The first week of March, I attended the annual meeting of Grantmakers in Health (GIH), a national affinity group for foundations that fund health-related activities. Although I don't attend every year, I always come back from meetings with information that I can incorporate into my work. I thought that I would share what I learned this year with you.
• Many foundations approach prevention from an advocacy point of view: converting vacant lots to vegetable gardens, making sure a park is a safe place for walking and other activities, lobbying for better fluoridation of water, or smoke-free environments, etc. Here at the Health Foundation, we have developed the Assistance for Substance Abuse Prevention (ASAP) Center which approaches prevention from a different perspective. The ASAP Center is less about advocacy and more about teaching individuals and groups to use specific prevention practices. It was interesting for me to contemplate how we might use the other approach. One foundation shared a readiness assessment they use when working with communities that are trying to change their community environment or social norms. I wonder how this might be helpful for communities in the Health Foundation's region.
• One session was a breakfast meeting for the Behavioral Health Funders Network, a group of about 70 funders within GIH. John O'Brien, senior advisor on healthcare financing at the federal Substance Abuse and Mental Health Services Administration (SAMHSA), shared the SAMHSA strategic plan for 2011-2014. As a group, we discussed ways that the federal government might partner with foundations in behavioral health. Even though I had heard the SAMHSA strategic initiatives before, I recognized nuances of the SAMHSA strategic plan I had not seen before. This will hopefully turn into an improved ability to coach grantees attempting to get SAMHSA funds.
• In a session about "what keeps you up at night," I learned that many foundations are in the midst of transitions in leadership. Since we have just gone through a transition in leadership here, it was good to listen to others and offer some guidance from our experience. I was reminded of some transition practices that might be helpful for our grantees that are or soon will be going through transitions. These included developing a succession plan before the time for new leadership emerges, using both board and staff involvement in the search process for new leadership, and forming a transition team from all parts and levels of the organization to help guide the new leader in the first few months of the job. For new leaders, those present recommended taking at least a year to get situated before making major changes.
• In many of the sessions, I was reminded that as grantmakers it is important to start where our communities are. What works in Los Angeles or New York or a small rural community in Nebraska might not necessarily work here in Greater Cincinnati. It might sound great, but I can't push it on people here. I can share, but forcing people to do something "my way" rarely works.

Does any of this raise questions for you? What did you learn at your last conference that you want to share?

You have to love Warren Buffet. When I grow up I want to be as wise as he is. Warren Buffet has a unique approach to making decisions. I think that it should be a mantra for all elected leaders when they make decisions that affect all of us. In John Rawls' 1971 book A Theory of Justice, Buffet noted, "Let's say that it was 24 hours before you were born, and a genie appeared and said, 'What I'm going to do is let you set the rules of the society into which you will be born. You can set the economic rules and the social rules, and whatever rules you set will apply during your lifetime and your children's lifetimes.' And you'll say, 'Well, that's nice, but what's the catch?' And the genie says, 'Here's the catch. You don't know if you're going to be born rich or poor, white or black, male or female, able-bodied or infirm, intelligent or [developmentally disabled].'"

I think that the economic and social rules are mostly set by people of privilege. According to Peggy McIntosh privilege is "an invisible package of unearned assets". Where and how you are born--rich or poor, white or black, male or female, able-bodied or infirm, intelligent or developmentally disabled as Buffet points out, is the luck of the draw. None-the-less, the moment you are born, where and how you are born will begin to chart your future.

For the past 12 years, I have been a member of a foundation team that returns money to society. Giving away money must be easy, you might think. Actually, it is very difficult and is best when done strategically to empower those you serve. Always the need is greater than the dollars available. Plugging one hole in the dike is not the answer for a weak dike. As Martin Luther King, Jr., said "Philanthropy is commendable, but it must not cause the philanthropist to overlook the circumstances of economic injustices that make philanthropy necessary."

According to Simone P. Joyaux, social justice "is about fair treatment in all areas of personal and community life" and equity "is about making the invisible, visible." In our foundation, we work with non-profit organizations that provide services to people with mental illnesses, people with problems related to substance abuse, and people who have difficulty accessing primary care, usually because of poverty. I don't think that 24 hours before they were born, these people knew what their life circumstances would be. I think that often they are invisible and that they don't have much of a voice in setting the economic and social rules of their or their children's lifetimes.

