Three Cases:
Healthcare Systems
Building the Health of Communities

by Joe Flower

During 1993 and 1994, Joe Flower followed the healthy communities efforts of three very different healthcare systems across the country, revisiting each system every six months for two years. The four installments were published as part of the Healthcare Forum's "Healthier Communities Action Kits."


  • Doing Well and Doing Good
    1. Intro
    2. Greater Southeast Health System
      Washington, D.C.
    3. Memorial Health System
      South Bend, Indiana
    4. Group Health Cooperative,
      Seattle, Washington
  • Catalyzing the community
    1. Intro
    2. Greater Southeast Health System (GSHS), Washington, D.C.
    3. Memorial Health System
      South Bend, Indiana
    4. Group Health Cooperative of Puget Sound
      Seattle, Washington
  • Putting it in place
    1. Introduction
    2. Greater Southeast Health System (GSHS)
      Washington, D.C.
      1. Leaders
      2. Steps
      3. Lessons
      4. Money
    3. Memorial Health System
      South Bend, Indiana
      1. Urbancare
      2. Tithing
    4. Group Health Cooperative of Puget Sound
      Seattle, Washington
      1. MAP
      2. Violence
      3. Steps
      4. Money
  • Going the distance:
    1. Introduction
    2. Greater Southeast Health System (GSHS)
      Washington, D.C.
      1. Built Around It
      2. Governance
      3. Culture
      4. Community
      5. Funding
      6. Corporate memory
    3. Memorial Health System
      South Bend, Indiana
      1. UrbanCare
      2. Giving it all away
    4. Group Health Cooperative of Puget Sound
      Seattle, Washington
      1. Mutual Partnerships Coalition
      2. The end of conventional wisdom


    Doing Well By Doing Good:
    An Introduction

    This is our dilemma: we run vast systems with powerful abilities to cure the sick and improve people's lives. But it costs enormous sums of money to help people, and we only get paid to help some people, not others. We have no contract to help the uninsured, the "medically indigent," the homeless, the working poor. They become SEPs -- "Somebody Else's Problem." And then the circle comes around again -- the SEPs walk into the Emergency Room, in labor three months early with no pre-natal care, in shock from diabetes that could have been stabilized, in fever from infectious diseases we thought we conquered decades ago.

    We all want to do our part. But "you gotta make a living." That means profit: whether we are "for profit" or "not for profit," we have to produce, add value, increase wealth. If we don't, then we are quickly or slowly killing the organization, putting its mission in jeopardy, endangering its power to do good.

    What can we do? Some institutions find themselves forced to pull back -- as when the California Medical Center closed its Level I Trauma Center because the "Saturday night knife and gun club" of downtown Los Angeles was draining tens of millions of dollars per year from the rest of the Center's mission. Some, such as Samaritan in Phoenix in the mid-1980s, have even contemplated selling the institution and putting the proceeds to work fostering the health of the community.

    Yet some institutions have explored ways to help the community on the ground, in the streets, without draining their financial life. We all ask ourselves, "Can I do well by doing good?" Some institutions have wrestled this question to the mat.

    I have followed three of those institutions: GREATER SOUTHEAST HEALTHCARE SYSTEM in Washington, D.C.; MEMORIAL HEALTH SYSTEM in South Bend, Indiana; and the GROUP HEALTH COOPERATIVE in Seattle, Washington. Each of these systems is working on a variety of community-based initiatives that take them far beyond the traditional role of a hospital.

    In order to focus on the nuts and bolts of the process, I picked one particular piece of each institution's work. I looked at Greater Southeast's extraordinary efforts to help the indigent elderly, Memorial's partnership in a program to help poorer women and children, and Group Health's outreach to the homeless.

    Over a period of two years, I followed each of these pieces through four phases: the groundwork, the mezzanine, the fulfillment, and the evaluation. We will look, in detail, at how each institution accomplished what it did.

    Greater Southeast Health System
    Washington, D.C.

    The southeast side of Washington's great ten-mile diamond is not an ugly place. The Anacostia River meanders up from the Potomac, past the Navy Yard, toward the Kenilworth Aquatic Gardens in Anacostia River Park. But the neat houses and brick apartments that pepper the tree-lined streets mask crime, violence, and a poverty that is far from genteel.

    It shows up in the statistics. The 90 percent African American population, especially in Ward 8, carries the highest infant mortality rates in the city, the highest violent crime rates, the highest breast-cancer rates, the highest unemployment rates, the highest percentage of children living in poverty. Fully 18 percent of the elderly population live in poverty.

    But the community does have a network of connections, and most of those connections link to Greater Southeast Healthcare System. If you want to start some community project in places like Oxon Hill, Maryland, or down on Livingston Road in the District, people will say, "Better take this over to Greater Southeast, maybe they'll have an idea." If you want to have a meeting, Greater Southeast will provide a room. When the mayor wants to meet with the community on this side of town, she calls Greater Southeast to set aside some space for it.

    This is not because Greater Southeast is some kind of Big Daddy with bottomless pockets, or a Big Fixer for every problem. It's more symbiotic than that. The people at Greater Southeast have developed networking, partnering, and leveraging to a fine art. They know how to make things happen. They have grabbed it fairly well in their two-step motto: "Caring enough to try. Smart enough to succeed."

    The Greater Southeast Healthcare System integrates two hospitals with nursing homes, adult medical day care centers, pharmacies and community service programs in a network that serves some 600,000 people in the District of Columbia and just across the line in southern Prince Georges County and Charles County, Maryland. Anchored by the 450-bed Greater Southeast Community Hospital and staffed by a force of 2700, the system has bocome the area's largest employer, and the most important local economic force.

    Over the past decade, Greater Southeast has pushed beyond its walls in an extraordinary variety of ways, including:

    • the WARD 8 YOUTH INITIATIVE, offering health promotion and health education for children
    • the BALLOU HIGH SCHOOL ADOLESCENT HEALTH CLINIC, the only school-based clinic in Washington, D.C.
    • the NEIGHBORHOOD BLOOD PRESSURE WATCH PROGRAM, in which volunteers sit people down with the rubber cuff at 24 area churches and two barber shops -- two cuffs, no waiting.
    • the KOMEN BREAST CANCER EDUCATION PROGRAM, bringing information, free mammograms, and follow-ups to low-income women
    • the BELVA BRISSET ADVOCACY CENTER, which trains volunteers citywide to provide women information about breast health, along with referrals to any help they may need.
    • the FORT WASHINGTON MEDICAL CENTER, with 33 beds and 24-hour emergency service in Fort Washington, Maryland

    But in many ways, GSHS has achieved its greatest successes in providing help to the elderly, both sick and well, able and frail. The services range from traditional health care through clinics, education, exercise and social clubs, intergenerational programs, and even housing.

    The CENTER FOR THE AGING (CFA) provides a continuum of care for the elderly -- from nursing home care to housing, nutrition education, and preventive health programs.

    CFA includes:

    • the HEALTH CARE INSTITUTE, a 183-bed teaching nursing home on the GSHS campus
    • the MULTI-SERVICE SENIOR CENTER (MSSC), on the GSHS campus, provides both well and frail older people with everything from comprehensive medical adult day care services to recreation, case assessment and management, meals, education, transportation, telephone reassurance, counseling (both for the older people and for their families), and "Saturday Socialization" group therapy. The MSSC serves about 70 people daily, with another 30 coming in on Saturday.
    • PROJECT KEEN provides many of the same services to over 1700 seniors in the community, including meals (both congregate and home-delivered), crisis intervention, literacy training, transportation, recreation, health promotion information, Alzheimer's support groups, counseling, and respite care.
    • the SERVICE CREDIT VOLUNTEER PROGRAM, in which volunteers provide whatever frail elderly people need to stay out of a nursing home, such as housekeeping or transportation. The volunteers' hours are "banked" for them against the day when they or their relatives will need help themselves.

    In September 1991 the CFA launched the KELLOGG COMMUNITY CONNECTION (funded by the Kellogg Foundation), involving seniors in unusual and creative intergenerational programs targeted at the most vulnerable members of the community, including:

    • the LATCHKEY PROGRAM and PARTNERSHIP IN EDUCATION -- after school, local kids jump on the "Kellogg's Dr. Feelgood Van" to go see the seniors at MSSC, who help them do their homework, do community service, and just plain have fun. It's a lot better than going home and locking the door until mother gets off work, and the seniors can see the positive effect they are having from one day to the next.
    • GRANDMA'S HANDS (GRANDPA'S, TOO!) links trained grandparents with teenage parents, as well as teenagers who seem "at risk" of turning into parents sooner than they are ready for. The surrogate grannies and gramps help give the youngsters the life skills and the self-esteem they need to become good parents and successful humans.
    • the RESPITE PROGRAM FOR ALZHEIMER'S PARTICIPANTS AND CAREGIVERS is, in fact, a respite program -- and a lot more. Besides special daily and weekend activities for people who suffer from the disease, it also includes training and education for the caregivers, referrals to other programs that might help, and peer support groups.
    • "KELLOGG'S DR. FEELGOOD VAN" -- besides bringing in the kids for their Latchkey Program and the older folks for their Alzheimer's Respite Program, this wheelchair-accessible van is itself a four-wheeled community outreach program. Equipped with audio tapes and printed community service information, it carries volunteers, health professionals and peer counselors on a regularly-scheduled round of visits to sites in the community to give out information and give consultations. Kwame Scott, the van's driver and the program's outreach coordinator (the kids just call him "Dr. Feelgood"), says, "We try to go to places where we know there will be lots of people, such as laundromats, shopping malls, parks and even unemployment lines."

    The WASHINGTON SENIORS WELLNESS CENTER, at a separate site, gives classes, workshops and seminars to promote healthy lifestyles -- but it serves as well as a social center and fitness facility, complete with pool. Healthy seniors come together here for book clubs, grief support groups, and even groups dealing with parenting problems, as many find themselves suddenly parenting again late in life -- this time to grandchildren whose parents are not able to care for them.

    The MALLWALKERS PROGRAM brings together 1500 seniors who get their exercise along with social contact, blood pressure screenings and a little health education at a local mall.

    GREATER SOUTHEAST CONSULTING, INC., a for-profit subsidiary of GSHS, manages one hospital-based nursing home, two nursing homes, an adult medical daycare center and a 69-unit independent living apartment house.

    This wide range of programs did not spring up overnight -- Project KEEN started in 1974, the MSSC in 1979, the Health Care Institute in 1982, and the KCC in 1991, for instance. Nor did they arise from some grand, unchanging master plan. They arose, instead, experimentally, in call-and-response fashion, in reaction to the growing and shifting needs of the community. For instance, the Mallwalkers Program started in 1978 with a simple request: a local mall wanted to know whether the hospital could come give people blood pressure screenings in the mall. But in 1988 the blood pressure screenings broadened to include exercise and socializing as well. Today an average of 300 people show up at the mall every Monday, Wednesday and Friday morning.

    Gloria Anderson, president of the Center for the Aging, says, "Like many other things that have been successful at Greater Southeast, the CFA did not arise from a master plan or a study -- it arose directly from the needs of the community, expressed to the hospital's foundation through a series of community forums."

    Some of the needs come to them through the GSHS board: according to its by-laws, 80 percent of the board members must come from the local community. Others arise from smaller institutions in the community -- a church that wanted a cancer support group, for instance, or the small Baptist church that had an empty lot next door frequented by drug addicts. The church's young, dynamic minister wanted to change things. He had a vision of building comfortable housing for the elderly on the lot. Church members hired a consultant for help, and took a grant proposal to the federal Department of Housing and Urban Development. But HUD turned down the proposal -- the small congregation did not show enough financial stability. The consultant asked them, "Who is the largest employer around here? Who could joint venture this with you?"

    "Greater Southeast. But they are a hospital. Why would they be interested in housing for older people?"

    "I don't know. Let's go see."

    What they didn't know was that GSHS had already set up an aging services arm, and would be happy to help. GSHS put up $50,000 seed money, formed a joint board with the Baptists, and re-submitted the proposal. This time HUD approved the grant -- just before the minister unexpectedly died. Today the 69-unit Robert L. Walker House, a 69-unit apartment building, bears his name, and his widow continues to serve on the board.

    Working with the community to determine its needs is a basic part of GSHS strategy. According to CEO Thomas Chapman, "There has been an assumption for some time in health care that the professionals know best. We've undermined ourselves by making the provision of health care a club that's almost exclusive to the professional ranks." This dedication to working with the community brought GSHS the American Hospital Association's Foster G. McGaw Prize in 1989.

    The community partners don't come to Greater Southeast because it is rolling in money. In fact, the GSHS budget is already strained by the more than $23 million in unreimbursed care it handles every year. According to Jacquelyn L. Lendsey, vice president of corporate and community development, "It's not that people think we have the finances -- it's that they know that we will find them. We'll never say that we can't do it because we don't have the funds. We'll say, `Let's sit down and figure it out.'"

    For instance, when GSHS saw need for low-income housing increase at the same time that the housing stock fell apart, it found a partner, bought a 150-unit apartment house across the street, renovated it, and got into the low-income rental business.

    "We look for partners in everything we do," Lendsey says. "If we don't find the financing or the partners, we will do it anyway, if it needs to be done."

