interviews were the
primary source of data to collect retrospective information about the Collaborative, including its
origin, planning for the collaborative, the collaborative’s early development, and to construct a
logic model. Semi-structured interviews were also used to gather information on the current
structure of the LA Health Collaborative, its achievements, benefits and challenges of the
collaborative, and recommendations for further action. Organizational documents were used to
verify and supplement data collected through interviews and also provide greater detail to areas
interviewees did not have full recollection. A web-based survey was used to assess LA Health
Collaborative participants’ perception of the key health policy issues in Los Angeles County
since 2000 as well as the stakeholders associated with each issue and with county health policy
issues generally. Participant observation of LA Health Collaborative quarterly, work group, and
steering committee meetings was conducted in order to experience first hand group dynamics,
decision making, and to trace the development of issue areas through the collaborative over time.
Semi-structured interview were also used for the follow-up case studies.

SAMPLING AND DATA INTERVIEW PROTOCOLS

Participants for semi-structured interviews were sampled purposively for the evaluation.
Purposive sampling was used to ensure individuals selected to participate could contribute to the
specific goals of the study. Individuals who were both current and former participants as
designated by the de facto leader of the LA Health Collaborative were targeted for sampling as
well as individuals from organizations that have never participated in the LA Health
Collaborative. Including individuals from the range of organizational types that make up the LA
Health Collaborative was also a factor in considering who to interview for the evaluation.
Organizational types included local government agencies, advocacy, professional associations,
hospitals, clinics, health plans, and universities/think tanks. Overall, 27 interviews were
conducted for the evaluation, excluding those interviewed for the case site comparison study: 10
participants, 7 former participants, 7 staff from The California Endowment, and 3 non-
participant stakeholders.

Evaluation participants were contacted via email through contact information available from the
LA Health Collaborative roster. Emails introduced the purpose of the evaluation and requested
30-45 minutes for either an in-person or phone interview. One week after emails were sent,
follow-up phone calls were made to individuals until a response was secured. Three individuals
who were contacted did not respond to emails or phone calls and did not participate in the
evaluation. All but two interviews were conducted over the phone. Once a convenient time was
selected by the participant, anonymous interviews were conducted using a semi-structured
interview guide (see appendices E, F, G and H). All interviews were tape recorded. Interview
protocols differed slightly based on their involvement with the LA Health Collaborative.
Appendix J shows the host organizations of individuals who participated in the evaluation.


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The sample of collaboratives for inclusion into the comparison study was identified through
existing referrals from participants of the current evaluation of the LA Health Collaborative and
selected for participation based on diversity of focus and activities, size, scope, and accessibility.
In total, four case study collaboratives were chosen. Two to four interviews were conducted with
key informants of each of the case study collaborative to glean “lessons learned” that may be
applied to the LA Health Collaborative. In a fashion similar to interviews conducted with LA
Health Collaborative members, a recruitment email was sent to key informants and a time was
scheduled for a telephone interview. Interviews were conducted at a time convenient for the
respondent following a standard protocol across case study sites (appendix I).

Interviews with The California Endowment staff were conducted from September to December
of 2005, participants from October 2005 to February 2006, former participants October 2005 to
January 2006, and non-participant stakeholders during March 2006. Case study interviews were
conducted from May through July of 2006. Additional interviews of Coverage Initiative
workgroup participants and Steering Committee members were conducted in February 2007.

DOCUMENT ANALYSIS

The primary documents used for the evaluation were meeting agendas and minutes and
informational material passed out at LA Health Collaborative meetings. Documents forming
early working papers on the thinking that went in to the LA Health Collaborative were not
provided for the evaluation, but instead read during an interview with one evaluation respondent.
Copies of diagrams and meeting notes from early meetings facilitated by a contracted facilitator
were also used in the evaluation.

