Business Community Partnerships

ECS had the right team when it came to funding, professional development, business guidance, and decision-making. This was ECS’s important advantage: Our business community supported us and was critical to our success in a variety of ways. When Pepper made Frank Smith, a senior P&G executive, available to us for a year to help us launch our program, we put processes and clear strategies in place that became the foundation for how we operated. What we knew then is that a nonprofit must have a strong business foundation to be successful and accomplish its mission. In the argot of the early childhood world—not only to strive but also to thrive.

Examples included tools for systematizing planning and priority setting by identifying the compelling improvement need—the value proposition—the killer issues and the reason to believe. Focus is essential not only in asking the hardest questions but also being clear-eyed about the answers. We had strategic OGSM analyses (objectives, goals, strategies, and measures) and STAR diagrams (structure, people, incentives, information sharing/decision making, tasks) for the more tactical work.

We used these tools to guide decision-making and were disciplined about our willingness to go back to basics when a problem or an opportunity arose. We committed ourselves to unifying our long-term direction, providing visible accountability, continually improving and learning from mistakes. In short, we accepted the challenge to assess our position, renew our commitment on a regular basis, and be courageous enough to make changes when they were warranted.

Walker, in his role as both ECS board chair and mentor, asked questions that were pointed and strategic. He wanted to see plans and proposals concerning agency profitability, maintaining quality, the real cost of service, the ability to build capacity internally and externally, the availability of government funding, and whether we were separating long-term strategic choices from near-term decisions.

Our for-profit business guides nearly always led with an admonition: run ECS like a business with market knowledge, subject expertise, data, and measurement. Ask the right questions, the hard questions. Identify the “killer issue,” get to root causes, continue to explore and clarify our value propositions, reject facile explanations, focus.

Examples from a senior P&G executive and ECS board member included these questions more than once: What are the most critical ECS goals that we absolutely must achieve over the next twelve months, over the next three-to-five years? What are the most foundational priorities—the no-miss action plans? What are new capabilities that we may not have today but that need to be developed? What are ongoing optimizations/improvements for what we are already working on today? Are we, as a board, and as a program, organized and structured to implement the most foundational actions we need in the next three-to-six months?

And from our P&G colleagues, we were encouraged to confine answers to one page and never use more than seven words on a slide in a presentation. If people are reading your slides or you are, the audience is not paying attention to what you would like them to know.

Another board member described our situation this way: We do not have laurels to sit on. Actually, no sitting is allowed.

The need for leadership that was focused, analytical, courageous, and thoughtful led to three recommended questions—call them “join-up” topics for potential board members or for anyone who might become the voice or the face of ECS in the community:

1. What are the three most important things that you would like to see ECS accomplish over the next two years?
2. And for you, personally, what would you like to do over roughly the same time period?
3. What do you think are the top one to three problems that ECS faces and what are the three opportunities?

Here is an example of how we applied those questions to our operation: When community pressure arose about reaching all mothers in the community or providing services beyond home visitation, Walker, as our board chair, effectively brought us back to the massive work we had already promised to do, letting us know that our focus was on the big assignment that we had accepted but not yet accomplished. We quietly but emphatically rejected those community requests, mindful of the P&G saying, “Make a little, sell a little, learn a lot.” The point being that we needed to get experience on a small scale, learn what works, and expand that later. That is what we did.

But the help and guidance didn’t stop with P&G. There was an entire group from our business community who stepped forward and, as I told The Wall Street Journal for an article that appeared on page one June 20, 2006, brought us time and ideas from the kinds of minds we couldn’t afford to buy. As a leader I have always welcomed a strong management team, people smarter and more accomplished than I am but who also bring the same work ethic and are focused on the same cause. With our business-minded partners, we were able to amplify our ideas and receive new ones, making the partnership the best of both worlds.

Acknowledging that we would probably always be swimming or rafting in “permanent whitewater,” we focused on our mission, made solid decisions even when they were difficult, documented our progress, and ensured that the investment made in us was well founded. Our friends in the private-sector world provided invaluable guidance.

There is a story here, too, from Walker, who let us know why he has spent nearly 40 years volunteering at senior levels for nonprofit organizations and making sizable financial contributions. He explains it this way:

An essential lesson for any nonprofit is this: An initiative must be able to survive as a business to even begin to deliver the social mission. We were fortunate to have outstanding guidance; to our credit, we were able to maintain our focus for more than two decades. Following recommendations and guidance from the business community allowed us to create a nationally recognized and applauded program. But even with our good advice and our entrepreneurial spirit, there is an essential limiting factor: Nearly unsurmountable challenges placed upon nonprofits frequently cause them to be unable to deliver on what they know to be true. Remedies come in the form of funders who demand verifiable outcomes, improved coordination among organizations working on the same problem, and funding that supports research and development rather than just service alone.[pull quote]

Strategically, the close relationship with our business community brought foundational design, growth, and systems development based upon best business practices. Among the advantages and knowledge our partnership provided and nurtured:

• The importance of clearly defining the problem to be solved and using a stringent, candid structure to ensure that the root cause is clearly identified
• The opportunity to access the “kinds of minds we couldn’t afford to buy”
• The open doors for meetings with people influential in the community and the fertile ground for the development of community will
• The emphasis upon accountability and return on investment
• The willingness to stop something that isn’t working
• The ability to leverage public money with private dollars to enhance program quality, and be as innovative as funds allow
• The respect in the community that comes with support and approbation from business leaders
• The integration of the need to find creative solutions rather than saying no to opportunities
• The significance of collaboration and a systems approach to solving problems

Our business partners taught us skills of negotiation and demonstrated tools to manage our work: Red Green Charts for quality assurance, dashboards and data requirements identifying the crucial numbers and information needed for good decision-making, and the benefits of understanding our competitive advantage and our outcomes. Crucially, our friends in the business world continued to let us know that our work mattered and that, regardless of the internal and outside pressure, we must never give up.