    But the search for partners does influence which needs GSHS will tackle: "Sometimes we go where we can find a partner," says Lendsey. It's not easy: the District's trans-Anacostia area does not boast many other large employers with local roots. The other major organizations in the area are almost all military: Bolling Air Force Base, the Defense Intelligence Analysis Center, the Washington Area Naval Reserve, Anacostia Naval Annex, and the Naval Ordnance Laboratory. Their focus is national and international, and most of their employees do not live nearby. GSHS' partners on various projects include local churches and schools, the American Heart Association, the Iverson Mall, the Geriatric Branch of nearby St. Elizabeth's Hospital, the Metropolitan Boys and Girls Clubs, the Alzheimer's Association, and the local branch of the AARP

    Just how this effects the GSHS bottom line is, of course, of critical importance -- it doesn't do the community much good if you run the institution into the ground by doing good works. But in fact in the nine years that Chapman has been in charge of Greater Southeast, two things have happened: the GSHS community involvement has greatly accelerated -- and the GSHS bottom line has improved markedly. Far from milking his institution dry, Chapman is actually credited with pulling off a financial turnaround at GSHS.

    There are several ways that this works.

    1) Some of the programs (such as the Health Care Institute, and the management contracts of Greater Southeast Consulting) make money, rather than spend it.

    2) Many of the programs attract business for the hospital. "The people who get a T-shirt for participating in Mallwalkers," says Lendsey, "the people who get their blood tested at the barber shop -- they look to us." As CEO Chapman puts it, "If you do good community service, you automatically have good public relations -- it's a by-product."

    3) Most of the programs don't cost that much. "For most of these programs, we're not talking structure," says Lendsey, "we're not talking bricks and machines. We're talking service -- going where the people are."

    4) Finally, of course, GSHS is able to pull in a lot of outside money. Lendsey says, "You've got to be adept at finding funds." The major funders of GSHS programs include the AT&T Foundation, the Kaiser Family Foundation, the Robert Wood Johnson Foundation, and the Kellogg Foundation, as well as a number of local foundations.

    In other cases the money is municipal government money -- not grants, but management contracts. The Senior Wellness Center, for instance, is a city program in a city-owned building. Its $275,000 budget is mainly funded by the District of Columbia Office on Aging. "They came to us," says Lendsey, "It fit our programs for older people. Now the city is putting up a new building. and they want us to widen what we do there to include new programs, perhaps even entrepreneurial ventures in the building that fit the mission."

    In other cases, GSHS has become the lead agency for Ward 7 for the District of Columbia Office on Aging. The MSSC receives funds from the District of Columbia Office on Aging, from Medicaid, the Maryland and District of Columbia Medical Assistance Programs, the District's Mental Health Commission, and the Prince Georges County Department on Aging.

    "If we believed that financial viability was the first question to ask," says Lendsey, "we would never have set any of these up. We start with the need."

    Memorial Health System
    South Bend, Indiana

    It's a lot of work being poor. People who complain about the "free ride" the poor get on social programs are not likely to have ever tried to manage it themselves: the seemingly endless rounds of bus rides to this or that agency, lines, waiting rooms, forms to fill with the same information you gave at the last place, waiting for notifications, returning for another interview -- all while trying to manage a family, look for work, find training, and worry whether the future will be any better. It's little wonder that some of our best attempts to help go underused, while the problems just get larger.

    Even in South Bend, Indiana, a modest-sized city by anyone's standards, the obstacles to making the best use of available resources can be daunting. The answer would seem obvious: bring a number of social agencies serving one clientele into one spot, convenient to that clientele.

    Yet what is obvious is not always simple, as South Bend's Memorial Health System has discovered. This June 1 [1993], URBANCARE opens its doors in a renovated building in the city's Studebaker School neighborhood, bringing under one roof an array of services for poor women and children, including family planning, pregnancy testing, prenatal care, well-baby care, WIC, and children's dentistry. These federally-funded Maternal and Child Health services are provided by UrbanCare's three partners: Memorial, Michiana Community Hospital, and Planned Parenthood of North Central Indiana.

    It's a neighborhood much in need of help: of all the neighborhoods in the county, it was among those with the lowest income, the highest concentration of minorities, and the highest percentage of female-headed households.

    To use any of the services in the facility, people need call only one telephone number. People who come to the facility will find one intake desk, staffed by an intake specialist, who will take basic information and let the client know about other services that may be available in the building or elsewhere. The intake specialist will attempt to match appointment schedules, so that the family reach all the services it needs in one visit.

    This basic step forward took eight years. The story of the building of UrbanCare is an object lesson in the persistence required of anyone who hopes to re-shape social services around the customer.

    The single-story building had been the Urban League's local headquarters. The Urban League had sponsored WIC in the building. But it still had some space and it could use some rent money. They invited Planned Parenthood to rent some of the space. Carl Ellison, in charge of facilities planning and development for Memorial at the time, was looking for more space for the hospital's HealthStart well-baby clinic, and its children's dental program. In 1986, the Urban League invited Memorial to join Planned Parenthood and the WIC program in the building. "It made sense," says Ellison. "We needed the space, and we knew that women and children were underserved in that area."

    The partners decided to create a separate entity with its own name, "UrbanCare, Inc.," to administer the common facility. Its board would be comprised of representatives of the three tenants. The separate name was a sign that UrbanCare would be a full partnership and not a subsidiary of Memorial.

    When Memorial took a look at the facility, however, it was clear that it would need renovating. "Give us lease commitments," said the Urban League, "and we'll find financing for it."

    But then things slowed to a crawl. The Urban League in South Bend was in a period of decline. It could not find the financial muscle to make the renovation happen, and years passed in the attempt.

    In 1987, surveys revealed that infant mortality in Indiana, was among the worst in the country, and the state began a major push to change that fact. In 1988, Michiana Community Hospital, an osteopathic facility, secured one of the resulting state grants, with Memorial's endorsement, to run a pre-natal clinic -- at the Urban League site.

    The building was getting crowded with potential tenants, but still there was no money to renovate it. Two more years passed, and the Urban League's situation only got worse. In 1990, it decided it no longer had the capacity even to sponsor WIC. At the turn of 1991, Memorial took over the WIC sponsorship and asked the other potential tenants to become its partners in renovating the building.

    Memorial had itself undergone a sea change in those years. CEO Phil Newbold had been mounting a massive effort to shift the culture through his own brand of "total quality management," a brand he called "Quality Through People." Despite its location in South Bend, a mid-to-small-sized city in the middle of miles of corn, beans, fruit trees, and hay rows, Memorial is a major downtown organization with 2400 employees, 526 beds and 80 bassinets serving 250,000 people in its primary market (and another 500,000 in its secondary market).

    Newbold began laying the basis for his quality program within months of his arrival in the fall of 1987, hired an executive to run it within his first year, and formally launched it in 1989. He put the entire facility through a major re-visioning process based on three "vectors:"

    • Empowerment both for patients and staff,
    • Prevention as an equal to treatment, and
    • Partnership, replacing hierarchy with collaboration and competitiveness with teamwork.

    Every department of the hospital and the health system was encouraged, prodded, cajoled, and led to re-think whom it was serving, what their needs were, and how those needs could be met.

    For Carl Ellison, by now Memorial's assistant vice president for community affairs, this "Vision Process" proved crucial to his thinking about the little project at the Urban League building out on High Street. The building became the answer to a different question. The question had been, "How can we meet Memorial's need for more space for these expanding programs?" The new question that emerged was, "How can we better meet the needs of our customers, the underserved women and children of the near southeast part of the city?"

    Ellison had a feel for such social service projects. He had a long history in social service agencies and in the federal government, and had lived in public housing himself earlier in his life. The respect inherent in seeing the recipient of these services as a "customer" was a dramatic shift from the traditional view -- a shift that Ellison found both refreshing and creative.

    The shift in thinking came to flavor the way in which the project was put together. For one thing, Ellison focused on partnership with the other tenants. Memorial would be the landlord, supplying the capital (which eventually would amount to about $850,000), and subsidizing rents below the market rate, but each partner brought their own expertise: "Memorial supplied the leadership and the capital to get the project done -- but it actually came about through trust and cooperation. We realize that by ourselves we cannot change the community health outcomes."

    According to Ellison, the most difficult part of starting UrbanCare has been "securing and maintaining a shared vision. We haven't seen anyone else doing this. At the worker level, they haven't yet fully realized the benefits of integrating the delivery of services."

    But, says Ellison, it is important to carry the vision forward, step by step: "It is one way that we can respond to the needs of the disadvantaged in the community -- and that is a core part of our mission."

    Group Health Cooperative
    Seattle, Washington

    At Seattle's Group Health Cooperative, the challenge literally walked in the door. The door belonged to Bill Beery, director of the Cooperative's Center for Health Promotion.

    The Cooperative is one of America's oldest integrated healthcare systems, and the largest actually owned by its members -- today it serves over half a million members. It has a 45-year history of fighting to make rational, integrated health care available for the lowest price. It has not been easy: when GHC first bought a hospital and a group medical practice and opened its doors in 1947, the local and national medical societies kicked out its doctors, other hospitals refused them privileges, and medical schools refused to allow them to take post-graduate classes, or to study for specialty certifications. Local hospitals refused to admit members of the Cooperative. It took a ruling from the state Supreme Court in 1951 to change these practices.

    The Cooperative pressed forward, not only in integrating healthcare, but in finding ways to reach underserved populations -- from working with Native Americans starting in the 1950s to designing special coverage for the "working poor" in the 1980s.

    So it was not a complete surprise in 1988 when Beery opened his door to three people: Dr. Bob Wood, head of the AIDS Prevention Program for the Seattle/King County Health Department, Bea Kelleigh, the executive director of the Northwest AIDS Foundation, and Jane Crigler, a healthcare consultant. There was this RFP from the National Institute of Drug Abuse about using community health outreach as a way to provide HIV/AIDS education and prevention to the people most at risk. It would mean starting a clinic designed to attract prostitutes and drug addicts. Would Group Health take the lead?

    "It's a great idea," Beery responded. "But it will be very controversial. I'll have to check with my boss." The assumption was not unwarranted. Five years ago, public awareness on AIDS was far more primitive than it is today, and many health care institutions were afraid to become known as "the place where AIDS patients go" -- or the place where drug abusers and prostitutes go.

    Beery dashed upstairs and caught his boss, then-COO Phil Nudleman, in the hall. He explained the idea, and Nudleman immediately said, "Let's do it."

    Beery went back to his office and said, "You're on."

    Woods' eyes widened, and he said, "Are you sure?"

    Later in the day, Beery echoed the thought to Nudleman: "Are we really going to do this?"

    Nudleman said, "If there is any flack on this, I'll help you take it."

    Yet it turned out to be easy. The funding came through in months, the board was very supportive, and when the news hit the papers, there was not a word of protest. Originally called CATCH-ON, the project became SOS (STREET OUTREACH SERVICES) once it was weaned from the original NIDA grant. At Second and Pike, on Seattle's old waterfront a block from the Pike Place Public Market, SOS continues a wide range of social and health referrals, a lot of education about drugs and AIDS, non-traditional support groups and skills-building groups, and meetings of AA and NA. There is no GHC logo on the building, but the Cooperative pays the rent, plus the salary of the director and several of her staff. The groups that originally asked the Cooperative to help have become its partners, as well as the SAFECO Insurance Companies and the Foster Foundation.

    In July 1991, the Cooperative's Board publicly and formally dedicated itself to serving the broader community in a resolution that emphasized:

    • meeting the needs of underserved populations at highest risk, e.g. low-income women, children, and teenagers
    • establishing and building coalitions with non-Group Health providers to address issues that affect the broader community
    • expanding existing comunity inititiatives rather than creating new inititiatives/projects; a balance of Group Health needs and community needs should be maintained
    • building upon the uniqueness and strengths of Group Health's delivery models
    • primary care services
    • enhancing volunteer opportunities for Group Health employees, staff, and consumers.

    In the 1990s, the Cooperative's commitments to the health of the community grew to include an array of projects such as:

    • the MUTUAL ASSISTANCE PARTNERSHIPS (MAP) COALITION, working to nurture relationships between low-income seniors and young people in Seattle's poorer neighborhoods. Among other things, these intercultural and intergenerational groups will teach each other healthy diet and exercise habits. Funded by the W.K. Kellogg Foundation, the project makes partners of GHC, the Seattle Housing Authority, the county's Senior Services, CAMP/ROPE, and United in Outreach.
    • the TEEN PARENTING PROGRAM, put on in the context of the Late Night Program of the city's Parks and Recreation Department, brings teen parents together with health professionals and speakers to improve the health of their children (get them checked every six months, and immunized), to work on their parenting skills, to learn more about making healthy choices for themselves, to enhance their personal development (learn about education and career opportunities, brush up on their resume-writing and interviewing skills), and to have a good time.
    • the WASHINGTON COMMUNITY-BASED PUBLIC HEALTH INITIATIVE, combines the resources of a Native American nation, two public health departments, two community college systems, a school of public health, the Seattle Parks and Recreation Department, and the Cooperative to help the Lummi Nation and the poorer ethnic neighborhoods of Seattle gain better control over, and access to, the resources they need to improve their health.

    But the Cooperative's most unusual and sorely-needed outreach is its growing attempt to help homeless families. The efforts are multiple, experimental, fully partnered and highly leveraged. They include:

    • the HEALTHCARE FOR THE HOMELESS COALITION, a group of Seattle providers bringing medical care to homeless families at clinics, shelters, and daycare centers -- the Cooperative supports one nurse practitioner and one LPN who travel between centers
    • participation in an immunization campaign of public and private partners that is attempting, by the end of the decade, to achieve a steady 90 percent rate of immunization among the area's two-year-olds -- including the homeless
    • medical care for homeless families in transition, staffed by volunteer GHC physicians<
    • a special project bringing medical care to homeless adolescents and teens in the "U District" near the University of Washington
    • work with a consortium developing a clinic for the homeless in Tacoma, to the south of Seattle.
    • PROJECT HEALTH, a clinic for families in the Housing Hope homeless shelter in Snohomish County, to the north of Seattle -- open two evenings each month, the clinic is staffed by GHC physicians, nurses and administrative personnel. Besides seeing individuals, the clinic volunteers do a full health assessment on one family each time. For follow-up care, dental care, specialty referrals, and no- or low-cost drugs, the clinic team arranges next-day appointments at the Community Health Center in downtown Everett.
    • the full time salary and benefits of one physician who works in 14 community clinics throughout King County
    • a free vision screening program for homeless children in Seattle and Tacoma

    According to Beery, "The Cooperative's Board challenged us to find ways to serve the community. Homeless families was one of the areas on which we chose to focus. But we couldn't find any useful models for doing what we wanted to do. We had to create it all locally."