WEB-BASED SURVEY

LA Health Collaborative participants were asked to complete an on-line survey to identify
critical health policy issues in LA County and key stakeholders in the county safety net system.
The stakeholder survey (appendix K) was posted on Survey Monkey, a web-based survey
service. An email was sent to LA Health Collaborative participants through the collaborative
listserv to recruit participants to complete the questionnaire. A follow-up announcement was
made at the April 2006 LA Health Collaborative meeting for respondents to fill participate in the
survey. A paper version of the questionnaire was made available at the meeting for respondents
to complete and return. No surveys were completed in this way. The order of the questions on
the on-line survey was changed after 24 respondents completed the survey in order to maximize
completion of the survey by future respondents. Eleven respondents completed the survey after
the question order was changed and a second email request was sent.

PARTICIPANT OBSERVATION

Evaluation team members attend LA Health Collaborative large group, workgroup, and steering
committee meetings in order to observe the nature of various meetings and to track the progress
of issues taken on the by LA Health Collaborative. Evaluators are fully engaged in meetings as
participants but make observations and take notes from an outsider’s perspective. After meetings,
the evaluation team debriefs on observations made.


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DATA ANALYSIS
All semi-structured interviews were transcribed and analyzed using Atlas.ti, a qualitative data
software program. This analysis served as the primary analytic focus of the evaluation. The
interviews were used both to reconstruct the overall timeline of the LA Health Collaborative as
well as identify the current structure and benefits, and challenges of participation. Interviews
were deconstructed into a standardized set of themes and categorized into substantively unifying
codes. Interview text was separated by codes and analyzed for patterns and variations reported in
the evaluation. This analysis protocol was used for the case study comparisons as well.

Interviews provided the core data for the evaluation, while documents were used to verify,
support, and add detail to topics and themes that arose from the interviews. Documents were
especially helpful when interview respondents were unclear on details of dates and meeting
content, complementing the opinions and impressions that could be drawn only from the
interviews.

Data from the web-survey were produced directly from Survey Monkey in a spreadsheet.
Because of the complex format data were presented from the on-line survey service, descriptive
analysis of responses was done manually.




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             APPENDIX H: The California Endowment Staff Interview Protocol


“Thank you for taking the time to speak with me about your knowledge and involvement with
the LA Health Collaborative, an initiative of The California Endowment. Before we begin, I
would like to give you this information sheet that describes the evaluation this interview is a part
of. Please read it and let me know if you have any questions.

[Hand participant evaluation information sheet.]

Do you have any questions that I can answer?

[Answer questions as needed.]

Now that you’ve read the information sheet, if you still agree to participate in this interview,
please read and sign the following informed consent sheet.

[Hand participant informed consent sheet. Proceed once signed and returned to interviewer.]

Thank you.

I’d like to begin our interview by asking:”


   1. How would you describe the LA Health Collaborative?
        a. Probe for its function, the scope of its work, the scope of its membership,
           governance structure, relationship to The California Endowment.

   2. Please describe your understanding of why The California Endowment started an
      initiative to form what would become the LA Health Collaborative.
           a. Probe for who came up with the idea/the genesis for the idea, the context in which
               it was conceived, when it was first conceived, the perceived underlying problems
               that led to discussions around creating the LA Health Collaborative.

   3. What role did you play in that process?

   4. What steps were taken to move the LA Health Collaborative from an idea to a wider
      discussion within The California Endowment, and finally a funded initiative of TCE?
          a. Probe for the various stages of development the initiative went through, people
             primarily and secondarily involved within and external to The California
             Endowment, reasons for support, opposition and barriers to the initiative, required
             levels of institutional approval, time frame for the process.

   5. What other options or alternatives to the LA Health Collaborative were discussed and/or
      proposed to address the underlying issues the LA Health Collaborative was designed to
      address?


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6. Once approval for the LA Health Collaborative was received, how did The California
   Endowment identify and determine stakeholders to invite into the Collaborative?
      a. Probe for decision-making criteria for inclusion, who was involved in the process.
      b. Probe for specific names of organizations or people that were invited to
         participate and who are seen as major players on the LA County health care
         scene.

7. What strategies were used to invite stakeholders into the LA Health Collaborative and
   garner their agreement for participation?
      a. Probe for the range of responses to invitations and get specific examples. Clear
           statement of time frame.