Deloitte Organizational Assessment

In 2000, soon after we opened our doors, and with the recommendation from our founding partners, the Health Foundation of Greater Cincinnati (now Interact for Health) commissioned Deloitte, a leading business consulting and professional services firm, to conduct a “thorough organizational assessment of (our) management structure and span, critical business processes, provider relationships and performance metrics.” In its report, Deloitte commended the community leaders who committed time and energy to develop ECS and who envisioned a quality program supported by a collaboration of business, nonprofit, and academic leadership. Their assessment included the following key findings:

1. Exceptional progress has been made in a short time.
2. Collaboratives can be beneficial but require respect, trust, and nurturing.
3. Agency growth will require more clear definition of management roles and responsibilities.
4. Sustainable funding and demonstrable outcomes are key.
5. Detailed business planning, including capacity and utilization, are vital to success.
6. Process and outcomes measures need better definition and presentation.
7. Subjective and informal measurements are implemented more often and consistently than are quantitative measures.

The assessment from Deloitte came after we had been operational for about 18 months. It reinforced what we knew and offered a valuable critical appraisal as well as ongoing guidance for our work.

IDEO

In 2010, as a result of my receipt of the Purpose Prize, I had the opportunity to attend a session with the IDEO group in California. Long recognized as a leader in human-centered design, IDEO provided a context for me to think about how we at ECS could clarify problems that needed to be solved. Remembering our P&G guidance about addressing the killer issue and solving the most limiting factor first, I was eager to better understand the logic model employed by the IDEO group.

Working with them was fun and thought-provoking as we moved away from the constraints and restraints that too often control us, and try to find creative but realistic solutions to problems. Basically, what I learned was this: Study how people behave in their environment, go out and actually see it. Tell stories about what you saw and felt, break down the stories into manageable pieces—a concept that, like Goldilocks found in the Three Bears’ home, is not too big but “just right.” Actually, create a prototype that you can walk through. For me that meant going through every step of the process in my mind, maybe creating a roadmap, maybe using props, but in some way putting myself in the shoes of one of our moms or one of our babies or one of our referring counselors. And finally, present ideas as experiments, allowing co-creation. In our case, the solutions must always include wisdom and guidance from our families.

Focus

If there is one single message here that has been the underpinning of our success, it is be focused—be clear about what we planned to do, how we planned to do it, and why we chose this path. What we learned early on is that if goals are not clearly defined—focused—there always exists the tendency to broaden the lane and move a little beyond the plan for funding sources, for “mission creep,” for joining a new initiative. The guidance about focus came from P&G but also from our longtime advocate and board chair, Jim Spurlino. As a successful small businessperson with a fervent interest in early childhood, Spurlino exhorted us to always go back to the original questions: the Toyota “five whys,” ensuring that we were remaining committed to our original purpose and staying in our lane.[pull quote]

In his book Business Bullseye, Spurlino explains how to “take dead aim and achieve great success,” a concept applicable to nonprofit and for-profit enterprises alike. One graphic example of Spurlino’s thinking continues to be part of his public comments. His business, building materials, concentrated on concrete foundations for large structures. When he talked about early childhood and ECS, he often used good construction as a metaphor for the importance of the early years, the foundation laid during the first 1,000 days of life. This was both a visual and true depiction.

In another indispensable way, Spurlino, from a small-business perspective, provided an important lesson—just saying “no” or offering an excuse is almost never the right way to solve a problem. Rather, before closing the door to an opportunity, be creative about how to address it or find another way to make it happen. An example is text messaging with families when phone minutes don’t work or meeting a family at the library when going into the home isn’t advisable. Our pandemic response was testament to our ability to find new ways to serve families when going into the home or being together wasn’t possible.

The Strategic Business Plan

The business plan that we wrote for ECS provided the blueprint for how the work would occur and who must be involved—the partners, the board, the funders, the agencies, the community members, the challenged families. We knew that guidance from our colleagues in the business community was essential for success. Involvement of large and small business leaders allowed ECS to be constructed on a firm foundation using the best principles of private enterprise so that we could respond to vagaries in the marketplace, the advent of competition, and opportunities for growth. Sometimes we say that there is P&G DNA in ECS and it has made us infinitely stronger. We have always been exhorted to clearly define our “unique selling proposition” and “reason to believe,” advice from the world’s largest and highly successful marketer.

The business plan that we presented in April 1998 had seven key components: the implementation strategy, the partners, the structure, the funding, the evaluation process, the marketing, and the timing. Those elements formed the blueprint for our work going forward. We characterized our work as moving away from incrementalism and focusing on prevention and celebrating children and their ultimate success.

By October 1998, we had a good list of the critical tasks that we needed to accomplish to open our doors for families. They were meticulously crafted, well researched and community informed. The tenets in the April 1998 business plan resulted in a strong program launch in March 1999 and their relevancy endures:

1. Contract development with multiple service delivery organizations and the states of Ohio and Kentucky
2. Quality improvement (QI) and evaluation protocols focused on both program operation and family outcomes
3. Funding and fiscal management structures to support internal operations and budgets, legal and IRS requirements
4. Marketing to create community awareness and boost voluntary enrollment of moms
5. Board identification to develop and delineate roles and assignments
6. Provider council (now lead agency) to begin engagement and collaboration process
7. People/staff to secure consultants where needed, hire staff, and determine which services will be provided by partners
8. Program to inventory referral sources, set up proper training, determine the best program elements, and make neighborhood/agency assignments
9. RFPs for program to determine which agencies want to operate the Nurse-Family Partnership and Healthy Families America models (other models ultimately used as well)
10. Outcome monitoring and information systems to describe primary and secondary outcomes and the computer hardware, software, personnel, and facilities for home visit service coordination, training, and outcomes assessment

The Public-Private-Sector Partnership

In other chapters, this book provides further detail to amplify and describe how ECS was able to construct and maintain the public-private partnership that allowed us to go beyond the basic public-sector funding and do—albeit in a small way—what Pallotta compellingly urges in his book Uncharitable (2008). Our nonprofit organization benefited from our public-private partnership but was still constrained by our inability to benefit from the opportunities that free-market capitalism allows. For a variety of programs that we piloted and demonstrated as effective, we could not secure funding to keep them going. In some of these, learnings and opportunities were lost, and money was not well invested. We did not sufficiently build upon what was working and failed to keep commitments that could have built more trust with the families and communities we aimed to serve.

Linking Home Visiting with Pediatric Primary Care

An attempt at improved program coordination was illustrated through a proposal we wrote to develop mechanisms to link home visiting more closely with pediatric primary care. Even though research studies and national recommendations pointed to the potential positive impact of such an alignment, it had not been widely implemented. ECS could be, we argued, a good resource for a busy pediatric office where the doctor typically has only minutes to spend with each patient. If the physician were able to use ECS as a resource, and refer the child to a professional home visitor, that home visitor could address nonclinical issues—the social determinants of health—as well as support the family in using recommended health services. By maintaining close links to and accountability with the health provider, the result could be improved service by the home visitor who would have additional information about the family to guide her work. Such links could also be a reliable resource for the pediatric primary care provider to address issues that couldn’t be managed in an office setting.