    The first thing that Beery did was talk to people who were already dealing with the problem. "We talked to the Healthcare for the Homeless Coalition. We talked to the people who run the shelters, to the Housing Authority, to the mayor's office, to the community clinics. We went to a self-governing shelter and sat down with the homeless people themselves.

    "We found that the homeless themselves have a very good idea of their health needs, but that they might not be what you would think. To take just one example, many of them complained about serious dental problems. Often they had not seen a dentist in 10 years."

    Beery found far more variety among the homeless than he had expected. "We tend to think of homeless people as a rather homogeneous group. But from a health standpoint, they fall roughly into three groups with rather different profiles and needs. The first I call the `there but for the grace of God' group -- people who just hit a bad patch of luck. A lot of the families are in this group. The second are the mentally ill, people who a decade or so past would have been in institutions. The third are people with substance abuse problems."

    But the Cooperative could not serve all the needs that were out there. Choosing between them was a very deliberate task. "We focused on the mission of the Coop, on what we do well -- prevention and primary care. We focused on opportunities to build coalition. We looked for places we could get involved, rather than just grant funds."

    Beery also considered just how to best leverage those funds. "For instance, what people wanted most was help with chemical dependencies. But that could be pretty salary-intensive. A CD counselor that we supported, say, one day per week, would see very few clients and have minimal impact. The same resources spent on immunizations would go a lot further."

    There was also controversy to consider. "We felt that a focus on women and children would be a little easier for the public and our members to support. When you're trying to build support for the idea that you have a role in the larger community, it's good to give some thought to where you start."

    Unlike some of the programs designed by Greater Southeast, none of these initiatives returns any money to Group Health. But neither do they cost Group Health very much. Beery puts the cash outlay for all the Cooperative's homeless projects at no more than $130,000 per year. The budgets of the community health programs in which the Cooperative is involved mount into the millions, but Group Health's share in cash out of pocket amounts to "a few hundred thousand." As elsewhere, the key is partnerships, leverage, picking your shots, and using the powerful energies of volunteers from among your staff and membership.

    "Our major concern is service," says Beery. "The quality of life in the community affects our members -- it's their community, too. We hold the belief that we must return something to the community.

    Catalyzing The Community:


    July 18, 1995: AIDS Walk San Francisco, a fund-raising walk-a-thon. Sunny skies, a bit of a sea breeze, and over 20,000 people gathered in Sharon Meadow in Golden Gate Park, with kids, dogs, balloons and flags, to walk 10 kilometers, to raise money and awareness over a health issue. This one morning event will raise over $3 million. But besides the vast crowd, the hundreds of volunteers, and the phalanx of city, state, and federal officials on the speaking platform, something else testifies to the passion, labor and skill of the organizers: the seas of corporate logos. Three hundred thirty people from the Mervyn's department store chain, hundreds each from Charles Schwab, the Bank of America, Marriott, the Gap, KQED, Macy's, United Airlines, American Airlines -- the list goes on for pages. Each contingent has its own specially-designed T-shirts for the occasion, each walker has canvassed friends and neighbors for donations, and each corporation has matched each donation. The massive walk gets under way with a gospel singer at the microphone belting out "You'll Never Walk Alone."

    You can't do it alone. It doesn't matter how big you are. Building a healthier community requires the energies of scores of organizations, and thousands of individuals, energies that you cannot command or buy. Moving a community to action is hard, detailed, uphill work.

    Yet, like most things, some people do it better than others. We have been tracking three healthcare institutions that do it better. In Module 1 we sketched their innovative programs in particular areas. We looked at the extraordinary array of programs for the indigent elderly created by Greater Southeast Health System in Washington, D.C.; at Memorial Health System's partnership to help poor women and children in South Bend, Indiana; and at Group Health Cooperative's special and unusual outreach to the homeless in Seattle.

    Now we re-visit the same organizations to focus on one question: how did they form the networks of partnerships that nurture these and other projects? How did they reach beyond their walls to the community, to other institutions and organizations within healthcare and outside of it? What really works? What are the obstacles? Is there a pattern to this skill?

    Greater Southeast Health System (GSHS)
    Washington, D.C.

    The first glance at Greater Southeast Community Hospital is not particularly promising. It seems both old and isolated, way down on Southern Avenue, the very border of the District, far across the Anacostia River from the pomp and circumstance, the ambassadors and justices. The building, a glass `60s-style slab, abutted in back by a warren of add-ons and temporary buildings, sits amid acres of parking lots surrounded by aging chain-link fences. Much of the land beyond the fences is taken up with tens of thousands of units of what must once have been fine public projects -- the brick buildings small and set apart in acres of rolling parkland -- but which now sit boarded, decaying, empty.

    The real story is far more complex, lively, and connected. Greater Southeast is the hub of a system that includes another, smaller hospital, along with nursing homes, adult medical day care centers, pharmacies, and social programs. And that system is involved in a yeasty net of partnerships with other systems, with other organizations, and with the community.

    These partnerships and projects are a long tradition at Greater Southeast -- some of them go back to the late 1970s. These connections arose not out of a master plan, but out of a basic orientation to the community. Greater Southeast responds to the needs of the community not with big plans and pots of cash (which it doesn't have -- the system shouldered more than $24 million in uncompensated care last year) but with a ferocious attention to finding some way to get the job done. As Gloria Anderson, the president of Greater Southeast's Center For the Aging, puts it, the CFA, like other GSHS programs, "just sort of grew."

    What it grew out of is Greater Southeast's strong roots in the community. The hospital itself was constructed with funds gathered painstakingly through bake sales and old-fashioned door-to-door tin-cup rattling. Most of the people and organizations involved with Greater Southeast come directly from the community it serves, as do many of the people that the system hires to work with them. As CEO Tom Chapman puts it, you can't make it work "without input from the people who have struggled to overcome the needs of their community." Gloria Anderson, for instance, first came to Greater Southeast's attention not as a professional gerontologist or as a management expert, but because she was involved with Anacostians Concerned for Senior Citizens, a local group that has organized to help older people find something to do with their time.

    The nature of the GSHS boards are equally important. By its by-laws, the Greater Southeast board must pull 80 percent of its members from the health system's service area. "And," says Beverly Anderson, Ph.D., "they are very good at identifying people to work on their boards, people who will actually do stuff." Anderson should know: she's a member of the board of Fort Washington Medical Center, the system's small suburban hospital in Prince George's County, Maryland.

    But despite these original strong roots, the recent exponential growth of community connections represents a significant shift. According to Gwendolyn Fields, who runs the Iverson Mallwalkers program, "People used to have no connection with Greater Southeast. The attitude on both sides has changed tremendously." Robinette Livingston, of GSHS' Kellogg Community Connection echoes Fields: "There has been a transformation in Greater Southeast's relationship with the community, and in the community's perception of Greater Southeast. There used to be a tremendous gap."

    By now, the ways in which Greater Southeast has gone beyond the traditional role of the hospital to work with the community are literally too numerous even to list here. This more direct and many-sided involvement has profoundly strengthened the system's credibility in the community. "If you're clearly committed," says Chapman, "to meeting the needs of the community you serve, people will spot that instantly. If you're hustling the public, they're going to spot that, too. In the long run, the proof is what you produce."

    As a result, the community tends to come up with opportunities and energy far beyond what anyone in the system could have generated. For instance, in 1989 when an ad-hoc Breast Cancer Resource Committee gathered people with various kinds of expertise from all over town to try to do something about breast cancer in the D.C. area, they immediately thought of GSHS as an appropriate partner. "They knew that the population that most needed awareness and education about breast health was the population that Greater Southeast served," says Zora Brown, president of the committee. "Greater Southeast was already involved in this area. It was just dedicating its new radiation oncology unit, it had a breast health awareness award, it participated in a big way in the Komen Foundation `Race for the Cure' fundraising event. We knew that they had a very good relationship with the medical community." (Indeed, according to Alfred Goldson, M.D., FACR, professor and chairman of radiation oncology at Howard University and Greater Southeast, GSHS is "many doctors' favorite hospital.") "We knew" says Brown, "that they would be interested, not in drumming up business, but in getting the word out." The result of that connection is the Belva Brisset Advocacy Center, a breast cancer outreach and education program for the entire D.C. area.

    We can follow the interplay of the system and the community through a typical program. Links of Prince George's County, a local chapter of a national African-American women's group, wanted to do something about glaucoma, which has a much higher incidence among African-Americans. They asked the system to help them put together a series of glaucoma screenings in the community. A member of Greater Southeast's staff developed a proposal that involved the system, Links, and Fort Washington Medical Center. The system found an ophthalmologist to provide the service once a month. Both Links and GSHS advertised it. GSHS prepared presentation folders about glaucoma. Fort Worth Medical Center provided the space. Links agreed to run the program, provide refreshments, and follow up the cases that needed referrals. The program now averages over 40 tests per month, at a minimal cost.

    Similarly, Links had adopted a homeless shelter, providing food, blankets, clothing, and holiday gifts. The Links women decided that the women of the shelter could use some education and screening about breast health. GSHS provided Links with flyers and posters to promote the meeting at the shelter, plus information and a video. Greater Southeast's Deborah Barnes spoke at the shelter and gave a demonstration of breast inspection, passing around a prosthesis containing the kind of lumps for which the women would be searching. Eighteen women came to the class, of whom four were sent on to the hospital for further screening. Once again, the class cost almost nothing. Beverly Anderson, who is also a member of Links, says the nature of Greater Southeast's attention is key: "They have a willing, gracious staff. I feel comfortable working with them."

    In much the same fashion, the Iverson Mallwalkers Program began in 1988 when GSHS matched a request for a safe place to walk from a member of the local chapter of the AARP, with a connection the system already had with a local mall, where it had done blood pressure screenings for over a decade. Today the system and the mall split the cost of incentive T-shirts and watches for the program's 1500 participants. Once each month the system provides a health seminar, for which the mall provides the space.

    For other programs, the appropriate partners are other large institutions. Greater Southeast was able to make radiation therapy available on the south side of the Anacostia River for the first time through a partnership with Howard University Hospital. Its relationship with Howard was already long. Many Howard residents have come to work at GSHS over the years. Dr. Goldson characterizes them as "a group of folks that have committed themselves to taking it back to the community."

    Greater Southeast linked up with the District school system, the Prince George's school system, the Washington Urban League, and over 40 local businesses (including the Washington Post and Amtrak) in the Commonwealth Fund's School-To-Work Transition Program. The program places ninth- through twelfth-graders in long-term, part-time relationships with local companies. The Urban League provides the "mentoring" part of the stew, while GSHS manages the program.

    Perhaps the most visibly successful of Greater Southeast's institutional partnerships is the F.W. Ballou High School Adolescent Health Center. Ballou High School, a half mile from Greater Southeast, sits in the middle of Ward 8, which has the highest rate of preventable deaths, the highest rate of teen pregnancies, the most kids and the fewest pediatricians in the District of Columbia, as well as the highest incidence of cancer in the nation. Trying to see how much could be done with the meager resources available, the school district, the D.C. Commission of Public Health, and Greater Southeast decided to put some of those resources as close as possible to those who needed them. The school district set aside two classrooms at Ballou, and spent $80,000 converting them into a compact suite of offices, two examination rooms, and a lab prep room.

    According the the health center's director, Randall McKennie, "We deal with everything here, from the flu to vision and behavior problems, to hepatitis, tuberculosis, and meningitis. We get trauma, broken bones, STDs, and pregnancies. We do everything but X-rays, and refer people on to specialists, Greater Southeast, or public health centers when they need it. We do a $185 full physical for $2. We have enrolled 800 of the school's 1500 kids, and log over 2000 visits per year. We catch 85 percent of all pregnancies in the first trimester. The District has a high infant mortality rate -- 19.6 -- and Ward 8 has the highest rate in the District, but the teen mothers who come through this program have had an infant mortality rate of 5.4."

    Their success in penetrating the student body comes partly from a decision to go after opinion-makers: they did the physicals for all the high school's athletes.

    The center's reach extends beyond Ballou High School, according to McKennie: "We give life skills classes at elementary schools, and health and wellness classes at middle schools -- and the students in those then go out and give a health fair for the whole school."

    The Public Health Commission kicks in for the secretary's salary, and the part-time salary of a dental hygienist. The D.C. Mental Health Commission picks up the part-time salary of a psychiatrist. GSHS pays McKennie, a half-time physician, a part-time psychiatric nurse, a full-time physician's assistant, a health educator, and a medical assistant, plus the part-time salaries of Rose Butler and Emily Grimes. Butler helps whole families, not just the student, apply for Medicaid. "Ward 8 has the highest illiteracy rate in the District, and Medicaid application is 10 pages of fine print," she explains. Grimes works both in the office and on house calls as a "new morbidity counselor:" she deals with the pathological social cycles of violence, addiction, and teen pregnancy. "A lot of these kids are `parents' at home," she says. "Their own parents are addicts or alcoholics, or not there. I deal with a lot of grief and loss. We have found that 80 percent of these kids have lost someone close to them in the last year alone."

    The center accomplishes all this on a budget barely over $200,000.