8. Please describe the original structure of the LA Health Collaborative as you remember it.
   What are the ways it has changed since it first began?
      a. Probe for the stages of development from the perspective of The California
          Endowment. Get specifically the level of involvement from The California
          Endowment over time and stages of development.

9. What level of involvement does TCE currently have with the LA Health Collaborative?

10. In your opinion, what resources have participating organizations brought to the efforts of
    the LA Health Collaborative?
        a. Probe for people, staffing, social networks, prestige/power, financial resources.
           Identify organizations that might have invested the most resources to the LA
           Health Collaborative, or at least concrete examples.
        b. Probe for speculation on why/how organizations were persuaded to bring existing
           resources into the LA Health Collaborative.

11. What have been the major accomplishments of the LA Health Collaborative since it
    began?
       a. Probe for specific outcomes, mainly changes in policy or actual access to care,
           including blocking detrimental change. Probe also for inter-organizational
           accomplishments, i.e., capacity building.
       b. Probe specifically for the ability of the LA Health Collaborative to enlarge
           discussion about access to health care beyond the “usual players.”

12. What expectations did you have for the LA Health Collaborative that have gone
    unfulfilled?
       a. Probe for large areas of unmet potential, but also smaller initiatives that have
            started but stalled. Probe also for other areas that need to be addressed but aren’t
            being addressed.




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          APPENDIX I: LA Health Collaborative Participants Interview Protocol



“Thank you for taking the time to speak with me about your knowledge and involvement with
the LA Health Collaborative, an initiative of The California Endowment. Before we begin, I
would like to give you this information sheet that describes the evaluation this interview is a part
of. Please read it and let me know if you have any questions.

[Hand participant evaluation information sheet.]

Do you have any questions that I can answer?

[Answer questions as needed.]

Now that you’ve read the information sheet, if you still agree to participate in this interview,
please read and sign the following informed consent sheet.

[Hand participant informed consent sheet. Proceed once signed and returned to interviewer.]

Thank you.

I’d like to begin our interview by asking:

ORGANIZATIONAL BACKGROUND

   1. What are the key health issues that your organization is involved in?
        a. Probe for past policy issues the organization has engaged with particular focus on
            access to care issues and issues faced with program delivery, as relevant.

   2. How relevant has your participation in the LA Health Collaborative been to the issues
      your particular organization deals with?
         a. Probe for thematic ties across organizations and non-material benefits accrued
             through LA Health Collaborative participation for the organization, i.e., extension
             of network, stronger social ties, social support.

   3. Who are the major organizations besides the LA Health Collaborative that deal with the
      key health issues your organization is involved in?
         a. Probe for range of organizations, i.e., governmental, legal, social work,
             supporting organizations, human rights, out-of-area organizations, coalitions.
             Probe which organizations are also part of the LA Health Collaborative.




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PARTICIPATION

  4. How would you describe your current level of involvement in the LA Health
     Collaborative?
        a. Probe for initiation into the LA Health Collaborative, decision-making process to
            decide to attend (pros and cons), meeting attendance, participation in LA Health
            Collaborative events, degree of involvement in leadership of the LA Health
            Collaborative.

  5. How has your level of involvement changed since you first joined the Collaborative?
       a. Probe not only for differing levels of involvement over time but reasons for
           changing levels of participation.

  6. Why did you decide to participate in the first place, and why are you still a part of the
     Collaborative?
        a. Probe for motivation, either personal, organizational, or for the greater good, also
            touch on barriers to greater participation.

  7. How much control do you feel you have over the resources and mission of the
     Collaborative?

  8. What resources does your organization commit to the LA Health Collaborative?
       a. Probe for financial, personnel, status, social network, contacts, particular skills.


ASSESSMENT OF LA HEALTH COLLABORATIVE

  9. How would you describe the structure of LA Health Collaborative?
       a. Probe for governance structure, decision-making processes, membership rules,
          relationships among members, location, frequency and nature of meetings,
          opportunities for informal communication and collaboration, communication
          channels, and level of involvement of The California Endowment.