A few small-scale research studies elsewhere had identified opportunities for improved engagement to better integrate services and systems, support the medical home, focus on healthy development and two-generational well-being, optimize existing capacity, and engage and empower families. Using our private-sector resources and the support of pediatric care leaders at Cincinnati Children’s, we began designing small tests of change (e.g., getting family permission, using the medical record, sifting workflow), and we were successful.

We prepared a proposal for a project called “Integrating home visiting and primary care to improve child and family outcomes.” Its purpose was to increase the efficiency, effectiveness, and quality of both home visiting and pediatric primary care through service integration. We then approached several national, state, and local foundations to seek funding for a demonstration project but were unsuccessful. The health foundations said they did not fund home visiting efforts, while those funders committed to home visiting told us they did not fund primary health care projects. We could identify no philanthropic sources of funds willing to step away from their siloed investment portfolio. We also could not identify a way to use government home visiting funds, other than public grants or Medicaid dollars, to launch this effort. While national expert recommendations continue to call for greater collaboration and linkage between home visiting and primary care, the promise of such efforts has not been fulfilled in greater Cincinnati or on a wide scale elsewhere.

University of Michigan Ross School of Business

The involvement of the business community and our business orientation was highlighted again in 2006, when we were asked by the University of Michigan Ross School of Business to present at a conference for graduate students enrolled in the nonprofit management curriculum. Al Spector, retired P&G executive and longtime ECS volunteer, and I made the trip to Ann Arbor to participate in the university’s social-enterprise symposium, “Quantifiable Outcomes to Support Funding Requests.” Our topic was: “Real People, Real Issues, Real Solutions.” The symposium leaders were intrigued with our close relationship with the business community and our focus on evidence-based decision-making. They told us we were 10 years ahead of our time. We were honored to be included.

The keynote speaker, Bo Burlingham, then editor of Inc. magazine, talked about his new book, Small Giants: Companies That Choose to Be Great Instead of Big (2005). The book focused on businesses who decided to remain small and, one would imagine, more manageable. Fortunately for all of us, one of the businesses he highlighted was the Katzingers Group in Ann Arbor, purveyor of a variety of wonderful food products and services that they liberally shared with us. Burlingham let us know that Katzingers was an outstanding example of why unbridled growth, as appealing as it may look on paper, is not always the best strategy to maintaining quality and control.

Spector and I focused on our relationship with private business—how it happened and why it mattered. We were gratified when the Michigan group complimented us, saying that we were far ahead of most social service organizations in terms of applying principles of entrepreneurship to a nonprofit organization.

To provide experience for their students and to help nonprofits, the Ross School created what it called a “domestic corps” so that organizations like ours could apply to have an MBA student assigned to us for a summer internship. Ethicon Endo-Surgery paid for the engagement with Ram Kapadia. We applied and were fortunate to have Ram Kapadia work with us in Cincinnati to create a financial model for ECS. His assignment was to analyze growth opportunities, including fiscal and personnel requirements, and at the same time, provide answers to a central question: What is a principled approach to growth, and what are the challenges?

Marketing: Procter and Gamble and Others

Nonprofit Marketing

As we considered how to best market our program, a single image became ubiquitous—a simple side-by-side illustration compared the brain of an infant swaddled and not stimulated and another infant with many sensory opportunities. In one brain, there were large dark spaces where synapses failed to close. The other was vibrant and full. From the beginning we emphasized that professional home visiting was vital to support many families to help their children achieve their best possible start. We used the dual brain image on publications and slide decks, in videos and as a part of most of our presentations, because there in stark contrast was the actual picture of why our work was so important. We could see the visible effect of early stimulation and exuberant brain development for an infant. Effective home visiting was viewed as a way to promote optimal brain development and the foundational relationships that support parents and children for a lifetime.

Our initial public awareness campaign worked, and we had extraordinary free and voluntary support, but what happened to us early on was only one component of larger marketing/branding difficulties for ECS and arguably for most nonprofits.

Marketing and messaging at ECS had two broad audiences. The first was the public at large, including the stakeholders, the funders, and the families we were working to enroll. Then there was the internal audience, the moms who are part of ECS, the home visitors who serve them, and the organizations that refer to us.

Unfortunately, marketing and branding are two areas that rarely get the attention that they need at nonprofits. Seen as too “commercial” or expensive or money spent on something other than the direct service, marketing budgets are too small and/or the first to be cut when a budget adjustment is needed. Further, marketing money does not come from public sources; rather, it requires grants or philanthropy or other nonpublic sources.

Compelling Words and Frameworks

We have been aware, since soon after the launch of ECS in 1999, that the language we were using to describe our work and its importance was not always compelling and was not reaching the people we needed to reach—moms in the community. Further, we knew that we had to do a better job convincing funders from both the public and private sectors that investment in evidence-based home visiting programs was a sound choice.

In 2018, David Willis, MD, with support from the Perigee Fund, launched a national initiative focused on early relational health. Among other things, Willis worked with the Frameworks Institute to better describe the “what and the why” of early relational health and to create a framework that would allow improved communication with the general public. Through the Frameworks’ early relational health survey, we were able to identify word and concept choices that would resonate with our stakeholders and our families as we worked to encourage support and enroll moms. Frameworks reminded us to emphasize the following in our messaging:

The work by Willis and his colleagues at the Center for the Study of Social Policy and previously at the Perigee Fund and in federal government roles urged us always to keep two essential questions in mind: How is the child doing? How is the parent doing? Then tell the stories that reflect recommendations from Willis and our P&G marketing consultants—show how relationships are joyful and gratifying, and focus on the positive, early and often. Be concrete and be alert to what we as a program can learn from parents.

Defining the Reason to Believe

We were fortunate in greater Cincinnati, because we not only had the approval of the business community but also guidance from P&G. The P&G folks understood messaging for both the groups we needed to reach. They let us know that we needed strong and recognizable external branding that emphasized the reason to believe in our work and to clearly define our role and our key outcomes. We needed to let the community know how we were making a difference and needed to highlight our key strategic partners. This would encourage participation by other groups and organizations.

