How Two Donors Collaborated To Address Rural Health Care and Safety Net Challenges


Health funders are increasingly collaborating with their peers to design research, grantmaking, technical assistance and field development activities to address complex health and care challenges. health.

As two of these colleagues from leading health philanthropic organizations, the Robert Wood Johnson Foundation (RWJF) and the Episcopal Health Foundation (EHF), our collaborative efforts over the past five years have helped advance a payments reform agenda among safety net providers; provided information on how to deal with the rural hospital closure crisis and deepened the understanding of the field on how to integrate social determinants of health (SDOH) into the Medicaid managed care environment. In doing so, we have also improved our own work by regularly sharing information, making connections with content experts and improving our strategy development through thoughtful partnership.

Advancing Safety Net Payments Reform

In 2015, RWJF supported the establishment of the National Safety Net Advancement Center (SNAC) to advance the capacity for payment reform among safety net providers by leveraging new and existing knowledge to create actionable tools for these providers to across the United States. Drawing on the initial experience of SNAC, EHF and RWJF decided to form a peer learning network of federally accredited health centers (FQHC) in Texas.

EHF has also recruited an additional donor in Texas, Saint David Foundation, to co-finance the learning network in 2016. Collaborative learning brought together payment reform experts, state Medicaid officials, and leaders of managed care organizations to discuss federal policies and mandates for value-based payments. Our intention was to enhance readiness and build the capacity of participating FQHCs to engage in payments reform.

The benefits of co-financing were manifold. RWJF, as the national funder, had a unique opportunity to learn first-hand the challenges that FQHC leaders face in approaching payments reform in Texas. RWJF staff members were able to take advantage of the EHF’s local knowledge, connections and network to deepen their understanding of the challenges of payment reform among safety net providers in a large non-expanding state of Medicaid. Alternatively, EHF and the St. David Foundation were able to leverage RWJF’s network, which brought in national payments reform experts and a facilitator in the learning collaboration. EHF has continued to develop its relationships with these thought leaders and consultants over the past few years.

In 2018, building on its previous support to the National Safety Net Advancement Center, RWJF launched the Delta Center for a thriving safety net project, a national initiative that brings together many state primary care associations (PCAs) and state behavioral health associations (BHSA) to advance changes in payments reform policy and practice. In launching the initiative, RWJF sought advice from EHF as a thinking partner on scope and structure. When the Texas Council of Community Centers (Texas Council) received a grant to join the Delta Center’s first collaboration for state associations, EHF co-funded the Texas Council, which enabled the council to provide one-on-one technical assistance to its members. By participating in the collaborative, the Texas Council has been able to help its member agencies gain state support Certified Community Behavioral Health Clinic status and in the collection, monitoring and reporting of cost data to create a Capita alternative payment model.

EHF participated in several Delta Center meetings, which allowed this foundation to forge additional relationships with national experts in payments reform and to obtain information from other state PCAs and BHSAs on how they have advanced their payment reform programs. Many state associations were grappling with issues familiar to those trying to evolve Texas. There is no doubt that our long-standing collaboration has accelerated efforts to strengthen the capacity of Texas protective clinics to participate in payments reform.

Dealing with rural hospital closures

In May 2017, the EHF published a study conducted by researchers at Texas A&M University (TAMU) on the crisis of growing hospital closures in rural Texas communities. The report, titled “And after?” challenged conventional policy responses to deal with rural hospital closures a ‘right size’ approach to health care, which takes into account the unique needs of each rural community.

However, the financial pressures facing rural hospitals are of course not limited to Texas, even though that state has seen the most closures in the United States since 2010. As a national philanthropy, RWJF had limited knowledge. field, expertise and insights on rural health care issues. For RWJF, this was another unique opportunity to leverage the extensive network and credibility of a local donor to gain real insight into a critical issue of national importance.

