Health Partners Fellowship Program

Operationalizing a Vision: Partnership Means Never Having to Go It Alone
Angela Ellison, MA

Angela Ellison is executive director of West Side Future YMCA, a community-based organization whose primary purpose is to reduce infant mortality and provide comprehensive services and resources to the families they serve. With more than 20 years experience in the area of maternal and child health, she is firmly committed to helping families attain the skills necessary to improve their overall health and quality of life. Furthermore, she believes in assisting her staff gain the knowledge, acquire the values and perfect the techniques to become leaders in their professional and personal lives. Ms. Ellison was educated in Chicago, receiving her bachelors degree in psychology from Loyola University in 1983 and a masters degree in education from the Chicago State University School of Guidance and Counseling in 1991. She has held several administrative and leadership positions in health care agencies and has experience as a program director, grants administrator and director of case management.

Ms. Ellison has been a part-time ICHLD faculty member for four years, during which time she has maintained her involvement in the community, leading or participating as a team member on a number of collaborative ventures. These initiatives have been varied - ranging in size, complexity, and diversity of membership and areas of focus. She has faced the challenges common to partnerships involving health departments and local service providers as well as those uniquely associated with university-community research collaborations. In this story, Ms. Ellison tells Marilyn Willis about a multi-year effort to operationalize a vision, to develop and maintain a one-stop health care concept and facility (Near West Family Center) to serve low-income pregnant women and families residing on Chicago's West Side. This neighborhood - the Near West Side of Chicago - had a long and well-documented history of elevated infant mortality. Not only was it the highest in the city of Chicago, often it approached rates of Third World countries. During the 1980s, the State of Illinois had spearheaded the "9/90" Infant Mortality Reduction Initiative which sought to reduce infant mortality to 9/1,000 live births by 1990. Researchers, community activists and many local health care providers had come to the conclusion that elevated infant mortality was largely the result of a fragmented and uncoordinated system of prenatal and infant care, institutional barriers and financial barriers. After 1990, infant mortality reduction efforts were funded at the federal level under the Healthy Start Program.

While Healthy Start supported a variety of program approaches, all were designed to deliver comprehensive services in a manner that would address fragmentation. During the 1990s, federal dollars were cut several times and an eventual phase out of funding was mandated. "My first reaction was disbelief (tinged with anger) at the idea that we would be expected to be able to maintain a program once state support was terminated. However, I very quickly decided not to be daunted by the contradiction embodied in the mandate and its seeming futility. Instead, I acknowledged my misgivings and put aside negative thoughts and 'spirit-draining' feelings. I made a deliberate and conscious decision to galvanize my energy . . . to redouble my efforts to bring about positive change and community betterment by striving to sustain (what might be considered) the unsustainable," Ms. Ellison explains.

Background

In 1991, the U. S. Department of Health and Human Services, under its Healthy Start Initiative, funded organizations in 15 rural and urban areas that had infant mortality rates 11/2-21/2 times the national average. These programs developed and utilized innovative approaches to design comprehensive, coordinated and culturally competent models of health care and related support services for mothers and infants. In Chicago, five agencies were the proud recipients of these federal dollars funneled through the state-run Illinois Department of Public Health (IDPH) expressly to address the needs of clients from predominantly low-income, minority families. The overall aim was to reduce the elevated infant mortality rates (IMR) by 50% by 1996 in six inner city neighborhoods, including the Near West Side.

To accomplish this goal, the key collaborating agencies established a comprehensive service approach in six neighborhoods. Case management, general support, home visitation services and early child development interventions were provided. In addition, resources were dedicated to improve access to medical care and to support and enhance advocacy efforts on behalf of mothers, children and families. During this five-year demonstration project, a viable relationship was formed between five critical entities, namely two case management services agencies, two outpatient health care facilities and one case-management/health care facility partnership. This mix of collaborators was significant because the very combination of resources exemplified the philosophy of service delivery they espoused and their approach to care.

"As far back as I can remember, maternal and child health care providers and other professionals in this city operated from the premise that infant mortality was not just a medical problem, but a medical problem compounded by social issues and other concerns. As leaders in the field, we recognized that the high IMR was influenced by the fact that clients who are facing tremendous ills cannot or will not access health care services - that these services do not represent their primary concern at any given point in time. We knew that it was imperative to address their basic needs (for shelter, safety, food etc.) before many of them would be able to focus their attention on medical care or recognize the value of preventive services," Ms. Ellison explains. For three years, under the umbrella of IDPH, these five partners operated within the Chicago Healthy Start Consortium. Initiated and led by IDPH, consortium members included the network agencies, other subcontractors and interested representatives from the field of maternal and child health. A formal organizational structure was developed in the early stages of the consortium's development, and included the general membership and an executive committee, which met for routine business matters on a regular basis. Task forces and subcommittees were convened as warranted to accomplish specific objectives. In 1994, at the time when the federal government began encouraging the IDPH to plan to sustain these valuable programs, Ms. Ellison was both a member of the consortium's executive committee and the director of case management at one of the partner agencies.

