The Strategic Planning Committee for Unified Healthcare for the Rural Underserved (UHRU)  was convened in March 2020. The committee was led by Donald Currie and consisted of Doug  Eza, Teresa McLean, Wanda Stitt-Gohdes, and Mark Wilson. The Committee developed a  Strategic Plan to guide UHRU, a young nonprofit organization, as it moves forward in fulfilling  its mission statement. The focus of this strategic plan will be on the state of Georgia, USA.

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Introduction  

Every day, people in rural and underserved areas are dying because our healthcare system is  unable to adequately meet their needs. UHRU has a 25-year plan which will ensure that  underserved populations receive the health care and health outcomes equivalent to or better than  those enjoyed by the average person. You can help us help others have the health care and  outcomes that your family enjoys. 

 

The health care of the average person is excellent. The average person lives in an urban area and  has easy access to some of the best health care in the world. However, underserved populations  in Georgia are dying unnecessarily because they lack access to adequate health care. As a result,  roughly 20% of Georgia’s population has below average treatment and health outcomes.  

 

The primary reason for the inadequate care is the lack of resources and infrastructure. While the  lack of resources and infrastructure is lamentable, it is also understandable. The resources  primarily flow to the areas where they originate. Infrastructure is built where it is needed the  most. Currently over 80% of the US population resides in urban areas, and the migration to the  urban environment is expected to accelerate over the next several years. The continued reduction  in rural population will make it harder for governments to increase support, which will  exacerbate the problem. In short, the problems experienced by the underserved rural populations  are unlikely to receive the attention they deserve from all levels of government. However, for the  sake of those who are suffering, this problem must be solved.  

 

UHRU was created to solve the problem. However, the problem is too big, complex, and  expensive to be addressed by any one organization. Therefore, UHRU has committed to doing all  it can for those in need and recruiting coalition partners to meet the needs that are beyond  UHRU’s capacity. As the coalition leader, UHRU accepts full responsibility for the improvement  of the lives of the target population. UHRU’s long-term goal is to ensure that the health care and  health outcomes of the target population match or exceed the care and outcomes of the average  person, as reported by state and federal reporting agencies.  

 

UHRU recognizes that all elements of individuals’ well-being contribute to their health  outcomes. While focusing on improving the health care each person receives, UHRU will also  include a well-being component. The well-being component will help to ensure that the benefits  and outcomes of the treatment are maximized. As a result, UHRU’s success measures will focus  on the individual outcomes as well as the effectiveness of the care they receive. Like all good health care measurements, those will be based upon evidence and compared to the services and  outcomes received by the average person.  

 

UHRU’s success will depend upon the engagement of the individual being served as well as the  service provider. Naturally, engagement will need to be measured and managed if UHRU is to  achieve its stated goal (better than average health care and outcomes). UHRU’s role is limited to  providing advice, resources, training and guidance to the service provider, with the expectation  that the provider will be able to deliver service directly to the person in need. Therefore,  UHRU’s services and service model must be tailored to meet the needs of both the service  provider and the service recipient. Since UHRU provides services across a growing list of  medical conditions, it must be flexible and have a general template for its service model, which  is easily customized for the treatment protocol, service provider (organization as well and  professional), and individual being served.  

 

The same flexibility is necessary in the coalition structure and membership. Different  communities will have different strengths and weaknesses. Therefore, UHRU must construct  unique coalitions for each community. This adds another dimension of flexibility to UHRU’s  service model.  

 

Fulfilling UHRU’s ambitious plan will require a robust business model, well-constructed funding  strategy, strong leadership, and have a high level of resilience. The breadth of its ambitions  exceeds those of many much larger organizations. Therefore, UHRU must ensure that everything  it does can be easily scaled, since growth will be critical to its short-term success and long-term  credibility. Since most of the service providers UHRU will be working with will be nonprofits,  they will expect UHRU to be a model which can be emulated. Fulfilling this expectation will  mean that UHRU must fulfill its mission and strategy by being committed to excellence in areas  such as fundraising, governance, data management and analysis, fiscal management and  reporting, and community engagement.  

