The Role of Health-Related Community Investing As a Strategy to Promote Active Living

Abstract

The National Prevention Strategy recognizes active living as a priority area for reducing the burden of chronic disease and emphasizes safe and healthy community environments as a key strategic direction to improve population health. New financial incentives created by legislation such as the Patient Protection and Affordable Care Act, complemented by recent private sector interest in health-related community investing, provide an unprecedented opportunity to support healthy behaviors while improving areas where we live, learn, work, and play. In this article, we qualitatively explore health-related community investing strategies that can be leveraged to implement active living strategies to promote healthy behavior. We provide a synthesis of case examples illustrating innovative cross-sector partnerships and discuss promising new initiatives to align resources. We found that although such partnerships are increasing nationwide, targeted support for cross-sector engagement is needed to strategically align investments, replicate and scale efforts, and maximize collective impact.

Keywords

community development active living policy implementation collective impact social determinants of health

Introduction

The National Prevention Strategy recognizes active living as a priority area for reducing the burden of chronic disease and emphasizes safe and healthy community environments as a key strategic direction to improve population health (U.S. Department of Health and Human Services, 2011). Recent community development (CD) sector interest in health-related community investing, complemented by financial incentives created by the Patient Protection and Affordable Care Act (ACA), provides an unprecedented opportunity to implement active living policies, creates healthy community environments, and supports healthy behaviors. The CD sector includes lending organizations, such as banks and community development financial institutions (CDFIs), nonprofits, real estate developers, foundations, and government partners (UNTERM, 1995). For example, CDFIs provide credit and financial services to underserved markets and populations (CDFI Coalition, 2015). Types of CDFIs include credit unions, loan funds, venture capital funds, microenterprise funds, and corporations (CDFI Coalition, 2015). Together, they leverage public and private investments to revitalize neighborhoods. Although not all CDFIs focus explicitly on health, several historical milestones catalyzed collaborative interest in reducing health disparities, in part by supporting healthy behaviors, such as physical activity and healthy eating. Two important milestones include the Home Mortgage Disclosure Act (1975) and the Community Reinvestment Act (CRA; 1977), which provided increased scrutiny of lending practices by requiring disclosure of mortgage data and documentation of meeting community credit needs through safe and reputable operations. The CRA also motivated certain financial institutions to create foundations, some of which focus on health, to provide funds to CDFIs and other organizations through various financial mechanisms. The Federal Reserve Bank of Dallas (FRBD) is one example that has created a framework for CRA compliance focused on community health (Blum, 2014).

In 2000, the Financial Innovations Roundtable (FIR) was created to stimulate cross-sector partnerships among conventional and non-traditional lenders, CDFIs, investors, and markets to provide low-income communities with increased access to capital and financial services (Swack, 2014). The FIR has invested in affordable housing, small/minority-owned businesses, and community facilities (Swack, 2014; Swack, Hangen, & Northrup, 2015). Motivated by new ACA mechanisms, the FIR recently partnered with the Federal Reserve Board of Governors and selected health-related community investing as its current focus. In 2014, the FIR engaged financial institutions, funders, and health partners to holistically examine the social determinants of health, including active living domains such as recreational environments, transportation, and transit-oriented development (Mair & Milligan, 2012; Reigel, 2011). Collectively, these institutions leverage funding to low- and middle-income communities to implement innovative CD strategies, which can support the implementation of active living practices and policies (Online Appendix 1).

ACA Mechanisms

The ACA has driven the development of various health reform strategies, such as “Place-Based Initiatives” (PBIs), which seek to improve community health through coordinated preventative measures (Bruner & Fine, 2011). PBIs build upon previous efforts to establish networks that promote innovation and collaboration between community, regional, and national tiers (Bruner & Fine, 2011). Specifically, the ACA highlights social, environmental, infrastructural, and financial provisions which promote affordable, equi, and effective services, supports, and health care within communities (Bruner & Fine, 2011; Fleming, 2013).