Approach to Program Sustainability

The partners' creative solution to the problem of sustainability for IMR programs came easily. It was firmly grounded in their own philosophy, their professional training and experience, and their value for and commitment to the community and its residents. It grew out of numerous deliberations, discussions and meetings regarding client needs that spanned disease categories to focus on the myriad of complex, interwoven issues that impact the daily life and well being of a family. Thus, the family center concept was proposed. The idea resonated with the planning group and, while clarifying questions were raised, the possibility of having comprehensive services in one location brought nods of consent and preliminary approval. The proposed initiative represented an important milestone and development in the life of the consortium. In the beginning, the consortium brought together providers who had independently designed and submitted applications and subsequently competed for the same funding to support community-based programs. (See Figure 1.) Now, after working together at various levels for three years, members were embarking on operationalizing a concept and designing a program, the core elements of which could be agreed upon and implemented by all. At that juncture, a concise and simply-worded vision statement might have been, 'Within three years, there will be five, full-staffed family centers in the city of Chicago providing medical care, comprehensive social services and case management to low-income pregnant women and their families.'

"We realized that if we were going to create a family center, we would need to have medical services. But more importantly, we would need to have social services and we would need to have operations and procedures regarding how each family center would work. Providing much needed medical services would be the key to sustainability, because medical services are billable, whereas case management services are not. We reasoned that if we were able to adequately bill and receive reimbursement, then we would be able to maintain some portions of a family center," Ellison explains.

Once the solution had been determined, the consortium began to move forward. Planning progressed over the months - sometimes quickly, sometimes slowly. As could be anticipated, the initial affirmative responses became modified as details regarding center objectives, services and procedures became agenda items for serious critique and final vote. Discussions were marked with . . . 'Yes . . . but' or 'Yes. . . but only if' or 'Yes, but how and when?' The goal - reduce infant mortality - was clear; the pathway to the goal was less certain and defined.

Design of the Family Centers - Facilitating Effective Planning

Several mechanisms contributed to the successful development of this initiative. Support came in many forms and from many different avenues. It is critical to acknowledge and single out each of these strengths because when taken together, they create synergy, a force that can exert a leveling effect and offset or neutralize negative influences.

Federal and state support. There was an adequate level of funding support from the federal agency (within existing local agency budgets) to allow the planning process to proceed over a 12-month period. In addition, other resources, including a marketing consultant, were made available to the consortium. In this way, dedicated monies accompanied the mandate. The incumbent director of the federal Maternal and Child Health Bureau Healthy Start Program affirmed this, stating, "Changes at state and federal levels can create new paths while closing off others. Community-based programs need vision to find their place in emerging systems, while holding on to their role in existing systems."
On the local level, the IDPH representative was actively engaged and worked diligently on development activities for the centers. Through this level of involvement, she demonstrated a deep and visible commitment, which in turn strengthened interactions and further enhanced the efficiency with which progress occurred.
Designate responsible individuals. The consortium established the Family Center Task Force which was charged with the following responsibilities: define what each center would look like; specify services to be offered; identify billable charges and the agency to which bills could be submitted (Medicaid, HMO etc); and design a marketing plan. IDPH and each subcontractor were represented on this body, thus ensuring equal access to information as well as input into the process.
Ensure compatibility of health care approach and commitment to effective programs. The proposed services were consistent and complementary with services then offered through the Healthy Start Program. However, expanded services were also recommended. Consequently, each family center would offer health care, case management, ages 0-3 early intervention, referral advocacy, nutritional services, health education, substance abuse counseling and referrals, as well as other support services (parenting classes, GED, male responsibility programs, etc.). Consortium members were committed to the delivery of quality care, sustaining valuable services, and solidifying existing program components before new initiatives were added.
Schedule consensus-building activities. Task force meetings were convened on a regular basis and periodic reports and updates were provided. In addition, a day-long retreat was conducted where draft documents were circulated for review, discussion and approval. City, state and community agency representatives, health care providers and consumers attended the retreat. Thus, Healthy Start Consortium members had both routine and specific feedback channels in place and ongoing access to mechanisms through which grievances and concerns as well as program information could be communicated.
Develop written, agreed-upon guidelines and protocols. Extensive outlines for policy and procedure manuals were drafted. Descriptions of all services were compiled. Sample memoranda of understanding were developed for those activities that required the execution of formal agreements. Organizations were able to add components that were specific to their circumstances. The 'write-review-rewrite-critique-refine process' necessary for the development of these materials helped to establish uniformity in approach, and at the same time strengthened the comprehensive programs which subsequently emerged.
Committed leadership is essential. Key members were willing to put in the time and effort and to take the risks necessary to ensure progress on many fronts simultaneously: conducting informal assessments and taking the pulse of the membership and the community; sharing information and soliciting feedback from multiple players at different organizational levels; developing, critiquing and refining draft documents tirelessly; staying "centered" when criticisms were sometimes leveled and conflicts arose.

