AF4Q Summative Findings: Research Briefs
The research briefs summarize the evaluation articles published online. These briefs detail AF4Q’s longitudinal impact on measures of population health, quality and experience of care, and cost of care; the alliances’ efforts to implement interventions in four AF4Q programmatic areas (performance measurement and public reporting, quality improvement, consumer engagement, and equity); and the sustainability of the AF4Q multi-stakeholder healthcare alliances.
The Longitudinal Impact of Aligning Forces for Quality on Measures of Population Health, Quality and Experience of Care, and Cost of Care
From a summative perspective, this article presents a unified empirical framework to examine the impact of AF4Q on a broad set of quantitatively measured outcomes, linked to the Triple Aim: improving population health, improving quality and experience of care, and reducing cost of care. Using 6 data sources, a total of 144 outcomes were analyzed. While the quantitative findings suggest several reasons why AF4Q had less impact than expected, these results are not the final statement on AF4Q. More nuanced discussions of the AF4Q alliances’ implementation of interventions in the specific programmatic areas and their potential success (or lack of success) are described in other articles in the supplement.
Reporting Provider Performance: What Can Be Learned from the Experience of Multi-Stakeholder Community Coalitions?
The signature accomplishment of AF4Q related to public reporting was a demonstration that alliances, differing in history and stakeholder support, could publicly report provider performance, given stable funding, technical assistance, and program guidance. However, at the end of AF4Q, which entities (e.g., federal government, state governments, provider associations, alliances, or some combination) are best positioned to assume broad responsibility nationally for providing and paying for transparency remained unresolved.
AF4Q appears to have created or contributed to meaningful and sustained changes in care delivery in about half of the 16 participant communities. In a few, the program helped to create a new quality improvement (QI) infrastructure; and in five, it accelerated or expanded existing QI efforts. However, policymakers and program planners take note: Our findings combined with a scant evidence base for alliance-led primary care interventions and strong qualitative data on the difficulties of implementing multi-stakeholder alliance-led QI, show that these entities may not be a panacea for driving community-wide change.
Consumer engagement (CE) was a key pillar of the AF4Q program; three areas of CE were required as part of AF4Q: self-management, shopping (i.e., choosing high quality providers based on publicly reported performance information), and involving consumers in alliance governance; a fourth, having consumers on healthcare quality improvement teams, was voluntarily developed by some alliances. For several reasons, there was large variation across alliances in the level of embrace within and across these areas, but overall, the AF4Q initiative pushed the field of CE and sparked alliances to try implementing CE programs, many of which would not have done so otherwise.
Under AF4Q, alliances were expected to (1) advance the collection of data on patients’ race, ethnicity, and primary language spoken (REL) by hospital and primary care practices; (2) stratify clinical quality and other healthcare system performance measures by REL or socioeconomic status data to identify local priorities for reducing disparities; and (3) implement programs or other interventions to eliminate observed disparities. Findings suggest the alliances struggled to advance REL data collection by hospitals and physicians, and had great difficulty creating community-level healthcare disparity reports. Funders and policymakers need to recognize, that identifying and raising awareness of institution- or community-level disparities does not automatically lead to implementing programs to address those disparities.
Aligning Forces for Quality Multi-Stakeholder Healthcare Alliances: Do They Have a Sustainable Future?
Answering the Robert Wood Johnson Foundation’s (RWJF’s) call “for people who get care, give care and pay for care to come together to lift the overall quality of health care in their communities,” the AF4Q supported a set of alliances comprised of diverse stakeholders (i.e., providers, payers, employers and consumers) to implement the program’s focal interventions. The ability of these alliances to accomplish their goal of improving healthcare quality at the community level is predicated on sustaining the interest and participation of community stakeholders over extended periods of time. Findings from the end of AF4Q indicate that alliances often struggle with how they should position themselves for their post-AF4Q future, reflecting the inherent difficulty that alliances face in transitioning from grant dependence to local support garnered by demonstrating value for key stakeholders in their respective communities.