This commentary, written by Suzanne Brundage of UHF, Irfan Hasan of The New York Community Trust, and Rachael N. Pine of the Altman Foundation, originally appeared in the Health Affairs Grantwatch blog.
For a combined 335 years, United Hospital Fund (UHF), the Altman Foundation, and The New York Community Trust (NYCT) have provided grants to improve the health and well-being of New York City residents. Although the three organizations have different structures—UHF is an independent, nonprofit, research and philanthropic organization; Altman, a private foundation; and the NYCT, a community foundation—over the past nine months, they have united to address the social, environmental, and economic causes of poor health in early childhood.
The resulting effort, Partnerships for Early Childhood Development, holds important lessons on how creative, flexible, and collaborative grant making can result in a ground-breaking initiative, with greater scale and scope than could be achieved individually. It also serves as an example of how grantmakers can model collaboration as they promote cross-sector partnerships among their grantees.
Focus on Nonmedical Threats
Poverty-related social and environmental factors during the first five years of life can interfere with a child's physical growth and brain development, resulting in poor outcomes over the long term in health, education, and well-being.
One pathway to preventing and reducing such adversity in early childhood is to build the capacity of pediatric primary care providers to identify nonmedical threats to a young child's health, and to connect the family to appropriate social services. This is challenging work that demands that health care institutions and community organizations find new ways of working together.
Drawing upon complementary priorities and expertise, our three organizations developed Partnerships for Early Childhood Development to help pediatric practices identify and address poverty-related health risks among children ages zero to five through clinical–community partnerships.
In March 2017, UHF, Altman, and the NYCT together awarded $700,000 in one-year grants to eleven New York City hospital-affiliated pediatric and family medicine practices to:
- Engage, and provide financial support to, at least one community-based social service partner that provides services to children and families;
- Use an evidence-based screening tool to identify children facing social and environmental risks to their health;
- Conduct and evaluate activities related to initiating, expanding, or improving screening, referral, and feedback systems that connect families to services.
Participating teams are focusing on a wide range of risks, including lack of access to nutritional food, food insecurity, parental depression, unsafe housing, and adult unemployment.
Partnerships Take Center Stage
A recent national survey of 300 pediatricians found that many health care providers lack knowledge of family risk assessment tools and available community resources. Differences in culture and organizational resources (such as capital, staffing, and infrastructure) between the health care and social service sectors act as additional barriers to cross-sector referrals. To overcome these challenges, we made partnerships central to our funding initiative.
A critical dimension of Partnerships for Early Childhood Development is a year-long learning collaborative for all participants, led by UHF and consisting of in-person meetings, webinars, and technical assistance on evaluation, data collection, and analysis. The first collaborative session, held in May 2017, focused on how hospitals and community-based organizations can establish shared goals for connecting families to services, on developing a joint logic model and evaluation framework, and on exploring what it means to work as partners. Future sessions will cover sharing best practices and common challenges; developing mechanisms for cross-sector referrals and information sharing; and identifying options for scaling and sustaining partnership activities.
At the end of the one-year grant period, we expect grantees to collectively have connected at least 7,000 at-risk children and families to appropriate community services and be able to sustain their work going forward. UHF will publish a report about the successes and challenges the teams faced and the most promising techniques for creating strong clinical–community connections.
The Benefits and Lessons of Collaborative Grantmaking
Similar to their grantees, grantmakers can also feel constrained by their organizational mission, resources, reach in the community, and skills. Our multifunder collaborative helped us overcome hurdles and develop new possibilities for our grant making in the following ways:
Development of a cross-sector concept: It was clear that we each had experience addressing some, but not all, of the complex elements of this project, be they pediatric care, connections between health care and social service agencies, or strengthening community organizations. Braiding these individual strands together enabled us to develop a far more nuanced and multidimensional grant initiative.
Resources: We collectively felt the need for external evaluation support. Altman and the NYCT provided grants to UHF to support bringing in evaluation consultants, in addition to providing funding for both the learning collaborative and the community partnerships. UHF took on responsibility for designing and managing both the learning collaborative and the project-wide evaluation components.
Reach: Bringing interventions to scale is always a challenge. Acting individually, each grantmaker would only be able to support three or four partnerships; collectively, we can support eleven health systems and sixteen community organizations in four boroughs. We estimate that the primary care sites involved in this initiative care for 26,000 children under the age of five annually—that is, 5 percent of New York City's population that is under age five.
Expertise: Each foundation has a long history of working with health care and community service providers. Shared insights proved critical to informed decision making on selecting grantees and estimating learning collaborative needs.
The logistics of providing both direct grants to participants and grants to support grantees through the learning collaborative and an evaluation were challenging as well. Three elements proved critical to success:
A common target: Early on, we aligned around a broad shared vision—that all 560,000 children in New York City under age five should receive services that address their health and social needs.
Flexible funding structure: Collaboration required much flexibility in how we stitched together our funding streams. Each grantee submitted one budget request for its entire project; we used this budget to decide among ourselves how to pool our resources. The NYCT provided direct grants partially funding six of the eleven grantees, while Altman contributed to the support of all eleven grantees through a single grant to UHF, which then contributed its own funding to provide the remaining budget support for all grantees.
Balancing partnership with an organizational lead: To ensure a genuine partnership, we are determined to communicate clearly and routinely, provide timely feedback, and welcome debate. At the same time, UHF is taking the lead on program development and on ensuring that the work stays on schedule and that decision making is expedited. Striking the right balance is helped by a history of strong institutional and personal relationships among UHF, Altman, and the NYCT.
As grantmakers tackle the complex roots of poor health, solutions will increasingly require multiorganizational responses. We hope Partnerships for Early Childhood Development will bring new energy and focus to supporting clinical–community partnerships, as well as unleash new ideas for other funder collaborations.