Community Leadership and Connections Ground Success

Not surprisingly, as ECS made a place for itself in the community, we faced challenges and skepticism, but we had strong support too. We made some good decisions. We focused. We relied heavily on our colleagues in the private sector, especially in the early years when our path forward was less clear. We listened to the admonition “fail early, fail fast.” We chose partners and funders who shared our belief in holding true to our mission and making decisions with evidence. We assembled a diverse board that was more than ceremonial and who, with their connections in the community, could help to generate public acceptance—not to mention resources when we needed them.

It was a boost when The Wall Street Journal featured ECS as a front-page story in June 2006. Our attention to research, our engagement with community, and our families’ results made this a compelling story at a time when home visiting was moving up on the national policy agenda. In addition, The Wall Street Journal and others were interested in how we had incorporated a business approach to implementation of a social service. In June 2006, I explained that our board brought us the kinds of minds we could not afford to buy, bringing immeasurable assistance that extended well beyond dollars alone.

At several junctures, our corporate volunteers were surprised at the paucity of data that was available to us to make decisions. They understood, as did we, that we would never have the complete information that we needed for the business plan but that we had to go forward with what we knew at the time. We had confidence in the need for the service and the geography we would serve. We had an administrative structure outlined and founding partners identified, we had funding commitments, and we had found two national home visiting models to follow for the initial program delivery. We still had to identify which outcomes we would specifically focus on, how we would contact moms and enroll them in the program, and how and where we would collect data.

I remember a seminal meeting that we held with a dozen corporate community leaders to discuss the possible road forward for ECS. After two hours of presentations by our program and evaluation/research staff, one corporate senior executive said emphatically that if he waited until he had all the answers that he needed to make a decision, he would be out of business. The message: don’t be afraid to try and don’t be afraid to fail. But if you fail, understand why something happened so that you can use what you learned to get better. Unless you can discern the why, you cannot replicate and/or improve. We have used our quality improvement strategies to answer those “why” questions.

Fundamental to all our planning was awareness and sensitivity to our community. If we did not present a program that responded to needs and worked with local leadership, we would never be able to deliver what we promised to the community and to the families. Our primary goal was to improve the lot of children and to ensure that all children were able to have the best possible start. So while we assembled the right structure, with many of the right players, it was the families who mattered most. That belief guided our decision-making, including the focus on quality and verified outcomes. We asked for trust, and we delivered trust in return. We infused our family relationships with respect, equity, and hope. With a little guidance from us and incredible work from our families, we all succeeded. We know now that what happens in childhood affects an entire life for one generation and beyond. The families deserve the credit because they not only did the hardest work, but they also knew what they wanted for their children, and they were willing to take a chance with us.

I strongly believe that there were two basic factors that were essential to our success: the inclusion of private-sector thinking into our deliberations and incorporating the voice of the community into our decision making. There were lessons for all of us as we struggled to assemble the right program with the right leadership and right commitment. Together, we created responsible and accountable systems to address opportunities and problems. Our community helped us identify the best paths to follow, let us know what was working, and told us candidly how what we were presenting was being received. Understanding of community and family perspective is essential, beyond data and research about model effectiveness. On both sides, we kept in mind what Dr. Bankston of the University of Cincinnati told us years before, “Trust must be the common denominator.” For over two decades, we have worked to establish and maintain that trust by delivering on our promises and ensuring that every child had a realistic chance to succeed.[pull quote]

Striving for a System: Not Just a Program

Working collaboratively, in a coordinated manner, community nonprofits can improve efficiency and effectiveness, reduce gaps among service systems, and get results. Going back to the Starting Points Initiative, many experts have called repeatedly for better integration of early childhood systems. In recent years, federal, state, and local governments, along with philanthropic partners, have invested in early childhood systems development. An early childhood system brings together health, early care and education, child welfare, home visiting and other human services, and family support programs—along with community leaders, families, and other formal and informal partners—to work collaboratively to achieve agreed-upon goals for thriving children and families.

Since 2003, the federal Maternal and Child Health Bureau, Health Resources and Services Administration of the US Department of Health and Human Services (MCHB-HRSA-HHS), has funded three distinct cycles of an Early Childhood Comprehensive Systems (ECCS) program initiative (the website for the Health Resources & Services Administration, Maternal & Child Health, “Early Childhood Systems Programming”). The first functioned through small grants to states (Johnson and Theberge 2007; Johnson and Knitzer 2006; Halfon et al. 2004) and the second through a collaborative innovation and improvement network (National Institute for Children’s Health Quality n.d.). The latest iteration (for 2021–2026) seeks to build integrated maternal and early childhood systems of care that are equitable, sustainable, comprehensive, and inclusive of the health system. This new grant cycle seeks to promote early developmental health and family well-being and increase family-centered access to care and engagement of the prenatal to age three population. The grants released in 2021 reflected a decade of incremental learning. At the same time, an entire generation of children has grown up without comprehensive, coordinated, and equitable service systems.

Some communities offer examples of success in organizing their services into systems. These include efforts like the Bridgeport (Connecticut) Baby Bundle Initiative (Gruendel, 2020), All:Ready in Greater Portland (Health Share of Oregon, All:Ready), and California’s First5 Alameda County, First5 Orange County, and First5 LA (First5 California). All have created notable successes in broad early childhood systems development. Sustained resources, effective leadership, collaboration, and community engagement are helping these efforts succeed. At the same time, in Cincinnati and communities across the country, early childhood systems efforts have had variable and mostly limited traction.

In 2015, Neal Halfon, MD, director of the UCLA Center for Healthier Children, Families, and Communities, issued a paper, “The Networks We Need for Early Childhood” (Halfon 2015). Based on ideas that emerged in the early 2000s concerning federal and state funding for early childhood systems development and reflecting on lessons learned in the prior decade, Halfon told us:

Where and How ECS Had Success in Collaboration

Our experience with ECS in greater Cincinnati includes the stories, the decisions, the barriers, and the successes. Collaboration and competition played a role in what happened and are both inescapable in the community context. They will coexist within the overall field of the nonprofit, with shared communication and understanding of the problem one is trying to address. Obviously, there are various solutions to try, strategies to deploy, and programs to carry out. Coming up with the best combinations of those may lead more quickly to an effective response.

Collaboration—especially over time—is difficult. A board member explained it this way when we were working to effect cooperation among local home visiting services. “It is tough and delicate work, trying to decide how to best collaborate and it gets more difficult as more people are at the table in the early stages. Our intent is to be neither secretive nor to exclude anybody but merely to be successful in getting relationships built in this area. We need to walk in these efforts before we try to run.”

Without a structure in place that offers incentives to initiate and then sustain a complex collaborative effort, attention and resources fade away. This means coming together to solve a common problem, each person or each organization typically giving up something to achieve a solution. Too often, modifications are made for short periods, but unless there is a compelling—and rewarded—reason to work together, interest wanes. The basic question is: Under what circumstances can cooperative thinking be animated and sustained?