A main provision of the ACA focuses on revitalizing current health programs (i.e., assessing the efficacy of non-profit hospitals to meet community needs; Bruner & Fine, 2011; Corrigan, Fisher, & Heiser, 2015; Evans, 2015; Kabel, 2013; Young, Chou, Alexander, Lee, & Raver, 2013) and transforming payment and service delivery models (Abrams, Nuzum, Mika, & Lawlor, 2011; James, 2012; Zusman et al., 2014). Importantly, the ACA also supplies vital funding for innovative PBI strategies. These include establishing the Prevention and Public Health Fund, which provided funding such as Community Transformation Grants, the Community Health Center Trust Fund, expanded funding for federally qualified health centers (FQHCs), and the School-Based Health Center Capital Program (Bruner & Fine, 2011). This multifaceted approach supports chronic disease prevention and reduces health disparities by addressing clinical care, the built environment, and the social determinants of health (Bruner & Fine, 2011; Chokshi, Singh, & Stine, 2014; Kansas University, 2014).

Our objectives are to

describe case examples illustrating relevant cross-sector partnerships that have leveraged health-related community investing (including new ACA-related funding mechanisms) to implement active living policies and practices, and

discuss promising new initiatives to align resources and maximize impact.

Method

We used a case study approach for practice-based research (Potter et al., 2006). Methods included semi-structured telephone interviews with stakeholders (n = 12) from health and CD organizations, analysis of transcripts from the FIR 2014 dialogue, and document review (Table 1). The following criteria were used to ensure case heterogeneity: geographic region, city size, state’s political orientation, and partnership configuration (Online Appendices 2-5). Purposeful sampling was used to select two or three interviewees per case who were mid-level managers or directors; one third were associated with the FIR. Interview notes were manually coded, and themes were identified using modified grounded theory (Bulawa, 2014). Cases were compared using the Collective Impact model (Kania & Kramer, 2011), a social change framework that emphasizes five “conditions” for success: common agenda, shared measurement, mutually reinforcing activities, continuous communication, and backbone support organizations (Table 4).

Table 1.

Methods Details.

Method/process	Description
Interviews	Semi-structured interviews were conducted with stakeholders (n = 12) from health and CD organizations. The following criteria were used to ensure case heterogeneity: geographic region, city size, state’s political orientation, and partnership configuration (Online Appendices 2-5). The figures highlight the types of partnerships/organizations from which the interviewees were sampled. Purposeful sampling was used to select two to three interviewees per case who were mid-level managers or directors within their organizations; one third of the interviewees were associated with the FIR.
	We developed an interview guide (available from the authors upon request) which contained seven reflective questions prompting respondents to describe their vision for a healthy community, how they defined “health-related community investing,” the history and evolution of their partnership (and who the most important partners were), examples of their organization’s collaboration in health-related community investing, funding mechanisms leveraged, how their organization may be advancing policies/practices with respect to active living/healthy behavior, important “outcomes” of their work (including policy, environment, and systems change), ways in which organizational practices or culture may have changed over time, whether/how their organization utilizes evidence-based or “best-practice” approaches to promote community health, how they measure “success,” what they perceive as the biggest challenges and opportunities for alignment, and what types of resources, information, technical assistance, or other support would be most helpful in the future.
Document review	We reviewed more than 25 documents in the following categories:ACA and community benefit
	ACA and place-based initiatives
	Active Living by Design—Fit Communities Case Studies (http://activelivingbydesign.org/resources/fit-community-case-studies/)
	CDFIs and healthy communities
	Community-centered health homes
	Community health needs assessments
	Collective impact
	Collaboration for impact
	CRA
	FIR
	Health-related community investing
	Population health
	Social determinants of health
	CD
The FIR	The FIR “creates cross-sector partnerships among conventional and non-traditional lenders, investors, and markets to provide low-income communities with increased access to capital and financial services. The Financial Innovations Roundtable (FIR) is known not only a ‘think tank’, but as a ‘think-do’ tank. Some of the most successful ideas developed at the FIR have been implemented, resulting in new tools, policies and practices that have resulted in millions of dollars being directed into investments in affordable housing, small and minority businesses, community facilities and other CD efforts. The FIR holds an annual meeting. Since 2014, the annual meeting has been hosted by the Federal Reserve Board of Governors in Washington, D.C.” (Carsey School of Public Policy, 2015). A summary from the 2014 convening can be found at https://carsey.unh.edu/sites/carsey.unh.edu/files/media/pdf/summary_of_the_14th_annual_financial_innovations_roundtable-july.pdf
Triangulation of data	Information from the interviews, transcripts from the 2014 convening of the FIR, and document review was triangulated to generate a summary of themes across cases, including the challenges and opportunities presented in Table 4.