An American Indian proverb comes to mind: "We do not inherit the earth from our ancestors, we borrow it from our children." Similarly, the society we create is our legacy to our children and grandchildren, regardless of where or how they are born: rich or poor, white or black, male or female, able-bodied or infirm, intelligent or developmentally disabled. Sometimes I ponder just what it was that we borrowed and just what it is that we are returning.

Now that healthcare reform has been signed into law, its provisions will phase-in over four years. The law creates a number of amazing opportunities. As a healthcare access grantmaker and supporter of high-quality patient care programs in our community, we believe that some of the provisions can help improve access for many previously uninsured people and sustain many struggling programs that provide care for the uninsured. Healthcare reform also treats mental illnesses and substance use disorders the same as other illnesses.

We recently abstracted some key provisions affecting consumers and providers from some Kaiser reports. Our document is on our healthcare reform web site at: http://reform.healthfoundation.org/happening/What%20Changes%20as%20a%20Result%20of%20Healthcare%20Reform.pdf. There is also a 13-page summary with more technical details available at: http://www.kff.org/healthreform/upload/8061.pdf.

One of the things I noticed is how many quality of care and cost containment components are included in the law. There is a partial list on page 5 of the Health Foundation's document. Several things are interesting about this:

• The programs provide for a lot of experimentation that could unfreeze our healthcare system, and which are likely to generate better services and lower costs. Examples include: several programs that help keep people out of institutions and in their own homes; bundled payment demonstrations; and sharing of cost savings with accountable care organizations that maintain quality.

• Quality and cost are linked. A number of efforts are targeted to find the sweet spots between quality and cost. High quality and low cost is the ideal, but in the real world, we are too often closer to low quality and high cost. Examples of what may generate higher quality at lower cost include: establishing a Patient-Centered Outcomes Research Institute; creating a national health quality improvement strategy; establishing an Innovation Center to study payment reforms that maintain or improve quality; and improving patient outcomes reporting.

• There is more funding of and payment for, evidence-based wellness

• Better care coordination is a goal affecting both quality and cost, with provisions to coordinate care between CHIP, Medicare and Medicaid, and to establish a Community–Based Collaborative Care Network.

• States will be given permission in Medicaid to develop medical homes for patients with chronic conditions, certain risks, or serious and persistent mental illness.

My question for you is: How might the Health Foundation best help its grantees and communities to prepare for a lot of change in four years, and to seize some of these interesting opportunities?

Ever wonder what grantmakers talk about when we get together? Each year, the Ohio Grantmakers Forum--a membership association of funders in Ohio--has an annual conference where grantmakers get together and share ideas. This year's conference is in Cincinnati, and I'm on the planning committee. We met earlier this week to talk about topics for the sessions. The conference has sessions specific to different types of funders--community, family, private, corporate, and other foundations--as well as sessions on different topics, including grantmaking.

We came up with a list of topics for the grantmaking session: responses to the economic downturn, capacity building grants, green initiatives, operating grants, how people look to grantmakers to replace funding cut from state budgets. The committee was charged to get some more ideas on what we could talk about during these sessions, or to come up with some specific topics or speakers related to these ideas.

Since our grantmaking affects you, what do you think we should talk about? What topics would you like to see Ohio's grantmakers tackle when we meet in November?

(And while the majority of the conference is open to funders only, the closing luncheon is open to nonprofits and others. We welcome you to join us on Wednesday, November 10, at 12:30 p.m. Mark your calendars!)

Choosing between something that looks good and something that is functional is a common decision; take shoes, for example. Let's admit it; beautiful shoes usually hurt your feet. However, ultra comfortable shoes aren't usually very attractive. So, which do you choose? The answer depends on the function of the shoe. A first date requires the pretty shoe, so you make a good impression. A hike requires the comfortable shoe, or you won't make it to the end of the hike.

What does all this have to do with grantmaking? Well, the decision of beauty versus function comes into play when you are packaging your proposal to a foundation. Now, like a first date, most grantees want to make a good impression and present their proposal in an organized, attractive package, so they bind it in a beautiful folder. I would encourage you to envision that your proposal is not going on a first date, but a hike. Your proposal will be reviewed and processed several times and in different formats; therefore your proposal needs to be in a comfortable and functional package. No folders or staples, just sheets of paper in the order the RFP or application asks for. That way your proposal will be ready for its journey and its companion--the potential funder--will be grateful. Plus, it will save you a lot of time and energy. You can spend that on a final read to make sure everything is included and that your proposal makes your case.

