Sustaining AF4Q Efforts

Between 2007 and 2015, Alliances received four rounds of funding from the Robert Wood Johnson Foundation, with approximately $64 million awarded directly to communities. Recognizing that health system transformation is an iterative process, an essential component of the AF4Q work was to identify alternative funding sources and opportunities for revenue generation, to ensure the innovative work occurring in each community continues beyond 2015. The ongoing impact of AF4Q and the ability to further AF4Q goals will be dependent, in some part, on how well Alliances demonstrate, produce, and articulate tangible value to stakeholders—physicians, hospitals, health plans, consumers, purchasers, and employers. Building Alliance and community capacity, knowledge, and skills to sustain the work of AF4Q has been an ongoing priority. At the conclusion of the program, each of the 16 Alliances was at a different point on the path toward sustainability. Many struggled to balance the day-to-day activities defining their organizations with the foundational work that is required to sustain these activities.

Although all Alliances worked to improve the quality and value of health care, their approaches and execution varied according to organizational characteristics, market composition, available data, agenda-setting choices by Alliance staff and stakeholders, and local needs. As the Alliances evolved and matured over the course of the program, each approached programmatic goals in a different way. As a result, each Alliance’s impact beyond 2015 is taking a distinct shape. Some are adept at data analysis, while many embody the role of neutral convener in otherwise polarized communities. Others have robust quality improvement programs in ambulatory or hospital settings. Sustainability can take on many forms, especially in light of the varied approaches pursued by each of the Alliances.

Measuring and reporting the quality of care that doctors and hospitals deliver is a cornerstone of regional health care improvement. To do this, Alliances collected and aggregated data across multiple sources for use in public reporting, quality improvement, and payment reform. Alliances were formed around this portfolio of work with the understanding that stakeholders—consumers, providers, plans, and employers—need access to uniform, actionable data in order to affect change.  But data alone are not valuable. Many Alliances created value by aggregating data across payers and systems and analyzing the data to facilitate quality improvement and payment reform strategies.

Improving health care quality and value requires targeted clinical quality improvements and transformative change to delivery and payment systems. Alliances supported providers in these activities through knowledge transfer and use of their rich data sets. Knowledge transfer activities can include leading learning collaboratives, exchanging best practices, facilitating agreement on new models of care delivery, piloting new models, and spreading successful ones. Establishing or augmenting the capacity to conduct ongoing and meaningful quality improvement in a region is a complex undertaking. Financial resources and staff must be dedicated and quality improvement viewed as one of the Alliance’s core functions by its leadership and board of directors. Throughout AF4Q, Alliances subsidized the cost of providing quality improvement services to health care providers using grant funding.  Alliances are now faced with the challenge of transitioning services formerly provided at no charge to a fee-based business model.

Several Alliances developed capacity to create a line of business around the provision of quality improvement services to health care providers. While not yet fully sustainable, ultimately, they hope that providing quality improvement could eventually become an income stream that contributes to sustainability.