Note. CD = community development; FIR = financial innovations roundtable; ACA = Affordable Care Act; CDFI = community development financial institution; CRA = Community Reinvestment Act.

Results

Case Examples

Representative examples of cross-sector partnerships that leverage innovative funding mechanisms to implement active living policies and support healthy behavior are described in Tables 2 and 3 and Online Appendices 2 to 5. These include the following:

Table 2.

Synthesis of Case Examples.

City	Main funding	Examples of key partners	Health and behavior issues addressed	Policy, systems, and built environment outcomes	Strategies
Fitchburg, MA	RWJF (Healthy Kids, Healthy Communities), Massachusetts Department of Health (Mass in Motion), Boston Federal Reserve Bank (Working Cities Challenge)	Fun ’n Fitchburg, Montachusett Opportunity Council, City of Fitchburg, Fitchburg Public Schools, Fitchburg Housing Authority.	Physical activity, healthy eating, safety	Citywide, youth-initiated Adopt-A-Park maintenance program, complete streets policy, healthy vending policy in city parks, a Safe Routes to School initiative, and converting a public-housing open space into a park	Collective impact model,^a collaboration; community engagement, ongoing assessment, and policy strategies
Detroit, MI	Trinity health care system, local city and state grants (e.g., Michigan State Housing Development Authority Downtowns of Promise grants)	Joy-Southfield Community Development Center, Covenant Community Care (Federally Qualified Health Center), Wayne State University’s Urban Planning Department, high schools, AHEAD^b	Physical activity, healthy eating, health care access, job training	Complete streets; access to free and safe physical activity programs; 100% of high schools require physical education for students, 78% of high schools teach key nutrition and dietary behavior topics in a required course.^c	Provide comprehensive wellness services and primary care under one roof, access to free childhood obesity prevention programs (e.g., Healthy Empowered Youth [HEY] Detroit); youth-led community gardening programs (Sowing Seeds/Growing Futures) that promote life/leadership skills and entrepreneurial experience.
Omaha and Douglas County, NE	RWJF, Centers for Disease Control and Prevention, Catholic Health Initiative (Community Benefit Funds)	Live Well Omaha, Douglas County Health Department	Physical activity, healthy eating	Complete streets and urban agriculture provisions integrated into city’s Master Plan, school policy changes to promote 40 min of daily moderate-to-vigorous physical activity in after-school programs, Safe Routes to School programs and infrastructure, bicycle infrastructure including 20 mile downtown bike loop.	Master planning process considers community health needs; standardized community health assessments; data sharing; GIS impact maps to highlight health disparities by showing children’s proximity to healthy neighborhood stores, play spaces, and other environmental attributes
Manchester, NH	RWJF, U.S. Department of Health and Human Services, Granite United Way, NH Charitable Foundation, Endowment for Health, Cogswell Benevolent Trust	NHIS Leadership Team (i.e., Mayor, Public Health Director, Manchester School District, local philanthropic organizations)	Social determinants of health—financial literacy, employability, access to health care, safety, childhood resiliency, and supportive living environments to promote healthy eating, active living	Shared use agreement with school district, free health education and fitness programs, Playworks, Health Impact Assessments, healthy homes visits, financial literacy and employability programs, resident leadership development, parenting education	NHIS plan to foster collective impact; community schools approach to transform elementary schools to year-round neighborhood hubs to improve access to programs and services for residents of all ages, results-based accountability.Granite United Way redesigned a portion of its annual grant-making program to align with specific goals of the NHIS, including those related to building adult capacities, improving childhood resiliency, and developing stronger family care coordination efforts.

