4--Grantee Annual Report on Coalition Functioning, Cost-Effectiveness, and Sustainability Planning

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Grantee Annual Report on Coalition Functioning, Cost Effectiveness, and Sustainability Planning

Section A. Coalition Functioning: The Wilder Collaboration Factors Inventory

Project Directors: Please distribute annually to individual members, and provide the number of people that completed each item, the average rating for each item, and whether the mean changed from the previous report as part of your annual reporting.

Source: Collaboration: What Makes it Work 2nd Ed. by Mattessich et al. Copyright 2001, Fieldstone Alliance. All rights reserved, used with permission. www.FieldstoneAlliance.org

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Name of Collaboration Completion Date

Please indicate the degree to which you agree/disagree with each of the following statements about [Your Collaborative Group]:

Factor	Statement	Strongly Disagree	Disagree	Neutral, No Opinion	Agree	Strongly Agree
History of collaboration or cooperation in the community	1. Agencies in our community have a history of working together	1	2	3	4	5
	2. Trying to solve problems through collaboration has been common in this community. It’s been done a lot before.	1	2	3	4	5
Collaborative group seen as a legitimate leader in the community	3. Leaders in this community who are not part of our collaborative group seem hopeful about what we can accomplish.	1	2	3	4	5
	4. Others (in this community) who are not a part of this collaboration would generally agree that the organizations involved in this collaborative project are the “right” organizations to make this work.	1	2	3	4	5
Favorable political and social climate	5. The political and social climate seems to be “right” for starting a collaborative project like this one.	1	2	3	4	5
	6. The time is right for this collaborative project.	1	2	3	4	5
Mutual respect, understanding, and trust	7. People involved in our collaboration always trust one another.	1	2	3	4	5
	8. I have a lot of respect for the other people involved in this collaboration.	1	2	3	4	5
Appropriate cross section of members	9. The people involved in our collaboration represent a cross section of those who have a stake in what we are trying to accomplish.	1	2	3	4	5
	10. All the organizations that we need to be members of this collaborative group have become members of the group.	1	2	3	4	5
Members see collaboration as in their self-interest	11. My organization will benefit from being involved in this collaboration.	1	2	3	4	5
Ability to compromise	12. People involved in our collaboration are willing to compromise on important aspects of our project.	1	2	3	4	5
Members share a stake in both process and outcome	13. The organizations that belong to our collaborative group invest the right amount of time in our collaborative efforts.	1	2	3	4	5
	14. Everyone who is a member of our collaborative group wants this project to succeed.	1	2	3	4	5
	15. The level of commitment among the collaboration participants is high.	1	2	3	4	5
Multiple layers of participation	16. When the collaborative group makes major decisions, there is always enough time for members to take information back to their organizations to confer with colleagues about what the decision should be.	1	2	3	4	5
	17. Each of the people who participate in decisions in this collaborative group can speak for the entire organization they represent, not just a part.	1	2	3	4	5
Flexibility	18. There is a lot of flexibility when decisions are made; people are open to discussing different options.	1	2	3	4	5
	19. People in this collaborative group are open to different approaches to how we can do our work. They are willing to consider different ways of working.	1	2	3	4	5
Development of clear roles and policy guidelines	20. People in this collaborative group have a clear sense of their roles and responsibilities.	1	2	3	4	5
	21. There is a clear process for making decisions among the partners in this collaboration.	1	2	3	4	5
Adaptability	22. This collaboration is able to adapt to changing conditions, such as fewer funds than expected, changing political climate, or change in leadership.	1	2	3	4	5
	23. This group has the ability to survive even if it had to make major changes in its plans or add some new members in order to reach its goals.	1	2	3	4	5
Appropriate pace of development	24. This collaborative group has tried to take on the right amount of work at the right pace.	1	2	3	4	5
	25. We are currently able to keep up with the work necessary to coordinate all the people, organizations, and activities related to this collaborative project.	1	2	3	4	5
Open and frequent communication	26. People in this collaboration communicate openly with one another.	1	2	3	4	5
	27. I am informed as often as I should be about what goes on in the collaboration.
	28. The people who lead this collaborative group communicate well with the members.	1	2	3	4	5
Established informal relationships and communication links	29. Communication among the people in this collaborative group happens both at formal meetings and in informal ways.	1	2	3	4	5
	30. I personally have informal conversations about the project with others who are involved in this collaborative group.	1	2	3	4	5
Concrete, attainable goals and objectives	31. I have a clear understanding of what our collaboration is trying to accomplish.	1	2	3	4	5
	32. People in our collaborative group know and understand our goals.	1	2	3	4	5
	33. People in our collaborative group have established reasonable goals.	1	2	3	4	5
Shared vision	34. The people in this collaborative group are dedicated to the idea that we can make this project work.	1	2	3	4	5
	35. My ideas about what we want to accomplish with this collaboration seem to be the same as the ideas of others.	1	2	3	4	5
Unique purpose	36. What we are trying to accomplish with our collaborative project would be difficult for any single organization to accomplish by itself.	1	2	3	4	5
	37. No other organization in the community is trying to do exactly what we are trying to do.	1	2	3	4	5
Sufficient funds, staff, materials, and time	38. Our collaborative group had adequate funds to do what it wants to accomplish.	1	2	3	4	5
	39. Our collaborative group has adequate “people power” to do what it wants to accomplish.	1	2	3	4	5
Skilled leadership	40. The people in leadership positions for this collaboration have good skills for working with other people and organizations.	1	2	3	4	5