EHF also saw RWJF’s involvement as a way to bring national credibility to a follow-up study to see how it would be viewed by local leaders and stakeholders. Subsequently, EHF and RWJF, as well as another donor from Texas, TLL temple foundation, co-funded a follow-up study by TAMU researchers. Here, they conducted three case studies of rural hospitals facing financial pressures in Texas. The report, entitled Optimizing rural health: a master plan for community health care, was released in 2018.

Building on these two earlier efforts to deal with rural hospital closures, TAMU received a competitive multi-year grant from the Federal Office for Rural Health Policy of the Health Resources and Services Administration in 2019 to create the Center for Optimization of Rural Health. It provides technical assistance to vulnerable rural hospitals across the country. Due to RWJF’s previous relationship with TAMU, the foundation awarded an Improvement Grant to help make the centre’s technical support tools more widely available to other hospitals across the United States.

Since 2019, RWJF, the TLL Temple Foundation and EHF have continued their partnership with TAMU, which now administers a rural health care “light spots” project. The project is now studying eight rural communities (both inside and outside of Texas) with hospitals that have thrived on meeting the health care needs of their communities. Of course, now these case studies will document how and why these hospitals have responded to the healthcare needs in their communities amid the COVID-19 pandemic.

Medicaid and the Social Determinants of Health

To address the SDOH challenges faced by Medicaid enrollees, the EHF has partnered with the Texas Association of Health Plans (TAHP) and the Texas Association of Community Health Plans to investigate managed care organizations to discover the facilitators and challenges for investing in SDOH. Seizing the interest of plans to participate in an SDOH learning collaboration, EHF contacted RWJF. Our organizations then launched the Texas Managed Care Organization Social Determinant of Health Learning Collaboration in 2019.

RWJF co-funded the collaboration during the first year and connected EHF with the Center for Health Care Strategies (CHCS), a health policy organization focused on the health of low-income Americans. The CHCS now leads the Texas Collaborative Learning in partnership with the two associations and Texas Medicaid.

An important spin-off project of the learning collaboration was a partnership between the EHF, CHCS and Texas Medicaid to convene a panel of SDOH experts provide feedback to the state’s Medicaid program as it develops SDOH strategies for care managed by Medicaid. The conclusions of the discussion have been used to the greatest extent report at the Centers for Medicare and Medicaid Services.

In part due to the interest and momentum created by collaborative learning, TAHP has been active in advance an SDOH program during the legislative session which has just ended in Texas. The association urged lawmakers to explore ways to incentivize and authorize Medicaid coverage for services that help meet social needs and improve health outcomes.

Although RWJF is no longer a funding partner of the Managed Care Organizations Learning Collaboration, this work has helped influence several other RWJF funded projects on Medicaid Managed Care Organizations and SDOH. In fact, EHF and RWJF recently co-funded a project led by the Institute for Medicaid Innovation. The project highlights innovative health equity approaches used by Medicaid managed care plans in and outside of Texas.

Thoughts on strategic collaboration

While we have found creative ways to leverage existing knowledge and partner and support each other in the projects mentioned above, our collaboration is not limited to funding opportunities. The majority of our conversations do not lead to co-funding opportunities.

Ongoing communication provides opportunities for EHF to learn more about the different priorities RWJF is developing nationally and for RWJF to see how a local funder that is so aligned with its mission is grappling with similar issues. RWJF brings a national perspective, connections and experiences to these conversations, while EHF brings equally valuable on-the-ground knowledge, expertise and insights from a part of the country that is very different from Princeton, New Jersey.

The lessons shared here clearly demonstrate the benefits of collaborating, learning from each other, and building on our existing work to address the major health and healthcare challenges we have faced at the local and national levels. .

During this time of working remotely, our ability to develop these relationships became even more important. Given the enormous complexity and challenges that await us as we embark on the long road to recovery from the global pandemic, we strongly encourage others to build upon and strengthen similar strategic collaborations and partnerships.


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