Summary

La Clínica del Pueblo (LCDP), a federally qualified health center that serves the low-income, Latino/a/x community in D.C., used the Partnership Assessment Tool for Health (PATH) to assess two cross-sector partnerships: a medical-legal partnership with a legal services agency and a five-year partnership with FRESHFARM focused on alleviating food insecurity.

Key words

Public-private partnership, cross-sector collaboration, medical-legal partnerships, food insecurity, social determinants of health.

Background

Partnerships bring together institutional capabilities and human resources to tackle problems that are beyond the capacity of a single organization. Recognizing that health outcomes are affected by more than direct services, organizations are increasingly developing cross-sector partnerships to address patients' social needs.1 In the treatment and care of chronic conditions such as diabetes, it is crucial to address a patient's social determinants of health.2 Access to nutritious foods and stable housing, employment status, and immigration status are a few examples of social determinants of health that have a direct impact on a patient's ability to manage chronic conditions.3,4

Even for successful partnerships, it can be difficult to measure the impact of partnership efforts to improve patient experiences and outcomes. Therefore, many efforts [End Page 222] have been made to formalize partnership evaluation and quantitatively measure improvements of patients' health outcomes that resulted from the impact of the health partnership.58 However, few have documented the process of partnership assessment and the resulting impact it has on shaping and molding the workflow of the partnership and its programs. This report describes the process of formal partnership assessment at a federally qualified health center (FQHC), the FQHC's motivations for engaging in partnership and partnership assessment, and the resulting impact the process had on the evolution of its partnerships.

Organizational Context

La Clínica del Pueblo (LCDP) is a FQHC that serves the low-income, Latino/a/x community in the Washington D.C. metropolitan area. La Clínica del Pueblo provides culturally competent primary care, medical interpretation and language access advocacy, and community health education programs. Many patients at LCDP have unrecognized immigration status, limited English proficiency, and low health literacy and are unfamiliar with the U.S. health care system. These circumstances affect how they access health insurance, health care, and community-based services. La Clínica del Pueblo is a grantee of the Merck Foundation initiative, Bridging the Gap: Reducing Disparities in Diabetes Care, a five-year program that aims to improve diabetes care and reduce health disparities for vulnerable populations with type 2 diabetes.

Medical-legal partnership with CARECEN

Founded in 1981, CARECEN serves the D.C. Latino/a/x population through direct legal services, human rights advocacy, civic engagement, and grassroots empowerment.9 La Clínica del Pueblo was originally founded as a health project of CARECEN to provide free medical services as a volunteer-run clinic in 1983. Over three decades of partnership, LCDP and CARECEN evolved from having a primary focus on access to immigration legal services (e.g., humanitarian applications, work authorization, green card renewal) and non-legal services (e.g., citizenship classes) to now offering advocacy and legal services for a range of needs (e.g., rental assistance, foreclosure prevention, housing rights, bankruptcy, eviction prevention).

Changes in both federal policy during the Trump administration and the onset of the COVID-19 pandemic spurred increased demand for legal services and advocacy for immigrants in the D.C. area.1011 This political and policy context pushed the partnership between LCDP and CARECEN towards advocacy and legal services focused on housing, immigration legal needs, and government benefits. For example, in response to federal policy changes, CARECEN provided Know Your Rights training to LCDP staff to support how staff could advocate for patients. During the COVID-19 pandemic, factors such as housing insecurity and the burden of eviction among immigrants in the D.C. area pushed the partnership towards advocacy and legal services beyond immigration legal services.1214

Food security partnership with FRESHFARM

FRESHFARM, based in Washington D.C., works to create resilient, equitable, and sustainable access to regional food systems and connect people to their food through hands-on education, farmers markets, and food distribution programs.15 La Clínica del Pueblo initiated a partnership with FRESH-FARM [End Page 223] in 2017 to support class retention and education strategies for LCDP patients who were enrolled in diabetes prevention and chronic disease self-management classes. Purchasing expensive healthy food was often cited as a barrier for these participants. La Clínica del Pueblo purchased FRESHFARM farmers' market tokens, conducted farmers' market tours with class participants, and distributed tokens to participants for purchasing otherwise unaffordable produce to increase vegetable intake in their diets.