Open-ended questions:

41. What is working well in the collaboration?

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41. What needs improvement in the collaboration?

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Grantee Annual Report on Coalition Functioning, Cost-Effectiveness, and Sustainability Planning

Section B. Cost-Effectiveness

Office on Women’s Health (OWH)

Coalition for a Healthier Community (CHC) Initiative

Grantee Annual Report on Cost-Effectiveness

Project Directors: Please use this form in collaboration with your coalition’s Evaluator’s and/or Health Economist’s Report Annually

PLEASE PUT YOUR GRANTEE NAME IN THE TABLE (FIRST ROW)—It will appear on subsequent sheets.

Person completing report: _______________________________

Role/Title on CHC Grant: _____________________________

Date: __________________________

GUIDANCE: The OWH is interested in the question of “What is the cost effectiveness of offering a gender-based approach in women’s health programming?” In addition, OWH would like to capture any information on the cost-benefits of such approaches. This form is designed to capture the status of your cost-effectiveness and/or cost-benefit analyses. Please consult your health economist or economic evaluation resource person, if available, to assist with completion of this form.

1. In Table 1, please report on:

   1. Whether you have or are collecting data for each indicator

   2. Any actual data or statistical results for the elements that are requested

   3. The time period over which/or for which data were collected (the shaded rows); and

   4. As applicable and available, the analytic/time horizon for your analysis.

Table 1. Program costs, cost-benefit analysis and cost-effectiveness indicators/measures