  10. What are the goals and objectives of the LA Health Collaborative?
        a. Probe for change over time, short-, intermediate-, and long-term goals, and
            compare to what The California Endowment intended them to be. Also probe for
            informal, unwritten goals and objectives as well as personal goals for the
            structure, function, and direction of the LA Health Collaborative.

  11. How would you assess the LA Health Collaborative’s capacity to meet its goals and
      objectives?
         a. Probe for finances, level of influence in wider health care environment (local,
              state, national levels), manpower, access to and quality of information.

  12. What have been the major activities and accomplishments of the Collaborative over the
      past two years?


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  13. To what degree is the Collaborative focused specifically on the issue of access to care?


OUTCOMES

  14. How has the Collaborative changed your relationship with key health-related
      stakeholders in Los Angeles County?
          a. Probe for number and quality of relationships built, level of trust formed, degree
             of collaboration and joint action, participation of large group of stakeholders

  15. How effective has the Collaborative been in providing information and having discussion
      about the major health issues of the county?
         a. Probe if issues of importance to the respondent are addressed; critical information
              is dispersed, information presented clearly and comprehensively, unnecessary
              information left out; issues of significance to LA County were addressed,
              common goals were identified.

  16. What overall impact has the Collaborative had on the health of Los Angeles County as a
      whole?
         a. Probe if common goals were identified, joint action occurred, enough influence
             existed within the Collaborative to initiate action and cause change, access to care
             has improved, health conditions have improved, disparities in health and access to
             care have diminished.

  17. What other outcomes have happened as a result of the Collaborative?




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       APPENDIX J: LA Health Collaborative Non-Participants Interview Protocol



“Thank you for taking the time to speak with me about your knowledge and involvement with
the LA Health Collaborative, an initiative of The California Endowment. Before we begin, I
would like to give you this information sheet that describes the evaluation this interview is a part
of. Please read it and let me know if you have any questions.

[Hand participant evaluation information sheet.]

Do you have any questions that I can answer?

[Answer questions as needed.]

Now that you’ve read the information sheet, if you still agree to participate in this interview,
please read and sign the following informed consent sheet.

[Hand participant informed consent sheet. Proceed once signed and returned to interviewer.]

Thank you.

I’d like to begin our interview by asking:


PARTICIPATION

   1. How would you describe your initial level of involvement in the LA Health
      Collaborative?
         a. Probe for how initiated into the LA Health Collaborative, meeting attendance,
             participation in LA Health Collaborative events, degree of involvement in
             leadership of the LA Health Collaborative.

   2. How has your level of involvement changed since you first became involved with the
      Collaborative?
         a. Probe not only for differing levels of involvement over time but reasons for
             changing levels of participation.
         b. If no longer participating, probe why they have decided to stop participating in the
             activities of the LA Health Collaborative, including competing interests,
             prioritization of competing interests, inefficiencies or ineffectiveness of the
             Collaborative, interpersonal conflicts, control over the direction of the
             Collaborative, logistical barriers to participation.




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ORGANIZATIONAL ASSESSMENT

  3. From what you understand, what are the goals and objectives of the LA Health
     Collaborative?
        a. Probe for change over time, short-, intermediate-, and long-term goals, and
            compare to what The California Endowment intended. Also probe for informal,
            unwritten goals and objectives as well as personal goals for the direction of the
            LA Health Collaborative.

  4. To the best of your knowledge, how would you describe the resources the LA Health
     Collaborative has to meet its goals and objectives?
         a. Probe for finances, level of influence in wider health care environment (local,
            state, national levels), manpower, access to and quality of information, status.

  5. What have you heard about the activities and accomplishments of the Collaborative since
     you stopped participating?
        a. Probe for which activities have made news, the image and reputation of the LA
            Health Collaborative as its activities become known, and the attitude and opinions
            of the participant toward the activities of the LA Health Collaborative.


OUTCOMES

  6. How has not participating in the LA Health Collaborative changed your relationship with
     key health-related stakeholders in Los Angeles County?
        a. Probe for quality of relationships built, level of trust formed, degree of
            collaboration and joint action, participation of large group of stakeholders.