In 2010, we were able to meet with one of P&G’s senior marketing directors, to help us plan both our messaging and our strategy. With him we concentrated on how best to touch and improve lives for our moms, to have the consumer value and benefit from the product. He urged us to emphasize the positive: encourage and celebrate success, rather than highlighting developmental problems or something that isn’t going well. Among his recommendations were: Let mom know that she is making progress, use rewards, and most importantly, build in delight for mom and child, continually reinforcing what is good.

He urged us to get clues and guidance by paying attention to what a mom says or doesn’t say or when she doesn’t respond. The nonverbal cues and clues matter, he made clear. He encouraged reviewing the data, of course, and keeping the objective measures in mind. Most important, he encouraged us to establish trust and generate confidence by responding to what moms need and celebrating things large and small.

Remember, this experienced marketing executive cautioned, the mother is never wrong, even if she isn’t doing the right thing. The role of the home visitor—and it isn’t easy—is to begin with respect for the mother and her ideas and to weave her accomplishments into the program and curriculum each day.

He further suggested that we think about our outcomes/achievements with families in three-month rather than one-month segments, because the longer time period offers a better gauge of progress. Again, part of the role of the home visitor is to celebrate accomplishments, and having real, sustainable changes to talk about adds credence to the relationship. Finally, he told us that there is a difference between an expert system and a system run by experts. It is the expert system that can be scaled, and at ECS, he said, we had developed the expertise and now needed the expert system.

Belonging

Because we understood the significance of delight, celebration, and positive reinforcement in the relationships we encouraged with the home visitors and the families, we began to concentrate on promoting a concept of “belonging” for our mothers. We were aware that most people want to be part of something larger than themselves. We hoped to address the social isolation endemic with ECS families and the stresses that come with unsafe neighborhoods, too little income, racism, single parenthood, and other challenges to family well-being and relational health. So we began offering safe, positive group experiences, as well as themed logo wear and purple bags to give tangible reminders of being connected. Our messaging emphasized not only our services and our availability but our caring and our belief in our moms. Our message was: We are here for you, we care, and you belong.

Parents and children today are often separated from their biological families, and they welcome the opportunity to create a new extended “family.” Each month when the Avondale Mom’s Group met, young women who lived close to one another but were often unacquainted, became friends through the group. It was fun to see them arrive together, pushing strollers, animatedly talking and laughing, finding friends and social support—being less alone. These experiences taught us the power of connection, belonging, and relationships.

Joining ECS meant that families were willing to share their time with us and to accept the vulnerability that comes when a new person wants to visit with them in their homes on a regular schedule for up to three years. The newness part disappears quickly as the mother and the home visitor develop their relationship. And to the mother’s credit, she begins to participate in the home visitor sessions, trying new ideas, using new resources, and providing information. Slowly, with open and honest communication, our mothers tell us that they begin to feel that they belong to a group that values her and her child. None of this happens without trust and valid connection.

The mothers frequently talked about belonging to ECS and about feeling safe and protected. During the pandemic, the mothers called their home visitors their lifelines.

What did this concept of “belonging” mean? For ECS, and no doubt for many other nonprofits, it meant making promises to those we served, promises of respect and caring, safety and trust—and keeping them. Whether mothers with new babies, seniors aiming to stay living in their homes, vulnerable youth, or another population served by a nonprofit, community-based organization, building trust, increasing safety, and keeping promises is fundamental to success.

The families prioritized the well-being of their children, were willing to learn and act on it in their daily lives, and wanted to be part of something bigger. They wanted to advocate for their children as they became more confident as parents, creating a good support system for themselves and their children. Families in ECS were wonderfully resilient, and by belonging to ECS, they were able to amplify their strengths. Moms voluntarily joined ECS because they wanted to learn and grow with a group of like-minded women, and they believed that becoming part of ECS had value. The ECS role was to ensure that their engagement with us met their expectations.

The Branding Issue

By 2018, we determined that it was time to refresh and reexamine our brand strategy and positioning in the marketplace. The environment had changed with new programs, improved program offerings, and funding opportunities from both Ohio and Kentucky health agencies. ECS home visits and enrollment had gone down 20% since 2016. We wanted to improve the appropriateness of our referrals, reduce the time from referral to engagement, and retain more families in the program once they joined. We saw our primary task as finding and engaging families.

Kay Johnson, consultant extraordinaire, quoted from Laurel Cutler, a branding leader, futurist, and advertising executive—in 1987 called by Inc. magazine one of Madison Avenue’s most powerful women (website of Inc., “Futurist Laurel Cutler”)—explained branding this way: “A brand is more than a visual identity, the name, logo and graphic design used by an organization. A brand is a psychological construct held in the minds of all those aware of the branded product, person, organization or movement. Brand management is the work of managing those psychological associations. In the for-profit world, marketing professionals talk of creating a ‘total brand experience.’ In the nonprofit world, executives talk more about their ‘global identity’ and what and why of the organization, but the point in both cases is that branding goes far beyond the logo.”

Challenges to Moving Forward with Branding

We felt ready to move forward and naively thought that we could base our next steps on what we thought were the answers to three primary questions:

1. What is the problem we are trying to solve?
2. What is our competitive advantage?
3. What strategies must we employ to regain awareness and market share?

But a candid and cautionary advisory email from two ECS board members with extraordinary marketing insight, Fama Francisco, CEO of Baby and Feminine Care at P&G, and Bryan Hamilton, formerly at P&G and now vice president of marketing and communications at Cincinnati Children’s, caused us to step back and reconsider what to do next. The P&G duo told us that we had two significant challenges to face before we began redesigning our communication materials—which should be the last step in the process, not the first. Addressing the killer issues was basic to the program and the board needed to be involved in decision-making.

The first killer issue was inadequate program funding. Like most nonprofits, funding streams cannot be taken for granted; new streams need to be identified and cultivated long before they may be needed. Could we find new sources of funding in the next six-to-18 months? Could we partner with another agency, privatize part of the service, determine how to do more with less, assume a smaller organization serving fewer families, something else?

