Healthy Tomorrows Partnership for Children Program in Review: Analysis and Findings of a Descriptive Survey, 1999

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History of the Healthy Tomorrows Partnership for Children Program
In 1989, the Healthy Tomorrows Partnership for Children Program (HTPCP) was initiated to engage communities in working to improve children's health through prevention and better access to health care. The program is funded by the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA). It is administered by MCHB in partnership with the American Academy of Pediatrics (AAP).

HTPCP was designed to provide communities with seed money to identify and address pressing local problems. A unique aspect of HTPCP, and one that dis-
tinguishes it from other MCHB programs, is the partnership that was developed with the AAP. The concerted effort to blend public health resources with the knowledge and skills of the pediatric professional community is the hallmark of HTPCP.

To date, 107 projects nationwide have been awarded 5-year grants, of which 54 have
completed the federal funding cycle.

The HTPCP evaluation is part of MCHB's larger effort to document the impact of its investment in Title V Block Grant programs and its discretionary grant programs. In particular, MCHB is interested in measuring the impact of the Special Projects of Regional and National Significance (SPRANS), which comprise an array of demonstration, research, and training grants.

Executive Summary

HTPCP Goal Number 1: Use innovative and cost-effective approaches to promote preventive health care among vulnerable children and their families, especially those with limited access to quality health services.

The clients of the HTPCP are women and children, 96 percent of whom either have no insurance or are Medicaid recipients. HTPCP grantees represented in this survey initiated a broad range of activities to meet the health needs of the children and families they served. New case management services were the single most common component added: Fully half of grantees reported that they initiated case management as part of their HTPCP project. Projects used a variety of settings to reach their clients: homeless shelters, clients' homes, elementary and high schools, and recreational centers, as well as community clinics and hospitals; all projects stressed coordination and linkage.

To capture insights about the impact of HTPCP projects in their communities, the questionnaire solicited open-ended responses on the perceptions of the project
directors, who reported a wide range of successful outcomes.

One noteworthy aspect of the HTPCP projects is the attention devoted to cultural competency. Cultural competence is especially important to the HTPCP program since the projects serve a racially and ethnically diverse population.

HTPCP Goal Number 2: Foster cooperation among community organizations, individuals, agencies, and families.

HTPCP projects generally attempted to work collaboratively in three venues:
(a) developing partnerships with a core of direct service partners;
(b) establishing a community network; and
(c) selecting influential persons to serve on an advisory committee.

Projects involved a broad array of partners -- in fact, half the grantees had five or more partners with whom they worked toward local program goals. Many grantees found this aspect of program development challenging and at times frustrating, and yet most grantees ultimately concluded that it was extremely important to their project's success.

HTPCP Goal Number 3: Involve pediatricians and other pediatric health professionals.

The majority of projects reported that they had pediatricians on staff; about half of the
project directors were individuals with medical degrees. Other types of providers were
also utilized, including nurses, social workers, psychologists, health educators, and nutritionists.

This survey suggests that HTPCP projects are successful in integrating a variety of health professionals into the program and that leadership positions are held primarily by pediatric-trained providers.

HTPCP Goal Number 4: Build community and statewide partnerships among professionals in health, education, social services, government, and business to achieve self-sustaining programs.

Goal number 4 stresses partnership building in the context of project sustainability. In fact, these projects were quite successful in leveraging funds during the period of the grant and in achieving a permanent service in the community. During the period FY 1990 to FY 1997, MCHB invested $15.95 million in these projects, which in turn leveraged a total of $67 million.

Questionnaire data from projects that had either completed their grant or were in the last 2 years of funding found that most had secured long-term funding. Those
projects directed by nurses or Ph.D.s were much more likely than those directed by M.D.s to use state or other federal sources of reimbursement to sustain their pro-
jects, while the M.D. group tended to solicit contributions from local sources, to contract with managed care organizations, and to merge with the local system of
care.

In sum, HTPCP grantees appear to be successful in forging partnerships that lead to additional support for children's health and the long-term sustainability of services, but their approaches to doing so vary.

Project Evaluations
HTPCP grantees are required to evaluate their projects. Few grantees attempted an
outcome evaluation, but most did undertake a process evaluation and monitored their own progress toward meeting project goals. A few grantees noted that the evaluation process had a positive, transforming impact on their agencies, but most found that their evaluation resources were very limited and that technical assistance was not easily available in this area. In short, grantees indicated considerable frustration with this aspect of their grants.

Program Oversight and Technical Assistance
A single federal staff member is responsible for implementing and monitoring the HTPCP. The creative MCHB/HRSA/AAP partnership has served both to enhance the support of and technical assistance for the HTPCP projects and to secure additional resources. Grantees gave high ratings to the technical assistance they received from MCHB and the AAP.

Conclusions
The HTPCP appears to be an effective strategy for promoting children's access to health services at the community level. The HTPCP has clearly enhanced community-based service programs by creating new services and adding
components to existing programs.

Modest funding provided to community organizations, with a matching fund requirement, can leverage significant amounts of money for children's health care. HTPCP grants are quite small by federal program standards. Yet, this amount appears to be adequate both to provide a valuable service and to attract additional funding.

The HTPCP includes elements that successfully foster the long-term sustainability of services. The match requirement forces grantees to begin searching for additional
funds immediately. At the same time, grants are funded for a long enough period (5 years) to both demonstrate success and value locally and enable grantees to develop the relationships with other groups that are needed to secure the resources that can sustain the program.

Small, community-based projects do not have the expertise or resources to conduct outcome evaluations. Valid outcome evaluations are challenging and expensive to
conduct. Expertise in evaluation design is costly and may be difficult to acquire.
Meaningful multiagency partnerships and collaborations can greatly improve the delivery of services for children, but they are challenging to develop and attempts to do so frequently fail.

Most HTPCP projects ultimately developed what they considered to be effective and productive partnerships that project directors believed critical to the success of their projects. However, many difficulties were encountered in developing these relationships.

Pediatricians and other pediatric health professionals, when provided with support through a mechanism such as a grant, can serve as leaders and advocates in improving children's access to services. Advocacy efforts on the part of HTPCP
granteesÑprimarily pediatric health professionals led to improved service components, permanent changes in local services, and new dollars for children's health.

The activities of staff at the federal level and at the AAP provide important guidance and leadership to HTPCP projects and contribute to the program's success. Projects
received care and feeding from a variety of both public and private sources. The overwhelmingly positive response of projects to the technical assistance they
received points to the effectiveness of this approach.

Recommendations

• Continue the programmatic focus on cultural competence. Continue to emphasize different types of partnerships with multiple groups. Consider the provision of intensive training in coalition building and partnership development for project staff within the first 6 months of the grant award.
• Continue to require outcome evaluations and provide training and/or special technical assistance materials within the first 6 months of the grant award.
• Consider adding community performance monitoring requirements for some projects to assess the usefulness of this approach to improving children's health care.
• Continue the partnership with AAP.
• Increase the technical assistance capacity.
• Increase staff at the federal level.
• Consider linking with State Children's Health Insurance Programs (SCHIP).