Within ECS, we had the incentives—our provider agencies had a financial interest in joining with us, we had political strength, we had identified solutions for addressing a well-documented problem, and we enjoyed both private-sector and nonprofit-sector leadership. And probably, of utmost importance, we valued our partners and our stakeholders, causing us to work each day to bring value to them. Together we had agreed on the problem that we wanted to solve: How to ensure that every child has an optimal start in life beginning with the prenatal period and continuing until age three.

For over two decades, we sustained a healthy collaborative within ECS itself, delivering a highly effective service. Admittedly, we worked better together because we had a contractual relationship between our ECS administrative group and our provider agencies. We needed each other, and together we endorsed our “reason to believe.” We each had something to gain and from the ECS perspective, without our community providers, as a home visiting program we could never do our best work.

We had long recognized that ECS is just one program with limited scope and influence. Building a system among a larger constellation of programs locally, statewide, or nationally must come from organizations with a bigger agenda and broader platform. ECS can be the example, the team member, but not the leader. ECS is part of a solution, but it can only be that—a part. What families and children need is a system that operates collaboratively, incentivizing cooperation, co-developed with families, using an evidence-based continuum of services beginning in the prenatal period and continuing until the child enters school.

An example of where there is a gap in the system is that ECS services end when the child is three, meaning that there can be as many as three years between leaving ECS and entering school. This is time that should not be lost but rather time that provides an opportunity for a bridge to the next point along the continuum, the next new opportunity. We termed this initiative, Ready for Pre-K. Partners needed to be enlisted, including community organizations and parents who could tell us what would really work and not simply what we might write down in a plan. Issues included transportation and cost and perhaps even creation of centers where the gap could be closed.

Barriers to an Effective Early Childhood System in Cincinnati

What happened in greater Cincinnati relative to ECS and other programs that either directly provide services to young children and their families or have the potential to be part of a continuum of early childhood services tells a revealing story. After the conscientious and comprehensive work from 1996 to 1999, led by the United Way, Cincinnati Children’s, and CAA to write a case statement and create an implementation plan for what was to be the first of multiple programs focused on creating an early childhood continuum, within a few years, multiple new early childhood programs emerged. They included programs addressing early care and education, infant mortality reduction, and literacy. But the link among these initiatives was tenuous, and because there was not an accepted forum for shared decision-making in place, programming became fragmented and competitive. Had there been an accountable body to amplify the value, build on programs that were working, and provide the incentives for cooperative work, the path forward would have been clearer and resources could have been used more effectively.

The problems are not limited to our community. National experts caution that existing policy and funding frameworks encourage balkanization of programs. Funding is typically not available for the systemic efforts needed to support program integration and/or collaboration. Data from various programs are siloed or not shared at all. To add further complication, the largest amount of public money is expended on older children rather than the youngest age groups, where the impact is stronger and the return on investment higher. To underscore the issue: the Carnegie Starting Points Initiative declared: “The period from prenatal to age three is demonstrably the most formative. Ironically, it is also the most neglected because there are no clearly defined institutions, such as preschools, to serve it (Carnegie Corporation of New York 1994, 5).” Heckman provided the economic argument for funding effective early interventions (Heckman 2012). Carnegie referenced the absence of advocacy/policy support that leads to change and noted that we are still arguing about policy and funding decisions, establishing new programs, and nearly ignoring what we have learned.

As of this writing, in our community, a unifying forum had not emerged, despite the efforts of many. The original United Way “umbrella concept” of ECS as a coordinator and not just a provider of home visiting services did not take shape.

There are, of course, legitimate reasons. Agencies are consumed with just getting their daily work done with little time left over for new work; funding policies tend to create silos as monies are available only for specific services and not for coordinated administration and innovation; there is not a common forum for considering how to create a community strategy to address community issues and to evaluate the effectiveness of various programs, supporting those that produce results and collaborate constructively. Our community has many programs of value, led by people eager to do good work and serve their constituencies, and they have made a difference, but often they have singular missions. The problems they address are real and their work extraordinary but not in alignment with true collaboration. What is absent is recognition of the strength that comes when programs work jointly to solve common problems, serving more families and expending resources more productively.

Building on her decades of thinking and writing about social policy, particularly her landmark book, Within Our Reach (1988), Lisbeth Schorr recently wrote:

Over the years, the situation became even more competitive rather than less so, more confusing and often less trusted by families, less effective, and less efficient. Too often administrative tasks that could be combined were not, services such as care coordination were duplicated, marketing money was spent to promote one program over another instead of educating the community about what children needed and how those services could be delivered. Families reported to us that instead of having one person coming to serve them, there might be several essentially doing the same job or similar jobs. In 2019, we identified 15 local programs or organizations focused on the ages birth to three (excluding those like housing, transportation, nutrition, and safety, which were germane to the well-being of the family but not considered strictly programs in the birth-to-three sphere). For our use, we created a matrix to highlight the mission of these programs, the challenges and the opportunities, and we distinctly saw the overlap. But ECS did not have the influence or the political power even to encourage effective collaboration. Efforts along those lines were seen as intrusive or threatening.

Thus, new programs were planned without building upon community experience and taking advantage of research. Existing work was either invisible or ignored, while money was spent to launch yet another new initiative. A prime example was the deployment of multiple and expensive demographic and ethnographic studies, repeated over and over again, going back to the same people to ask the same questions. Most often the exercise just reaffirmed what was known, but the new work was commissioned because a governmental or philanthropic funding source asked for a new assessment of needs and risks. Rarely did such requests include questions about existing community strengths or existing successful programs. Had there been a forum for collaborative thinking, there would have been an opportunity to use what had been learned and/or to build upon previous work. Expenses could have been minimized, and more importantly, collaboration and systems development would likely have led to more sustainable programs and better results for families.

Periodically, in most communities, a person or an organization gives voice to the need to work together, schedules a few meetings, creates community enthusiasm, perhaps spends community dollars, and makes pronouncements for improvement. But nothing really happens except that a lot of money is spent and, tragically, the community is disappointed. What are the barriers? Politics at all levels, absence of funding to do the collaborative work, organizations feeling threatened, unequal ability to evaluate success and collect clean data, leadership with insufficient influence to cause organizations to come together. All of these contribute. Until there is community consensus around recognition of the value of forming and supporting a coordinating group, one with families in shared power roles, and long-term committed funding to allow the work to happen, the situation will no doubt fail to improve.

With relatively dysfunctional guardrails in place and no influential organization stepping forward to lead change, the loosely configured system will continue. But if the community and/or the community leaders seek something better, how can improvement occur?

On a small scale, ECS offered a good example of collaboration success in the early childhood space in greater Cincinnati—an exemplary organization, doing many things right, collaborating within our structure and with our partners, agencies, and a few other organizations outside of our immediate range. And, although there continues to be room for improvement, we worked within an environment where collaboration was valued, and we learned what was required for success.