The second killer issue was how to widen the funnel that brings new moms to us. In order to capture the target audience, an organization must cast a wide net. This should be done knowing that every contact will not end up in a successful partnership, but that those who are served by your organization need to move through smoothly. Do we understand what the current funnel looks like and why? Do we know how many moms we can really serve in a year? Do we have sufficient staff capacity? Are there other agencies or partnerships that could help to widen the funnel and achieve a win/win? Without clear answers to these questions, new communication materials would have limited impact. Further, they advised, when we do revise our marketing materials, they must be more consistent, have a more visible identity, use program language that isn’t so academic, that speaks to our target moms, and is crisp and actionable. The P&G pair urged a brand that is simple, differentiated, and unified.[pull quote]

We followed their advice, engaging the board and defining a path forward. On the money side, the Ohio Department of Health was willing to raise its funding rate, a small increase but an increase, nonetheless. We launched a successful philanthropic fundraising campaign and raised over $4 million, ending just as the COVID-19 pandemic began (website of Bethesda Inc. bi3, June 15, 2022).

For the referral piece, we renewed and expanded our efforts to engage moms both by working more closely with referral sources and improving our internal processes for enrolling moms once we had received their names. Limits on capacity, especially in a small organization, can have crippling effects on outcomes and success rates. Having enough home visitors continued to be a problem, and that was probably the single biggest operational deterrent to growth.

Following Francisco and Hamilton’s marketing guidance, we prepared a request for proposal (RFP) to hire a firm to help us create a consistent and easily understood ECS brand presence. It would be one in which our communication materials offered uniform language, logo, and messaging. We hoped to stand out among competing service providers and resonate with families eligible for our home visiting program and with our referral and funding sources.

The admonitions from P&G were apt and continued to guide not only what our marketing materials said but also to inform program growth. We could not promise what we could not deliver and without enough home visitors, mothers would be put on a waiting list. This would amount to poor service for the mother who wanted help now and would discourage referral sources who had been asked to make more referrals. This could amount to disappointing messages to a community whom we had asked for support.

The next step was creating the strategy to regain our leadership role. That is where hiring an agency became paramount. Like many other nonprofits we had limited money to spend on marketing/communications, and our dependence upon our own staff, freelance workers, and volunteer hours had led to the confused ECS image so clearly visible to our P&G marketing advisors. We determined that we needed to move beyond our piecemeal work to something more impactful and reflective not only of our achievements but also the services that came with joining ECS.

Time Warner

In the early days, television and radio stations would often accept public-sector social service messaging, but the nonprofit had to be able to create the video or the audiotape to be placed on the various channels. We didn’t have the money to even create what could become a public service announcement to send our message out into the wider world.

Soon after we opened our doors, Time Warner Cable (now Spectrum) stepped in to help. They produced four different public service announcements (PSAs) for us and aired them on a frequent and timely schedule. We estimated that the annualized value of the contribution was close to $300,000. We used their warm, nurturing spots to generate emotional appeal, making them part of a series so that one message could build upon another. The objective: Encourage moms to enroll in ECS and educate all moms in the community about the value of early nurturing for babies. As the PSAs were included in the Time Warner viewing schedule, two to three moms each day let us know that they learned about ECS through our public service announcements.

In addition to sponsoring our first annual ECS Mother’s Day party with hundreds of moms in attendance, Time Warner proved to be an exceptional conduit to TV channels, media coverage, Roadrunner, and other early forms of internet access. They helped us get coverage in Parenting and Baby Talk magazines and their own large monthly Time Warner printed (then!) TV schedule. We were even featured on the cover.

Time Warner joined other major Cincinnati area businesses, including P&G, the Kroger Company, Federated Department Stores, and Cincinnati Bell to support what became our large regional partnership. All of these companies and more were leaders in promoting a high quality of life in greater Cincinnati, and they saw ECS as a key to what we needed to do for families.

Dissemination of ECS to Other Communities

In 2007, as we began to assess our success and think about how we could expand our reach, we explored the possibility of taking our ECS program to other communities as our national presence grew, and other communities approached us about replicating our program. We couldn’t really call ourselves a “model” because we were not a model in the sense that the Nurse-Family Partnership, Healthy Families America, or Parents As Teachers were home visiting program models. But how else to describe our work? What we had was a regional operation delivering enhanced evidence-based home visiting through multiple community-based agencies. We had built what we had on the strength of what the model developers and other researchers had learned, and we hoped to make the services even better. One of our then board members and later board chair explained as we deliberated our dilemma that it was like putting good chocolate and good peanut butter together and creating something even better—the Reese’s Peanut Butter Cup.

We talked with contacts that we had at the Arkansas Children’s Hospital and made several trips to Little Rock to exchange information. Excitement was high. There seemed to be an opportunity to grow the existing Arkansas program using elements from ECS. We offered as benefits the business approach, the management structure for billing, marketing, data collection, evaluation, quality and system improvement, program and curriculum development, training, robust research, compelling outcomes, and the advantages of public-private funding. And the “products”—Bringing Literacy to the homes of birth-to-three-year olds, success priorities, maternal depression treatment, medical home protocol, and ECS enriched curricula.

Arkansas’s clinical pediatric leadership was especially intrigued with the involvement of our Cincinnati Children’s and how that relationship supported the medical center’s teaching mission, as well as research and community care. Ultimately, funding wasn’t available from private sources for either program delivery or administration, and the state policy makers decided to stay with the traditional models, even though there were significant reasons to make changes. Therein lies a challenge in the nonprofit world.

We also explored collaboration in our neighboring state of West Virginia, because its private-sector banking and community organizations approached us and were interested in what we were doing. I grew up in West Virginia, my father practiced pediatrics there for decades, and when he retired from private practice he became the state’s Director of Maternal and Child Health. I had written the West Virginia emergency medical plan as a graduate student. The West Virginia business leadership was seeking new programming for young children. Again, there were meetings, visits, and information exchanged and promises made. We had learned with Arkansas that we needed to be better prepared to ask the right questions:

1. What home visiting programs do you have that are designed to serve pregnant women and parents with children ages birth to three? What geography do you serve? Who is the organizer? How long have the programs been in existence? Are they affiliated with the national models? How many families are being served? How many home visitors? What is your annual budget and the sources of funding?
2. How has the state used the federal MIECHV funds to structure a home visiting system? What models are being funded with federal/state dollars? What requirements does the state have for local home visiting programs?
3. What is the level of need? How many at-risk moms? First-time moms? What is the infant-mortality rate in the geography you serve?