  7. What do you think the impact of the LA Health Collaborative on the health of Los
     Angeles County as a whole has been?
        a. Probe for focus of and communication within the LA Health Collaborative,
           including if issues of importance to the respondent are addressed; critical
           information is dispersed, information presented clearly and comprehensively,
           unnecessary information left out; issues of significance to LA County were
           addressed, common goals were identified.
        b. Probe if common goals were identified, joint action occurred, enough influence
           existed within the Collaborative to initiate action and cause change, access to care
           has improved, health conditions have improved, disparities in health and access to
           care have diminished.




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                       APPENDIX K: Stakeholders Interview Protocol



“Thank you for taking the time to speak with me about your knowledge of and involvement with
the LA Health Collaborative, an initiative of The California Endowment. Before we begin, I
would like to give you this information sheet that describes the evaluation this interview is a part
of. Please read it and let me know if you have any questions.

[Hand participant evaluation information sheet.]

Do you have any questions that I can answer?

[Answer questions as needed.]

Now that you’ve read the information sheet, if you still agree to participate in this interview,
please read and sign the following informed consent sheet.

[Hand participant informed consent sheet. Proceed once signed and returned to interviewer.]

Thank you.

I’d like to begin our interview by asking:


   1. What do you know about the LA Health Collaborative?
        a. Probe for reputation, impact, first-hand dealing with the LA Health Collaborative
            or member organizations/individuals.

   2. In the past few years, what have been the major issues surrounding access to care in Los
      Angeles County?
          a. Probe mainly for regional issues, financial and budgetary issues, private and
              public sources of health care, health infrastructure, issues affecting specific
              populations or geographic areas, changing national, state, and local policy and its
              affects on LA County.

   3. In your dealings with these issues, who would you say are the major decision-making
      voices that have shaped their outcomes?
          a. Probe for LA Health Collaborative and member organizations, as well as other
              constituents, including non-profits, governmental agencies, politicians, public and
              private advocacy groups, community representatives, private sector companies.
          b. Get examples or go issue-by-issue as they were named by the respondent.

   4. What or who are the major influences on the positions you have taken on these issues?




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       a. Probe for direct and indirect influences, superiors, organizational
          constraints/loyalties, constituents, service groups, political pressure, financial or
          other contextual constraints?

5. What would your prescription be to improve access to care for all residents of Los
   Angeles County?
      a. Go beyond pat answers like “more money.” Probe for changing mechanisms of
         operation, political, financing, and institutional structures. Don’t settle for
         diagnosis, go for prescriptions for improved access.




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 APPENDIX L: LA Health Collaborative Case Site Comparison Study Interview Protocol


“Thank you for taking the time to speak with me about [name of collaborative of interest
interviewee belongs to]. Before we begin, I would like to go over the information sheet sent
earlier that describes the case studies that this interview is a part of. Please read it and let me
know if you have any questions.

[Hand participant evaluation information sheet.]

Do you have any questions that I can answer?

[Answer questions as needed.]

Thank you.

I’d like to begin our interview by asking:


Coalition/collaborative background

   1. What was the impetus or rationale that led to the formation of [name of collaborative]?

   2. How would you describe the purpose of [name of collaborative]?

           a. Probe for broad v. specific focus

   3. How many organizations were involved in the collaborative when it began? How many
      are there now?

           a. Probe for what led to any change in size

   4. What are the specific activities or strategies that the collaborative uses to achieve its
      goals?

           a. Probe how these were identified among collaborative participants.

   5. What would you say are the most important successes of the collaborative over the past
      few years?

   6. What have been the biggest challenges to [name of the collaborative] over the past few
      years?


Course of action



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   7. How was the collaborative able to identify the issues it eventually decided to act on?

           a. Probe for how it was able to break down complex issues into manageable and
              winnable actions.

   8. How does your collaborative deal with conflicts of interest, both among members who
      have differing stances on the actions and positions the collaborative takes on, and
      conflicts that arise between the interests of the collaborative and those of participant’s
      home organizations?