Emerging Directions at the National Level

On the national level, more is happening. The Early Childhood Working Group that started back in the 1990s continues to convene dozens of national leaders and organizations to advance the vision for early childhood systems. Their efforts are intended to keep focus on the need for early childhood systems and to encourage funders to think systems, not just programs and projects. Start Early (formerly The Ounce of Prevention) continues to grow and support early childhood services and systems nationwide, including early care and education, home visiting and others. With federal funding, the Association for Maternal and Child Health Programs (AMCHP) retained David Willis, MD, and Kay Johnson to study the relationship between home visiting and early childhood systems programming (Willis and Johnson 2020). They created a “Roadmap for Improved Collaboration” to encourage national, state, and local cooperative work (Corona et al 2020).

Also, with federal funding, the National Institute for Children’s Health Quality (NICHQ) convened a network of state and community initiatives that are designed to use early childhood systems development to yield a 25% increase in age-appropriate developmental skills among three-year-olds in their communities (NICHQ, n.d.). This NICHQ effort concluded with a call for stronger, more comprehensive early childhood systems that include:

1. Funding to coordinate state and community-level supports.
2. Leveraging two-generational approaches.
3. Using intentional design to address system gaps.
4. Putting families first.
5. Maintaining adequate data.
6. Focusing on equity.

Like early childhood systems, every small, locally based program is part of the solution that can be viewed at a national level. NICHQ reports, not surprisingly, that states and local communities with coordinated systems were better able to respond to the coronavirus pandemic crisis. They are using this outcome as evidence for the need for building broader systems of care.

In an “Insights” paper, “Strengthening Early Childhood Systems: Lessons from the Pandemic and a Call to Action,” NICHQ early childhood comprehensive systems project director Loraine Swanson, MPH, says,

It is important to mention, as well, that since the early 1930s, the prestigious member organization of pediatricians, the American Academy of Pediatrics (AAP), has served an important unifying and collaborative role for advancing the health and well-being of children and youth. AAP updates and disseminates valuable guidelines for early childhood immunizations, well-baby visits, safety protocols, parental interaction, early care and education, and school readiness. The August 2021 release of a new AAP policy statement “Preventing Childhood Toxic Stress: Partnering with Families and Communities to Promote Relational Health (American Academy of Pediatrics et al. 2021),” specifically emphasizes the importance of linking the community, including home visiting and other supports for families with the medical home, in efforts to build out a public health approach to advance relational health. In addition, the articulation of the high performing medical home, by Kay Johnson and others, includes intentional efforts to create team-based care models that are intentionally linked to home visiting and the community (Johnson and Bruner, 2018).

Moreover, although most of what home visiting does is outside of the clinical setting, when we take a focus on population health and community engagement for future child health care, the relationships among the physicians, home visitors, the community, and families offer the best opportunity to generate a tiered team-based community approach. Many expert papers and recommendations have noted the overlap in goals and the complementary nature of activities between home visiting programs and pediatric primary care. ECS work at Cincinnati Children’s with pediatric primary care providers speaks to the importance of the interaction. Bringing the community into the mix is essential, yet carefully developing an innovative process, given the historical struggles with failed collaborations, will be required to be successful. The four leadership sectors including families, home visitors, child health, and community must chart a new course with shared vision, collaboration, and humility. The weight of the findings of AAP provide needed leverage to make change occur in coordinated ways. Some communities will respond favorably to this while others will continue with the siloed overlapping approach. Nonprofit leaders who can navigate these waters and stay on top of the research, news, and funding availability for broader systems can feed this information back to state and local leaders and inspire community change.

Such efforts must lead the co-design with families and other community stakeholders–the people with lived experiences in disinvested communities for whom the services are designed. Decades of experience, particularly since the 1960s Great Society and War on Poverty programs, demonstrate that the most enduring and successful efforts engage community stakeholders and clients as partners in the design and management of the programs. Two notable examples are federally funded community health centers and Head Start sites. In 1965, the founders of Head Start understood that parents are essential partners and that parents should help decide how Head Start services can most benefit their family and other families in the community. As a result, Head Start programs instituted a policy council that serves as a formal mechanism for engaging parent leadership. Federal regulations call for parents of children currently enrolled in the Head Start site to be proportionately represented on the policy council. The same is true for the community health center movement and federally qualified health centers, which have requirements for community policy councils made up of 50% community members. Leaning on the learnings of community leadership for system building for the prenatal to age three population seems to be a new opportunity, too.

As we talk about cooperation and collaboration, there is a case to be made for independence, but there is a stronger case for working together. Competition should not live where working together is the better option.

Some years ago, I had occasion to meet with Paula Bennett, who at the time was a New Zealand member of Parliament and minister of Social Development, Employment, Disabilities and Youth Affairs. She later served as a deputy prime minister and held portfolios in services for women and state services, among other roles. Having had experience as a young single parent with M ̄aori heritage, Bennett had a strong interest in early childhood issues and family support. Her role in government, social investment, and social services reforms included efforts to build early childhood systems and supports—including home visiting programs—that worked for families. Under the leadership of this extraordinary woman, the New Zealand early childhood effort achieved success through collaboration. They enrolled all children. They had data for who needed what, and they endorsed better ways of operating that could be shared. Bennett was a big personality, enthusiastic and articulate about these issues in particular. She was proud of New Zealand’s moms, and she had the courage and charisma to encourage policy makers and moms to follow her lead. Her obvious joy was contagious, and the benefits for families remarkable. There is a lot we can learn from this example of vision and leadership!

Public and Private Leadership Driving Local Change

I have often thought that a wise initial step would be to engage a well-regarded national organization—independent, neutral, out of town—to guide needed change. Under the influence of a group with an excellent understanding of the subject matter and with endorsement by community leaders, the process could move forward without the baggage and parochialism naturally resident with local groups. Such an activity would require the blessing of our community fathers and mothers who possess the influence necessary to make big decisions and assure compliance and sustainability. The potential benefits of a stronger system of service systems are inescapable in terms of increasing numbers of families served, strategies that produce measurable, validated results, and allocation of scarce resources. At the same time, it seems likely that no national organization or consultant would have all the best or right answers for our community.

As with most endeavors, good leadership makes the difference between success and failure. Delivering social services is no exception. Leadership, in the finest sense of the word, brings with it a vision, a commitment to accountability, and the bravery to make hard choices. Outstanding leadership does not come with a title, rather it comes with an ability to execute a plan that not only asks the question, “What is the problem you are trying to solve?” but follows with the essential questions: “How are you planning to solve it? How will you know when you are making progress?”

Most nonprofits operate with an independent board structure. Effective leadership requires integrating the strength of a committed and knowledgeable board with strong nonprofit administration and accountabilities.

Focus and sustainability are required as efforts to concentrate on one problem dissipate over time as other issues or causes rise to the top of the public agenda. Focus on early childhood requires a special kind of patience because the promised outcomes may not be seen quickly. We must wait months, sometimes years for the child to grow and demonstrate what we promised. I remember meeting with elected, sometimes appointed, public figures to explain the importance of support for children birth-to-three years of age and being told that what we promised was outside of their tenure in public office. They wanted results that would help them get elected, not in three years or five but in one or two. This could be considered a reasonable consideration for them but not compatible with creating and sustaining a system of services for our youngest children.[pull quote]

ECS board member David R. Walker put it this way: “Organizations don’t change until they hurt, and the amount that they change is proportional to the amount that they hurt.”

