Like many funders, The Duke Endowment supports cohorts of grantee partners to facilitate shared learning, build community networks and create a collective voice for advocacy. Our cohort work is rooted in the understanding that making broad and lasting change in complex social problems like access to health care requires stakeholders – such as community leaders, nonprofit organizations, public agencies, advocates and others – to connect deeply with one another. Cohorts create and foster those connections at a personal level.
As they learn and work together, our cohorts teach us vital lessons as well. To demonstrate these learnings, we’re sharing lessons from two of the Endowment’s multi-year cohort-based programs: our School-Based Oral Health initiative and Healthy People, Healthy Carolinas.
The oral health initiative was a five-year investment begun in 2018, co-funded with Blue Cross and Blue Shield of North Carolina Foundation and BlueCross BlueShield of South Carolina Foundation to support five 10-member cohorts to provide oral health prevention and treatment in schools. Since it began, initiative participants have provided 130,000 preventative services to more than 7,000 children each year.
Healthy People began in 2015 as a decade-long commitment to support diverse, multi-sector coalitions as they implemented evidence-based, evidence-informed, and promising programs that address chronic health issues. Their effect on community-level changes was tracked and evidenced by the introduction of 324 policy changes, 800 infrastructure changes, and 1,082 system changes. Examples of these changes include school-wide policies that integrate physical activity into curriculum, the addition of walking trails at local parks and the implementation of employee wellness programs. Healthy People has grown to include four cohorts with a total of 33 coalitions at work in over 48 counties in North Carolina and South Carolina.
The lessons we have learned from each of these programs illuminate six elements that we believe are essential for cohorts to be effective. These are:
- Leadership Buy-in and Continuity
- Technical Readiness
- Curriculum Development
- Hands-on, Ongoing Support
- Peer Connection and Voice
- Data and Evaluation
Leadership Buy-in and Continuity
Securing leadership buy-in for cohort participation is absolutely critical. We learned the importance of taking time early on to explain the history and reasoning behind a cohort’s proposed work to the leadership of all participating organizations – and to patiently repeat this process when leadership changes or priorities shift. One school-based oral health program was on pause for more than two years after a leadership change, but our team checked in every few months and reconnected when a new leader came in with aligned priorities allowing us to resume our work together.
We also learned to engage with the leadership of all key stakeholders outside of the cohort. For Healthy People, we encouraged our emerging cohorts to take time to think about who other potential stakeholders might be, and to connect with leaders there. Our Healthy People cohorts gained greater alignment as a result.
Technical Readiness
Technical readiness is not the same as eagerness or willingness. In our oral health initiative work we learned that some partners who thought they were ready often could not collect or share the data they thought they could. Within Healthy People, readiness had more to do with cohort knowledge and capacity to work with local data and assets documented in Community Health Needs Assessments, while also identifying activities already underway through Community Health Improvement Plans to avoid duplication of effort.
For both cohort programs, we realized that all of us – funder and funded partners – needed to slow down to determine what “readiness” really meant. In doing so, we learned that achieving readiness often requires that key cohort elements are in place at a project’s onset, such as curriculum and technical assistance. Understanding the critical importance of this, we added an extra year of funding up front for both programs to focus on readiness. This was a lesson in patience – and one particularly challenging for funders working in shorter 2 – 3‑year cycles – but investing in a year of readiness paid off in terms of effectiveness, building relationships and trust.
Curriculum Development
Getting on the same page is important. A curriculum provides a consistent experience, common language, and shared knowledge for all cohort members. We developed curricula for both the oral health initiative and Healthy People in conjunction with subject-matter experts and on-the-ground practitioners. The North Carolina Healthcare Association and South Carolina Hospital Association supported curriculum development for Healthy People focused on evidence-based programs and data that address chronic diseases. This curriculum is delivered by coaches working with each Healthy People collaborative. East Carolina University and the National Association of Young Children, meanwhile, designed a 15-component video curriculum for school-based oral health that is coupled with group assignments and in-person technical assistance coaching.
Hands-on, Ongoing Support
As they learn and work together, cohort members benefit greatly from the guidance and insight of others. Both Oral Health and Healthy People participants receive coaching through regular calls and in-person meetings. Coaches share experiences and information tailored to each cohort member’s needs, with a goal of each member working with the same coach throughout the process.
Later, as our first cohorts reached the end of their implementation funding periods, we learned that peer and professional mentoring are solid strategies for keeping members engaged, and for leveraging the wisdom and insight of mature cohorts to fuel newer ones. Healthy People added an extra year of support at the end of its first cohort program for mentoring. For oral health, the Endowment supported the establishment of the School-Based Oral Health Institute at the Medical University of South Carolina (MUSC), which contracts with peer coaches who continue to mentor former cohort participants.
Peer Connection and Voice
Peer connection and voice create the incredibly powerful “heart” of a cohort. This goes beyond just learning together — gathering in person and sharing experiences is empowering, especially for sometimes isolated rural health departments and health centers. We quickly learned the importance of fostering that connection, and we now host large convenings each year for both Healthy People and the oral health initiative with intentionally designed agendas based on input from participants and technical assistance providers. Agendas include educational components as well as plenty of structured and unstructured time for participants to share experiences, questions, and learnings. Beyond these gatherings, Healthy People incorporates a grantee feedback loop at every stage of the cohort process – both through surveys and informal conversations.
Data and Evaluation
The Endowment was intentional about incorporating data and evaluation to create more shared learning but also realized that we must be adaptable, realistic and relevant for our partners. Collecting consistent data was a hurdle for organizations in the oral health initiative. It required us to minimize the amount, frequency and type of data we gathered – reminding us that simplicity is often the most effective approach.
We also learned there is no one-size-fits-all evaluation model to apply across cohorts. We must think about evaluation differently depending on each program’s needs. For example, our school-based oral health initiative initially looked at numbers of children served, but has evolved to look at disparities in access to school-based oral health services. Healthy People is building its capacity to use the Results-Based Accountability (RBA) evaluation framework to track the progress of its collective impact model and is beginning to see state public health departments adopt RBA as well.
Leveraging our Learning
Our cohorts are vital teachers, and what we have learned continues to inform the Endowment’s work. We actively share these lessons with all staff and trustees and are currently applying what we’ve learned to our emerging work in school-based mental health and to the next phase of Healthy People, as well as other programs. The knowledge, insights and creativity of our cohorts continue to inspire us, and we look forward to learning more from them.
