November 18, 2022
Chatham County Health Department, North Carolina

Introduction

Health equity work requires the cooperation of business, education, health care, community development, faith communities, community-based organizations, social services, and many other sectors — health departments cannot do this alone. Cross-sector partnerships that identify collaborative solutions to community health challenges and advance health equity are essential. The report Public Health Forward: Modernizing the U.S. Public Health System promotes partnerships between health departments, stakeholders, and other sectors. Specifically, the report recommends that health departments clearly delineate shared goals, respective responsibilities, and collaboration guidelines for decisionmaking, conflict resolution, and data sharing, and use this body of work as a foundation for sustainable collaborations.

Context

The Equity for Moms and Babies Realized Across Chatham County (EMBRACe) Coalition was established in 2019 with the aim of ensuring that all pregnant women in Chatham County, NC, have positive birth outcomes. Coalition partners include the Chatham County Public Health Department (CCPHD), Chatham Hospital (a critical rural access hospital that is part of the University of North Carolina Health system), Piedmont Health Services (PHS, a federally qualified health center), Chatham County Department of Social Services, and Chatham Organizing for Racial Equity (CORE) (a grassroots nonprofit organization dedicated to deconstructing systemic inequities and achieving equitable outcomes for all people in Chatham County). The catalysts for cross-sector collaboration in pursuit of birth equity included:

  • poor overall and significant disparities in birth outcomes in Chatham County,
  • Chatham Hospital’s plans to open a maternity care center (the county’s first labor and delivery unit in 30 years), and
  • CCPHD and PHS’s existing efforts to align services to provide a comprehensive continuum of prevention and care.

When discussing the potential establishment of an accountable care community in the context of these local conditions, these partners recognized the opportunity to leverage their efforts and interests around a single, critical population health issue.

Key Actions

Dedicate time to build the coalition.

Establishing a sustainable collaboration requires dedicated thought, relationship-building, planning, and organization that cannot be undertaken without sufficient staff time.

  • CCPHD served as the backbone organization for EMBRACe by convening the partners and facilitating efforts to define a shared vision for the group.
  • On behalf of EMBRACe, the CCPHD secured a grant that supported the coalition during its first two years—for both planning and initial implementation of coalition efforts.
  • Recognizing the need for a structure to lead and evaluate the development and implementation of coalition strategies, each partner organization contributed in-kind staff time to establish a Coordination Committee responsible for facilitating and administering the project.

Develop operational procedures at the outset to facilitate the coalition’s work.

  • Building on best practices in advancing institutional equity, collaborative governance, and shared leadership, the Coordinating Committee prioritized the establishment of processes and practices that reflected the shared values and principles of the group. The group worked together to define the procedures that would be followed to foster inclusion, transparent and clear decision-making, brave conversations, collaborative leadership, and relational power.
  • These procedures also were applied in the coalition’s facilitation of the EMBRACe Steering Committee, a group of executives from each partner organization brought together to build systems alignment around shared goals. The procedures were also incorporated into the Steering Committee charter, which was signed by leadership from each partner agency.

Too often in collaborative meeting spaces, the decision-making process is unclear; there is lot of discussion, but no clarity on what was decided and how the group will move forward. Or, there are a standard set of rules for decision-making that follow a majority vote based on little intentional discussion. Both approaches perpetuate unequal power structures that are neither inclusive nor conducive to meaningful collaboration.

  • By adopting a consensus-based decision-making process centered on facilitated discussion, EMBRACe found that coalition members were better able to identify and work through areas of disagreement to make decisions that the group was committed to upholding.

Rotating responsibility for agenda development, meeting facilitation, and note-taking helps to share power and lessen the workload for group members.

This builds system alignment and accountability and ensures organizations’ participation and commitment to the coalition’s work.

  • The EMBRACe Steering Committee, comprising executive leadership from EMBRACe’s partner organizations, was originally convened to guide the launch of the Chatham Hospital Maternity Care Center (MCC).
  • The importance of having leadership engaged was demonstrated recently when rumors began to circulate that Chatham Hospital was considering closing the MCC less than two years after it opened. The EMBRACe Steering Committee, with representation from all the key stakeholders in the local perinatal system of care, was leveraged as a forum for directly discussing the rumors with the CEO of the hospital. In an emergency meeting, members of the Steering Committee engaged in a transparent and open dialogue about the potential closure within the context of the shared goals of the group and the needs of the community. The Steering Committee reminded the hospital that the MCC was part of bigger whole and that partners at the table were vested in its success.

A public health coalition is not sustainable without the support of the community, so it is important to identify meaningful ways to engage the community.

