Overview

In this chapter we present a step-by-step approach for getting the community involved in the site development process. Involving the community early on in the process is critical to the success of the site development.

A "community," in the context of this manual, includes a group of people who share a common set of values or directions that may be defined by a common geographic area, such as a county or grouping of counties, a cultural grouping such as Native Americans or an economic grouping (homeless). It can also be a single entity such as a hospital or ambulatory clinic serving a specific population.

COMMUNITY EMPOWERMENT

To empower a community in relation to primary health care is to give it the power or authority to make choices and decisions about the system of care it creates and sustains in its community. It means enabling a community to determine what they want in a primary health care system and how that system is to be organized. It does not mean that "outsiders" or a single inside entity direct a development or improvement effort. Impetus needs to come from the community itself. This concept of community empowerment is critical to the success of a primary health care system and is a central theme upon which this manual is built. Wherever possible, the manual discusses strategies that will lead to and facilitate community empowerment and ownership of both the process and outcome of a system of care.

COMMUNITY PRIMARY HEALTH CARE COUNCIL

There is no "best" approach to organizing a community to develop or improve a system of primary care. Factors such as timing, community stability, past experiences and stakeholder involvement all influence the starting point of an initiative. Therefore, there is no one approach that will work for all communities. Every community must create a structure and design a process that takes into account its local needs and conditions. The National Civic League's Healthy Communities initiation structure and process offers one model of a successful and proven approach. That model, with some modifications, is outlined here.

A Community Primary Health Care Council can be formed, comprised of 10 to 15 people who are willing to lead the initiative and invest a significant amount of time during the development/ improvement phase. The Council needs to be comprised of individuals who represent the community and the various stakeholders in an acceptable and well-balanced manner. There is no "sure fire" formula for a successful Council but one must consider and ensure the diversity and credibility of the group. Exhibit 4-1 presents suggested questions to use when preparing a list of candidates and identifying representative groups to consider for a well-balanced Council.

COUNCIL ROLE AND RESPONSIBILITIES

The role of this Council is multifaceted. However, its primarynd purpose is to design a structure and process that will lead to decisions about the development or improvement of a primary health care system. The Council will undertake the following tasks:

• Setting the overall time frame for action;
• Identifying and securing needed resources;
• Defining a structure and the roles and responsibilities of persons involved;
• Outlining the process for development/improvement;
• Creating a structure and process for community involvement;
• Engaging staff to undertake administrative and other functions; and
• Securing meeting space.

Exhibit 4-2 presents a schedule which identifies some of the major activities and tasks that will be undertaken during the development process and suggests realistic timing for these tasks. Recognize that each community will need to review and modify this schedule to suit its own particular needs. It is offered only as a discussion tool for communities and it is not intended to serve as the only model for defining the timing of specific development activities.

Experience has shown that a comfortable schedule for the planning phase is to have the Council meet once every three weeks over a 10 to 12 month period. However, this time frame will need to be adjusted to accommodate the nature of the community's effort, local scheduling realities, and the urgency surrounding the need for developing a site.

PRIMARY CARE SYSTEM ADVOCATE

Every project needs a champion, someone who strongly believes in what is being proposed and can encourage others to put their faith and resources behind the idea. This person has the capacity to lead, communicate, inspire, embrace, strengthen, uphold and reinforce what is intended by the community and spearheaded by the Council.

Without focusing on the pure definition of the word advocate, we are, calling this person the Primary Care System Advocate. This could be a volunteer or a local person hired by the Council to work on the project until the development plans are in place and the doors of the primary care system are opened. The Advocate's role beyond this point, if any, will be determined by the Council and depend on the specific needs of the community.

The Advocate is to work with the Council as the primary staff person with an emphasis in four areas:

• Increasing the community's awareness about primary care needs;
• Involving the community in decisions about primary care and the system to deliver the care;
• Providing community and Council education regarding primary care; and
• Facilitating the primary care site development process.

The Advocate will assume primary responsibilities in the following areas:

• Organizing the Council and Subcommittees, if any;
• Serving as the primary liaison between the health care community and the Council;
• Assisting in data collection and other research efforts;
• Gathering information from and disseminating information to the community;
• Providing the Council with necessary training and resources to carry out functions;
• Building relationships with other health organizations, primary care associations and universities; and
• Coordinating the required technical assistance.

The Primary Care System Advocate will be critical to the success of the project. Therefore, it is important to recruit the "right" person to the position. The successful Advocate has experience in the areas of planning, public relations, public policy and health care. It is an individual who:

• Is from and respected by the community;
• Has no vested interest in the outcome of the project;
• Can get the community to rally around the issues; and
• Can facilitate a change process and get others to reach consensus on sensitive issues.

The Advocate must be someone who is committed to seeing the process through from start to finish. This position, given its limited duration and part-time status, may be attractive to individuals who are retired, reentering the work force or volunteers interested in some compensation.