Note. AHEAD = aligning health equity and development; NHIS = neighborhood health improvement strategy; RWJF = robert wood johnson foundation; GIS = geographic information systems.

Collective Impact is a framework for collaborative social change that requires five “conditions” for success: common agenda, shared measurement, mutually reinforcing activities, continuous communication, and backbone support organizations (Source: Stanford Social Innovation Review; http://www.ssireview.org/articles/entry/collective_impact, accessed May 27, 2015).

Centers for Disease Control and Prevention, Divison of Adolescent and School Health (2013) The obesity epidemic and detroit students. http://www.cdc.gov/healthyyouth/yrbs/pdf/obesity/detroit_obesity_combo.pdf

Aligning Health Equity and Development; http://www.phi.org/uploads/files/AHEAD%20-%20Opportunity.pdf

Table 3.

CCHH Model and Implications for Behavior Change.

Phase of CCHH^a	Processes^a,b	Strategies for health institutions to impact behaviors
Inquiry	Collect data on social, economic, and community conditions	Develop data collection tools that measure community members’ behavior
	Aggregate symptom and diagnosis prevalence data	Train staff on language and impact of environment and policy on health behaviors
		Collect information about exposures and symptoms (e.g., asthma triggers, extreme heat)
		Collect information about community conditions (e.g., availability of healthy foods, safe spaces for physical activity, and public transportation) and programs (e.g., nutrition classes, community gardening programs, park programs).
		Collect information pertaining to cultural and linguistic composition of the community
Analysis	Systematically review health and safety trends	Develop strategy to change community conditions that ensure long-lasting behavior changes (plan should be specific about how the proposed changes will affect behaviors and how those behaviors will be measured)
	Identify priorities and strategies to improve community environments with community partners	Develop partnerships with organizations that educate community on behavior changes
	Align with Community Health Needs Assessments conducted by hospital partners	Evaluate evolution of partnerships and networks
Action	Implement a coordinated, comprehensive strategy	Implement changes that affect social determinants of health and will support long-term, community-wide, behavioral improvements
	Advocate for policies and organizational change to improve community environments	Implement evidence-based environmental and policy changes whenever feasible, also consider innovative, emerging/promising strategies.
	Mobilize patient populations to engage in changing community environments
	Strengthen partnerships with local health care/public health organizations, community development institutions, and other community-based organizations	Evaluate behavior before and after environmental and policy change
	Establish model organizational practices/policies within health institutions	Measure usage of new environmental components such as parks, schools, and safe routes to school.

Note. CCHH = community-centered health home; BCBSNCF = blue cross blue shield of North Carolina foundation.

Adapted from The Prevention Institute. (2015).Clinical/Community Population Health Intervention Model. http://www.preventioninstitute.org/component/jlibrary/article/id-298/127.html

The BCBSNCF initiated a deliberate process to build capacity for community-based prevention. It hosted events and trainings to develop a common understanding of concepts pertaining to community-based prevention, CCHH, and related practices. Twelve county-based community partnership received a US$15,000 grant to pursue short-term capacity-building projects (“action learning” phase) designed to test and grow collaborative. Coaching and technical assistance was jointly managed by Active Living by Design and Care Share Health Alliance. The BCBSNCF plans to expand the learning collaborative over time for both funded and non-funded communities.