GRANTEE NAME:
INDICATOR/MEASURE	GRANTEE’S REPORT ON WHETHER DATA ARE COLLECTED AND ANY STATISTICAL DATA AVAILABLE
Program Planning Annual cost per participant for program planning	Cost for start-up period of Phase II grant (do not include Phase I) Grant-funded cost: In-kind or other sources: Total cost: Number of participants in the phase II evidence-based interventions and comparison groups (see measure #3, should have the same number of participants) Intervention group Comparison group Total number combined: (DO NOT INCLUDE OUTREACH OR SOCIAL MEDIA NUMBERS)
Time period:	The time period for which planning costs were calculated (from start up through end of planning period for Phase II grant [do not include Phase I; just the start of the Phase II grant]):
Program Implementation for Overall Program Annual cost per participant for program implementation--Overall (includes all costs for coalition, outreach, social media, intervention and comparison activities)	Cost for implementation of the project From start of implementation of any activities (do not include planning cost above)—include costs for outreach, social media, and intervention and comparison group activity through the end of the implementation of all activities at the time of your economic analysis Grant-funded: In-kind or other sources: Total: Number of total participants reached Intervention Group(s) Comparison Group(s) Total for all other activities (other than in intervention and comparison groups) Total (1+2+3) =
Time period	Start date of implementation activities: End date of implementation activities (end of implementation of all activities, not just the intervention, at the time of the economic analysis): What is the total duration of the implementation period in years and/or months? (e.g., 2 years; 2 years and 4 months)
Intervention Cost per Participant (include cost for those in the intervention group separately from those in the comparison group; also include the numbers of participants in each group)	The cost for implementing the evidence-based intervention (intervention group only) Grant-funded cost: In-kind or other sources: Total: The cost for implementing the comparison group activities Grant funded cost: In-kind or other sources: Total: Number of participants in the evidence-based intervention group Number of participants in the comparison group Total number combined of intervention and comparison group
Time period (this period might be the same as for the overall implementation; however, consider that you might have started outreach activities at a time prior to actual implementation of anyone into the intervention or comparison groups; the latter is what is requested here)	Duration of the intervention implementation Date of start of first session for first intervention group/participant: End date of last session for last group/participant in the intervention: What is the duration in years and months over which the intervention implementation took place (e.g., 3 years 2 months)?
Direct Medical Care Cost Avoided (Averted)	Actual or Estimated medical care costs (can use average price for specific costs such as those in “b” below [e.g., cost of an ER visit] for your geographic area; ideally, report on or capture actual costs to the extent you can have them or can get them) The number of participants in the program who are using ambulatory, ER, inpatient and outpatient care, rehabilitation/counseling services, etc. [medical care items might vary based on your HP 2020 priority areas: At baseline At post-test Are you collecting these from/on program participants? Indicate whether you are using: ___Questionnaires? ___Electronic medical records? ___Other methods to gather the data? (please specify)
Direct Non-Medical Costs Avoided (averted)	Are you collecting any data on these or other non-medical costs? At baseline? ___Transportation ___Childcare ___Waiting time costs ___Other non-medical costs (please specify) At post-test? ___Transportation ___Childcare ___Waiting time costs ___Other non-medical costs (please specify) NOTE: This should be calculated per participant in the program to examine participants receiving services at baseline compared to post-test
Time period	Do you have data for a baseline? ___Yes: What data and when collected? ___No: Do you have a way to establish a baseline? ___Yes ___No ___Not sure/Don’t know Do you have data for at least one follow up point? ___Yes: Please indicate follow up point(s)—e.g., 6 and 12 months after program ___No: Do you have a plan to capture follow up data? ___Yes: At which point(s)? ___No ___Not sure
Indirect Morbidity Costs Avoided (Averted) (productivity gain)	Do you collect any data for this measure—e.g., # of disability days and hours of work taken by women with the condition; hourly wage rate by women with the condition? ___Yes: If so, what are you collecting? ___No Are you collecting a Quality of Life (QoL) Measure? If so, what QoL instrument are you using (e.g., SF12)? Did you use this measure at both baseline and post-test(s)?
Time period	How frequently are you collecting: Indirect morbidity costs data (other than quality of life) Data using the Quality of Life measure you are using:
Quality Adjusted Life Years (QALYs)- OWH expects that each grantee will use a health economist or other economic evaluation resource person to generate this measure, as applicable for their HP 2020 priority area(s).	Is your project collecting data or using existing literature to generate QALYs? ____YES: What measure are you using? _____ ____NO: What is your plan to generate these?_____ ____NOT SURE/DON’T KNOW
Gender- based costs	Do you have a way to estimate the cost for the specific gender-based approach (es) incorporated into your overall coalition, the intervention(s), outreach activities, or social media activities? ___YES: Please describe your method._____ ___NO ___NOT SURE/DON’T KNOW
Other (specify):	Please describe any other cost measures you are collecting or plan to collect and analyze.
Time period

2. Does your project have a health economist or other economic evaluation resource person that is assisting with the economic evaluation?