So, for those of us who work in social service and especially those of us who work with young children, we just keep trying. We produce results that are compelling. We tell our stories over and over. We build upon small changes, as in the 20% example of families ECS can serve. We can lament that we aren’t seeing 40% or 50%, or we can be proud of the work that we have done for families and for the community. ECS stands as a worthy and replicable example of what is possible. It’s not the complete answer to the community challenge but a step forward, maybe more than a baby step.

In 2021, as we entered another decade, changes were visible in greater Cincinnati. The City Council formed and planned to fund and staff an Office of Children and Families to serve as an “administrative hub for tackling the most prominent issues that impact our children and the families that support them.” They cite their three primary functions: use data more accurately to address issues, pinpoint interventions, and execute problem solving measures.”

The County Commissioner’s Association of Ohio was bringing individuals from a variety of disciplines together to consider early childhood issues as a group. At the start of his administration, Ohio Governor Mike DeWine created a Cabinet level position for children’s initiatives to improve coordination among the many state programs. The Ohio Legislative Children’s Caucus was focused on the issues of early childhood.

Groundwork Ohio and the Bethesda Inc. bi3 initiative in greater Cincinnati began working cooperatively on advocacy and public awareness for early childhood. The United Way and local leadership contracted with a skilled, neutral third-party consultant to provide guidance for better community coordination.

The Ohio Department of Health is now requiring central data collection and central referrals for their Help Me Grow home visiting program. Both are effective strategies for centralizing decision making and program operation.

The commitment to collaboration was further highlighted for me early in the development of ECS when board member Carter and I traveled to Cleveland, Ohio, to meet with the early childhood advocates in their community. Together, the Cleveland/Cuyahoga County group sat around a large conference table: public-sector directors, foundation chairs, senior program officers, volunteer leaders, philanthropists, elected officials and families—all searching for the solution to their children’s dilemma. They outlined the problems and examined possible solutions. I wish that I could say now that they have a perfectly integrated set of services for children. What I can say is that they made progress and are better aligned than many other communities and they were talking with each other. Through their Invest in Children initiative that includes everything from a variety of home visiting services to mental health and early literacy programs, they successfully raised awareness about the importance of addressing the needs of children early and helping families not only access services but also understand the importance of quality services in the early years.

Over the last few years, groups such as Ready Nation, a national-business membership organization whose 1,500 executives support improving the workforce through effective public investments in children and youth, the Ohio Business Roundtable, Ohio governor Michael DeWine and Department of Health have taken notice and identified a focus on early childhood as basic to their public platforms and funding decisions (website of Mike DeWine, September 30, 2022). For example, on the administrative side, the Ohio Department of Health is encouraging better coordination among the programs within the state home visiting program, Help Me Grow. A giant step forward because, by requiring and monitoring the provision of data from programs throughout Ohio, the state will know what is happening with all children in Ohio home visiting programs not just those in one program or another and they will be able to better coordinate their initiatives, target their strategies, and base program expectations on real time data.

Moreover, in 2017, former State Senator Shannon Jones revitalized an existing organization called Groundwork Ohio to bring together like-minded organizations interested in improving the lot of children in the state—to “lay a strong foundation.” Jones was recently term limited after serving 10 years in the Ohio General Assembly (two years as a representative and eight as a senator), where she focused her legislative work on the needs of young children and their parents. When she moved to the private sector, she identified Groundwork as the vehicle to become “a research and advocacy organization that champions high-quality learning and healthy development strategies from the pre-natal period to age five.” Jones’ leadership made Groundwork Ohio the outstanding Ohio “go-to” group to advocate for children. Through their newly launched Center for Family Voices and their continued coordination of children’s advocacy, lobbying and public education, and with a grant from the Pritzker Children’s Initiative and one from Cincinnati based Bethesda Inc. bi3, they have support for their statewide work to advance early childhood programming.

In Columbus, Ohio, Celebrate One, through its infant-mortality-reduction initiative, created a simple-to-use phone network that quickly links pregnant women needing prenatal care with clinics and private physicians. Supported by more than a dozen organizations, ranging from the Ohio Department of Health to the Franklin County Board of County Commissioners and the Columbus Urban League, Celebrate One began implementing the recommendations of the Greater Columbus Infant Mortality Task Force. This is an excellent example of an effective collaborative endeavor.

Collaboration Opportunities within ECS

What follows are examples of collaboration opportunities that ECS either identified or that had been presented to us by other groups. Some worked; some didn’t. Leadership was key. Sometimes we were in alignment with a prospective partner and collaboration served interests on both sides of the table. But not surprisingly, at other times there was a moose on the table that could not be dislodged. Collaboration is not always the answer, but it should always be among the options.

Collaborations that worked well included those with Cincinnati Children’s, CAA, and United Way; the Ohio Department of Health; and the Kentucky Health Cabinet. Others with promise didn’t materialize.

ECS has been able to demonstrate that collaboration is possible. It currently operates with seven provider agencies, three founding partners, and numerous other funders and stakeholders. ECS has maintained an effective collaborative for more than 20 years with centralized management and contracted agencies. We had core elements for the organization from the beginning: a clear mission, a common data system, an agreement to deliver the program with fidelity, an incentive structure that offered more to the provider agencies than they could have produced on their own, and access to increased resources.

Basically, what we offered was a way to deliver our services to families more efficiently and effectively based on a reason to believe in our mission and a reason to believe in what ECS could provide to the agencies and families who joined with us.

Collaborating across community organizations was more complex, because control and leadership were often diffuse, and the problems to be solved could differ from one group to another. We struggled from the day we opened our doors to gain traction for the needs of children birth to three. We found ourselves competing with school systems, childcare centers, and individuals who believed that early care is best left to parents. Some of these organizations or individuals did not view what happens in the first 1,000 days of life as their priority. Yet, as those of us who work on early childhood have aimed to demonstrate why the first three years of life for a child are foundational for everything that follows, movement is accelerating to support the birth-to-three work and to create the links that are required for sustainable community solutions.

Through its newly launched Center for Family Voices and continued coordination of children’s advocacy, lobbying, and public education, Groundwork Ohio received a large grant from the Pritzker Children’s Initiative and another grant from Cincinnati-based Bethesda Inc. bi3 to support statewide work advancing early childhood programming. Groundwork Ohio and Bethesda Inc. bi3 collaborated on an innovative maternal and child health-transformation center to improve systems to better serve Ohio’s pregnant moms and young children. That is the good news, but historically there are three examples where we failed to forge collaborative relationships—Medicaid managed care, a regionalization proposal for the Ohio Department of Health, and P&G Pampers.

Managed Care Organization Partnership

The first of these instances was with a large managed care organization (MCO) contracting with Medicaid in Ohio. We approached the MCO to explore ways to use Medicaid financing to sustain and enhance home visiting services. While Medicaid funding cannot be blended with federal funding through the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program, Medicaid could, we believed, be one of the several sources of funding for home visiting. Our proposal was to create and deploy a pilot project to demonstrate how home visiting programs could cooperate most effectively to serve at-risk families and help them achieve important positive birth, child development, and parenting outcomes.