Fitchburg, Massachusetts

Since 2009, the Fun ’n FITchburg (FnF) partnership has stimulated health and CD in this small city (City of Fitchburg Massachusetts, 2015). The Montachusett Opportunity Council led and helped form the partnership to plan and implement grants from Robert Wood Johnson Foundation and Massachusetts Department of Health to address childhood obesity. Important strategies and outcomes are shown in Table 2. Fitchburg’s mayor and other leaders embraced the FnF collaborative approach to organize action and leverage further investments. The city secured one of six Working Cities Challenge Grants awarded by the Federal Reserve Bank of Boston (Jackson, 2014; Working Cities Challenge). The Federal Reserve provides financial management and staff support, in partnership with a local CDFI, Boston Community Capital (Boston Community Capital, 2011, 2015; Online Appendix 2). The partners used the Collective Impact model to capitalize on their assets.

Detroit, Michigan

In Detroit, the Joy-Southfield CD Center partnered with Covenant Community Care (a FQHC) and multi-sectoral partners to provide comprehensive wellness services under one roof (Joy-Southfield CD Corporation, 2014). Covenant delivers primary care, allowing Joy-Southfield to dedicate its resources to obesity prevention and the social determinants of health. Trinity health care system supports Joy-Southfield through its community benefit funds and other mechanisms (Advisory Board Company, 2014; Online Appendix 3). This partnership has facilitated a variety of active living strategies (Table 2) that support healthy behaviors while simultaneously promoting life/leadership skills and entrepreneurial experience.

Omaha and Douglas County, Nebraska

In Douglas County, health providers and funders of clinical care invested in infrastructure projects and other efforts to support the implementation of active living strategies. Following a 20-year history of public health-hospital collaboration, Live Well Omaha (LWO; a 501c3) and the Douglas County Health Department (DCHD) have convened a cross-sectoral partnership with hospitals, funders, universities, nonprofits, and government agencies (LWO). For example, in 2006, LWO Kids was formed with community benefit funding from the Catholic Health Initiative specifically to address childhood obesity (LWO Kids, 2015,; Online Appendix 4). In addition, LWO and DCHD coordinated a common Community Health Needs Assessment (Barnett, 2012) with all area hospitals to enhance data coordination in their Community Health Improvement Plan (outcomes shown in Table 2).

Manchester, New Hampshire

The City of Manchester Health Department facilitated the development of a Neighborhood Health Improvement Strategy (NHIS; Bazos et al., 2014) through a multi-sectoral Leadership Team (Table 2). Currently, the Team is utilizing a Community Schools approach to transform three elementary schools into year-round, neighborhood hubs for providing educational opportunities for residents, linkages to physical and mental health services, and access to social services (Young, 2015; Online Appendix 5). This robert wood johnson foundation (RWJF) -funded initiative also received 100% matching support from the local funders; the Granite United Way has committed US$1.5 million to implementing the NHIS over the next 3 years, redesigning a portion of its annual grant-making program to align with specific NHIS goals to support children and families.

Future Directions

Although the aforementioned examples showcase innovative partnerships between the CD and health sectors, future efforts should focus on strategic alignment of investments to better replicate, evaluate, and scale PBIs. Two recent initiatives, identified from the document review and interviews, exemplify this approach.

Community-centered health homes (CCHH)

The Blue Cross Blue Shield of North Carolina Foundation (BCBSNCF) created an initiative to increase the capacity of safety-net health care organizations and communities to implement CCHH model (Cantor et al., 2011). This model recognizes that health is largely determined outside the health care system and prepares clinical providers to participate actively with community partners in changing policies/systems to provide a foundation for healthy behavior (Active Living by Design [ALBD], 2015; Table 3).