  • EMBRACe partnered with CORE to help the coalition build a learning community centered on equity and accountability to the community.
  • With CORE, EMBRACe reimagined community engagement within a community organizing framework. Instead of inviting women with lived experience to be advisors for the MCC, EMBRACe stepped out into the community and opened spaces for catalyzing collective action in pursuit of birth equity. In pursuit of this aim, EMBRACe began community-based story circles for moms and birthing people as well as health care and service providers.
  • EMBRACe’s partnership with CORE and adoption of the community organizing framework was integral in mobilizing the community in support of the MCC. Through its community relationships, EMBRACe was able to mobilize nearly 80 people to attend the Chatham Hospital’s Board of Trustees meeting to advocate to keep the MCC open and raised enough awareness about the issue to spark the creation of a UNC-backed community taskforce to identify opportunities to sustain the MCC in Chatham.

Recommendations

Policy

Conduct organizational equity assessments.

Organizational equity assessments provide insights into practices that promote or stifle equity in the workplace. These assessments can provide a shared understanding of equity that facilitates the coalition’s efforts to address the root causes of health inequities.

  • EMBRACe members conducted organizational equity assessments and worked individually to improve diversity, equity, and inclusion in their respective organizations. This work has created a common vocabulary among coalition members and has better equipped them to address equity as a group.
  • Leadership from each of EMBRACe’s member organizations expressed a desire to learn more about diversity, equity, and inclusion after seeing the results of the organizational equity assessments.

Financial

Seek shared funding.

Seek shared funding that draws people to the table. Given the infrastructure needed to manage grants, the public health department may be best fit to receive funding. However, it is important to distribute funding to coalition members in a way that ensures the coalition meets its collaborative goals.

Successful coalitions require a great deal of work that typically is not listed as a grant deliverable, such as:

  • nurturing and tending to relationships,
  • providing the time and effort to engage community members in discussions and center the community’s voice in coalition efforts,
  • revising plans and making course corrections that result from using an equity lens to plan and execute programs, and
  • ensuring that coalition members are accountable for their commitments.

Without dedicated staff time for these efforts, coalitions may be much less productive, or they may even dissolve altogether. Therefore, when writing up grants, it is important to request funding that not only supports grant deliverables but also supports these aspects of maintaining a robust and effective coalition.

  • After the initial two-year grant, EMBRACe received another grant that listed system alignment as one of its three overarching goals. Funding for system alignment supports training for, and implementation of, structured facilitation; development of a communication network across prenatal providers; and training on equity for EMBRACe. Collectively, these actions support a system for continuous community engagement and decision-making.

Anticipated Impacts For Public Health Departments

Additional Grants

As a result of its work, EMBRACe has received several additional grants to further support its efforts to decrease birth inequities.

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Several more non-profit organizations have asked to join EMBRACe, demonstrating that this collaboration structure is gaining visibility within the community. It is anticipated that additional partners will increase the coalition’s impact on birth inequities.

The story circles for providers with lived experience offers space for them to voice their frustrations due to difficulties of providing care in a community with limited resources and from within a system with systemic difficulties. These perspectives add avenues for growth in advancing health equity in the county and offer additional avenues.

The Chatham Hospital Maternity Care Center is still open and a UNC-led community taskforce and Keep the MCC Open Coalition are actively engaged in finding solutions to sustain and stabilize the unit for at least three more years.

Potential Challenges To Implementation

Bureaucratic processes can hamper progress.

When a coalition is overseen by a team of executives, work can be delayed because it may be difficult to find mutually agreeable times for all to participate, the coalition may not be viewed as a priority, and executives may not have enough bandwidth for this work. To avoid these potential barriers, EMBRACe developed a multi-level oversight structure to ensure that the coalition could progress in its efforts without needing leadership approval for every decision. The steering committee provides broad oversight and support for staff participation. A coordinating team, comprising senior staff of member organizations, is responsible for leading coalition meetings and activities. Within this structure, it was possible for EMBRACe to call the emergency meeting described above without the express permission of the hospital.

It is important to engage clinical providers when working on clinical practices. This is most easily accomplished by meeting with providers after work hours, and it is helpful for participating health care organizations to allow administrative time for providers that includes coalition work.

Sustainability

Intentionally cultivate trust among participating organizations.

A cohesive partnership may take years of concerted effort to build. As coalition membership changes due to staff attrition and the addition of new organizations, foster trust between new and existing members of the group by conducting intentional relational meetings with new and existing members, establishing “rules of engagement” that prioritize transparency, inclusion, and relational power within the collaborative structure. This also includes calling partners “in not out” when issues emerge, i.e., bringing partners into a constructive conversation instead of openly criticizing them.

  • For example, the EMBRACe partners chose to call in Chatham Hospital leadership when they learned about the potential closure of the MCC. Despite feeling blindsided and frustrated, leaders in the group chose to leverage the partnership to show support and a shared commitment to the MCC’s success.

Governments, hospital systems, academic institutions, and other potential partners can have a lot of red tape to navigate. Rather than making a pre-determination that a specific action will not occur as a result, commit to finding a way around the bureaucratic barrier.

  • The EMBRACe Coordinating Committee realized that they were most effective by building a bridge between the system and the community, and by staying grounded in two fundamental priorities: equity and accountability to the community. By investing in this values-driven, bridge-building work, EMBRACe has been able to operate outside of many bureaucratic barriers faced by other coalitions.

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