Design of the Family Centers – Challenges and Barriers to Progress

Consortium members encountered any number of challenges as they engaged in these project development activities. From Ms. Ellison's perspective, several critical issues threatened the accomplishment of the proposed plans. They are indicative of the nature and complexity of experiences faced by any given coalition as it modifies its structural characteristics and moves through various stages during its lifespan. These are issues that both designated leaders and members struggle with - struggles that can lead to enlightenment and self-fulfillment, thus bringing their own rewards.

Agreement on services. The majority of the originally funded partners were case management agencies, focusing on social services. Thus, discussions regarding the need to include medical services as an essential component were viewed as potential threats by some individuals. On the other hand, members who were health care providers needed to ensure that their social service component was as strong as their primary focus, the delivery of medical services.
Change in original partners. In the midst of the center development phase, one of the participating case management agencies closed its doors and its role was assumed by a health care delivery agency. Thus, as is the case when new members join a coalition, the mission and goals had to be revisited and explained. It was essential to obtain the buy-in of the new partner. However, in this instance, timing was critical because the work of the group had to proceed while one of the participating member agencies gained a fuller understanding of past deliberations and future plans. To ensure progress, consensus had to be reached, decisions had to be made and carried out within predetermined timelines that had previously been agreed upon. Understandably, and perhaps not unexpectedly, tensions arose.
Selection of additional partners. Establishing a program that provided the services considered essential posed different concerns for the various partners. Some case management agencies needed to identify interested medical providers and work though critical administrative steps for establishing sub-contractual relationships. On the other hand, the two Federally Qualified Health Centers were being called upon to strengthen and emphasize their social service component. These activities were time consuming and labor intensive, requiring time for assessment, planning and implementation of ideas.
Buy-in of executive directors. In the main, senior leadership was not represented in the membership the Healthy Start Consortium. While there was concurrence by middle management, approval from higher levels of authority had to be solicited and obtained. Convincing arguments had to be made not only regarding the desirability but, more importantly, the viability of the proposed centers. Furthermore, these arguments had to be presented to leaders of five different entities with different agendas, varying interest in the "one-stop" concept, as well as varying approval processes and time frames for making decisions.
Member roles and contributions. The consortium had taken on a complex project. Over time, it became increasingly clear that members needed to play different roles, roles that varied in degree and extent of involvement. Broad-based involvement, critical to progress, did not come without personal costs. While individuals accomplished tasks and made headway on plans, at times they were subject to what some perceived as overly critical scrutiny from peers. Acknowledging these perceptions and conducting open, objective discussions were key to addressing this issue.

Leadership Role - The Larger Process

Ms. Ellison reflects, "I think the most important and perhaps the strongest leadership trait that helped me get through this phase of working with the consortium was being a visionary. I was very clear as to what the vision was and I held a deep commitment to that vision. Most critically, I tried to stay true to what we were trying to do."

Ms. Ellison also believes that her ability to be a team player played a key role. "I was able to put the 'me' aside and think about the 'we.' I was willing and prepared to work. I identified those areas and arenas within which I could make a contribution and proceeded to roll up my sleeves and act. Sometimes, I operated behind the scenes, motivated and compelled by the possibility of success, rather than by the need for personal recognition."

Ms. Ellison's efforts did not go unnoticed. While she was hard at work supporting the efforts of the Healthy Start Consortium, she was offered a new role and challenge. She was hired by the key partners to serve as the coordinator of one of the proposed family centers. At this point, she began to wear two distinct, though complementary hats - she was now coordinator of the Near West Family Center while still serving as chairperson of the Healthy Start Consortium's Family Center Task Force. She started on the ground floor to lead the creation of an entity, the overall design of which was still being refined and crystallized by the very consortium of which she was a member.