Aligning Health Equity and Development (AHEAD)

The AHEAD (2014) initiative uses targeted investments by the CD sector to stimulate collective impact through partnerships with selected communities. Funded by partners, including the Kresge Foundation, the Public Health Institute, and The Reinvestment Fund, this new 5-year national effort will be launched in Detroit, Michigan; Boston, Massachusetts; Atlanta, Georgia; Dallas, Texas; and Portland, OR and aims to expand to other sites. AHEAD aims to (a) align the resources of health and CD stakeholders into balanced portfolios of investment in comprehensive health improvement strategies with shared measurement systems, (b) focus resources in neighborhoods where health and social inequities are concentrated, and (c) build a field of practice that provides the tools, evidence, and models for replication.

Discussion and Conclusion

Opportunities to leverage innovative financial mechanisms that integrate health and CD are increasing nationwide. CD stakeholders are deeply committed to addressing the social determinants and supporting PBIs. However, challenges include competition among organizations, risk aversion, and a lack of resources to support cross-sector engagement. Collective Impact was a common framework employed across cases to address these challenges. Table 4 provides a synthesis of challenges and opportunities with respect to the conditions of the Collective Impact model. Notably, more chronic challenges were identified with respect to the conditions of shared measurement/evaluation, mutually reinforcing activities, and backbone organizations compared with other conditions. This supports recent literature suggesting that increased investment in building “capacity for process” (Thompson, 2014) will be required for Collective Impact models to succeed.

Table 4.

Challenges and Opportunities Across Cases, in Relation to Collective Impact Conditions.