We moved forward at both sites with guidance and requirements from our board and our business advisors: Make sure that all costs are covered by the new communities, be sure that there will be no impact on the local program as we continue to grow our ECS approach. Do not add staff without a funding source, and be extra careful about how and when to formally transfer knowledge. Most important: make sure that there is tangible benefit to ECS-Cincinnati, preserving the quality of the ECS brand and ensuring that the organization will willingly comply with our transparency and data collection protocols. Measure performance and monitor standards.

What could we offer the new location? Surely, our know-how and best practices; our concentration on a system approach rather than on piecemeal components; research and scientific direction; a continuous quality improvement system; capacity to deliver multiple evidence-based home visiting models; the ECS service model, program, training and course materials; the eECS data platform; and the use of the ECS trademark and logo along with ongoing consultation and centralized shared services, just as we were doing with our disseminated but centralized ECS provider agencies.

A tangible benefit to ECS would be the ability to share central office costs, thereby freeing dollars to expand the number of families we could enroll in Cincinnati. We examined types of fee structures or a form of a franchise model, and although any profit margin would be small to nonexistent, we would be able to share overhead and thereby expand the number of families.

The value proposition was clear: The new community would receive a turn-key home visiting system with demonstrated best practices, established credibility, program enhancements, reduced start-up costs, and the centralized administrative functions at a fraction of the cost. For Cincinnati, we would have all dissemination costs covered, shared support for centralized functions, reinforced credibility for the ECS program itself, and opportunities to use additional national, state, and local funding sources.

We had proposed pilot projects in both Arkansas and West Virginia. But to move forward, the states needed to receive their appropriate approvals, and we needed to find a $300,000 grant to ECS to fund upfront costs for our first community (dissemination costs per community would decrease as more sites were added) and to hire an ECS business-development director to initiate dissemination tasks and to assemble a dissemination advisory board.

That did not happen because we could not find the $300,000 in seed money needed to get the project off the ground. The situation represents a good example of why nonprofits are typically unable to fulfill their potential for growth even when validation and opportunity are established and the need is clear. The funds were simply not available to us to go forward.[pull quote]

Program replication/scaling is not without enormous challenge. In Spring 2003, the Stanford Social Innovation Review published what I continue to view as the seminal work on the subject, “Going to Scale: The Challenge of Replicating Social Programs” by Jeffrey L. Bradach (2003). Here are two excerpts:

ECS has been driven by an entrepreneurial spirit from the beginning. I credit our private-sector guides for helping us to view the world with innovative ideas and creative problem solving. We always were looking for new information to improve our work and for new ways to share what we were learning with our colleagues. Certainly, our attempts to disseminate ECS to Arkansas and West Virginia are examples. There is a strong economic motive as well. Having new sources of revenue that are not dependent upon grants and donations means that the organization itself, in this case, ECS, could begin to move toward independence, at least in part. A program like ours will always need public monies for the service and private monies to augment the public funds. However, when there is an opportunity to generate new and additional revenue by selling a product or a service, the organization thrives, and its good practices are spread.

An Entrepreneurial Approach

As early as 2004, our business colleagues urged us to consider identifying and then leveraging ECS intellectual property that would be of value to others. By creating a strategy to sell the product or the process to other home visiting programs, we could generate new revenue for ECS.[pull quote]

As nonprofits struggle to find money to support their initiatives, they seldom can turn what they learn or what they create into products that they could provide to another organization. There is money (limited) for provision of direct service from both public and private-sector sources and sometimes there is money for operations (even more limited) but rarely is there funding for the seed money required to take expertise or a product to market and do two things: share something that is valuable and has been proven and/or create a new revenue source for the organization.

ECS faced this many times over the two decades when I served as president. Multiple times we sought to create products and/or programming that would not only bring new revenue to ECS but also disseminate findings that would be useful to the home visiting and early childhood system fields writ large. Examples of such products and services include workshops, training, consulting and mentoring services, manuals and tools for program planning and launch, and ongoing operation support. In addition, five programs we developed had the potential to improve and/or enhance other home visiting programs: the eECS data platform, the maternal depression treatment intervention called Moving Beyond Depression, the StartStrong community focus and activation strategy, the early literacy curriculum called Let’s Talk Baby, and the child development/parent awareness plan, Pampers University.

Moving Beyond Depression

Early into the deployment of ECS and as a result of our comprehensive data collection, we noted that nearly one-half of our mothers had measurable signs of clinical depression. Further, we knew from decades of research that when the mother was depressed, it was difficult for her to parent effectively; to be attentive, nurturing, and responsive to her child’s needs; to take care of her own needs; and to create a dynamic relationship with the home visitor (Ammerman 2017; Folger et al. 2017; Ammerman et al. 2012; Ammerman et al. 2010). Early relationships and, in turn, child development were affected, sometimes seriously. Too often, these moms lived in an environment where poverty, violence, underemployment, and social isolation were not only common but pervasive. Few of these mothers were able to receive treatment in their communities, even if sought, because of limited access to mental health services. In addition, many new mothers lost health coverage from Medicaid 60 days after the birth and had no means to pay for mental-health treatment. And even if there were a way to pay and a treatment was available, it was nearly impossible for the mother to even keep appointments given the real-life challenges of transportation, time off from work, and childcare availability.

A few years into our development, ECS scientific director Frank Putnam and ECS evaluation director Robert Ammerman began the work and the grant writing that led to the creation of our national ECS Moving Beyond Depression program, which linked effective treatment for depression with home visiting (Ammerman, Putnam, et al. 2012; Ammerman, Putnam et al. 2009). This new in-home cognitive behavioral therapy approach was designed to work in tandem with home visiting programs and had demonstrated significant positive results. ECS obtained funding from the United Way, three local foundations, and the National Institute of Mental Health for the research startup, two randomized clinical trials, and the creation of the infrastructure for program delivery.

Results for the mothers were gratifying, with 85% of mothers served experiencing a substantial reduction in depressive symptoms following the sixteen in-home treatment sessions (Ammerman et al. 2017; Ammerman et al. 2016; Ammerman et al. 2015; Ammerman et al. 2013; Ammerman, Peugh, et al. 2012; Ammerman et al. 2011; Ammerman et al. 2009).