___Yes: Name and Affiliation _______________________________________________

___No:

2. What is the status of your cost-effectiveness analysis (CEA)?

1. Have you established a time horizon/analytic horizon for your analysis?

___Yes: Please state the horizon and describe how you established your horizon.

___No: When might you have this information?

2. Are you conducting a cost-benefit analysis?

__Yes: Have you established a time horizon/analytic horizon for your analysis?

___Yes: Please state the horizon and describe how you established your horizon.

___No

__No

__Not Sure/Don’t Know

2. Additional comments about your economic evaluation.

Thank you for your participation.

Grantee Annual Report on Coalition Functioning, Cost-Effectiveness, and Sustainability Planning

Section C. Sustainability Planning

Program Sustainability Assessment Tool*

Office on Women’s Health/Coalition for a Healthier Community

Please insert the grantee’s name and project year below. Check one response for each item based on your overall OWH CHC coalition activities in the past project year. Please submit each year at the end of the project year with your Annual Report.

Grantee Name:

Project/Coalition Title:

Project Year: 201__ - 201___

In the following questions, you will rate your program across a range of specific factors that affect sustainability. Please respond to as many items as possible. If you truly feel you are not able to answer an item, you may select “NA” (not able to answer). For each statement, circle the number that best indicates the extent to which your program has or does the following things.

Subscale and Items			1- To Little or No Extent			2		3		4				5	6	7- To a very great extent	NA Not able to answer
Environmental Support: Internal and external political environments that support your program
1. Environmental champions advocate for the program.
2. The program has strong champions with the ability to garner resources.
3. The program has political support within the larger organization.
4. The program has political support from outside of the organization.
5. The program has strong advocacy support.
Funding Stability: Establishing a consistent financial base for your program
6. The program exists in a supportive state economic climate.
7. The program implements policies to help ensure sustained funding.
8. The program is funded through a variety of sources.
9. The program has a combination of stable and flexible funding.
10. The program has sustained funding.
Partnerships: Cultivating connections between your program and its stakeholders
11. Diverse community organizations are invested in the success of the program.
12. The program communicates with community leaders.
13. Community leaders are involved with the program.
14. Community members are passionately committed to the program.
15. The community is engaged in the development of program goals.
Organizational Capacity: Having the internal support and resources needed to effectively manage your program
16. The program is well integrated into the operations of the organization.
17. Organizational systems are in place to support the various program needs.
18. Leadership effectively articulates the vision of the program to external partners.
19. Leadership efficiently manages staff and other resources.
20. The program has adequate staff to complete the program’s goals.
Program Evaluation: Assessing your program to inform planning and document results
21. The program has the capacity for quality program evaluation.
22. The program reports short-term and intermediate outcomes.
23. Evaluation results inform program planning and implementation.
24. Program evaluation results are used to demonstrate successes to funders and other key stakeholders.
25. The program provides strong evidence to the public that the program works.
Program Adaptation: Taking actions that adapt your program to ensure its ongoing effectiveness
26. The program periodically reviews the evidence base.
27. The program adapts strategies as needed.
28. The program adapts to new science.
29. The program proactively adapts to changes in the environment.
30. The program makes decisions about which components are ineffective and should not continue.
Communications: Strategic communication with stakeholders and the public about your program
31. The program has communication strategies to secure and maintain public support.
32. Program staff members communicate the need for the program to the public.
33. The program is marketed in a way that generates interest.
34. The program increases community awareness of the issue.
35. The program demonstrates its value to the public.
Strategic Planning: Using processes that guide your program’s directions, goals, and strategies
36. The program plans for future resource needs.
37. The program has a long-term financial plan.
38. The program has a sustainability plan.
39. The program’s goals are understood by all stakeholders.
40. The program clearly outlines roles and responsibilities for all stakeholders.

*Source: https://sustaintool.org/ and http://www.cdc.gov/pcd/issues/2014/13_0184.htm

OPEN-ENDED QUESTIONS:

41. What aspects of the coalition can be sustained beyond the coalition’s funding from the OWH?

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42. What are your coalition’s plans for sustaining these aspects of the coalition?

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Grantee Annual Report on Coalition Functioning, Cost Effectiveness, and Sustainability Planning

Section A. Coalition Functioning: The Wilder Collaboration Factors Inventory 6