    Sometimes, as with the intergenerational Latchkey Program and Grandma's Hands (Grandpa's, Too!), Greater Southeast will do without a community or institutional partner, if it can find a funding source, and the community need is clear. But though Greater Southeast is "adept at finding funds," as vice president Jacquelyn Lendsey puts it, the hospital does not dedicate a lot of energy to the search for funders. Most of the time it only has one development person on staff. Working with community partners is more important.

    These programs carry their own special burden. Since they have no partners in the community, they come with no built-in connections. The program's managers have to make those connections. Robinette Livingston, who directs the Kellogg Community Connection, with its "Dr. Feelgood" van, says, "We do a lot of homework. We take the van to small parades, to local gatherings, to places where the kids hang out. We try to connect with the local people that everyone in the neighborhood calls `grandma' or `grandpa.' We look for those at risk, the ones who are missing from the picture, who don't show up at the Boys Club or at church. School counselors help identify them, also. Once you get rapport, the other kids will tell you who's not coming in, who gets beat up, whose mother is sick. The reputation of Greater Southeast gives us a bridge to begin that shift from advocacy to empowerment to self-sufficiency."

    This fine-grained approach also results in lots of volunteers. "When you help people," says Livingston, "they turn around and say, `What can I do?' I say, `Give us an hour.'"

    Greater Southeast's remarkably fruitful approach is actively to seek partners wherever they can find them -- in other institutions, in community organizations, or directly in the community itself. Though the hospital has strong roots in the community, much of what it is doing now is recent, engendered intentionally by the hospital as a way to strengthen its ties to the community, and improve the health of the whole area.

    Memorial Health System
    South Bend, Indiana

    Since Module 1 appeared, UrbanCare has opened its doors, bringing together an array of services for poor women and children, all in one renovated building in South Bend's low-income Studebaker School neighborhood. Family planning, pregnancy testing, pre-natal care, well-baby care, the Special Supplemental Food Program for Women, Infants, and Children (WIC), and children's dentistry all share one address and one telephone number. The building has less of the chewed-Naugahyde-and-stained-linoleum look of traditional social-service offices, and more the plants-and-natural-light appearance of a pleasant suburban medical building, the kind of place where mothers say, "Keep your shoes off the furniture." These federally-funded Maternal and Child Health services are provided by UrbanCare's three partners: Memorial Health System, Michiana Community Hospital, and Planned Parenthood of North Central Indiana. Memorial supplied the capital for the project, and owns the building.

    This kind of true partnership, with no one partner's name on the door, and an equal share in risks and responsibilities, is rare, and it is not easy to manage -- but in the end will likely prove more fruitful for the community than anything any one of the partners, or any one government agency or foundation, could have done by themselves. Big as it is, Memorial "couldn't do it as a stand-alone institution," says Carl Ellison, Memorial's assistant vice president for community affairs. "That's why it has its own name."

    How did the partners come together? What are the roots of this partnership? Is there something about the partners, or about South Bend, that makes it especially likely here?

    Elizabeth Mooney, executive director of Planned Parenthood, tells the story: "The thing that was bothering us was the number of no-shows." As we saw in Greater Southeast's Kellogg Community Connection, once again the visible part of a problem sometimes is invisible: the people who aren't there. "We would follow up and we would hear a variety of problems: the car wouldn't start, there was no child care, there was no transportation. We began to realize that we and other agencies were forcing the least capable people to run all over town for the services they needed to survive. And they were being asked to deliver the same information everywhere. It was dehumanizing, it was demeaning, it was not pretty -- and it showed a pretty cynical attitude toward the poor."

    But South Bend had something different going for it, something that, oddly enough, arose at least in part from one of those vicious, gut-wrenching, community-destroying bussing battles, complete with federal court cases, that many cities faced in the late `70s. "There was a lot of peace-making after that was over," says Mooney. "People became more aware of the haves and have-nots."

    For years South Bend community and business leaders had gathered in a Community Education Round Table, a kind of floating think tank that featured regular lecturers and discussions about critical issues. Similarly, the United Way regularly convened the heads of all the agencies that it funded in a forum known as United Way Executives. They met and talked, not only among themselves, but with executives invited in from non-United Way organizations, from businesses, the school district, youth agencies, or the Catholic Social Services. "These were operations people," says Mooney. "The territorial and political stuff just wasn't there. They had a high trust level."

    These were just two of the more formal meeting groups. Informal cross-fertilization and connection went on all the time. "Among professionals in South Bend," says Mooney, "the level of communication and coordination was unusually high."

    Against that background, by early 1986 Mooney had been holding meetings in her office twice a month for five months around the question, "What can we do for services to the poor?" The usual participants were Mooney, Barbara Wind, and Leon Miller. Wind was director of United Health Services, a group that brought together agencies dealing with hearing, arthritis, kidney disease and other specialized problems all in one building. Miller was executive director of the Urban League.

    The League was in trouble, mired in lawsuits and losing money fast. it would lose its building if Miller couldn't find a good use for it. The two presenting problems -- Miller's empty building and the problems of serving the poor -- came together in Mooney's mind with the model provided by Wind's agency. She said, "Why don't I go to the state to enlarge the WIC program. You can put that in your building, and we'll put in a family planning clinic."

    Before long, Mooney was out looking for a compatible tenant to help fill out the building. Michiana Hospital was small and family-oriented, with a heavy load of obstetrics and pre-natal work. They were a natural to put a pre-natal clinic in the Urban League's building.

    The project began to make sense, to take on a coherence of its own, so much so that when the Urban League could not keep up its end of the bargain -- and even lost the WIC contract -- the project continued. Memorial stepped in to provide the needed leadership and capital, and to add its well-baby clinic and its children's dental clinic.

    Mooney says, "I have never seen a community hospital with such a strong and active community commitment." She had no difficulty shifting dance partners in mid-whirl. Her attitude was, "If I believe the community needs this, I'm going to give it to anybody who can do it," an attitude that she says prevailed among all the partners.

    To share the risks and responsibilities evenly, the three partners incorporated UrbanCare on its own, rather than take it under the wing of its landlord, Memorial. According to Carl Ellison, "We came up with a six-member board, with two members from each partner. And we made sure that certain important questions, such as bringing new services into the building, take a unanimous vote, so we all get a veto on the big stuff."

    But to Mooney, the informal connections are far more important. What works, she says, is to "get a group of people together, start talking and see what develops." They can't just be any random group, though. "They have to know how to talk. They have to be tenacious. They have to know what it is they do best. And they have to have a common focus."

    For the partners of UrbanCare, the common focus is the concept of empowerment ("I won't say `helping people,'" says Mooney. "I don't know how to do that. I will never foster dependency."). In this case, says Ellison, empowerment means "looking holistically at all the family's needs, looking at the barriers the family faces, tracing the outcomes, and documenting the extent to which the system itself is a problem. The whole approach is antithetical to the traditional patchwork system."

    Group Health Cooperative of Puget Sound
    Seattle, Washington

    "Including the larger community," says Dorothy Mann, a trustee of Group Health Cooperative, "is a learned behavior. HMOs and hospital-based healthcare organizations have typically been somewhat insulated. But here we have gone beyond what is required."

    "We are responsible risk-takers," says Mann. "We don't say, `We never did that, so we can't do that.'"

    GHC makes it a normal part of business to weave itself into the web of the community, finding partners to help it leverage its funds to do what needs to be done. This reflects its policy, its learned behavior, its institutional personality, and its history as a cooperative representing the community, battling the medical establishment in court for survival.

    It finds these partners in ways that are active and varied. They include:

    • Hiring medical professionals to work with other people in the community. "I was in private practice in Coeur d'Alene," says Dave Beck, M.D. "I was looking for a change. I just called up Group Health and said, `Do you have a place for a general internist?' They said, `No. We don't have anything but this one oddball position.' I said, `Tell me about it.' Then they described what sounded like the perfect job, the best doctor's job in Seattle."

      The job called for a roving doctor to work with the community clinics in the area, filling in where he's needed. In seven years on the job he has become a major support person for the clinics, consulting for them about how to improve their operations, as well as "a major vector of information," as he puts it, between the clinics, and between GHC and the community.

      The cost to GHC: the salary, benefits, and clerical support of a seventh-year staff physician, plus some $20,000 in drugs and supplies per year.

    • Building coalitions around a particular task, such as the consortium that established the Street Outreach Services (SOS) storefront center in downtown Seattle. Similarly, Group Health joined with the University of Washington and the Healthcare for the Homeless Coalition to pay the salaries of a pediatric nurse practitioner and a practical nurse working with homeless families and children at clinics, shelters, and day care centers.

      Nurse Practitioner Susan Kline calls the job "so satisfying." We talked in a small basement room in a large run-down former Catholic school on Seattle's poor working class Capitol Hill. "I can make quick differences," she says. "The needs are obvious. I keep focussed on the small goals. If I look at the big picture it's too overwhelming." At her feet is a large canvas bag stuffed with vaccines, with tests for hearing, vision, and growth, and other tools of her daily trade, which she carries to schools and homeless shelters. The school we are in, First Place, shepherds 46 children from a homeless shelter for families on the run from abusive spouses. The children, bussed here in secrecy, shriek happily outside in a fenced play area, guarded by teachers with walkie-talkies, on the lookout. "I do a lot of reassurance," Kline says. "All parents want to be good parents. I spend a lot of time saying, `You're in a tough situation, but you're doing a good job.'"

      Kline's good job would not be possible, realistically speaking, if not for the partnership between the University, where she teaches ("I bring my nursing students down here," she says), and Group Health, which funds half of her time.

    • Joining groups that are already working on a particular problem, including the Healthcare for the Homeless Coalition, and another consortium of organizations working toward building a clinic for the homeless in Tacoma

    • Doing a lot of what Bill Beery calls "going out and talking to people."

    For Beery, director of GHC's Center for Health Promotion, this kind of direct, up-front-and-personal organizing comes naturally, going back to his days in the Peace Corps and the Poverty Program.

    One of the best examples of how aggressively Group Health can forge connections that work is the new Mutual Assistance Partnerships (MAP) Coalition, an innovative program just getting off the ground. MAP brings together young urban African Americans, seniors of all different ethnic backgrounds, food programs, and other groups to look for ways in which they can cross-fertilize. Built on the "empowerment" ideas of John McKnight, ideas about building from people's strengths, rather than their needs, MAP is what its director, Craig Shimabukuro, considers basic community organizing: "making connections that weren't there before."

    MAP is beginning with four partners under the wing of Group Health. Two of the partners are large institutional organizations: the Seattle Housing Authority, and Senior Services of Seattle and King County. Two others are neighborhood community non-profits: the primarily African-American Central Area Motivation Program (CAMP), and United In Outreach, a neighborhood not-for-profit bringing free food to the sick and to frail elderly shut-ins.

    These partnerships did not just happen. GHC sought them out. In the phrase of Greg Davis, director of the Rites of Passage Experience, a coming-of-age program for African American youth, "Beery dispatched Joani Greathouse to look for partners." One person she turned to was Larry Gossett, executive director of CAMP -- Davis' boss. "Larry handed me the ball," says Davis.

    Similarly, John Froyd, director of United In Outreach, says, "They came to me. Someone from Group Health had run across me on a working task force dealing with senior issues." We talked in a small office in another church, this one on Seattle's First Hill. "So when Group Health put together a round-table discussion about aging services, they invited me to that. Then they invited me to come talk about something larger, more comprehensive. They knew about the Kellogg Foundation's interest in the community. They were disaffected with the straight medical model of health. They had found a model for something different in listening to John McKnight and in looking at programs in the Third World in which the community got together and did everything themselves."

    Group Health formed the group before it applied for a Kellogg grant because Beery wanted MAP to be a true partnership -- in fact he wanted to pull back and let the partnership run itself once it was established -- so he wanted the partners themselves to shape the grant application.

    I had first heard the thought from Shimabukuro in GHC's headquarters in a steel-and-glass highrise looming over I-5 in downtown Seattle, and now I heard it again from Davis in his ramshackle storefront a mile away, across the street from an enormous wasteland excavation of some stalled redevelopment. The walls were lined with pictures of Malcolm, Martin, and W.E.B. duBois, and Davis wore an X-cap as he spoke: "We talked a lot about mutual capacity-building -- that's what the MAP Coalition is about -- and we need to model that in our interactions. I hope that those values not only infuse us here at ROPE, but leak back into the rest of the organization. So we couldn't do this thing the usual way. And the members of the coalition, as a group, had to go through a training together. If we were going to model the behavior of giving value to other cultures, we needed to deal with ourselves first."

    In fact, they wrote the grant to include a half-time training position to help the partners develop new partnering skills. "Eventually," says Shimabukuro, "we will train other agencies, and we will train trainers."

    As Froyd put it, "We wanted to ask not, `What are your needs?' but `What are your gifts and capacities?' But we don't have a handbook on this. We had always looked on people as clients with needs. So how do we avoid doing business as usual?"

    One way, they decided, was to put some community people -- some of the "clients" -- on the MAP Policy Management Team, the coalition's governing body, along with the staff from the four agencies. Davis says, "We needed more than the usual suspects. We had to get input from people who know a lot of people -- like crossing guards, and the guy who gives out the food bank tickets." Three such people ended up on the PMT. Some of the ROPE teenagers took part, too, including two 14-year-olds. In fact, one 14-year-old sat on the committee that interviewed candidates for the job of director. Before hiring Shimabukuro, the committee -- at the urging of the 14-year-old -- turned thumbs-down on another candidate whose understanding of community, she felt, was not deep enough. "We have to constantly remind ourselves of this new mindset." says Froyd. "We have to ask, `Are we doing business as usual? What does it mean to work this way?'"