   9. How does your collaborative stay on point with the activities it takes on and not get
      distracted by other relevant and important issues that arise?


Group dynamics

   10. What would you say are the main incentives for participants of the collaborative?

           a. Probe mainly for how incentives for participation were identified and
              implemented that were greater than competing interests for people’s attention and
              time.

   11. What level of investment exists among participants of the collaborative?

           a. Probe for a range and why highly involved people are highly involved.

   12. Among organizational representatives who participate in the collaborative’s activities,
       what would you say is the most common position or title they hold in their organization?

   13. How has the collaborative fostered a sense of ownership of the collaborative among
       participants?

Identity

   14. What three characteristics of the collaborative would you say most accurately describe its
       “identity”?

              Probe for how it decided on a specific course of action from a larger more
              idealistic goal and why that particular course of action was chosen.

   15. How does the collaborative balance decisions to invite organizations as participants who
       might also be seen at time as targets of the collaborative’s efforts?

   16. In your opinion, how important are personal relationships among collaborative
       participants to its effectiveness?



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              Probe for how these relationships are nurture within and without the formal
              activities of the collaborative.

Closing Question

   17. Are there any other features of [name of collaborative] that you think contribute to its
       effectiveness that we haven’t discussed?


Thank you for your time. Would you like us to send you a copy of the mini case study we are
doing on the collaborative when we are dong with it? If so, where can we send it?




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      APPENDIX M: Coverage Initiative Workgroup Case Study Interview Protocol

Planning
1. Were individuals talking to each other about the Coverage Initiative before getting together
   through the Collaborative to work on this issue? What were those discussions about?

2. What was the overall goal of initially putting the Coverage Initiative workgroup together?
   Who brought it together? Who generated the idea (e.g. who’s spark was it)?

3. Were you involved in the previous LA County 1115 waiver process? If yes, how has this
   process differed from the last one? [PROBE particularly for the extent of stakeholder input
   and the responsiveness of DHS to that input]


Organizational Participation
4. How were you/your organization brought in to Coverage Initiative workgroup?
5. Why did you/your organization choose to get involved?


Workgroup Participation
6. What did members of the workgroup do? What were the roles or duties of workgroup
   members? [PROBE: for involvement beyond providing input at meetings]
7. Who or what organization(s) had a stake in the drafting or the outcome of the initiative but
   were NOT involved? Were there organizations that should have been part of the work group
   but weren’t?
       a. Why do think they were not involved?
8. Were there organizations or individuals who were involved at the beginning of this process
   but then dropped out?
       a. What was their level of engagement before dropping out?


Process
9. What were the key issues of the Initiative that the workgroup focused on? What strategy was
    used to promote those ideas?
10. How would you describe the role of the Coverage Initiative workgroup in the process of
    drafting the LA DHS proposal?
        a. Are there other accomplishments of the Collaborative that you can think of?
11. How did the Coverage Initiative workgroup guide the process/work? What resources did the
    Coverage Initiative workgroup bring to the table?
12. Was work on the Coverage Initiative a melding of ideas from various people? Or did one
    person drive its inception and development?
13. Who were the people most important in this process within the workgroup? Outside the
    workgroup? How/why were they important? Had those people not been at the table but
    another person from the same organization was do you think the impact would have been the
    same?
14. Were there policy issues or challenges that influenced the final Coverage Initiative proposal?


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15. Who else was trying to influence the Coverage Initiative in addition to the LA Health
    Collaborative? To what extent were these organizations aligned with LAC’s goals? To what
    extent were they not aligned? How was this dealt with?
16. How did LADHS (and the CA DHS) respond to the work group’s input? [PROBE: ask for
    concrete examples of following or rejecting new ideas, processes, etc]
17. How much were you and your organization involved in working with LA DHS on the
    Coverage Initiative OUTSIDE of the Coverage Initiative work group?
18. Who was in charge of the LA County response at DHS?
        a. Was there an initial plan to do outreach to the community or did planning the
           Coverage Initiative response stay within the department? How did the workgroup
           influence seeking community input?