Interest was high among MCO leadership. Multiple meetings were held to demonstrate value, with information exchanged about services, data, size and length of the pilot, its policies and definition of operational concepts. But when it was finally time to determine what the pay structure would be, the MCO offered $64 for a home visit that cost $178. The proposed payment could not substitute for our private-sector dollars and supplement what the Ohio Help Me Grow was paying us for the visit. Moreover, the state of Ohio had not given permission for this dual funding approach. We pursued the relationship with the MCO probably longer than we should have, because we knew that the pilot project offered the opportunity to test how the Ohio Help Me Grow program could be delivered within a Medicaid managed-care environment, providing controlled, data-driven, and thoughtful strategies to measure outcomes and identify best practices.

Ultimately, after two years’ work to determine how to collaborate with an MCO to test a new funding and service-delivery structure, the project had to be abandoned. Our efforts at private-sector collaboration had failed, not due to lack of goodwill and diligence on the part of the two parties but due to siloed funding and lack of flexibility in state policy and finance structures.

Regionalizing Ohio Help Me Grow

The second effort also involved the State of Ohio and its Department of Health. This time it was a proposal to restructure the state home visiting Help Me Grow (which includes the federal MIECHV) program for improved organization and service delivery. In February 2011, we wrote to the Ohio Department of Health suggesting a new regional administrative structure for Help Me Grow that would mirror what ECS had been using for more than a decade. We cited our proven track record for delivering program outcomes, supporting our work with an enviable public/private funding mix, using a business model in a social service world, reducing program operating costs, and enlisting community cooperation.

We recommended using ECS as a prototype for restructuring Help Me Grow. Basically, the idea was that rather than having administrative structures in 88 counties with the attendant redundant expense, the counties could be consolidated into six regions defined by the existing and effective six perinatal regions. We offered eight reasons for supporting the new structure:

1. Reduced administrative cost and duplication of effort
2. Improved collaboration and coordination for scarce resources, program delivery, evaluation, communication, training, and education
3. Opportunity to augment public dollars with private dollars and/or earned income to bring in additional funding
4. Increased private-sector involvement
5. Benefit of economies of scale
6. Balanced resources for urban and rural settings
7. Accelerated return on investment
8. Better use of resources to serve more at-risk families and thereby improve outcomes for families and the state

There was some conversation about the proposal and a few meetings, but once again, this movement toward a more collaborative structure was not implemented and barely considered. As a result, most home visiting program grantees in Ohio are small operations without organizational efficiencies, economies of scale, the capacity to deliver multiple models, ability to enlist private-sector dollars to augment public monies, or enough resources to reach more families in underserved and rural areas.

P&G Pampers

A third effort occurred from 2012 to 2013 with the private-sector P&G Pampers and New Chapter vitamins. You can imagine our delight when we began to have conversations with a Pampers marketing team about the opportunities to essentially co-brand our ECS home visiting service with Pampers. We envisioned millions of boxes of Pampers diapers with ECS logos, nationwide acknowledgement of our effectiveness, the link with P&G Pampers quality, and a chance to disseminate our new early literacy curriculum not only for our ECS families but for any family with children in the birth-to-three-year-old age group.

We recognized that stress was ubiquitous in most families with infants and young children, and that the issues we addressed with our programming crossed socioeconomic lines. For example, our Let’s Talk Baby interactive online early literacy curriculum we knew would be useful not only for our enrolled families but for other families which often had two working parents, limited time with their young children, and an interest in having ready-made/tested digital tools to enhance cognitive development. P&G acknowledged our proven success, saying:

We envisioned a partnership where Let’s Talk Baby could be digitized and delivered through the Pampers Village. I thought of it as Pampers University. We saw collateral activities for families using Pampers to collect points for gifts. Pampers saw Let’s Talk Baby and ancillary activities as a strategy to expand its interaction with moms, attract new moms, and improve the lives of other moms they were not reaching.

In the P&G vernacular, we were going to be able to “bring the concept to life.” Ultimately, the plans did not materialize largely because ECS, as a regional program, did not have national-brand recognition.

This collaborative effort didn’t work out, not for lack of leadership or shared vision. It was rejected as a business decision and, for ECS, an organization founded on a business model, the decision was one that we understood even though we were disappointed.

Collaboration through Initiatives

Cincinnati Children’s

Our collaborative relationship with Cincinnati Children’s had several facets beginning with our cooperative research agenda, continuing with our involvement with pediatric primary care, our joint Start Strong project in the Avondale community of Cincinnati, our contribution to medical resident training, and our exploration of linking the field of home visiting with children’s hospitals across the country. Further, Cincinnati Children’s included us as part of its quality brand, along with the expectation that we would perform to meet the high standards of the academic medical center. We felt the pressure and, at the same time, welcomed the challenge, knowing that we were committed to delivering on the promises we had made. Although important work remained to be done, for more than two decades we had demonstrated that the hospital’s contract with us was well made.

As Cincinnati Children’s has expanded its community footprint, holding to the belief that the hospital is essential for children who are sick or injured but that the hospital also has an important role in community health, ECS has had a place within the medical center’s community continuum. While we brought our own public and private money to the table, Cincinnati Children’s provided a fertile place for us to grow and the goods and services to help to fund our infrastructure.

For all of the first 20 years, Cincinnati Children’s had an essential role in defining and executing our research agenda as we were forming as an organization. It was clear from the beginning that if Cincinnati Children’s was to be a partner, robust research and evaluation must be an integral part of our work. This stipulation allowed us to hire research staff, work with the University of Cincinnati to build our eECS data collection platform, submit joint funding applications with scientists from Cincinnati Children’s, and host the Maternal and Infant Data Hub. The Data Hub consisted of over 20 years of comprehensive records and yet-to-be uncovered material from nearly 700,000 home visits for 28,000 at-risk families. The ECS data file has the potential to become a highly valuable learning resource; it is focused on some of the following learning-agenda items. It was clear that in addition to finding additional money to serve more families, we also needed to formulate and answer essential questions about service delivery and outcomes, including:

• How can we enroll pregnant women earlier?
• How can we retain families in the program longer?
• How can we effect better transitions to programs for three-to-five-year-olds?
• How do we determine which families need which levels of service?
• What home visiting interventions work best for each family?
• How should/could funding structures change?
• Should funding mechanisms based on pay for performance be considered?

Through our Cincinnati Children’s research-and-development staff and our scientific advisory committee, answers to these questions were explored. Without access to our partners at Cincinnati Children’s, this level of exploration would have been difficult if not impossible.