Collective impact condition	Definition^a	Challenges and opportunities^b
Common Agenda	Developing a common agenda involves creating shared vision for change. This includes a common understanding of the problem and a collaborative approach to solving it through mutually agreed-upon actions.	Challenges:Finding a common vision was frequently cited as a challenge that hindered development of a common agenda, especially during the early stages of partnership between health and CD sectors.Opportunities:The social determinants of health framework proved to be a unifying lens for many partners, particularly when coupled with a focus on children and families.Messages emphasizing “We all have a role in community health” helped to reinforce the common vision.With the passage of the ACA, partners identified common ground in its language regarding population health and PBIs.Several of the case study communities developed strategic initiatives, which codified the common agenda and defined partner organizations’ roles/responsibilities:Neighborhood Health Improvement Strategy (Manchester, NH),Alignment of Live Well Omaha with the Community Health Improvement Plan (Omaha, NE)
Shared Measurement and Evaluation	Refers to partner organizations’ agreement on the ways in which success will be measured and reported, as well as mechanisms to accomplish this.	Challenges:Shared measurement and evaluation were frequently cited as ongoing challenges across cases.A recent review of regional data-sharing systems^c mirrored the challenges faced across our cases. For example, the review suggested that many health systems still lack infrastructure and knowledge about population health and associated metrics of community benefit. Competition for market share also poses barriers to shared measurement, both within the health sector and across health/CD sectors.The PHI review underscored the need for infrastructure that permits “drilling-down” to smaller geographies to support PBIs.Federal privacy laws (e.g., the Health Insurance Portability and Accountability Act of 1996 [HIPAA]) often prevent organizations from sharing health data at more granular levels.
		Opportunities:Several interviewees cited tools, such as the PromiseScorecard™ used in the U.S. Department of Education’s Promise Neighborhoods initiative,^d that feature drill-downs enabling customized views of data, and trends for performance measures. Community Balanced Scorecards^e offer another example.Maps and GIS data were commonly cited as powerful visual tools, particularly when contextualized with other relevant community information.(e.g., Impact Maps; Omaha, NE)Interviewees cited a need for all partners to focus on outcome evaluation, not just process evaluation, using metrics that are data driven and evidence based.An emerging theme was the need to strike a balance between flexibility and structure with respect to evaluation (this was mentioned as both a challenge and an opportunity).One funder articulated plans to allow individual grantees substantial freedom in developing innovative ways of demonstrating success, provided that evaluation is evidence based and aligned with the community’s strategic initiative.Interviewees also cited the need for strategy-level evaluation metrics that measure population “dose” (e.g., the impact of a bike path on physical activity levels within a community).^fThe need to incorporate built environment metrics into these tools was also mentioned, an area that active living researchers could contribute to.
Mutually Reinforcing Activities	Refer to the coordination and differentiation of partner organizations’ efforts through a mutually reinforcing plan of action. This ensures that the partners’ activities are aligned toward achieving the common agenda and shared measures.	Challenges:An ongoing challenge that emerged from the interviews, supported by current literature,^d,g was the paucity of process and planning tools to support multi-organization, cross-sectoral teamwork.Research suggests that typical strategic planning processes used by government and community organizations reinforce isolated impact rather than collective impact. Categorical grant funding, which is still the predominant model, can also reinforce isolated impact.
		Opportunities:The following efforts, identified from the literature and from the interviews, begin to address this gap:The CCHH process in NCGranite United Way’s investment in implementing Manchester’s holistic Neighborhood Health Improvement Strategy in New HampshireThe activities/products generated by the FRBD Healthy Communities initiative (Dallas, TX; Blum, 2014).^hThe FRBD describes five best practices for a new generation of CD modelsⁱ:Use innovative methods to leverage private capitalBlend people- and place-based strategies to implement a broader visionProvide equal opportunity to quality education so that everyone can reach their highest potentialMeasure outcomes to identify what worksInvest resources in what works.Interviewees articulated the importance of each partner organization having a clear understanding of their responsibilities, which should be well defined, to promote greater accountability. This helps to reduce redundancy and competition, and allows the strengths of each organization to be optimized within the coalition.Role flexibility (the ability of an organization to play a leadership role for some activities, and a supporting role for others) was also a frequently cited as an important attribute of successful partnerships.Although infrequently mentioned by our interviewees, formal agreements such as “Community Compacts”c,j are emerging in the literature as mechanisms to improve clarity and accountability among partner organizations.
Continuous Communication	Refers to partners’ long-term commitment to develop a common vocabulary and to build trust.It “provides a platform for concerns to be addressed, ideas to be discussed and trust to be developed between organizations that may have previously been in competition.”^k	Challenges:Interviewees reported that considerable time and resources were needed to support continuous communication.Interviewees emphasized the importance of devoting time for continuous communication with residents as well as with other organizations.Finding a common “language” across health-CD sectors requires creating forums for interaction, such as the 2014 FIR convening,^l in which participants engaged in facilitated dialogue to generate mutual understanding.Opportunities:Interviewees reported using multiple channels of communication, including online platforms, face-to-face meetings, and distance learning modalities. The value of “face-to-face” meetings and community listening sessions were cited as being particularly valuable in promoting trust.The concepts of a building a culture of learning and intentionally creating a more risk-tolerant environment were also articulated by several interviewees (e.g., encouraging individual grantees to innovate and learn from each other’s experiences).For example, Granite United Way’s revised grant-making program in Manchester exemplifies this approach, as grantees develop shared goals and outcomes for their work, creating a learning community focused on informing and improving the integration of place-based service delivery.
Backbone Support Organizations	A separate organization dedicated to coordinating the various activities of the collective impact initiative.The functions of a backbone organization include guiding the common vision and agenda, facilitating alignment of activities, establishing shared measurement practices, building public will, advancing policy and practice, and mobilizing funding.^m,n	Challenges:An important theme that emerged from the interviews and the literature was that backbone organizations require their own targeted investments from funders.Most interviewees did not explicitly identify a separate backbone organization in their collaborations; instead, they described a few key partner organizations that shared backbone functions.Opportunities:Reflecting on the evolution of collective impact, Thompson (2014)^o concluded that funders need to invest in creating “a supporting infrastructure” and build “capacity for process”—for collective impact models to succeed. Recent initiatives, such as AHEAD, the CCHH initiative in NC, and Granite United Way’s grant-making approach in Manchester, exemplify this transformative shift, but more attention to this issue is warranted in the future.The interdisciplinary literature on boundary organizations,^p,q although not synonymous with backbone organizations, contains examples of organizational practices that may be particularly helpful to organizations who wish to play a stronger role in integrating research and evidence-based practice with policy.