    It turned out the the largest difficulties in the formation of the coalition came not from personal or cultural friction, but from what Davis calls "the implications of certain realities." For instance, some of the parent agencies of the various partners became less enthusiastic when they found that they wouldn't actually make any money from the project. And to take another example, the idea of GHC stepping into the background ran against the reality that it had all the information, the experience with funding and contracts, and the infrastructure in place. "It turned out that Group Health remained central to the project," says Davis. "It was expedient for getting it done."

    They face future difficulties in the very nature of what they have taken on. For instance, one of the group's goals is to match up youth and seniors, "to break down fear and stereotypes," according to Shimabukuro. Yet those very fears and stereotypes are major obstacles. "We have to decide whether we are going to attempt cross-cultural, as well as intergenerational, matches. Will we be bringing, for instance, young black people into the homes of elderly Asians? How will we deal with that?"

    Other problems are structural, and will have to dealt with as the coalition grows. The coalition hopes to grow into a much larger, self-determined community group that can drive considerable "empowered" change. The staff consists of four community specialists, directly supervised by Shimabukuro, with input from the four agencies. "But how will we structure it when there are 30 agencies involved?," says Shimabukuro. "We haven't worked that out yet."

    In attempting such an ambitious partnership, some things make a big difference. "It helps," Beery says, "to have a working knowledge of funding sources." (His salary, for instance, is paid partly by a grant from Kellogg.) "It helps that Group Health is stable and big, that it has a deep history in the community -- people mortgaged their homes to start it. It helps that Seattle has its own real sense of community. It helps that the CEO and the board chair are committed to it."

    But in the end, his emphasis falls on a kind of "Nike philosophy:" "A lot of it isn't expertise, it's doing it."

    Putting it in place


    Through the first two Action Kit modules, we have examined in detail the initiatives of three healthcare systems which, each in its own way, has taken "building a healthier community" as its overall goal. Re-visiting the same sites, interviewing scores of participants over the past year, has allowed us to have a 3-D view of each organization, and has given us a chance to watch several projects go through growth and change over time. Our intention is to ferret out what works and what doesn't, in the experiences of a number of people who have been hip-deep in this work for a long time.

    Greater Southeast Health System (GSHS)
    Washington, D.C.

    We have looked in the first two modules at Greater Southeast's deep, long-term involvement in its community, its numerous programs, and its systemic determination to build a healthier community despite its financial strictures.

    In this chapter we'll take a look at some of the building blocks of this effort, the strategies that make a difference, the lessons learned, and the system's tactical shifts under a new CEO.


    The first thing that a healthcare system has to provide in building community is not money or expertise, it's leadership. That leadership has to start with the board and the CEO together. Carolyn Lewis, GSHS board chair, in writing about the board's role in moving the system through the changes necessary to keep it focused on its community mission, has said that "a clearly defined mission with specific goals and objectives should drive virtually every action a board takes." Building a healthier community, she says, "is not just an add-on. It has to be intrinsic to your vision of who you are. If the way you spend money does not match the needs of the community, something is really wrong. Reviewing the budget is not just doing the numbers game, it sets the direction of everything you do. Most boards hold management accountable for the bottom line. Here, we also hold them accountable for addressing the health of the community. We work out written goals for a healthier community with our top officers every year."

    "When I took this job," says Dalton Tong, the new CEO, "the board told me: 'The community is what made us, we can't forget that.'" They needn't have worried. Says Tong: "This is what excites me. I have a real passion for it."

    According to Lewis, the GSHS board acts as "a catalyst and bridge-builder between the hospital and the community." Not only must most of them come from the system's service area, as we have mentioned before, but they tend to be people who are "involved in politics and policy-making in the life of the region," she says. This serves the mission because the mission is "shareable," as she puts it: "There are ways of stating the mission that open it up to partnership. Partnership makes sense. It's a way to leverage your own resources."

    Competition with other healthcare institutions, in contrast, is a "death myth," according to Tong, "a macho notion that many seem to think is an answer. The solution is collaboration. If we analyze the needs of community together, and share the risk, we can co-exist, though perhaps in a scaled-down fashion. That's good stuff, that collaboration."

    Partnership, with other healthcare institutions, with other not-for profits, with government, and with business, is even more critical for Greater Southeast than for many institutions. It has never been wealthy, and uncompensated care continues to grow. In 1993, out of some $176 million in operating expenses, an estimated $25 to $28 million went for uncompensated care. Occupancy is down from 85 percent four years ago to the mid 60s today.

    Yet one signal of Greater Southeast's leadership is the fact that it has not allowed itself to be led by its financial incentives, in spite of its difficult financial situation. Tom Chapman, until just recently GSHS' CEO, comments, "Hospitals have only done what the re-imbursers want them to do." Once the financial incentives shift direction, he says, "They will understand that there is a big value in having effective social services. Suddenly doing non-healthcare services for people will have a very big priority."


    The first step is finding ways to get beyond the walls into the community. Greater Southeast, born in community fund-raising drives, has always tried to hold onto that direct connection. For instance, it has been holding community forums since the late 1970s. Yet a clear gap persisted betwen the system and the community.

    By all acounts, the system's relationship with the community has been transformed and deepened over the last few years. One reason is that, in its growing focus on the community, GSHS looks for ways of attacking problems that have multiplier effects, that use the "each one teach one" principal, so that people themselves can do what it takes to build community. One example is the Parent Empowerment Project Office, a project of the National Black Child Development Institute, funded by the DeWitt Wallace - Reader's Digest Fund. The project's volunteers focus on 40 families with young children at a time, bringing the parents together to learn the skills of parenting, and in the process the skills of taking charge of their own lives. It's a small project, but it is aimed at the root of the social pathology of the area, not just at its fruit. This is not the hospital doing something for the community - it's more the hospital giving a boost to people in the community who want to do something for each other. There is no surer way to distance yourself from someone than by doing something for them, making yourself the helper, the one not in need.


    Building a healthier community is a large-scale, long-term change project, both for the community and the institutions engaged in it. And, as Carolyn Lewis has emphasized, "frank and frequent communication is critical to fostering an openness to change." Like the DNA and enzymes in a coccooned caterpillar, the free flow of information is a prerequisite to any metamorphosis.

    Tactical flexibility is equally important to any large-scale change effort. In the 1980s, Greater Southeast tried to do something about the abysmal housing situation in Southeast Washington. It was an essential part of its decades-long emphasis on rebuilding the community, but in the process it exposed itself to considerable risk in the real estate market, and lost the gamble. In 1991 it had to write off some $6 million lost by its real estate subsidiary -- at the same time that it was losing money at a subsidiary hospital.

    Faced with this crisis, GSHS not only changed its tactics to lower its real estate risk, sold the subsidiary hospital and opened a different, better-located facility, it also underwent an intense soul-searching, driven by the board, to find what had gone wrong and put it right. The result was a major re-organization in 1992 that brought subsidiaries under more direct financial control and heightened communications between the system's disparate parts. At the same time, driven by Tong (who was then the CFO), the system succeeded not just in patching up the fiscal damage, but in completely refinancing its existing debt and borrowing another $15 million to give it more flexibility in the future. It was flexible enough as an institution to learn from its mistakes, and to make use of a crisis to propel internal change which left it better-equipped to be a catalyst in changing its community.

    This combination of increased communication and tactical flexibility have nurtured the rapid growth in the system's community-building work in the past few years.


    Chapman notes that "in our society we don't really have cross-sector mechanisms that could look at a community as a whole and suggest ways to move funds between sectors in a real creative way. And those resources are limited here in the D.C. area anyway. It's an urban community with high rates of poverty and social pathology." So Greater Southeast has developed remarkable abilities in keeping down the costs of its initiatives, finding partners, in gathering volunteers from the community, and in articulating its needs to major funders such as the Pew Memorial Trust, the Kellogg Foundation, and the Robert Wood Johnson Foundation. "The key," says Tong, "is that we don't let the cost get that prohibitive. We have mobilized voluntarism in the community. That's the trick - to empower people and teach them to do it themselves, then say, 'When you run up against obstacles, let us know. Maybe we can send out a team. Maybe we can help you out in some way.' Sure, we incur some costs, but the really significant investment is on the part of the community."

    Tong admits that "the juices start flowing when they make you CEO," and he already is striking out in a new direction. He plans to put more emphasis on working with one particular part of the community: big business. He says, "I want to respect the community's efforts, but as far as resources go, we need to do more unconventional things, and seek new funding, especially from business coalitions, banks, and major corporations. It's easy for corporate America to sit on the sidelines and criticize. It's quite another to work with us. We haven't made an organized effort to involve the corporations who have employees around here. We have to go out and knock on the doors of the companies that have a vested interest. We have to articulate how it might represent a financial return to them, that helping us build the community in this part of town would decrease a lot of cost shifting. We will talk about dealing with the streets, with the garbage pickup, with education at the clinics, with funding an RN's salary - the whole range of possibilities."

    With the corporate donors, it may be easier to find funds for programs that show results. For instance, since Greater Southeast opened its Adolescent Health Center in nearby Ballou High School, the hospital has recorded a significant drop in ER visits by teenagers. "The cost that is saved," says Tong, "is easy to imagine, but difficult to measure. So we are in the process of thinking how we can best document the outcomes of community involvement, so that we can more easily persuade larger corporations to help us. For example, our blood pressure program has grown steadily over the last ten years. We know it has avoided significant hospitalization for the people that have used it. The composite cost of hospital treatment can vary from $2500 to $10,000 per person, so it's easy to extrapolate that the amounts saved are enormous. We did do some charts showing a downtrend in the area in diseases like congestive heart failure that are caught in blood pressure testing. But we need to get more sophisticated ways of measuring and writing about the tremendous cost avoidances, so that corporations will get the 'Aha!' effect that I am looking for."

    Tong also plans to seek corporate help in non-medical areas. "We will talk to the banks about rehabilitating housing in this area. We would like to replicate here what the Rouse Company Foundation did at Sand Town in Baltimore - they not only re-habbed a lot of dilapidated housing, they really transformed the community into one with a whole new kind of energy.

    That's the prize that Greater Southeast keeps its eye on: not just fixing people, retail, one by one, but revitalizing the whole community. Says Tong: "That's part of our vision and our mission here."

    Memorial Health System
    South Bend, Indiana


    UrbanCare is open, and going through growing pains. A joint project of Memorial, Michiana Community Hospital, and Planned Parenthood of Northern Indiana, UrbanCare brings together family planning, pregnancy testing, pre-natal care, well-baby care, the Special Supplemental Food Program for Women, Infants, and Children (WIC), and children's dentistry all under one roof: a renovated building in a low-income neighborhood, convenient to the people who use the services.

    The actual opening was rocky, for reasons that have nothing to do with UrbanCare's mission -- and everything to do with it. The Catholic Church and Right To Life, on hearing that Memorial was doing business with Planned Parenthood, mounted demonstrations against the project, started a letter-writing campaign, and put up billboards all over town that read: "Shame on you, Memorial!" The bishop ordered all parish priests to urge their parishioners from the pulpit to boycott Memorial.

    All this because of the impression that Planned Parenthood would do abortions at UrbanCare. Planned Parenthood of Northern Indiana has never done abortions, and did not plan to do abortions at UrbanCare. But when this fact became clear, the furor continued, on the grounds that Planned Parenthood does abortion elsewhere, and that they might well hand out information at UrbanCare telling women where they could get an abortion.

    Even some members of Memorial's board questioned the system's involvement, and it helped that the board had been involved in discussions of UrbanCare from the beginning. Janet Thompson, chair of the board's Community Health Enhancement Committee, says, "I feel that our committee was helpful in that they knew a lot about UrbanCare. We were able to tell the rest of the board that is is the right way to go."

    On the surface the furor would seem to be a fluke occurrence, a chance rousing of one of the fiercest political debates of our time, based on a misunderstanding of UrbanCare's mission.

    But on a deeper level, it had everything to do with UrbanCare, and with what is required to build healthier communities. In any attempt to build community, it becomes clear at every turn that if you search for differences you will find them. If you focus on those differences, if you put energy into them, they will do what anything does when you put energy into it: they will grow. They will ramify. They will strengthen. But if you focus on what people have in common, the bonds between them will get stronger.

    People on both sides of the abortion issue care passionately about children, about families. Politics is fundamentally about winners and losers. Building communities is about winners and winners. In politics, if we disagree, then we fight it out in elections, demonstrations, boycotts, and the courts until one of us wins. In building community, if we disagree, then we take a step back. We look for the common ground, not because we're such nice people but because it works. It gets things done.

    UrbanCare is about that common ground. The three founding organizations all want to enable poor women keep their families together, keep their children healthy, and have some energy left over to try and improve their financial situation. Once they found this common ground, putting all these services together in a poor neighborhood was simple common sense, and quite effective in helping children and families that greatly need the help.

    UrbanCare continues to search for common ground in a deeper sense. The three organizations shared some common purpose, and now a common address, but they still did not have a common culture. They were not a single organization.

    Yet they were successful in reaching more people. In the first six months, with no marketing besides word of mouth and press coverage of the opening, the unduplicated population served by the agencies expanded almost 20 percent, from 6000 people to 7100. "We are just now developing our marketing plan," says Memorial's Carl Ellison, "so we expect more growth. In fact, if we are successful, managing that growth will be our main problem.

    "One lesson," says Ellison, "is that co-locating is one thing. If you want to have the separate agencies operate in more integrated manner, that requires time."

    And they had no one to imitate in creating a single culture. According to Nancy Chertok of La Rabida Children's Hospital in Chicago, who has consulted with the UrbanCare all through the project, "Other models of 'one-stop shopping' were nothing more than co-locating."

    At the start, UrbanCare had no executive director, no central figure. "We decided only to add structure when it was needed," says Ellison, "rather than have a bunch of rules from the start. That's the only way to blend different cultures. They have to have some joint experience before you can decide what to do. Over-structuring it at the start would have been a mistake."