Linking Home Visiting with Pediatric Primary Care

One area where I feel we missed an opportunity to learn and to improve the way home visiting was delivered was linkages between ECS and pediatric primary care (i.e., practices and clinics staffed by pediatricians, family physicians, nurse practitioners, and others who deliver primary care to children) in our community. This care was most often affiliated with Cincinnati Children’s, where most of the pediatricians in our area were trained. There is a growing national movement to, as Kay Johnson told us, reinforce the role of pediatric primary care as the “hub” where 90% of infants and toddlers are served (compared to about half who are seen in organized child-care centers and 2% to 3% by home visiting). A partnership between home visiting and the medical home has the potential to advance healthy development from birth to age three and to connect to the community. A few studies show the potential impact, and organizations such as the American Academy of Pediatrics have made the case with recommendations for collaboration and partnerships (American Academy of Pediatrics et al. 2017; Garner 2013; Paradis et al. 2013; Toomey et al. 2013; Tschudy et al. 2013; American Psychological Association et al. 2013).

Within ECS, we had an active medical home committee. We executed pilot work at several pediatric primary care sites using care consent forms to allow information to be shared, and we had credibility based upon decades of work with Cincinnati Children’s. In the end, the primary care linkage effort limped along for a while, but the barriers of the Epic medical records system, which barely included us; the large number of staff members who were already too busy at many pediatric primary care sites; and the paperwork we requested doomed the effort. Despite a proposal based on pilot efforts, a strong relationship with Cincinnati Children’s, and national recommendations, ECS attempts to secure funding from philanthropy for a large and focused pilot study failed. Some health foundations maintained they didn’t fund home visiting projects and those foundations funding home visiting said that they didn’t fund health projects. Such funding would have provided support for practice redesign, demonstration of proof of concept, and startup of a more systematic approach to collaboration and integration of home visiting and pediatric primary care.

Joint efforts between primary care and home visiting are still a good idea but would necessitate a system change and financial investment to seriously implement such efforts. To date, no major philanthropic or public investments have been made. Shifts in thinking about the role of pediatric primary care may eventually support this type of change. Similar issues arise for nonprofits with other types of missions (e.g., aging, adolescents, housing) when they attempt a paradigm shift in the status quo for delivery of services focused on optimal child development, early relationships, and collaborations with families and communities. Within this new paradigm, embedding or linking home visiting makes even more sense.

Collaboration between Home Visiting and Other Children’s Hospitals

Realizing that our relationship with Cincinnati Children’s had the potential to show other home visiting programs and children’s hospitals what collaboration could look like, in 2012, we assembled a small team of ECS board members, national leaders in the home visiting field, the Pew Center on the States Home Visiting Campaign, and the Association of Children’s Hospitals to explore avenues for collaboration. We based our proposal on our demonstrated experience with Cincinnati Children’s and characterized home visiting services as a bridge between the hospital and high-risk children. We cited the benefits that would accrue for communities and families if these linkages could be more clearly defined.

In 2019, the Ohio Children’s Hospital Association asked me to speak to their group about the benefits of partnership between home visiting programs and children’s hospitals. Ohio at that time had two examples: Cincinnati Children’s and Nationwide Hospital in Columbus. Again, we talked about the possibilities for sustainability, quality, better integrated community services, and successful families. I cited the trust that families have for children’s hospitals and their pediatricians and suggested that home visiting should not be an entity unto itself, but rather part of an integrated team where scarce and precious resources are used in the most effective way—morally, ethically, programmatically, and economically—with the hospital at the center. We identified seven areas in which collaboration between home visiting programs and pediatric hospitals had potential value:

1. An avenue to help to integrate a pediatric hospital with the community
2. A joint commitment to high quality, innovative research, and evaluation
3. The development of interventions to further improve the health of at-risk families enrolled in home visiting
4. A focus on prevention along with treatment of disease and injury
5. An emphasis on actionable research
6. The use of quality improvement strategies in a community setting
7. Access to large data sets for further exploration and learning

We never got beyond the planning stage. Hospitals, facing a variety of pressures, were not interested in taking on new programs. Most other children’s hospitals were using community benefit funds and in-kind resources for other priorities. In the end, we considered ourselves fortunate that the situation was different in greater Cincinnati. Again, an effort to change the nonprofit business model was not successful.

Collaboration with the Community: Our Learnings

Tiered Care Teams

The need for early childhood tiered-care teams underscores the importance of improved collaboration in our community and need for collaboration to achieve maximum gains for the population. ECS, along with others, has advanced the concept of creating care teams so that together, various disciplines could blend skills and resources without duplicating effort. Within the early childhood community, home visiting services have been delivered by home visitors, community health workers, doulas, home health care workers, lactation consultants, health care navigators at Cincinnati Children’s and at the Hamilton County Department of Health, social workers at the Hamilton County Department of Job and Family Services, early care and education providers, and physicians and nurses at prenatal and pediatric clinics. Clearly, not all these functions overlap, but if roles and responsibilities for each of these disciplines were defined and opportunities for collaboration available, existing fragmentation and confusion could be minimized and barriers to implementation could be reduced. But saying that is easier than doing it. Long-term sustainability in the nonprofit role needs an organization or a group of organizations serving as a coordinator and offering incentives for collaborating. In the breach, programs have grown to serve their individual mandates even though working together would lead to better outcomes and serve more families.

The relationship between home visitors and community health workers offers a good example. As with other adjacent agencies and programs with similar target groups, both workers are valuable, and each provides a distinct service. But without a clear scope of work, both are often deployed to improve family outreach, engagement, resource and referral, and timely receipt of health and other services. Without coordination between home visitors and community health workers, services are duplicated, messaging confusing, and the strength of each diminished. Home visitors have a parenting and child development curriculum to deliver, while community health workers have expertise in outreach, community education, informal counseling, social support, and family advocacy. With careful planning they could work together, educating the family, encouraging good parenting, connecting with services, and creating community support.[pull quote]

Consistent with the importance of collaboration, as ECS negotiated with an MCO, we described the tiered-team approach to serving families. We explained that we were eager to launch a pilot project to demonstrate how a tiered team of home visitors and care coordination/community health workers could more effectively deliver services to pregnant women and families with young children by integrating two distinct yet related disciplines. Our plans for working with an MCO did not materialize, but we continued to refine the tiered-team concept. In 2019, we applied for and received a grant from Bethesda Inc. bi3 to examine the relationship between home visitors and community health workers, offering ideas for improvement. We ended our report with the following conclusion:

As an aside, by 2021, there was still not a clear or operationalized definition to describe how home visitors and community health workers can work together most effectively. With the growing movement to include doulas as part of the perinatal care team, another segment of the workforce has emerged. As we said in our proposal: “The integration of community health workers into existing home visiting practice is novel and holds promise for creating synergies and greater efficiency in service delivery while also fostering social networks and leveraging community assets.” Yet, how home visitors, community health workers, and doulas each play a role has not been well articulated in public policy or local action. Collaboration needs to be a value at all levels of organizations to build a continuum of services from prenatal to age three that uplifts mothers, their children, and their families. The opportunity for teamwork is great. The potential for creation of an effective continuum of support for families, providing the opportunity to better address their social determinants and supporting good parenting and life skills that will result in positive child development. Encouraging and operationalizing this particular type of collaboration is increasingly important as the federal government spends millions of dollars to both expand home visitor roles and increase the number of community health workers available as part of the response to the COVID-19 public health emergency.