The partnership was formalized in 2020 when LCDP initiated the partnership assessment process. La Clínica del Pueblo recognized the crucial relationship between food access and diabetes management and actively sought a partnership with an organization based in the community where patients lived. FRESHFARM was preferred over larger food providers or distributors because of the emphasis on alleviating food insecurity with access to fresh produce. Moreover, because LCDP and FRESHFARM are active participants in local and regional policy advocacy efforts for those underserved in the community, each organization recognized the inherent value of addressing food insecurity as a step towards improving outcomes for patients with diabetes. During the early months of the pandemic, the partnership adjusted to deliver produce to LCDP patients, and eventually pivoted to produce distribution at LCDP's clinic.

Partnership Assessment Tool for Health

After reviewing literature and available partnership assessment tools, LCDP selected the Partnership Assessment Tool for Health (PATH) to assess their cross-sector partnerships with CARACEN and FRESHFARM. Partnership Assessment Tool for Health was originally developed with support from the Robert Wood Johnson Foundation through Partnership for Healthy Outcomes, an initiative of the Nonprofit Finance Fund, Center for Health Care Strategies, Inc., and Alliance for Strong Families and Communities to capture insights on partnerships between community-based organizations and health care organizations.16 Partnership Assessment Tool for Health is one of several partnership assessment tools for assessing health partnerships, but it is unique in that guiding dialogue among partners and active partner engagement are the cornerstones of the tool during the assessment process. Moreover, it focuses on established partnerships between community-based organizations that provide health care or human services to low-income or underserved populations. Since PATH is designed to maximize impact and facilitate communication among partners regarding partnership workflow, strengths, challenges, and sustainability, PATH is well aligned with LCDP's evaluation goals.

The tool has two components, a partnership check-up which measures along four benchmarks with three to four subcategories and a partnership discussion guide. The four benchmarks are internal and external relationships (subcategories: shared goals, maximizing partner value, leveraging external relationships, internal buy-in), service delivery and workflow (subcategories: service alignment, workflow processes, service delivery capacity, engaging the target community), funding and finance (subcategories: covering full cost, securing revenue, financial goals & priorities), and data and outcomes (subcategories: data collection, data use, demonstrating outcomes). Assessment of benchmark progress is rated on a scale of "needs development" to "well-developed" (1–5) with notes to capture key ideas and examples for each benchmark. [End Page 224]

The partnership check-up is followed by guiding questions for each benchmark, which allow partners to identify areas for development and strategies for improving partnership efficacy. Through repeated use of PATH, partnerships can measure improvement in each of the four benchmarks.

Assessment

Following PATH guidelines, CARECEN, FRESHFARM, and LCDP independently completed the PATH assessments for their corresponding partnership(s) twice, once in 2020 and again in 2021. For all four assessments, multiple staff members were involved in completing a single assessment. Participation in each assessment included a range of staff from executive leadership to program implementation staff. Staff reported a score for each subcategory under each of the four benchmarks. The scores are summarized by averaging the subcategory scores and reporting them as the mean benchmark scores from each partner. Approximately two months after completion of the assessment, LCDP met with CARECEN and FRESHFARM to discuss results of the partnership assessment, guiding questions, and determine key areas for further partnership development.

The assessment process itself ensured each partnership could 1) develop and implement joint recommendations and 2) provide accountability for each partner involved. La Clínica del Pueblo and its partners were particularly interested in identifying benchmarks where scoring did not match among the organizations and understanding the cause of the discrepancy. When partners scored benchmarks differently, it may indicate misalignment in that facet of the partnership. Through discussion, LCDP and its partners identified strategies for rebalancing program workload and workflow to maximize involvement of both organizations.

Results from PATH assessments with CARECEN

From the first assessment, LCDP and CARECEN found that alignment in their scoring could improve in three of four benchmarks (Table 1). Through assessment feedback, they identified the need for a referral system, addressing understaffing, long-term funding, and developing robust data collection systems. Through guided discussion, partners collaborated on joint strategies to address these concerns. One strategy was creating a formal, bi-directional referral system that was crucial for increasing service provision to the community after both organizations could no longer accept walk-in referrals due to the pandemic. Recognizing the cost of partnership was not fully covered, partners also developed a joint financing strategy, which led to securing two additional grants to fund the partnership. Moreover, the partners developed a strategy for monitoring data outcomes to report to leadership.