Outcomes
19. Of the activities and accomplishments, what could not have been achieved without the role of
    the Coverage Initiative workgroup?
20. What were the most important factors when trying to influence the Coverage Initiative? For
    example people, organizations involved, or circumstances such as having a short window of
    time to influence the process.




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               APPENDIX N: Host Organizations of Evaluation Participants


Participants (some organizations include multiple respondents)

Asian Pacific American Legal Center
Community Clinic Association of Los Angeles County
Community Health Councils, Inc.
Hospital Association of Southern California
LA Care Health Plan
Los Angeles Area Chamber of Commerce
Los Angeles County Department of Health Services
Office of the Los Angeles County Chief Administrative Officer
UCLA

Non-participants

Asian Pacific American Legal Center
Hospital Association of Southern California (retired employee)
Los Angeles County Department of Health Services
Insure the Uninsured Project
USC

Stakeholders

National Immigration Law Center
T.H.E. Clinic
The Children’s Partnership




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               APPENDIX O: LA County Safety Net Issues and Actors Survey

Each safety net issue is likely to involve a different set of actors. The following question
addresses the overall importance of each type of stakeholder in the mix of policies that affect the
safety net.

1. For each of the following stakeholders, please indicate how often they have influence in policy
decisions and implementation concerning the health care safety net in Los Angeles County

                                          Always      Usually     Sometimes      Rarely    Never
LA County Department of Health
Services
LA County Board of Supervisors
State-level officials (legislative &
executive)
Federal-level officials
LA City Council
L.A. Care Health Plan
Kaiser Health Plan
Other private health plans and insurers
LA County Medical Association
Other physicians’ organizations
Nurses’ unions
Other health care worker unions
Hospital Association of Southern
California
Community Clinic Association of LA
County
Health care advocacy organizations
Mental health advocacy
Other community advocacy
organizations
The California Endowment
Other Foundations
News media (LA Times, local TV
news, etc.)
Local think tanks & universities


2. Are there any other stakeholders that always or usually have influence? Please list.

_____________________________________________________________________________

_____________________________________________________________________________
3. In general, how important do you think it is to have the top leader of the organizations above
personally involved in key safety net issues?

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                                           Critical     Very      Moderately    Somewhat    Not
                                                      important   important     important important
Attend quarterly meetings
Participate in subcommittee meetings
Be accessible for consultation
Publicly support Collaborative agenda
Devote organizational resources to
Collaborative
Take a leadership role in Collaborative
Work to shape the issues addressed


  4. Please give three words that you think best describe the LA Health Collaborative.

  _________________________________________________________________________


  5. Please list up to three key policy issues that have been important to LA County's health care
  safety net in the past few years.

  Issue 1: ________________________________________

  Issue 2: _______________________________________

  Issue 3: _______________________________________

  6. For each issue, please list the most important stakeholders (name and/or organizational
  affiliation) who shaped the policy on that issue.

               Issue 1’s most important      Issue 2’s most important    Issue 3’s most important
               stakeholders                  stakeholders                stakeholders
  Name 1

  Name 2

  Name 3

  Name 4

  Name 5

  Name 6+


  7. Which of the following best describes your current employer?

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       __ LA County Department of Health Services
       __ Local government official
       __ LA Care Health Plan
       __ Kaiser Health Plan
       __ Other private health plans and insurers
       __ Hospital or affiliated professional association
       __ Community clinic or affiliated professional association
       __ Legal services organization staff
       __ Health care advocacy organization
       __ The California Endowment
       __ Other Foundations
       __ News media (LA Times, local TV news, etc.)
       __ University or research center
       __ Other (please specify): _________________________________


8. Which of the following best describe your position in your organizations?

       __ Executive
       __ Management
       __ Direct service provider
       __Other staff

9. What is the zip code of your primary affiliation?

       ___________________________________

10. What is your level of involvement in the LA Health Collaborative?

       __ High
       __ Medium
       __ Low
       __ None
       __ I don’t know what the LA Health Collaborative is

Thank you for your assistance!




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