    Soon the board decided to add not an executive director but a "systems coordinator." "We had suspected it might be necessary," says Ellison. "Some degree of struggle for turf still exists, some inability to look objectively across the whole model."

    In November, after five months of operation, the three partners closed UrbanCare for a day and took the whole staff to a retreat at a hotel downtown to hammer out with them what UrbanCare was about. "We redid the mission statement," says Ellison. "For first time we were able to really articulate what we're trying to accomplish."

    According to Chertok, "Really working in a collaboration is one of the toughest things to do, but it's the most important."


    In the meantime, as the UrbanCare project has taken root, Memorial has institutionalized its drive to catalyze a healthier South Bend through a commitment that seems simple, but can be difficult to make. The commitment is this: at the end of each fiscal year, 10 percent of the year's margin will be set aside in a fund dedicated to new projects focused on building a healthier community.

    Board member Janet Thompson says, "The idea first came from the board members. Several themes had emerged from the visioning process that we all took part in, starting back in 1990. One was community responsibility. At the spring 1991 board forum, several members said we should be doing more. We had no specific amount in mind, just a sense of our duty to the community as trustees. By August we had our first committee, an ad-hoc group that became the implementation team for the vision process. Before long, we became an official committee of both the hospital and the system boards."

    As the committee began to search for ways to define what it wanted to do, it still didn't know what they meant by "more." And they made CFO Rick Annis nervous (As he says, "I'm a financials guy"). After all the work and care to cut costs and keep a decent margin to keep the system healthy, the board, it seemed, wanted to just give it away. Once you opened that gate, it would be a deluge. There would be no end to it. And if you committed a specific dollar amount for each year, what if the margin shrank in lean years - the commitment might eat every extra dime.

    Then Leland Kaiser made a suggestion. "He said we should be talking about tithing," says Thompson. In a religious context, familiar to many members of the board, that meant giving 10 percent of your income. There was nothing magic about that specific fraction, but it seemed to solve the worry that the giving could balloon wildly. On the other hand, it represented a lot of money, a sizable commitment. Thompsn says, "Suddenly we began asking ourselves, 'Do we have the courage to do that?'"

    It turned out that they did. "At a certain point, it really was not a problem. For one thing, a number of us on the board had been exposed at the Healthcare Forum to the importance of building a healthier community."

    In the end, even Annis was won over: "In the long run, it will probably be make us financially stronger. My worry is: what if we go down the road four or five years, and we can't afford it any more, we have a bad year, the government shuts off an entitlement program. It's a risk. We might have to turn off the spigot. Right now we're able to do both. We have to have the excess resources, we have to worry about our financials, our bond ratings. I don't know what Moody's or Standard and Poor's would think if we had a negative cash flow and were giving money away. It's the community money, but if you don't have a viable hospital, you won't have the hospital. But we're a hospital, not a bank. We make money to provide healthcare, and the more that we provide today for free, the fewer people are going to show up in my Emergency Room with no coats in winter, malnourished. "

    They voted to do it, and to limit the fund to seeding new projects. The money would not be used to support any operating budget over the long term - each project would either be designed to be self-sustaining, or the system would fold it into its regular operating budget. Nor would the fund pay for anything the system was already doing, since the intention was to expand the commitment.

    So the first order of the day was to figure out just what the system was doing, in a detailed, disciplined manner, using the Catholic Hospital Association's social accountability budget process.

    Next came some self-education. "We don't know how to do it at all," says Thompson. So each of the committee's 10 members interviewed two to four people - welfare workers, police, ministers, social workers, prosecuting attorneys, people from the Department of Health - "people who would know what problems not being taken care of."

    The committee got on a bus and took a tour of the Southeast side of town, near UrbanCare. "We picked up some local people to ride with us. It was emotionally educational. We got a good feeling for the struggles, the successes, and the pride of people in that neighborhood. They know they have problems, but they want to tell you about the good things that are going on. Then they will be willing to share their problems with you. It brought us down a notch - we're not the big boys from the other side of town."

    CEO Phil Newbold characterizes some of the elements that make for a good project: "We're always looking for a partner, whether it's a school, a neighborhood, a church group, some other agency or intitution. We like to work in areas where we have a lot of experience and a lot to offer, such as mothers and children. And the project has to have a CQI element - we have to be able to measure, and monitor it to tell how well it's working, and what might work better."

    By the turn of the year, the committee, the board, and management was ready to start on three initiatives. One was a free HMO which will cover for two years some 400 families who do not now have health insurance, at a cost to Memorial of about $1 million. The hospital is lining up doctors who agree to take on the new patients at discounted prices, but otherwise is paying the whole tab. There are good business reasons to do this, including the fact that soon all the uninsured will be insured, and major systems need some experience in influencing the behavior of the formerly uninsured. According to CEO Phil Newbold, though, the system's motives are not all commercial: "We're doing it to get experience with that populatoin and because these folks need it."

    Second, board members and staff have duplicated their own "visioning process" in miniature at the Studebaker School near Urbancare, gathering the people of the area to envision what they want their school and neighborhood to be.

    Finally, the system has set out to start a parish or congregational nurse program. It sent letters to 120 churches and synagogues in the county, and got serious interest from a diverse dozen - including Mennonite, Jewish, Presbyterian, Baptist, and Methodist congregations and, yes, several Catholic parishes. Memorial will completely fund the first year of the program, then work with the congregations to find their own funding as the Memorial funding drops to zero over a four-year period.

    And the proverbial bottom line? "We have managed to keep up our financials up," says CFO Annis. "The floodgates have not opened. CFOs are often too oriented to the numbers, not to the big picture. They need to realize that they're not accountants, they're finance guys. Accountants look backward and say, 'This is what happened.' A finance guy looks forward. This is one of those things we have to look forward for."

    Group Health Cooperative of Puget Sound
    Seattle, Washington

    In the two previous modules, we have looked at the tactics and philosophy behind a number of Group Health's unusually numerous and deep connections to its community. To explore further the strategy and tactics necessary for launching healthier communities initiatives, we will look this time at several specific areas: The MAP coalition, whose development we have been following; the rapid growth of a new city-wide anti-violence initiative; and the step-by-step development of two smaller health outreach initiatives that arose out of the community contacts of Group Health's roving Dr. Beck - and we will look at how all of these relate to Group Health's budget and overall strategies.


    The Mutual Assistance Partnerships (MAP) Coalition, Group Health's most ambitious attempt to go beyond medical outreach to building a healthier community, has moved forward several steps. MAP brings together Group Health with two big partners (the Seattle Housing Authority and Senior Services of Seattle and King County) and two small neighborhood community non-profits (the primarily African-American Central Area Motivation Program [CAMP] and United in Outreach, which brings free food to the sick and to frail elderly shut-ins).

    The staff was hired in the late spring, and almost immediately - mid June - all five of them headed off to Montreal to spend two weeks training with John McKnight. "It was great to study with him," says MAP director Craig Shimabukuro, "and it also helped build the team as a team. It gave us a good sound base in McKnight's philosophy of community building - that everyone in the community has a gift or a capacity to share, that those can definitely be developed and nurtured. I would recommend it for anyone attempting something like this, especially the timing - doing it right at the beginning." This training was written into the grant budget as part of the original submission.

    Once they were back, the staff set to work on a survey they had developed, making calls for the better part of a month both to develop baseline, and to get a feel for part of the population they were working with.

    Next they began reaching out to the community. From August to November staff members spoke to some 150 organizations, including social service groups, youth groups, government agencies, and churches, "just to familiarize them with who we are and what we are doing," says Shimabukuro.

    Next they started a community association, which had its first meeting in December. "This is more than just an advisory board," says Shimabukuro. "Before the period of the 4-year grant is over the community association and our current board will merge and become the project's permanent board."

    The purpose of the community association, says Shimabukuro, is to "help build mutually beneficial relationships within the community." To this end, for instance, they break into small groups so that the project staff can get direct feedback. And together the staff and the association identified eight association members from 15 to 60 years old, each willing to make a one-year minimum commitment, to be sent for 12 hours of leadership and board training.

    In the meantime, in selected neighborhoods in the central district, staff members are going door to door, starting with 40 names of isolated seniors. A preliminary letter and phone call got a 50 percent return from people willing to have a team visit them. "We wanted to make contact," says Shimabukuro, "and we also wanted to see who might be interested in attending or holding a block party. Now we are literally going door to door to get the block parties together, to match up people, and to let them know what we are doing."

    As one early result of this effort, a staff member has been putting together projects that match Capitol Hill's Reunion House senior housing with nearby Lowell Elementary school

    Another goes door to door in the Seattle Housing Authority building that houses his office, creating matches based on people's gifts and capacities training. One minor dividend: a half-dozen music lovers, formerly isolated, have formed a music group.

    "After we are done going door to door in these first neighborhoods," says Shimabukuro, "we want to sit down and evaluate how we did: how effective were we, how many people did we engage, how much are those people now willing and able to operate by themselves? We will modify our tactics based on that, and start with another neighborhood."

    MAP's ultimate interest is to spread its skills widely to other groups and individuals. "For instance, we have already met with the head of a group called 'Powerful Schools,'" says Shimabukuro, "teachers, parents, and businessmen involved with three schools. They are interested in using school sites for continuing learning, keeping them open from 7 a.m. to 10 p.m., so that people can use them, so that they can become more vital parts of the community. They heard about what we were doing, and they want to do same thing in the neighborhoods around the schools."

    To the end of training others and spreading the point of view, MAP is sponsoring a conference on community-building in Seattle at the end of September, 1994. John McKnight has agreed to come, along with other national and local speakers. But, true to the ideas the conference is about, "people won't just listen," says Shimabukuro, "it will be interactive, there will be plenty of questions and open discussions."


    Violence is one health problem that is on everyone's mind. When two young people were killed and three wounded in one weekend in 1992, some Seattle folk decided to see what they could do about it. Two white women, owners of small businesses downtown, got together with the head of the state African-American Commission to form a group called "Stop The Violence." Together, they persuaded the Bon Marche department store chain and a local radio station to sponsor a gun buy-back in September of 1992, raising over $100,000.

    State and local laws can make things difficult for some kinds of initiatives. In Washington State, cities are forbidden by state law from enacting any gun control legislation, and police departments are forbidden to destroy any guns - guns they buy or confiscate must be auctioned back to the public. It was to get around this problem that the gun buy-back had to be privately funded and operated.

    Margaret Pageler, chair of the city council's Committee on Public Safety, called the Centers for Disease Control in Atlanta, asking whether anybody in healthcare was working on the issue of gun violence. The answer was right in her backyard: doctors at Seattle's Harborview Medical Center had done a surveys before and after the gun buyback that showed that it raised public awareness of the danger of having a gun in the home.

    Things continued to build on the state level. The African-American Commission got legislation passed funding anti-violence youth programs around the state. This led, in the spring of 1993 led to a state conference on youth violence. In connection with health reform, the state Board Of Health identified gun violence as a key public health issue.

    Meanwhile, Pageler started writing to hospital CEOs and board presidents, asking whether they would be interested in meeting as a state commission to discuss gun violence.

    When Group Health approached the Mayor's Office on its own to ask what could be done about violence, the Mayor - popular and recently re-elected African-American (and Group Health member) Norman B. Rice - sent Group Health to talk to Pageler. "We knew that Group Health has been involved in the 'healthy community' approach for a long time," says David Bley, the Mayor's deputy chief of staff, "as has our Health Department. Some only now beginning to look at this differently because of healthcare reforms."

    The result was an two-year anti-violence project in the Mayor's office, funded by $150,000 from the Group Health Foundation, headed by Beverly Mann (Group Health's board chair and a former regional director of the U.S. Public Health Service) and Dale Tiffany, a city department head with public safety training. "Our vision," says Bley, "is to cut across departmental boundaries, and the boundaries between people and government."

    The anti-violence project called together a task force of CEOs and board chairs of healthcare institutions in the area, plus other medical and public health experts. They first met in November, 1993, and by March, 1994, they had come up with a report, containing a series of recommendations on reducing violence. Group Health's traditional involvement in the community was perhaps best shown by the number of Group Health doctors who served on this task force because of their other roles. One came as head of an association of Emergency Room physicians, another as head of a group looking at gun safety issues on a statewide basis. A third, the head of Group Health's domestic violence effort, came as chair of a community domestic violence organization.

    Meanwhile, the anti-violence project set itself to do an inventory of what's being done already. "We are actually doing a lot," says Bley, "a lot of it is collaborative, and cuts across departments and communities. We are looking at 'idle time' issues. We already have extensive recreation centers, including, for instance, some computer centers. But we are not doing enough of that. We want to expand that program a lot more. Our new police chief is into 'community policing,' which Seattle moved into early. The mayor wants to take it to the next level."


    The first step in many of these initiatives, and the most powerful, seems to be simply gathering the people and bringing up the issue. For instance, Group Health's roving community doctor Dave Beck heard from community clinic doctors that they often wanted to urge paitents to quit smoking, but there was no program to direct them to, no one to call, not even a pamphlet to stick in their pockets. Beck asked the people who worked in the clinics whether they would be interested in meeting to share techniques, and to hear what Group Health might have to offer. They did: 10 to 20 medical assistants and health educators from the clinics showed up at each of the meetings.

    Now a representative of the state's Project Assist (funded by National Cancer Institute and the National Institutes of Health) has started coming to meetings to finding out what works with pregnant and low-income people. "This group is just who they need to talk to," says Beck.

    The institution's own bureaucracy can be an obstacle. Beck, for instance, ran into what he characterizes as "a blind wall" when he asked Group Health's own Center For Health Promotion for a supply of stop-smoking handbooks. So he went to another hospital. "It was the typical bureaucratic hassle getting in the way of action," says Beck. "No one would say, 'let's do it.' At Providence [Catholic] Hospital they had a stop-smoking handbook with a nice, low reading level. The information person there is empowered, she'll give us as many as we want."