From the second assessment, benchmark scoring improved in three of four domains. Both partners reported decreased benchmark scoring for funding and finance. Through assessment feedback, partners discussed how previously obtained grant funding could no longer support the number of services demanded by clients and the need to secure additional funding. Partners noted a scoring discrepancy of internal buy-in, and CARECEN recognized that newer staff lacked knowledge of the organizations' shared history. Through discussion, the partners developed joint strategies including coordinating regular meetings among partners to discuss long-term financial sustainability of partnership, CARECEN educating newer staff members on the history of [End Page 225]

Table 1. PATH EVALUATION RESULTS FOR LCDP/CARECEN PARTNERSHIP
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Table 1.

PATH EVALUATION RESULTS FOR LCDP/CARECEN PARTNERSHIP

[End Page 228] the partnership to increase internal support and commitment, and developing data collection systems that equip the partnership to describe the impact and reach of the partnership's programs.

Results from PATH Assessments with FRESHFARM

From the first assessment, LCDP and FRESHFARM found that scoring alignment could improve in three of four benchmarks (Table 2). Through guided discussion, they agreed short-term goals were clear and aligned, but both partners wanted more involvement from the other and acknowledged mutual capacity to support additional opportunities and pilot programs. Partners emphasized the need for a long-term financing plan to maximize sustainability. The assessment revealed mutual recognition of the importance of data collection to demonstrate the impact of partnership on clients and highlighted discrepancies in how each partner scored the data and outcomes benchmark. This discrepancy fostered discussion on a previously unrecognized imbalance in data collection (e.g., collection led by LCDP), limiting FRESHFARM's knowledge of program impact. In response, partners developed a strategy for LCDP to share data more frequently and pursue data collection to capture long-term program impact.

From the second assessment, benchmark scoring improved and became more aligned across all domains relative to the first assessment. FRESHFARM continued to score data and outcomes lower than LCDP. Through discussion, LCDP noted that some data are protected under HIPAA, which inhibits their ability to summarize in aggregate and report frequently. To address the imbalance, the partners identified types of data that they could collect together and with which they could capture program impact when reporting to funders.

Discussion

A tool such as PATH offers a structured assessment process that can yield unexpected opportunities to assess and guide cross-sector partnerships. Partnership Assessment Tool for Health offers a framework for organizations to communicate their individual goals as well as shared goals. Additionally, PATH offers the structure of assessing and rating benchmarks in specific domains, which organizations can track over time to review changes in their discrepancies and alignment. Through PATH's guided discussion, notable discrepancies in benchmark scoring among partners provide an opportunity to assess the factors underlying different perceptions of the partnership, engage in dialogue about their work together, and develop strategies for increasing partnership alignment. Low scores spurred partners to discuss ways to focus their partnership activities and develop strategies to help the partnership evolve. All partners found the use of PATH beneficial for understanding, guiding, and improving the impact of partnerships because of its focus on dialogue and strategy development.

Implementation of PATH was successful because each partner acknowledged the importance of joint decision making, each partner had established relationships with the target population, and external grant funding from Bridging the Gap: Reducing Disparities in Diabetes Care supported staff time to engage in the partnership assessment process.

Conclusion

The process of assessment itself can be a powerful tool to redirect, [End Page 229]

Table 2. PATH EVALUATION RESULTS FOR LCDP/FRESHFARM PARTNERSHIP
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Table 2.

PATH EVALUATION RESULTS FOR LCDP/FRESHFARM PARTNERSHIP

[End Page 231] strengthen, and maintain partnerships. La Clínica del Pueblo's PATH experience highlights an assessment process that opens dialogue among partners, assesses the structure and dynamics of collaboration, and identifies ways to strengthen the impact and sustainability of partnership.

Cynthia Turner, Angela Suarez, Jacob P. Tanumihardjo, Kathryn E. Gunter, Rodrigo Stein, and Suyanna Linhales Barker

CYNTHIA TURNER is affiliated with the Harris School of Public Policy at the University of Chicago and the Section of General Internal Medicine at the University of Chicago. ANGELA SUAREZ, RODRIGO STEIN, and SUYANNA LINHALES BARKER are affiliated with La Clínica Del Pueblo. JACOB P. TANUMIHARDJO and KATHRYN E. GUNTER are affiliated with the Section of General Internal Medicine at the University of Chicago.

Please address all correspondence to Cynthia Turner, The University of Chicago, Section of General Internal Medicine, 5841 S. Maryland Ave. MC2007, Chicago, IL 60637; email: cindyturner@uchicago.edu; phone: (832) 715-3901.

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