Example 1: Sharing Information through Participatory Evaluation—Enroll Wyandotte: A Community Mobilization Effort for the Affordable Care Act
The passage of the Affordable Care Act (ACA) created for the first time the opportunity for Americans to receive health insurance that previously could not afford it. Healthcare insurance marketplaces were established to ensure healthcare access to those in need. State-level support for ACA marketplace enrollment varied considerably from the development of state-managed health exchanges to erecting barriers to impede marketplace access. In Kansas, local efforts were required to assure access to healthcare through community mobilization and partnerships. Wyandotte County (Kansas City), Kansas (pop. 160,384) is a low-income and culturally diverse area that ranks 96 out of 98 in the county health rankings. One in four residents are without health insurance, a rate twice that of the national average, with an equal number of residents below the national poverty level.
Enroll Wyandotte, a local ACA exchange navigation effort, engaged multiple partnerships across a different sectors to support enrollment. Collaborative partnerships included government health organizations, public institutions, hospitals and health organizations, community and cultural organizations, community health coalitions, and universities.
Efforts of the Initiative
The initiative employed a community mobilization approach to assist Wyandotte County residents with obtaining health insurance through the ACA marketplace exchanges. This effort consisted of four broad components: a) Providing information and enhancing skills (eg, one-on-one education through the walk-in enrollment center, door-to-door education referral campaign to identify eligible community residents); b) Modifying access, barriers, exposures, and opportunities (eg, one-on-one enrollment assistance through the walk-in enrollment center, conducted community enrollment events in collaboration with community partners); c) Enhancing services and support (eg, hired a full-time navigator/project coordinator, trained a workforce of university volunteers as Certified Application Assistors); and d) Modifying policies and broader systems (eg, established collaborative partnerships with community organizations, provided testimony to senate committees on legislation that would have required expensive certification of volunteers trained as Certified Application Assistors).
A participatory evaluation involved the leadership of the Enroll Wyandotte effort and staff of the Center for Community Health and Development at the University of Kansas. The partners developed a monitoring and evaluation plan that identified some key indicators for success: a) Community/organizational changes (ie, new or modified programs, policies, or practices to facilitate enrollment in the ACA; eg, expanded enrollment hours at the health department; new sites at local public libraries, community organizations); b) Services provided (eg, media communications to promote awareness, direct assistance in enrollment sites); and c) Created accounts (the total number of family accounts created within the ACA website at three enrollment sites).
Measurement and Results
The KU Center for Community Health and Development designed an online documentation and support system (the Community Check Box) that included prompts and supports to: a) Capture instances of community/organizational changes and services provided (ie, what was done when and by whom toward what goal; b) Code by type of activity (ie, using definitions of community/organizational change and services provided); c) Characterize the activity (eg, by goal, strategy used, sector in which implemented); and d) Communicate progress (eg, graphs of the unfolding of community/organizational changes over time). The results showed that activities that created lasting changes in the environment (eg, programs, policies, and practices) and services provided were associated with increased enrollment. More than 500 new accounts were created as a result of the work of the initiative.
Providing Feedback through Participatory Sensemaking
Staff from the KU Center for Community Health and Development reviewed documented activities captured using the Community Check Box to assure data quality and to provide feedback on a monthly basis. The Check Box also supported participatory sensemaking by pairing graphs of activities/outcomes with reflection questions: a) What are we seeing? b) What does it mean? and c) What are the implications for adjustment? Enroll Wyandotte and KU Center for Community Health and Development staff met on two occasions to review the data and apply these questions. Participatory sensemaking provided an opportunity to evaluate data patterns to check for data completeness and identify key events (eg, when grants were received, when essential community/organizational changes occurred) that were essential to implementation of the marketplace navigation initiative. For example, the illustrating the unfolding of services provided over time showed a marked increase at the end of December, 2013. Enroll Wyandotte staff identified that this was associated with the hiring of a project coordinator made possible by community foundation funding and collaboration with community partners. Additionally, the use of sensemaking included the leveraging of additional funding from grantmakers and community partners through the use of data from the evaluation. In this initiative, providing feedback through participatory sensemaking helped guide systematic reflection of the data to make adjustments for continuous improvement and to communicate an objective story to community partners, grantmakers, and other stakeholders.
This example is based on the following article:
Fawcett, S. B., Sepers, C. E., Jr., Jones, J., Jones, L., & McKain, W. (Submitted for publication) Participatory evaluation of a community mobilization effort to enroll residents of Wyandotte County, Kansas through the Affordable Care Act.