Over time, with the effort in Cincinnati as the national model, programs in 11 states signed on to include Moving Beyond Depression as a part of their home-visitation offerings. However, the programs who purchased Moving Beyond Depression from us had trouble finding financial support. They used a variety of short-term solutions; they reported that the mothers, the therapists, and the home visitors were all pleased with the program results; but the organization simply had no way to pay for it. For ECS, we were not able to hire staff to find new clients, train the therapists, maintain the data file, and provide the frequent communication and training between ECS staff and off-site purchasers. Repeated visits with elected and appointed officials were disappointing, even as we explained why the service was needed and how effective it was. Invariably, they expressed support, but did not make money available and were unwilling to include Moving Beyond Depression as a part of the state-level supported home visiting programs in Ohio and Kentucky.

While some initially used the federal MIECHV program dollars for a short period, Moving Beyond Depression was disqualified as an evidence-based home visiting program under MIECHV, as other evidence-based mental health models have been, because it was considered more of a mental-health intervention. As a result, states were asked to stop using those funds. In addition, Moving Beyond Depression was being poorly accepted by public mental health authorities as an appropriate use of their funds because it was delivered in homes rather than in clinical settings. Further, as mentioned previously, in many states 50% to 60% of women who had a Medicaid financed birth lost their coverage at the end of 60 days following the birth (postpartum) and had no health coverage for this or other mental-health treatment. While many states were launching early childhood mental health projects, most did not include the pregnant women in these efforts (Willis et al. 2021; West et al. 2020).

This was another opportunity lost for those who needed the service and the children who needed engaged parenting. Optimistically, we can see that as states use their option to extend postpartum Medicaid coverage to one year, perhaps a new window of opportunity is opening to deliver Moving Beyond Depression and successfully treat perinatal depression in conjunction with delivery of home visiting model services.

StartStrong

The StartStrong program (as described in Chapter 5) tells a different but similar story. In 2018, ECS and Cincinnati Children’s responded to a request for proposal from the local foundation Bethesda Inc. for a bi3 grants initiative to transform health. They were offering sizable funding for organizations who could engage families, communities, health systems, and physicians to transform the current system of care and improve birth outcomes.

We felt this work was just right for us at ECS and so did the community component of Cincinnati Children’s. Unaware the other was making similar proposals, the Perinatal Institute at Children’s and ECS both wrote proposal letters. Upon receipt of the two proposals, a representative from the funder, Bethesda Inc. bi3, wisely came to each of us asking, “Why can’t you work together?” Of course, they were correct (collaboration again). We revised our two proposals into one and received a three-year $3.2 million grant, and Cincinnati Children’s agreed to match the Bethesda Inc. bi3 contribution.

Partners for this collaboration included Cincinnati Children’s, ECS, and Tri-Health/Good Samaritan Hospital. The goal was to determine how to bring down the unacceptably high infant mortality rate in our community.

It took nearly the first year for us to determine how to work together—new leadership, new committees, new work plans—coordinating data systems, identifying outcomes to be monitored, materials that would be needed, and sites where the work would occur. The activity was neither rancorous nor obstructionist. Rather, to paraphrase from Johnson’s ECS Occasional Issue Brief, No. 4, August 2018, “The planning was complex with many players and partners . . . establishing the structure, the roles and responsibilities had to happen before we could begin delivering the program.” Besides and ironically, we had to agree on a name, and that took longer than one would expect, but StartStrong eventually won out.

As year three ended, the program was running smoothly. We were coordinating our approach to engaging families, communities, health systems, and physicians. We were transforming the system of care and reversing trends in birth outcomes in the Avondale community by using dedicated nurse managers, evidence-based home visitors, trusted community health workers, physician champions, and supportive hospital administrators. Families played a more active role in defining what they needed and wanted. Focused on the perinatal period, we were positively impacting the lives and health of mothers and babies, making care more person-centered.

Results? The Avondale infant mortality death rate dropped from 21/1,000 live births to 8.6/1,000 live births. There were fewer preterm births in Avondale and no extremely preterm births (less than 28 weeks) in the two-year period. Costs for hospital care for preterm birth were reduced by more than $1.3 million over the three years.

So, the logical questions include: What happened next? Did this grow? Were learnings reapplied? The answer to the latter questions is no, with a few exceptions: families were more often placed at the center of the planning, structural changes at the hospitals continued, ECS incorporated the perinatal curriculum we wrote for this project home visitors, and community health workers continued their cooperative relationships where they existed. But the funding ended.

While StartStrong continued to exist in name, the program effectively closed, and a great opportunity was missed. We had planned to add a second community, Price Hill, but that work barely began when year three ended and the funding door closed. The gains did not hold.

However, and this is important, Bethesda Inc. bi3 leadership highlighted the long-term positive effect of the StartStrong program that led almost a decade later to lowered infant mortality rates in Hamilton County. This accomplishment, they stated, stemmed from the work that began with StartStrong.

So, Bethesda Inc. bi3 did two remarkable things: first, they insisted that two like-minded grant applicants work together, and second, they worked with Cincinnati Children’s to provide sufficient funding for the grant to identify and implement strategies that could be reapplied across our community. Grants are not meant to sustain programs over time, rather, they are there to provide the seed money for testing, for piloting, for determining what can work. Would we have liked another year or two of grant-funded activity? Certainly, but we learned enough in those three years to make a difference, and that counts.[pull quote]

Once the work was complete with the private sector, the public sector could have stepped in to build upon what philanthropy allowed us to demonstrate. We kept good records. We validated our experience and our findings. We knew what to do next and we were eager to teach others. We responded to a need, and we found solutions. As with the home visiting and pediatric primary care partnership, this innovation, in the form that we delivered it, fell into the cracks between siloed systems.

Philanthropy did its part, allowing us to test and pilot, but even though we had robust health and economic outcomes, we had no way to grow the program and allow more families to benefit.

As maintained throughout this book, health and social-service problems cannot be solved with funding from short-term philanthropic contributions or government siloed and limited resources. Even with new payment approaches in health care, such as accountable-care organizations or value-based payments, it is not clear that something as broadly conceived as our StartStrong demonstration project, or the primary care and home visiting collaboration, will be funded with payer dollars from health plans. Federal policy proposals for locating child development experts in primary care clinics might result in new funding and make a difference. But even with new investments in childcare, the focus will not be on improving the quality of parenting and relationships in the first three years, and there is still not a focus on expanding home visiting federal dollars.