StartStrong

StartStrong was a geographically focused initiative to redesign health-care delivery in the Avondale community adjacent to Cincinnati Children’s. The project to reduce preterm birth rates was a collaborative effort among Cincinnati Children’s, Good Samaritan Hospital, and ECS. The Avondale community had one of the highest infant mortality rates in Ohio. But following the focused StartStrong work and with dedicated and place-based efforts, at the end of the three-year grant period, the rates were better than the countywide average and no very preterm births were reported for 2015 to 2017.

Our engagement with the StartStrong project began with a request from a potential funder. Both ECS and Cincinnati Children’s had made application for grant funding from Bethesda Inc. bi3 to address the high incidence of preterm birth in two low-income communities. The funders liked our proposals but asked that we combine them—exactly the right advice to encourage cooperative work. Through the three StartStrong years, we not only developed new strategies and alliances but also realized the benefit of working together with our partners Cincinnati Children’s, Good Samaritan Hospital, and later the University of Cincinnati Medical Center and Cradle Cincinnati. Funding came from both Bethesda Inc. bi3 and Cincinnati Children’s.

Community engagement and redesign was at the center of this effort. With the support of Bethesda Inc. bi3, three core areas were explored: 1) engaging the community to support pregnant women and their young children and to begin prenatal care as early as possible; 2) improving the referral and enrollment process to seamlessly connect women to community home-visitation programs and service agencies; and 3) improving the experience with healthcare and community support programs to increase mutual trust and communication.

Our primary takeaways were five: 1) an infrastructure is needed to support quality improvement training and data collection/analysis and to standardize best practices in prenatal care, 2) community outreach tools (family strong dinners, parent groups, block-by-block activation) make a difference, 3) transformation of prenatal care at clinics led to verified reduction in preterm birth, 4) ongoing innovation was necessary and 5) the social service referral system was inefficient.

Although our start-up year took longer than we had anticipated, by the end of the three-year period, we had good approaches in place to address the key issues and had collected sufficient data to verify what was working. We knew that leadership champions were required for success; that the systems, rather than just the people, needed to change; that opportunities existed to form cohesive partnerships; that competition among agencies delayed progress; and that common goals and regularly reported data were essential to engender trust and to ensure buy-in from all parties. However, not atypically, by the end of year three, funding was no longer available, and the formal work ended. Parts of the change that we had effected could be continued, most notably improved coordination within hospital prenatal clinics and improved customer service for mothers coming to the hospital for prenatal care. At ECS, we were able to use our StartStrong perinatal curriculum as a part of our overall work with perinatal moms. These were significant and important outcomes, but there was much that was lost.

Bethesda Inc. bi3 produced a StartStrong report as a part of its bi3 Learning Series to capture what happened with the project and to document what their investment produced. StartStrong is to be credited with truly focusing attention on infant mortality reduction in our community, as previous efforts, albeit well-meaning, had been scattered and episodic. Its funding commitment, augmented by Cincinnati Children’s, and the work initiated over the three-year period, is viewed by Bethesda Inc. bi3 as germane to garnering public attention and leading to the current low infant mortality rate in Hamilton County.

What happened with StartStrong represents a typical challenge in community-level change. Philanthropy funds a project—for example, initial piloting or dissemination of a new strategy or evaluation of a new approach—the work occurs, and learnings are identified, but little really changes at the population or community level. The new approach and its demonstrated impact may become the subject of a professional journal article or a bullet point in an annual report. The gap is not closed between the philanthropic initial investment and the major public or private investment needed to sustain change and take the program to scale. Systems development or service transformation doesn’t take hold. This failure to institutionalize positive changes also continually undermines the trust of families and communities. They become increasingly less likely to invest in community partnerships with nonprofit and governmental organizations, less trusting that their time and other resources will result in sustainable change.

Avondale Community Partnership

The Avondale Community partnership was one of the important collaborations in ECS history. By engaging the community of Avondale, we enhanced engagement in our program. It also gave an opportunity to understand how a focused effort in partnership with the community made a difference in program participation, mother-baby relationships, and levels of community support. Yet despite measurable success, we were never able to expand the funds to spread this partnership approach to other communities.

The Avondale partnership—and we deliberately called it a partnership—was launched in 2007 with private-sector funding obtained by then Cincinnati Children’s and ECS board members Lee Carter, Thomas Cody, and David R. Walker. Our goal, over three years, was to build upon the success of Geoffrey Canada’s Harlem Children’s Zone by designing special community and collaborative programming for Avondale, the community that was home to Cincinnati Children’s, ECS, 65 churches, and a population of approximately 10,000. Our idea was to concentrate on a community-based approach. We would partner with Avondale churches and other organizations serving challenged families to eliminate our Avondale waiting list and to enroll all eligible moms living in that city neighborhood. We would offer them not only home visiting but also links with a full range of services, everything from medical care to nutrition to safety to social connectedness and employment.

As we began to build relationships with the families, we were sobered by the daunting social, community, and system challenges they faced. Financial pressure, limited formal education, lack of employment opportunities, inadequate access to food, transportation, and affordable housing, exposure to drug dealing and violence—all were obvious obstacles to effective parenting. We were fortunate that Reverend Clarence Wallace, pastor of the Avondale Carmel Presbyterian church; Anita Brentley, ECS community coordinator; and CAA were energized by the possibilities the Avondale Partnership represented, and they skillfully led the initiative.

Through monthly moms’ groups, a caring network pantry, health fairs, community walk-throughs, individual family follow-ups, frequent text messaging, the indefatigable work of community leaders Brentley and Wallace, ECS home visitors, and the CAA, we were able to enroll 85% of eligible Avondale moms, 70% of them prenatally. A detailed study of the community-based enrichment effort found a significant improvement in participation in home visiting among more than 2,000 families, compared to a group of peers who were not touched by this effort. Families reached by the community-engagement efforts stayed in the program longer, participated in a greater number of home visits, and lived in homes with children in stimulating environments for learning and development. Parents were acquiring new parenting skills, and it was truly exciting—and fun (Every Child Succeeds 2016; Folger et al. 2016).

A poignant conversation offered additional insights and opportunities for action. Brentley asked me to speak at one of the moms’ group meetings to thank the many volunteers who showed up each month to make dinner, help with the babies, or lead a conversation group. After my talk, two young mothers with strollers approached me with their question: How can we volunteer too? We want to help. Here were two women with unimaginable stress and few financial resources offering to help others, to bring their lived experience and wisdom to our effort. Their question caused me to reflect and compare them to other women with too much time on their hands and too many resources, not able to get out of bed before 10:00 a.m.

Each moms’ group meeting was an affirming event—the interaction among moms, home visitors, church members, and ECS staff was thrilling, people were happy and engaged, attendance ranged from 60–80 moms each month, church volunteers prepared dinner. Brentley believed in celebration, and we had ceremonies with presents for babies showing new teeth or taking their first steps, moms who continued breast-feeding or got jobs or attended school, dads who attended the moms’ group meetings, dads who helped with parenting. We were building connections and fostering relationships, with parents and between parents and babies. The incidence of preterm births plummeted.