    The next spin-off will be a train-the-trainer piece that will feed back into the community. And the smoking initiative has become the first CQI project for the community clinics. At the same time that the clinics staffs help people stop smoking, they learn how to look at their goals and outcomes, adn how to measure their progress. At the same time it is getting some of the Group Health staff talking to the clinics and sharing techniques on a regular basis. A little inquiry about finding the right pamphlet has turned into "one of the most vital things I have done," says Beck.

    Another question started a similar initiative, when one woman told Beck, "A lot of lesbians have Group Health insurance, but they don't go because they don't know a doctor who won't give them a hard time about their weight or their sex practices. Do you know any Group Health doctors who are sensitive to this? We would like to put their names in our resource book, and we are looking for volunteers to staff an evening pay-if-you-can clinic."

    That led to the woman addressing a medical staff meeting, and asking for volunteers. One doctor he asked, "How many women do you think this would effect?"

    She said, "Estimates run up to 10 percent of all women. If that's so, that would mean as many as 24,000 Group Health members."

    The reaction was: "Wow!" She signed up nine volunteers. Soon after, another medical center asked her to do an in-service, and now she regularly teaches lesbian sensitivity to medical professionals. And the evening clinic is off and running - all from following up a conversation with action.


    With the advent of health reform, working with people outside the mainstream may well turn out to have business advantages. Dave Beck says, "Group Health does not have a lot experience in taking care of these people. They are interested in learning from these community health clinics. How do you deal with homeless people, with people who speak different languages and have different cultures, with people who are in a dangerous or abusive situation? They need to be able to provide sensitive, effective healthcare that hopefully won't cost them an arm and leg. For instance, if you're not real familiar with post-traumatic stress disorder, if you don't know that you don't necessarily have to do a CAT scan for every headache, you have a lot to learn from those community centers that are operating on a shoestring, that don't have to practice cover-your-ass medicine and can't afford to."

    Bill Beery, head of Group Health's Center for Health Promotion, makes the same point: "We are involved in bringing in new members, including a lot of Medicaid members. Their demands and needs are very different from the rest of our members. If we are to meet those need, we need to be involved in those communities.

    "For instance, a lot of these pregnant teens are just not used to coming in for the healthcare that we provide. If they get any prenatal care at all, they get it in the clinics, late in the pregnancy. Availability is not enough. Even outreach isn't enough. We need to build trust. That's only going to happen by people getting to know people. So, for instance, we get involved in late-night recreation programs where these teens. When we try to serve them as enrollees, they see us as credible source of care - and we know how bes to serve them."

    Besides, says CFO Grant McLaughlin, "What we do isn't that expensive." Since Group Health's various community programs are so interwoven with its operating budget, and some so difficult to categorize, McLaughlin does not know how much the organization spends on building a healthier community. His best estimate is one half of one percent of the operating budget. "I am absolutely convinced, without any data, that these efforts have more than half a percent positive impact on the bottom line. The need is so clear. The initiatives are so well-conceived. It would be easy to convince our major customers, the employers who offer Group Health, that it works. Employers very well-motivated to work with their employees on health. They would think of one half of one percent as a very modest investment if it would help keep their employees out of the Emergency Room, and help them cut down on alcoholism, smoking, and other behavioral problems that contribute to poor health. Most business people, the Boeings of the world, are community oriented. They know that they can only be successful if the community they are in has a minimum of violence, has good immunization for the children, and so forth."

    Group Health has actually proven the cost-effectiveness of medical outreach programs for Medicaid members. It has been involved in Medicaid for over 25 years, but didn't want to do what McLaughlin calls "the coupon business." Instead, Group Health enrolled them as full members. "We convinced Medicaid 15 years ago that it would reduce costs to have a half dozen outreach workers to teach these new members how to use the system."

    In the mid-1980s, Group Health commissioned a Rand Corporation study that confirmed that, in this situation, spending money saves money, with hospital use about half of the usual fee-for-service Medicaid level, and Emergency Room use less than a fifth. Now the new state "Healthy Options" Medicaid program mandates a model almost identical to Group Health's full HMO enrollment.

    With the advent of health reform, says Group Health CEO Phil Nudelman, "Some people will want to totally de-medicalize social issues such as drugs and poverty, which as a society we have effectively added into our medical bill. But I don't know how you can separate them."

    Going the distance

    "Organic change takes organic time." - - - Out of Control, by Kevin Kelly


    For the fourth time, we will visit three health systems who have taken "building a healthier community" as their goal. Each in its own way has rolled up its sleeves and gotten to work in the community. Over the two years we have watched them, these efforts have changed significantly. None have crashed and burned, but some have gone through crises, changes of leadership, or difficulties in the community. Some have gone through heartening growth and maturation.

    In each case, this time, we asked, "How do you build for the long haul? How are you shaping your effort to sustain it over the years and decades?" The answers were useful, and had the ring of experience.

    Greater Southeast Health System (GSHS)
    Washington, D.C.

    Since we started this study two years ago, Greater Southeast has gone through a financial reorganization and a change in CEO that brought Dalton Tong to the top position, as Tom Chapman moved on to George Washington University Hospital.

    As we have seen in previous modules of the Action Kit, Greater Southeast has built an astonishing array of programs and partnerships in the community, even though it has never been a wealthy institution. From Southern Avenue on the edge of D.C., GSHS serves an area that stretches over the southern wards of the city south of the Anacostia, as tough and poor as any in the nation, as well as parts of suburban Prince Georges County across the line in Maryland. The programs Greater Southeast nurtures outside its doors run from the purely health-oriented (such as blood-pressure screening, breast cancer screening and advocacy, and a clinic built into a local high school) to the health-related (a Center For Aging with elder day-care, long-term care and a senior center) to programs that are purely about community, including one that links "at-risk" teenagers with older people, a children's day-care center, and efforts to support low-income housing.

    We rarely see efforts with this range and depth centered in health systems. And rarely do we see such long-term efforts. Greater Southeast founded the Center For Aging, for instance, over 16 years ago.

    What are the roots of this longevity?

    Built Around It

    At the core of the stability of Greater Southeast's commitment to the community is a fact that is almost too simple: the system is built around this commitment, top to bottom and reaching far back in its history. This commitment is the story of Greater Southeast, from the time 30 years ago when the community contributed to building the present main hospital by holding bake sales and rattling the tin cup from door to door all over Anacostia.


    The commitment is built into the system's governance. According to their own rules, 80 percent of the people on the boards of the system and each of its subsidiaries must come from the system's service area, half from Prince Georges County and half from D.C. "In practice," says Jacquelyn L. Lendsey, vice president of corporate and community development, "we narrow that down to Wards Six, Seven, and Eight," those closest to the hospital.

    "Even that won't get you there," says board chair Carolyn Lewis, "so we have a very rigorous board development process, which includes involved, detailed interviews with people whose names surface. As we go through this, we do our best to discern both an active interest and some evidence of community connection, some indication that they have a stake in the outcome of community programs, that they are connected to a church, a community group, or a political organization. That gives us another point of accountability."

    According to Lendsey, "The board members ask themselves, `What are the skills we need on these boards? How do we get them?' They look for people who are involved in the community -- religious leaders, community activists, people involved in aging projects, people in social organizations. We try to bring together various constituencies. We also work to get people who are movers and shakers, and people who are able to raise funds."

    For instance, in late `70s, when Greater Southeast accelerated its involvement in the community, it moved that direction largely because its board included such community activists and professionals as Vivian Smith, a social worker by training and part of the D.C. mental health network.

    "She helped the board focus on some of the needs from her perspective, including the needs of an aging constituency that no one was really meeting," says Gloria Anderson, president of GSHS' Center For the Aging. "This is governance that knows the community heartbeat. It's a board that asks, `What can we do?' As a result, they built a reputation as a board that was doing things."

    The members of the parent board can serve three three-year terms. The members of the subsidiary boards have one-year appointments, but most are re-appointed. So the process of board membership itself gives the system continuity and corporate memory.


    The employees reflect that same feeling. Some 82 percent of the employees live in the service area, half in Prince Georges County and half in the District. The system runs regular community education sessions for their employees, publicly commends their volunteer efforts and (perhaps most important) tries to assign them to efforts in their own areas, so that they can get recognition from their neighbors.

    Dalton Tong, the CEO since the beginning of 1994, says, "You have to make sure that people don't lose sight of the bigger picture. We have a lot of egos around here. Even Dalton Tong may have his own agenda. As long as we keep track of the big picture we'll be all right. That's why we have not become the most high-tech center in the city. We keep ourselves on track, linked to the health of the community. It pleases me as president to walk through the halls and talk to people and find that their concerns are the same as mine, whether it's a physician in the parking lot, a nurse on the wards, or a guy sweeping the floor. If I were to leave, I would leave feeling assured that the mission will not be abandoned."

    "Success helps," says Anderson, in building credibility and momentum. "So it helps to choose goals that are achievable, to lay out visions that are realistic."

    Tong agrees: "You sustain the spirit by producing results that are counterintuitive. People say, `This is not a sinking ship. It is buoyant.'"


    Besides multiple, ongoing contacts with the community through the board, through participation in projects, and through the volunteer efforts of employees, Greater Southeast uses three other methods to keep a sense of continuity with the community: advisory boards, focus groups, and a lively network.

    Community advisory boards often need need tweaking to make them useful. For instance, the parent's group for GSHS' daycare center was good at complaining, but not so skilled at articulating what they felt would work better. This called for more careful facilitation, and more regular meetings, to help them move beyond the complaint stage to the brain-storming and problem-solving stage. "We will not lead it," says Lendsey. "We have some ideas, but we don't want to say, `This is what you need.'"

    Focus groups help the healthcare system uncover obstacles that might otherwise have remained hidden. Lendsey gives one example: "We have a focus group about a managed care plan we are working with in the projects. They told us they have no problem with being assigned to a certain physician. But we also found out that if they don't have a telephone so that the doctor's office can confirm the appointment, if they don't have transportation, if the appointment comes at the end of the month and money for the bus is running short, if they don't know how to read the message that someone else takes for them, the appointment is not going to happen."

    At the same time, the community and the hospital nurture a lively and dense bundle of connections between them. Lendsey calls this "our network of tentacles" into churches, student groups, and local governments. "We're not so naive as to say that there isn't something we've missed," she says, "but if it's big we wouldn't miss it."

    For instance, one group approached the manager of a housing project under renovation in Ward 7 with a proposal to develop a health corner for it. The manager responded: "Have you talked to Greater Southeast? I'm not going to do it if they're not involved." In the end, GSHS was able to help the housing project move forward with its health corner.

    "Be clear on the front end," says Lewis, "that your program is meeting a real unmet health need that is out there. If you do a health fair, people see that as a one-shot. But if you tackle something like breast cancer that is already looked on as a serious community health problem, you can approach it at all levels that make sense. You can talk to the young women in high school, you can go to the churches and women's groups, to all the places where they are. You can design the program so that it touches every point of reference, and builds in a continuity and commitment across community lines. The various community efforts reinforce each other breast cancer. People take ownership. Women tell us how their daughters took the responsibility to remind them that it was their own health and life they were protecting, and the mothers then took the responsibility to spread the word in the projects and in the churches. It was not something we were doing, it was something of theirs that we were helping them with.

    "We do the same with blood pressure screening by taking it into the barber shops, training the barbers. We train people to be both advocates and service providers. It puts them in charge of their own health."


    "We look for programs not because there is a short-term funding opportunity, but because there is a need in the community," says Lendsey. "Then we look for the funds, but with a built-in philosophy of sustainability. We don't undertake a program that we don't feel we can sustain once the short-term funds are gone."

    "Sometimes people come in with wonderful ideas," says Anderson, "but if I can't see the possibility of endurance, I back away. We are serving a community that has been disappointed so often before. We have never had to completely abolish something after the foundation funding ran out."

    For instance, funding ran out for the Service Credit Volunteer System, an exchange bank of volunteer hours. But the equipment was all in place, so the Center For Aging turned it into a volunteer activity, and kept it going.

    It is equally important, when you are 10 or100 times the size of many of the organizations with whom you partner, to know when not to go after a grant. "We try to be careful," says Lendsey, "about staying out of the competition for money that is life money for other organizations -- or saying `Let's do it together.'"

    Corporate memory

    There is a skill to working a particular community, a skill built up over time, and passed on from one person to another in a kind of corporate memory. As Lendsey points out, these are often the kinds of things that can't be written into a handbook: "It can be a truly personal kind of knowledge, which requires an informal passing on, such as `under no circumstances do you bring these two people in the same room,' or `if you're working with the Organization XYZ, make sure that Organization ABC doesn't feel slighted.'"

    This corporate memory is focused in the Community Development Department. But bits of it are distributed throughout the board, the management, and the organization as a whole.Working in the community is deep in the organic fibers of Greater Southeast.

    Memorial Health System
    South Bend, Indiana

    We started these Action Kits focusing on one particular project in South Bend: UrbanCare, a multi-service, one-stop center for women's and children's health in the poor Southeast neighborhood.

    But over these two years, Memorial has moved out into the community on a broad front. It has taken up tithing, delivering 10 percent of each year's margin into a separate fund dedicated to new projects focused on bulding a healthier community.

    Each of these efforts tells us something about continuity and longevity.