Let’s Talk Baby and Pampers

The Let’s Talk Baby project began as a part of our scientifically researched early literacy program and provided language and literacy training for all ECS families via their home visitors. We wanted to make sure that ECS parents not only understood the importance of language and early literacy development for their children, but also were encouraged to talk with their children early and often, reading to them at least three times per week. Through our volunteer-initiated Bringing Books to Babes program, we were able to ensure that there were age-specific books in the home by distributing more than 14,000 developmentally appropriate books each year to ECS enrolled families. The home visitors were asked to observe and document language and literacy skills as a part of their regular visits, and many of them reported back that the toddlers greeted them at the door and were eager to get their new books.

In 2014, we developed Let’s Talk Baby, an early language-learning app to promote parent-child interaction and optimize early childhood development during the critical period of brain development, birth to age three. Parents received two weekly activities on their mobile device or computer. The app had a mechanism to provide feedback to the parent. P&G funded the development of the app, and Cincinnati Children’s supported the creation of the web platform. The plan was to test the app with Pampers’ rewards members. Our promotional video described it this way:

Informed by research and backed by ECS’s proven track record for positively influencing parents and young children, Let’s Talk Baby was a tool to help parents create a nurturing and stimulating relational environment, essential for the first three years of life and beyond. Parent Talk Tips, activity handouts coordinated with the Let’s Talk Baby app, were provided to families by the home visitors at every visit, beginning with the first infant visit at week one. Each parent tip had three elements: the suggested activity, an example for the suggested activity and age-appropriate developmental information for the parent. Parents were encouraged to talk and talk and talk with their child—it is never too early. Narrating life to a baby matters. Hearing words matters. Reading is crucial.

As we began to work with P&G to consider how Let’s Talk Baby and the Parent Talk Tips could be coordinated with Pampers sales, we were excitedly optimistic. Suddenly we saw ourselves as a provider of information about early childhood conveyed through national, even international sales of Pampers diapers—maybe messages on the boxes?—thousands of boxes with the ECS logo, maybe through a website, maybe through the Pampers Rewards program, maybe cited as an authority for the “your baby’s stages of development record book” that Pampers distributed to their moms.

We had a good product that had been professionally developed and tested with our ECS home visitors and moms. In my mind I was calling this Pampers University and the curriculum was Literacy 101. We had reasons to believe that a personalized literacy curriculum would be appealing to parents at all economic levels because parents were telling us:

• “My life is too busy. I don’t have time to figure out how to find resources to meet the literacy needs of my baby.”
• “There is almost too much information on the web, in books and periodicals.”
• “I need to know what to do for my baby on a regular basis, but not for babies in general.”
• “I want a reliable source of information that is credible and of the highest quality.”
• “I want to be the best possible mom.”
• “For a small amount of money, I can make sure that my baby gets the best possible start.”

Seeing the potential, we worked on this for months with a talented team from P&G. Eventually, to our disappointment, it didn’t work for several reasons, but first among them was the fact that the ECS brand did not have adequate currency outside of our service area. P&G knew that what we were proposing together had value, but in the end, it wasn’t compelling enough nor distinct enough to warrant further investment. Early literacy materials with our enrolled ECS families continued, but our dream of a wider play became simply that, a dream.

Home Visiting as a Benefit for Employees

Several years before I stepped down as president, we began to talk about the possibility of offering an ECS type product for employers. Understanding that middle-class mothers shared many of the child-rearing and development issues that we address with our challenged moms, we talked with several large employer benefit managers about purchasing ECS home visiting services and making them available to their employees as part of a benefits package. We were aiming for middle-to upper-middle-class moms who had jobs and, if they were married, so did their partner. They would have a new baby, probably daily day care, could spend limited time with their children, but like our moms, they wanted to be good parents. They wanted to give their child the best possible start. They wanted guidance and often lived far away from their own extended families. Some had their own adverse childhood experiences or stresses that they wanted to avoid with their own children. We had the experience, the curriculum, and the tools to help them.

Debbie Vargo, a retired P&G executive and a past ECS board chair, agreed to investigate the possibilities. I asked her to identify critical questions and possible strategies to determine whether employers and benefit managers would see an evidence-based home visiting option as a value for their employees and whether there would be a revenue opportunity for ECS.

Relying on her P&G background (Cincinnati is fortunate to have such people), Vargo developed a working-knowledge template that organized the key questions into the following categories: finances, population, selling proposition/concept, curriculum for paying parents, curriculum options beginning prenatally and continuing for three weeks, six weeks, twelve weeks, six months, a year? She suggested that we work with one of our provider agencies to test the concept. We agreed that offering the benefit through an employer was more realistic than trying to sell and serve an open-market population and trying to enroll one family at a time.

Vargo reminded us that her approach would be to address the killer issue first—the P&G approach to problem solving. Solve the hardest, most limiting factor first and don’t address any of the easier issues until later. Vargo believed that the killer issue for this endeavor may be whether new parents would pay the relatively high cost.

We were never able to do even the preparatory work to pursue this concept. Our volunteers offered guidance, but again, we needed staff and seed money even to conduct a pilot. It was another good idea unfulfilled, both for the services that it could have provided for the target population and for the potential revenue that could have been generated to add more at-risk families.

Lessons

1. Focus, focus, focus. Write a realistic business plan to deliver services and to sustain the operation. The plan must be flexible yet stable. (The ECS plan, written nearly 24 years ago, was amazingly prescient and was guided by our business-leader partners.)
2. Find business sector partners who believe in your mission and will foster your success. Understand that dedicated involvement of the business community can accelerate success by emphasizing return on investment, entrepreneurial thinking, focused activity, accountability, transparency, and marketing.
3. Take advantage of private sector and business involvement when possible. Collaborate with like-minded organizations and people as often as possible. Seek partners that share your understanding of the mission and its value. Learn from people across sectors.
4. Don’t automatically say no to new ideas and/or challenging opportunities. Weigh the potential advantages and disadvantages. Find a path for making changes that will improve services and outcomes. Get to yes.
5. Build upon documented successes and what works for your field, for your nonprofit. Stop doing what is not working. Document how and why things worked and use those lessons to improve. Do not over-promise but always strive to over-deliver.
6. Make investments to support the mission, not to make or save money. This distinguishes mission-driven nonprofit work from for-profit business endeavors. Many businesses are often accountable to shareholders and under additional pressure to generate a profit. Help your business partners and funders understand this distinction.