INITIATING CONTACTS

Early in the process, it will be important to identify individuals critical to the success of a primary health care site and begin to develop a relationship with them. Developing relationships early in the process will minimize "the unknown" in the development process and will enable the community to quickly address all of the planning issues. This relationship will allow the community to inform and educate others about its process and also to reach out and solicit ideas, concerns, feedback and support regarding their ultimate plans.

Groups of individuals likely to impact the success of the project include:

• Regulators such as health care licensing boards;
• Primary Care Associations;
• State Primary Care programs;
• Offices of Rural Health;
• Health care providers;
• Social welfare programs;
• Decision makers such as local, county, state and federal politicians; and
• Funding agencies and sources such as foundations that have supported health projects in the past include the RWJ Foundation, http://www.rwjf.org, and the W.K. Kellogg Foundation, http://www.wkkf.org. Additionally, a copy of the publication entitled Rural Health Services Funding: A Resource Guide (September 2002) may be obtained from the Rural Assistance Center at (800) 270-1913 or alternatively downloaded from the following Web site: http://www.raconline.org/pdf/healthguide.pdf.

FINDING PROJECT WORK SPACE

A simple question with a less than simple answer is where the Advocate will conduct day-to-day activities when s/he is working on the project. Several options are possible:

• local hospital;
• nursing facility;
• Chamber of Commerce;
• Government office;
• school district offices;
• senior centers;
• church offices; and
• county extension offices.

Each of these options has its advantages and disadvantages and the final decision is likely to rest with the Council. The challenge is to find visible public service space that is perceived as "neutral"-a place where the Advocate can access needed office equipment, such as photocopier, telephone, facsimile, word processor and supplies. Also desirable is a location that is equipped with rooms capable of accommodating Council meetings. It is expected that the host organization supports the primary care site development initiative.

ESTABLISHING EXPECTATIONS

One of the first tasks of the Advocate is to bring together the community and the Council in establishing goals and expectations for the project. The National Civic League has identified several key success factors in any community based process. One of these factors is to reach consensus on all desired outcomes whenever possible. This means that very early in the process, there is a need to create a shared vision, one that will unite the community and spur it forward on its journey towards an ideal system of primary health care.

According to the National Civic League, a vision is the dreams, hopes and desires of the entire community. It is the ideal future state resulting from the community's combined effort and it is the first step towards building the path to reach a specific destination. It is important to create the vision, to provide a focus that gives the community direction and builds the foundation for determining priorities and strategies to reach the ideal state. A vision is also necessary as a vehicle to get the community to buy into the need for or improvement of a primary health care system. Further information about the National Civic League and its resources for community development may be obtained from the League's Web site http://www.ncl.org or by calling its national headquarters at (303) 571-4404.

BUILDING A VISION AND ESTABLISHlNG GOALS

The Healthier Communities Action Kit developed by The Healthcare Forum identifies five steps to building a vision.

1. Problem Identification - let the community talk about its dissatisfaction with the current system and help them articulate the specific problems or issues they face.
2. Past Successes - get the community to talk about past successes in order to identify factors useful for the future and to minimize the dissatisfaction that can be generated in the earlier stage.
3. Future Desires - give the community permission to imagine the best that they can expect from a primary health care system using tools to suspend their assumptions about the past and current system.
4. Measurable Goals - take the future state developed in the previous step and layout those goals that will help the community reach its vision. Focus on identifying all of the pieces and how they fit together.
5. Resources to Achieve Goals - finally, this step focuses on defining the steps necessary to take the community from its current state to its desired end. It provides the path to change.

See Exhibit 4-3 for a list of key ingredients necessary to create and achieve a successful vision.

COMMUNITY SUPPORT

Key to the development of the vision, regardless of the outcome, is the involvement and support of the community. The more involved they are in its development, the more vested they are in the project and the more likely they are to ensure its success. Several strategies exist for gaining community involvement, such as:

Town Meetings - large gatherings where everyone is encouraged to attend, listen to what is happening and offer their views on the subject. An effective meeting requires sound advertising in advance including press releases, flyer distributions, and information dissemination by Council, Committee and other involved parties. Neighborhood meetings can accomplish the same objectives with smaller sections of the city or town.

Focus Groups - small gatherings of eight to twelve persons representative of the group to be involved in the process. The group is facilitated by an objective person who gets them to focus on specific issues or questions that are developed in advance.

Community Survey - a questionnaire designed to solicit input on specific aspects of interest. Keep the survey simple, short and easy to complete.

Interviews - meetings with providers and health agencies to discuss the overall effort. Whatever strategy is used must take into consideration the various cultural groups represented in the community.

SUCCESSFUL COMMUNITY/HEALTH SYSTEM STRATEGIES

Readers wishing to further explore a variety of community development success stories from various parts of the country are invited to familiarize themselves with a W.K. Kellogg-supported initiative entitled Community Voices at http://www.communityvoices.org. In addition to general information about the Community Voices initiative, the site contains links to 13 Community Voices projects located in both urban and rural areas, such as Denver, New York, Baltimore, El Paso, Miami, West Virginia, New Mexico, etc. Each project has a unique story which conveys a strategy to empower community change to solve health related problems.