The Health Foundation puts a lot of emphasis on funding sustainable projects. We always have some projects to which our sustainability standards don't apply (such as surveys, planning grants, grants that match other money, policy-oriented grants, etc.). However, we put a high premium on sustaining the programs that we help grantees start. And of course, the sustainability of the grantee's organization is important, too.

That's why we offer capacity building resources to help grantees with project planning, advocacy, fundraising, evaluation, communications, and other topics (See http://www.healthfoundation.org/events/bytopic.html for capacity building workshops). We've tried to structure our grant agreements, evaluations and reporting to help grantees reach sustainability. Our program officers are available to consult with grantees both on sustainability strategies and overcoming bumps in the road. We also use challenge grants in some of our programs as a way to help grantees build up their fundraising skills and successes. We hope that our emphasis on sustainability helps grantees in both good times and bad.

Our interest in sustainable change comes from our desire to use the Foundation's resources to change things for the better - to make a real, long-term difference in outcomes. We like to be pragmatic about all the different ways that programs can become sustainable, where programs are starting from, how long attaining sustainability will take, and when to throw in the towel.

This emphasis turns us away from most emergency requests, requests for things that organizations should be doing as part of their normal operations, and requests to fund continuing operations when there is a revenue shortfall. Looking at the financial stresses shaping up for nonprofits in the near future, we can feel uncomfortable with this approach at times.

But, in uncertain times, should we fund to continue unsustainable operations? We fear that we don't have enough money to hold back the tides, and we might inadvertently enable organizations to avoid hard decisions to respond to new financial realities. We think a better case for funding is to create a new future and make those hard changes. One of our advisory groups told us that if money is tight, they would prefer to see us help fewer agencies, giving them more money and time to achieve sustainability, instead of shaving funding to everyone and underfunding all the projects until no one is likely to sustain the work.

What kind of technical assistance could we be providing now to help grantees (and other nonprofits) to weather this perfect storm? Are there hidden opportunities in this dreadful economy?

Since our beginnings, our goal has been to be a hybrid of a grantmaking foundation and an operating foundation. Consequently, the Health Foundation has always done some of its work directly rather than through grants to other organizations. In both cases, our work benefits the communities we serve. In doing work directly, the funding flows through us to create community benefit; in doing work through grants to other nonprofits, the funding flows through a grantee to create a community benefit. An example is illustrative:

Early on, we learned that many of our grantees needed to develop their skills in fundraising. We made a small grant to an organization so that it could send its home-grown development director to the Indiana University Center on Philanthropy Fundraising School. Their courses are excellent. The costs covered by the grant and the agency included: course tuition, travel to the course site, five days of hotel, and of course the salary and other incidental expenses of sending a staff member away on business. In some projects, agencies have to cover the cost of a replacement, too.

There was, and is, tremendous need for this content among our grantees. It was clear, however, that providing dozens of Fundraising School grants to dozens of organizations was not the way to go. For about the same money that could send one person to the IU courses, we could bring the IU speakers here and allow up to 55 people to attend a program that is more tailored to our grantees' needs.

This is how our capacity building program began. We now spend around $180,000 a year to provide various highly-subsidized workshops to 1400 attendees; these programs would have cost the community an estimated $450,000 more than our registration fees if priced at market rates (All figures are for 2007). To see our Capacity Building courses for 2009, go to: http://www.healthfoundation.org/events/Capacity%20Building%20Programs%202009.pdf (Please copy & paste this into your browser – a hyperlink on the blog site is beyond my ability just now!).

Other reasons that push us to do a project ourselves:

• Projects that need to serve all three states and twenty counties in our service area have a hard time finding a good home
• Occasionally, we need or want something done that is far more important to us than it can be to any potential grantee
• Grantees rightly resist being pushed off-mission just because we would fund it
• Grants that are stepchildren in an agency seldom thrive; we can see to it that some programs get the attention and priority they need
• Some projects are critically important to us meeting our objectives, and we do not want to leave execution or timing to another organization
• Sometimes, for some projects, it just is easier, or more value-added, to do it yourself; for example, our staff can learn more by directly providing group technical assistance to many agencies than they would learn dealing with just a few grantees
• Sometimes we want to maintain ownership of intellectual property or some other issue
• Every now and then there is no one we can choose as a granteee without ticking off someone else.

That said, we will always make a project as a grant if it involves providing or financing direct client care. We do not aspire to be a provider or a source of funding individuals' care.