Note. CD = community development; ACA = Affordable Care Act; PBI = place-based initiative; PHI = public health institute; CCHH = community-centered health homes; FRBD = Federal Reserve Bank of Dallas; FIR = financial innovations roundtable; AHEAD = aligning health equity and development; CBSE = Community Balanced Scorecard; GIS = geographic information systems

Collaboration for Impact. http://www.collaborationforimpact.com/collective-impact/

Information from the interviews, transcripts from the 2014 FIR convening, and the document review was triangulated to generate this summary of challenges and opportunities.

PHI (2014).

Results Leadership Group. (2016).PromiseScorecard. http://resultsleadership.org/promise-scorecard/

Community Indicators Consortium. (2015).Community Balanced Scorecards for Collective Impact. http://www.communityindicators.net/sustainability_detail,4D-balanced-scorecard-effective-community-governance

Schwartz, P. (2012).CHI Academy Dose Refresher. http://share.kaiserpermanente.org/media_assets/pdf/communitybenefit/assets/pdf/our_work/global/chi/CHI%20Academy%20Dose%20Presentation%2011_8_12.pdf

http://www.ssireview.org/blog/entry/channeling_change_making_collective_impact_work

Blum (2014).

Andrews and Erickson (2012).

Live Well Northwest Florida. (2015).Community Health Improvement Compact. http://www.pfahc.org/join. (This is a formal, voluntary agreement between organizations working together to collectively impact performance on targeted community health priorities.)

http://www.collaborationforimpact.com/collective-impact/continuous-communication/

FIR (2014).

http://www.ssireview.org/blog/entry/understanding_the_value_of_backbone_organizations_in_collective_impact_2

http://www.collaborationforimpact.com/collective-impact/the-backbone-organisation/

Thompson (2014)^m.

Morse (2009).

Perkmann and Schild (2015).

Targeted support for alignment, as exemplified by the AHEAD and CCHH initiatives, is needed to strategically align investments (Barnett, 2014), replicate and scale efforts, and maximize impact. Policy, systems, and environmental change approaches are new to many investors, who may require assistance with prioritizing community investments, identifying evidence-based strategies and evaluating outcomes. Similarly, community partnerships could benefit from assistance in choosing, implementing, and evaluating best practices for active living.

In summary, raising awareness about health-related community investing is an important aspect of implementing active living strategies. Through better cross-sector alignment, the National Prevention Strategy’s active living goals are more likely to be achieved.

Footnotes

Acknowledgements

The authors thank Dr. Michael Swack at the University of New Hampshire for his insights on health-related community investing. They also thank the interviewees who generously shared their insights and passion for healthy communities with us.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Semra Aytur is an assistant professor in the Department of Health Management and Policy at the University of New Hampshire, and a fellow at the Carsey School of Public Policy. Her research focuses on relationships between policy, environment, and systems change to prevent chronic disease.

Timothy Marquis is a Biomedical Sciences, Medical and Veterinary Sciences Major (BS, Class of 2015) at the University of New Hampshire. He aspires to attend medical school and specialize in oncology.

Philip Bors is technical assistance director at Active Living by Design (ALBD). He provides coaching, technical support, and consultation on policy, environment, and systems change strategies for healthy eating and active living and oversees cross-project learning and quality assurance at ALBD.

Julia Katz is pursuing dual master’s degrees in public health and city and regional planning at the University of North Carolina, Chapel Hill. She specializes in health behavior and transportation and is interested in changing the built environment to facilitate active living and improve community health.

Richard Bell is a senior project officer at ALBD. He provides coaching, technical support, and consultation on policy, environment, and systems change strategies for healthy eating and active living, and leads ALBD’s services related to Community-Centered Health Homes.

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