As manager, Brentley worked with the moms to create a mission statement for their moms’ group. It took several meetings and careful thought but the words that they agreed upon are these, and they used this short statement to open each meeting: “Starting prenatally, we want healthy, happy babies. We want to become resourceful and instill goals and values in our children that will carry them into adulthood.”

We were able to secure some special United Way funding for what they termed a Place Matters initiative. With those monies we hired some of the Avondale moms who participated in ECS to be community liaisons and present the services to other women in their community. Words from one of our liaison moms:

So, you might ask, “What happened?” Why wasn’t this positive work continued in Avondale and other neighborhoods? The answer, like so many others, is simple—the money ran out. Without sustainable funding for our community work, the work had to end. Grant money most often is episodic. It is welcome, certainly, and provides opportunities to learn about new services or programs or to grow services. But there are few if any private-sector funds committed for long-term support, and public money typically pays for a basic service such as home visits but not much beyond that.

Even though we were able to document the success of the community engagement in Avondale, eventually the moms’ groups were discontinued. The pantry closed, and our intensive ECS community focus ended. We wrote a community engagement manual for other communities to use, and we offered consulting services, but other communities faced the same problem that we did—recognition of the importance of community engagement but no funds to support it.

Ironically, evidence has continued to accumulate documenting how social determinants of health—neighborhood, income, family and household structure, social support, education—have an impact on health and healthy development. The US Department of Health and Human services reports on how social determinants of health also contribute to wide health disparities and inequities by race, income, and other factors (the website of the US Department of Health and Human Services, Office of Disease Prevention and Health Promotion, “Social Determinants of Health”).

Who Is Poised to Be the Backbone of an Early Childhood System?

United Way as a Backbone Organization

United Way had been operating in the greater Cincinnati area for many decades when the ECS initiative was launched (United Way of Greater Cincinnati, LinkedIn). United Way of Greater Cincinnati, which partners with hundreds community-based agencies and nonprofits (website of the United Way of Greater Cincinnati, “Welcome to Our Nonprofit Portal”), began an intensified focus on young children and a program strategy based on collaboration by heeding the challenge from Pepper to the Haller task force to the steering committee. In many ways, United Way of Greater Cincinnati, with campaign contributions in excess of $50 million annually (UWGC 2020 Annual Report), was the logical organization to guide improved program integration community-wide. But one could also make a case for Cincinnati Children’s or a new “backbone” organization or a large community organization with a strong community footprint. Whatever the structure, community will, accountability, transparency, visible and effective leadership, and a path to sustainability are essential. But most important, the focus needs to be clearly defined and maintained.

A focus on neutrality was critical going forward, because the mandate from the original work of the Blue Ribbon Task Force on Focus called for creating a framework so that all groups funded by the United Way and providing service to children would be asked to coordinate their work through an umbrella organization, and create interlocking sets of services for our community’s children. The organization would have been required to analyze all the groups’ work and report outcomes with precision and transparency. This would threaten agencies that would have difficulty meeting high standards, not only locally but also with the national shift toward greater government accountability and evidence-based practices.

One of the most contentious meetings I attended during my entire career was held by United Way to alert its 135 agencies to the new requirement to collect and report data—good, sound, verifiable data. ECS was set up to meet those requirements from day one, but many other groups had not collected data, didn’t have anyone who knew how to do it, couldn’t afford to hire additional staff, and generally were intimidated, wondering why, if they were doing good work, this was necessary. The audience erupted even though the United Way offered to provide technical assistance if needed. It was an emotional afternoon. The United Way president and board chair conducted the meeting and explained that donors were not only asking for validation for program outcomes but also would begin to require it. Long gone were the days when a philanthropist would be willing to send in a check to “do good” without feedback and/or evidence of outcomes effected by their contribution.

Nonprofit boards and senior leadership have a responsibility to hold agencies accountable for documenting effectiveness, which includes not only defining outcomes but also on occasion trying new strategies with the potential to achieve better outcomes.

Cincinnati Children’s as a Convener

Having a major community institution as a convenor, patron, or parent organization can benefit nonprofit organizations in multiple ways. Considering Cincinnati Children’s as the convener for this work reflects in principle what Children’s itself has long advocated. Although as a free-standing pediatric hospital, Cincinnati Children’s concentrates on clinical expertise, its leadership strategy has consistently emphasized a community commitment and the importance of community partnership. Its position has been to participate but not lead, understanding that no one knows what the community needs better than the community itself.[pull quote]

With its support for ECS and led by its former president, Michael Fisher, Cincinnati Children’s has intentionally characterized its role as a partner, not the leader. It operates in a partnership with a willingness to bring formidable resources and expertise to the table, acknowledging that it does not have all of the answers. In other words, it sought to be a great collaborative partner even though it was understood that in many ways Cincinnati Children’s is larger and more influential than the rest of us put together. Cincinnati Children’s brings sizable resources, including in-kind services and access to the science, the rigor, the excellence that is emblematic of that organization.

Fisher’s history with this expansive thinking extends over decades, beginning with his service on the United Way board, his role in the United Way 1999 major gifts campaign, his co-leadership of the 2003 United Way campaign with his wife, Suzette, and his willingness to make home visits with our families so that he could experience ECS’s methods for himself. Fisher often describes sitting on the floor with the mom and the home visitor, hearing her story. He continued the example set by Cincinnati Children’s leadership including prior CEO Jim Anderson and board members Lee Carter, Thomas Cody, Jane Portman, and Mark Jahnke, expanding the organization’s commitment to the community.

When we began the journey that led to ECS, Anderson was president of Cincinnati Children’s, and Carter was board chair. The two men initiated support for our endeavor with zeal. Fisher and subsequent board chair Jahnke advocated not only for the ECS outcomes but also high-quality program delivery, evaluation, and research. They had a good understanding that evidence-based home visiting is part of a solution to a complex problem that has been festering for generations—how to increase the life chances and opportunities of every child. Or, as longtime ECS board member and P&G CEO Pepper once told us, “Our situation (in the US) is morally and ethically wrong.”

Lessons

1. See and seize opportunities for collaboration and systems building. Identify joint, mutually endorsed, and defined goals. Know that collaboration requires true and not perfunctory mutual decision-making. Sustained partnerships require synergy, shared interests, trust, and cooperative action.
2. Engage strong leadership. Brave, diverse, and strong leaders have the credibility and political clout to bring key partners together. Partners should include the families, the other consumers of your services, the workforce who delivers the services, and other nonprofit agencies, advocates, and policymakers.
3. Avoid territorialism. Encourage funders, policymakers, and program leaders to make decisions that encourage collaboration. Competition for scarce resources is an enemy of collaboration. Press for resource allocation that leads to shared interest, effective collaboration, and sustainable outcomes.
4. Build a system, not a program. Use leadership and partnership to link programs more effectively in order to reduce balkanization, improve transparency and accountability, and create an accessible and equitable continuum of services for families.
5. Focus on long-term sustainability. Recognize that sustainability is not only dependent on predictable funding but also on wise leadership, program coordination, data sharing, mutually agreeable outcomes, and demonstration of value. Trying hard to do good is not enough. Results matter.