    UrbanCare, in particular, has gone through significant changes over these two years. When we first wrote about it, the doors had not opened yet. Over the next two modules we watched it go through growing pains. Some of these pains came from the outside, as anti-abortion groups protested Memorial's partnership with Planned Parenthood, despite the fact that Planned Parenthood of Northern Indiana does no abortions. Others came from within, as the corporate cultures and operating procedures of the partners (which also included Michiana Hospital, an osteopathic facility) failed to meld smoothly and naturally. But the partners weathered the protest storm, hired a "systems coordinator" to help operating procedures mesh and, last November, held a retreat with the entire staff to smooth the transition to a common culture. Things seemed to be moving.

    Now the project has come to what Memorial's Carl Ellison calls "a significant crossroads." Things have gotten really interesting -- in the sense of the ancient Chinese curse, "May you have an interesting life." Three things are happening at once.

    1) Planned Parenthood's Betty Mooney, in many ways the original "godmother" of the project, is retiring. That would be no big deal if the project were just sailing along, but

    2) Ancilla Health System has bought Michiana Hospital. That would be no big deal, except that Ancilla is a Catholic system, and it was the Catholic Church in the area that spearheaded the anti-Planned Parenthood protest. So Michiana, which had provided the site's pre-natal clinic, pulled out as of October 1, 1994. According to Ellison, Memorial's assistant vice president for community affairs, "the partnership as we have known it will be dissolved." As if that were not enough,

    3) Hoosier Health Watch, the state's new managed care plan, has made primary care physicians the gatekeepers for Medicaid, including the federally-funded Maternal and Child Health Services that UrbanCare provides. UrbanCare is an "extender-driven" model, designed to keep costs down by minimizing the use of physicians. If a clinic wants to engage a doctor under Hoosier Health Watch, it has to have the physician on site for 20 hours per week. So, as Ellison says, "UrbanCare would have had to changed in any case."

    Is this a disaster? Or is it a another turn in a long and winding road, another darned learning opportunity? At this writing, no decision has been made. "All parties are in intense discussion," says Ellison. But, if you ask his point of view, he already has a new vision for the center: a federally-qualified health center "lookalike." It would qualify for grant subsidy money and cost-based reimbursement. The governance would be re-structered around medical services. The board would be dominated by consumers, the governance ceded to the community and the neighborhood. Memorial and other organizations would act as "sponsors." "It was women's and children's care," says Ellison. "Under this plan it would be complete primary health care -- an `UrbanCare II.'"

    "Whether UrbanCare as a collaboration is possible is in question," says Ellison. "In the real world, primary care is becoming increasingly competitive, not collaborative. Ultimately, I ask, `What are gains for the community?' Collaboration for its own sake is hollow, and in the end we may not support it unless there is a gain for the community"

    "This is not in the textbook," says Ellison. "We've learned a lot of valuable lessons from UrbanCare." For instance, building something collaboratively may make it more stable -- or less stable. "If you start something with a partner, your partner's status may change."

    As board member Janet Thompson puts it, "One of the difficulties of collaboration is that more of the future can be taken out of your hands. You have less control of the outcome."

    Secondly, melding corporate cultures and operations is harder than it looks. "If we continue collaboration," says Ellison, "we might spend a year on training and team-building. We didn't do enough of that. And you need a driving force. We had no director, no czar, so the depth of integration we hoped for has yet to be achieved."

    And finally: "Collaboration is a learned behavior that requires some faith and experience. Short-term commitment in collaborative effort is by definition not appropriate. Collaborations require time. You don't get there overnight."

    Giving it all away

    Memorial's tithing programs are encountering the same lesson, in a different guise. It turns out it's not that easy to give money away, if you want to do it toward a particular end, and do it wisely.

    For some reason, it reminds people of 1950's TV shows, like Michael Anthony in "The Millionaire" ("I have in my pocket a check made out to you in the amount of one million dollars."). After going door to door in the southeast side of town, Memorial's CEO Phil Newbold says, "I feel like Art Linkletter, saying, `Hey, would you be interested in this free health insurance?'"

    When the board decided to allocate approximately $1 million per year to the Community Health Partnership, an experiment giving free health insurance to some 400 poor families, Memorial's staff and lawyers pored over the details, considering every possibility: how do we mainstream people when the program is over? How do we decide who is eligible? Are the liability issues any different? What no one anticipated was that you would have to sell the program, that families in the targeted neighborhood would look on it with a combination of apathy and skepticism. "Everyone wants to know, `What's the catch?'" says Newbold. Memorial had to recruit the area's ministers to help out. One personally brought 12 families into the program -- an undertaking that took a fair amount of time and effort. The program opened for registration on June 1. In the first three months, 28 families signed up.

    "I try to do a little door to door work every few weeks, or just hang out," says Newbold. "It's a mixed area, part African-American. I go door-to-door with an African-American woman from the area, inviting people to come to a town hall meeting about the plan, or just to sit down and talk about it. People invite you to come in and sit down. It's a great way to find out how absolutely irrelevant we are in people's lives. We live in a Ptolemaic world that revolves around the hospital. They're caught up in day-care, the car, what the house needs. But that's a realistic view, even of health. Most health is created by the jobs, the neighborhoods, the family unit. The bricks and mortar, machines and expertise at the hospital play a very small part."

    One problem in trying to build something long-term in poor communities is that the communities themselves are not that stable. Some neighborhoods and schools have as much as 30 to 50 percent turnover per year. "It helps if you can institutionalize the model in churches and schools, and in the minority of families that stay put for many decades," says Newbold.

    As the name suggests, Community Health Partnership is itself a collaboration. One partner is an agency that counsels people on their financial situations. Others include a case management group (Family and Children's Services), a PPO (Partners), and the Southeast Neighborhood Association.

    Another small partnership goes after a very particular problem: children who have reportedly been sexually abused often have to go through repeated interviews -- by a prosecutor, by someone from Child Protective Services, by someone from the welfare department -- usually in scary, cold, unfamiliar offices. Dr. Robert White, chief of Memorial's neonatal services, had grown alarmed by the amount of child abuse he saw, and equally alarmed at what almost amounted to more abuse in the interviewing process. He did something about it: he brought together the St. Joseph's County Prosecutors Office and the South Bend Junior League to put together a Children's Center. There, in a homelike atmosphere, surrounded by toys and stuffed animals, one person conducts an interview. All involved parties get a video of the interview. Memorial pays the rent on the building. A small thing, but in the lives it touches a very big thing.

    The community itself remains the touchstone. Newbold points out that "the projects that came out of the felt need of the community have been somewhat more successful than the ones that we thought up."

    "A lot of the staff, and some of the doctors, want us to just go out, put a couple of people on the payroll, put together a budget and a hierarchy and knock this thing out. But it doesn't always work just so. You also have to do these spider-web kind of things that don't lend themselves to the traditional models."

    So in the third year of dedicating a "tithe," the account continues to grow. "It takes a lot longer than you'd think to build the infrastructure of these things," says Newbold. Meanwhile, as the account rolls over, it builds stability into the system for multi-year commitments.

    One of these commitments, the Parish Nurse program, is similarly growing, solidly and well, but more slowly than planned. Despite the anti-abortion protest (which included billboards that read "Shame on you, Memorial!'), dozens of religious congregations have expressed interest, and three have begun the program -- one Church of Christ, one Methodist, and one Orthodox Jewish schul. The nurses work through two months of training in religious and cultural sensitivity, as well as learning the basics of social work, and getting to know the local referral network. At each site, the entire congregation goes through health assessments. And each congregation takes on a commitment to provide greater amounts of the nurse's salary -- until, in five years, they will provide all of it.

    But even here, change is organic, and each program has to be tailored to that particular congregation. The Orthodox, for instance, average six children per family, so their program is far more involved with pre-natal and well-baby care. But they practice a fairly strict segregation of the sexes, so the female nurse has difficulty providing care for the male members of the congregation.

    On the other hand, at the Methodist congregation, in a lower-income neighborhood, the nurse has more call to go out in the neighborhood and bang on doors, to become much more of a public health nurse.

    If the goal is to go the distance, "We have to end up with multiple models, and not just be a money partner," says Newbold. "We have to keep experimenting. People get locked into a mindset of `Let's get a model and go with it.' Change is more the rule than the exception."

    Group Health Cooperative of Puget Sound
    Seattle, Washington

    Group Health's commitment to the community goes back to its founding nearly half a century ago. But during the two years we have been tracking it, it has rapidly and powerfully expanded its involvements outside the walls.

    In earlier modules, we have described these multiple involvements, ranging from a storefront drop-in center for the street people and homeless of the waterfront area, and a "Teen Parenting Program" run through the city's Parks and Recreation Department, to one doctor and several nurses detailed to working in community clinics and homeless shelters throughout King County, and involvement in an area-wide anti-violence program.

    We have spotlighted especially the public and explicit commitment of the Group Health board to the health, not just of the cooperative's members, but of the whole community, in a detailed 1991 resolution.

    Mutual Partnerships Coalition (formerly Mutual Assistance Partnership)

    If you want to meet this commitment face to face, you could stop by Council House, a Seattle Housing Authority building for seniors, and meet Mr. Jacques, a former merchant marine ship captain. He used to be isolated from his community, but now he works with young people. When the big summer SeaFair festival comes around, he likes to take a few of his young proteges out for special tours of the Navy ships that come to the Fair. It was the Mutual Partnerships Coalition, based at Group Health, that linked him with his young friends.

    But at Council House they know Mr. Jacques as "the computer guy." One of the MPC staff discovered that he was fascinated with what computers could do, and took him to down to the Madison Street YMCA, which has a state-of-the-art computer center. The Y's YouthTech program trains "at-risk" young people in how to use and repair computers, and how to develop a business plan for a small, computer-based business. Mr. Jacques' interest in using computers grew, and he took to walking down to the Y on his own steam. He got other seniors at Council House interested, and started taking them down to the Y with him. Pretty soon a whole cadre of computer-fascinated seniors had developed inside Council House. With a little deal-making from the MPC staff, and a few donations of computers, printers, and software, the YouthTech kids came over to Council House to work with the seniors to develop their own computer center.

    This kind of matching is central to the the Mutual Partnerships idea, based on John McKnight's ideal of "building community from the inside out," of searching for a community's gifts and capacities rather than just for its needs. In the McKnight vision, everybody -- every person and every organization in a community -- brings something to the table. Lloyd Shelly, like Mr. Jacques an older MPC volunteer "community guide," goes around and speaks to seniors in the community and in Seattle Housing Authority (SHA) buildings. He gets them to call one another on a regular basis, just to check up and say hello, just to see if they are taking their medicine and doing their exercise. At Gideon Matthews, another SHA building, MPC staff matched one older African-American woman who had been walking for health and exercise with another whose doctor had been urging her to exercise. Now they walk together and are nurturing a friendship.

    Over at Reunion House, another senior building on Capitol Hill, the seniors have linked up with the kids at nearby Lowell Elementary School, tutoring them and getting involved in other activities. There is no senior center near Reunion, so the MPC staff has helped the Reunion seniors form a new group called :Seniors On The Hill. Lowell's principal is giving the seniors space at the school for senior center, as well as for inter-generational activities.

    And now Reunion House has begun holding neighborhood meetings with other seniors, the staff of the school, the local bank and business community, and representatives of other community resources, such as the library, the community council, and the mayors' Office On Aging.

    MPC is a partnership between Group Health, the Seattle Housing Authority, Senior Services of Seattle and King County, and two neighborhood community non-profits: the primarily African-American Central Area Motivation Program (CAMP), and United In Outreach, a neighborhood not-for-profit bringing free food to the sick and to frail elderly shut-ins.

    In its first year of knocking on doors and going to meetings, MPC has made some 150-180 such mutually beneficial community matches. "It's the approach and the design that will make it last," says project director Craig Shimabukuro, "because everybody gets something out of it. Whether or not it continues as a staffed, funded project is less important, because of people like Mr. Jacques and Mr. Shelly, who are now going out and working with others."

    Unlike a lot of grants, the W.K. Kellogg Foundation funding for MPC has the transition to community control written into it. By the time it is over, the current board Policy Management Team (which includes representatives of the partners) will merge with the Community Association, and the project will become fully self-governing.

    To that end, the grant also provides for ongoing leadership training, not just for the half-dozen people on the MPC staff, but for the community guides, and members of the Community Association.

    The whole purpose of the grant is to grow the capacity to build stronger community bonds into the community itself. The output of this engine is sustainability.

    The end of conventional wisdom

    Bill Beery, director of the Cooperative's Center for Health Promotion, has thought a lot about sustainability, ever since he worked in the Peace Corps and the Poverty Program. "Forming partnerships and coalitions like the MPC, so that it becomes the way people do work in the community, is one major way of giving things some legs. It's also important to use volunteers, and to leverage internal funds by getting funds from the outside. It's hard to sustain something if it's seen as something that we alone are doing -- or if all we ask from others is money.

    "`Coalition' is the big buzzword now. But building a coalition that works is a lot harder than it appears. For one thing, the goals of the partnership have to be perceived as consistent with the goals of each of the sponsoring organizations. There's no way the partnership will endure unless the partners truly see the partnership's work as consistent with their own mission.

    "Second, you have to commitment resources that are dedicated to the care and feeding of the coalition as a group -- space, administrative support, clerical help, and a kind of coalition memory. These things don't happen by themselves.

    "Finally, you have to have people representing organizations who can speak for them, who can commit the resources and the direction of their organization. It's very different when you have someone sitting at the table who can say, "I am signing my organization up for this."

    Experience and depth of craft like Beery's are central to building for the long run -- not just his particular bits of knowledge, but having people in the organization who have a lot of experience working with community, here, in the community where you are. In the end, the only way to get that level of experience is to do it, and to do it for a long time. That means that the will to do it has to be built into the roots and stems of the organization -- not just into the community development department or some separate project, but into the board and the management, into the foundation, into the annual and long-term budgets, and into the organization's reputation and stance in the community.

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