How has your career prepared you for your current role?

Over my first year on the job, I’ve found that leading a health foundation takes a measure of technical knowledge, intuition, and the ability to listen and build good relationships with a range of stakeholders. This is a pretty good description of the skillset needed to practice family medicine in rural Alaska, which is where I spent many years in my earlier career. Since I left full-time clinical practice, working as a public health policy advocate for tribes in Alaska, and most recently as the founding director of a national grantmaking and policy-oriented initiative for Robert Wood Johnson Foundation (the Health Impact Project) provided a pretty solid foundation in the links between public policy and health, and an introduction to the world of health-focused grantmaking.

What are the most important health issues in your community?

Montana is a healthy state overall, but that’s not to say there aren’t major challenges. Over a year of strategic planning that involved reviewing a ton of health data and traveling Montana to understand the on-the-ground reality of health and healthcare in this large, rural state, we settled on three priority health issues:

1. Mental illness and substance use disorders (which we lump under the heading of “behavioral health.” Montana has one of the nation’s highest suicide rates; drug and alcohol problems are prevalent; adverse childhood experiences are all too common; and the behavioral health system is somewhat siloed and faces perennial workforce shortages.

2. American Indian health disparities. Montana is home to federally-recognized tribes on seven reservations, one state-recognized tribe, and a large urban Indian population. American Indians in Montana die at a median age of 50 years (more than 20 years earlier than non-Indian Montanans); death rates for specific illnesses, including heart disease, cancer, respiratory illnesses, injuries, and suicide, are substantially higher as well. Statistics such as these are only a starting point for understanding the problem of health disparities, which are rooted in longstanding challenges such as racial discrimination and historical trauma, poverty and unemployment, inadequate housing, and food insecurity.

3. The need to get better value from our investments in the health system. In recent years, Montana has seen per capita health spending rise faster than 41 other states, yet still, many communities have limited access to needed health services and healthcare workforce shortages and budget shortfalls are widespread. So-called "value-based" approaches that seek to realign incentives to produce better outcomes have emerged as a priority in Montana. MHCF seeks to help communities use limited resources wisely, through service integration and new inter-agency partnerships, and through community-based approaches that improve health through addressing upstream risk factors such as poverty and poor housing.

What are your core strategies for addressing these health issues?

As a young foundation, we’re still learning the answer to this question. Our investments during these formative years will undoubtedly help us build and refine a more specific set of strategies. Broadly, we make grants, conduct research, convene strategic discussions, seek out partnerships with other funders in order to leverage our own investments, and devote considerable time on the part of our professional staff to working on policy and systems-level solutions.

Montana is a great state for this work: everyone from community members to senior tribal and state government officials has been remarkably open to collaboration. We’ve found that many of our early impacts relate to direct efforts on the part of our staff—convening important policy conversations, helping to build partnerships between organizations that can achieve more together than working on their own, and conducting research that elevates important health questions to spur more public discussion about possible solutions.

With regard to grantmaking strategy, we are starting with a fairly responsive approach. Within our three focus areas, which are quite broad, we allow applicants to target specific health issues and propose their own solutions.

We are more prescriptive when it comes to sustainability: we focus on grants that will improve outcomes and can chart a path toward sustainability through the value they generate in the healthcare system. We are particularly interested in approaches that address the upstream influences on health (aka the “social determinants of health), and find ways to involve the healthcare system in addressing them. We also focus on new partnerships that show a potential to increase the efficiency and effectiveness of the health system.

As a foundation with an explicit mission to serve a community, how do you include that community as an integral partner in your work?

I think I put more than 25,000 miles on our car in my first year on the job! Our strategic plan, focus areas and approach to grantmaking and other activities were directly and substantially driven by what people around the state told us about their needs and priorities, and we have invested a great deal of time in listening. We emphasize transparency, and strive for an open and accountable decision-making process in our grant and programming decisions.

We’ve structured our selection criteria carefully to avoid the pitfall of funding the largest organizations with the best grantwriters and ignoring the smaller organizations that may lack resources to apply. We organize board education sessions at each meeting so the board can hear directly from a wide range of stakeholders. We also work hard to meet people where they are, rather than imposing our own approach. In our outreach to tribes, for example, we found accomplished, visionary partners, but many who were doing at least two peoples’ jobs and had no time or staff to engage with us. So, we have done whatever we can to streamline the application process — even hiring grantwriters to help put together proposals to us in a couple of circumstances.

What’s been a recent big success for your organization and what excites you about it?

Over the past year and a half, the Montana Healthcare Foundation engaged with tribal leaders and state and federal health officials to help develop a framework for addressing the health disparities that affect Montana's American Indian people. With strong leadership from Montana’s tribes, this work culminated in a decision to create a new Office of American Indian Health in the director’s office at the Montana Department of Public Health and Human Services (DPHHS). In our view, what is most important about this effort is the roadmap it creates for addressing a long-standing problem: the new office will be charged with developing and implementing a strategic plan that requires contributions on the part of each division of DPHHS, and even includes other state agencies such as transportation, housing, and corrections. The office will also help hold the state accountable through overseeing annual, public reporting on steps that are taken to improve the health of American Indian people in Montana. Our work on this effort has also helped cement strong working relationships with Montana’s tribes and urban Indian health centers. In turn, this will help us make sure that our programming continues to respond to the areas of greatest need in these communities.

What’s the single biggest challenge your organization is tackling right now?

Well, beyond the obvious challenge of figuring out how to make a difference in some complex, longstanding health problems, the question of how to gauge our impact is one we are just beginning to wrestle with. Assessing whether or not our investments are making a difference is essential to allow a foundation to refine and strengthen its programming. Some of the most important health problems in Montana, though — problems such as health disparities among American Indian people and the state’s high suicide rate — result from complex, multi-factor social problems and lack simple solutions. Our efforts to understand our impact will need to balance the desire to make tangible improvements in health outcomes with the value of some of the intermediate steps, such as strengthening the system of care. So, we are beginning to wrestle with the question of how to evaluate our investments and how we will know if we’re making a difference.

What are the most important public policy issues for you this year, and what are you doing about them?

I’ve already talked about American Indian health and the foundation’s policy work in this arena, so I won’t reiterate here although we consider these issues to be very important.

Two other issues to which we’re beginning to devote a lot of thought are:

1. Improving care for people with complex, co-occurring illnesses: people with untreated mental illness and substance use disorders may die far earlier than the general population, often from poorly treated medical issues. The reimbursement and administration of treatment for mental illness and substance use disorders in Montana is quite separate, so people with complex, co-occurring disorders face significant barriers to care. Our first step in addressing this is to produce a background research report that begins to map out potential opportunities to address this issue through both policy and delivery system innovations. Second, we are creating an integrated behavioral health grant initiative, in which grantees will work as part of a cohort to plan and implement integrated service models.
2. Ensuring that the state’s recent expansion of Medicaid is successful. Montana’s Medicaid expansion represents an unprecedented opportunity to improve the health of some of Montana’s most vulnerable people. We made two grants in 2015 to strengthen outreach and enrollment efforts, and we are working with stakeholders to define the most effective ways to invest over the next two years.

Aaron Wernham is CEO of the Montana Healthcare Foundation, joining us this month for our virtual roundtable with healthcare conversion foundation leaders.