Leadership Role - Establishment of the Near West Family Center

Once Angela came on board as coordinator of the Near West Family Center, she spent an inordinate amount of time in meetings to discuss the center's operations, developing mundane items like a clinic supply list, or refining clinic operating procedures, or designing patient flow patterns - all elements needed to open a comprehensive one-stop health care facility. As Ms. Ellison recounts, "Needless to say, nothing ever worked the way we planned it while we sat around the table. Nonetheless, it was a good exercise at the time. I encountered several issues that were not amenable to resolution within (what seemed to be) a reasonable time frame. As can be imagined, these problems challenged my mental and physical energies."

Selecting a site for the center. Her team visited dozens and dozens of locations in and around the West Side of Chicago. Some spots were ideal but far too expensive. Others were appropriately situated, but were not for rent. Other buildings were in a suitable place but the layout and space requirements were not adequate. The criteria for site selection included accessibility to public transportation, affordability, spaciousness and safety for clients and staff alike. "We wanted the building to be attractive, one of which the community would be most definitely proud. It had to be a place where you would want to bring the whole family and where you would be comfortable staying a while," Ms. Ellison remembers.
Promoting the center concept. While consortium members were dedicated to the family center idea or dream, not everyone wished it would become a reality. Outside of the active consortium membership, many of the local players in the health and social service arenas were not well informed concerning the concept or specific plans. Once the consortium had sketched out the structure and scope of work, it became very important to promote the concept to staff at various agencies and to the community members to whom the services would be offered. All parties needed to be apprised of the preliminary plans, given opportunities to raise questions, provide input, and receive feedback. This process was not like the one-time briefing sessions so popular today, but rather an ongoing dialogue held in various venues that continued until key parties were satisfied.
Switching roles, not loyalties. When Ms. Ellison first joined Healthy Start, she worked with two agencies, but was employed by only one, the health care provider. Now as the Near West Family Center coordinator, she was equally employed by both the health care provider and the case management agency. Essentially, she entered a new situation, assuming responsibility for an initiative that linked these two agencies in a formal partnership. This partnership was grounded in their coordinating relationship, a time when information had been shared and activities adjusted for mutual benefit to achieve a common purpose. For one of the agencies, she now became the leader rather than a dedicated member of their team - someone who visited the site for scheduled meetings but had no administrative responsibilities. She readily admits that juggling the expectations and demands of two parties was difficult at times. She believes she survived because she stayed loyal to the vision. "I am not saying that it was not intense. Some days were more difficult than others. But believe me, when I look back, trying to be neutral and goal-centered made the situation and circumstances more manageable overall," Ms. Ellison recalls.

The Near West Family Center Becomes a Reality

The Center opened its doors on Chicago's West Side on a sunlit day just as the leaves were beginning to change colors and turn red and gold. The beauty and brightness of the surroundings perhaps served as a signal that a new day was dawning. It had taken over a year to reach the goal. Space had been acquired in a newly-constructed building that more than satisfied the agreed-upon criteria.

With the new found space came new found partners. The two Healthy Start providers now joined the two original occupants - the WIC Food Center run by a local charity and supported by the State of Illinois and the WIC Certification Center operated by the Chicago Department of Public Health.

This unique collaboration was spearheaded by the IDPH Healthy Start representative and reflected farsighted thinking and an approach that had the potential to benefit all. The partnership continues to this day and the center has been promoted as a model comprehensive one-stop health program.

Reflecting on Lessons Learned

"When I try to sort out all the lessons I have learned, I am struck by the fact that I keep coming back to the same themes. At any given point in time, one lesson is more significant or relevant than another," Ms. Ellison remembers.

The vision must be in your head and in your heart. In your head because you have to identify your path and know how you will travel the road in order to reach your goal. In your heart, because it becomes reflected in your very being. It helps to define you and helps you to recognize and connect with the vision of your partners and peers.
You need to have belief and passion and find ways to stoke those fires and keep those inner feelings strong.
You have to be willing to engage in critical thinking, take risks, share ideas, and commit thoughts to paper. Planning and establishing the groundwork is critical to program success.
Partnership means never having to go it alone. You have to have dedicated staff and team members to carry out action plans, to support the efforts of the group, and to stimulate and refresh the mind and spirit.

A Final Note

To this day, Ms. Ellison has remained working on the Near West Side, assuming increasing levels of responsibility and supporting initiatives that promote quality of life, dignity and health for the residents she serves. "I believe in people and in myself and I am committed to trying to make a difference in the lives of the clients that our center serves."