 

Background 

 

When Jitendra “Jay” Mehta retired, he knew that he wanted to give back to both his current  home, Georgia (USA), and his birth home, India. At age 67, Jay retired from a successful 35- year long career in pharmaceuticals with Johnson & Johnson and felt a calling to help people and  communities get healthier and improve their quality of life. Jay also had a strong sense of family  and support networks in both places that encouraged him to follow this desire to help others.  

 

In 2017, Jay, drew on his family support, their medical backgrounds, and their combined passion  to found UHRU. Through discussions with his wife, Gita, a microbiologist, and his two sons,  Hitesh and Minesh, both physicians, they centered the organization on the mission to improve  the health and well-being of rural and underserved communities. This would begin Jay’s journey  to dedicating himself and his family to helping people in two very different geographic locations  worldwide get access to health care. 

 

Having lived and worked in both India and Georgia, Jay possessed a unique understanding that  both had rural communities that shared a common health care challenge: limited access to health  care, especially cancer screening. Therefore, the first two health care initiatives at UHRU focus  on increasing awareness of and access to cancer screening. The Georgia Colon Cancer Prevention Project strives to eliminate barriers to colon cancer screening across the state of  Georgia, and the Gujarat Breast and Cervical Cancer Screening Project aims to raise awareness  of and increase breast and cervical cancer screening among rural women living in India. In 2018,  UHRU received IRS approval as a public charity under 501(c)(3). 

 

Environmental Assessment 

 

UHRU is a nonprofit organization founded with the goal of improving the health outcomes of the  underserved. UHRU strives to ensure that underserved Georgians have equal access to health  care, especially cancer screening. The underserved populations UHRU targets include medically underserved, rural and urban uninsured, and underinsured Georgians.

 

Federally Qualified Health Centers (FQHC and hereafter referred to as Centers) provide health  care programs partially funded by the Department of Health and Human Services. They provide  primary and preventive health care services to persons of all ages, regardless of their ability to  pay or health insurance status. Therefore, these Centers provide critical health care services to  the communities they serve.  

 

Operating in Georgia are 34 centers and 207 clinic sites spread across 111 counties throughout  the state and serving around 500,000 patients. Each Center embodies a network of clinics and  provides care to uninsured and underinsured patients, making them ideal partners in UHRU’s  efforts to reach this population. UHRU has partnered with Centers to increase access to  colorectal cancer screening for underserved Georgians. However, UHRU recognizes that other  coalition partners may need to be recruited to better serve their target populations for this and  other health initiatives, especially when a Center is unable or unwilling to partner with UHRU. 

 

Most of the Centers in Georgia struggle to meet the medical needs of their patients. For example, in 2014, the Georgia Department of Public Health reported the statewide colon cancer screening  rate to be 65%. In contrast, the 2017 data show the screening rate at Centers was 39% nationally,  and even lower, at 32% in Georgia. 

 

Factors that contribute to the Centers’ struggles to meet the health care needs of their patients  include underfunding by federal and state government, understaffing, and lack of skills and  training of the medical providers. In 2018, The Commonwealth Fund conducted a survey of a  nationally representative sample of Center executive directors or clinic directors. When asked  about anticipated challenges over the next two years, 40% reported increased primary care  physician shortages and 20% reported increased staff turnover, among other challenges.  Additionally, a training and technical needs assessment was conducted of Centers in 2018 by the  National Association of Community Health Centers. The top ranked needs among Georgia’s  Centers included workforce, building staff skills, and leadership development. UHRU is in a  unique position to help Georgia’s Centers address their need to improve staff skills and  understaffing. 

 

UHRU’s multifaceted approach to improving the health outcomes of underserved Georgians  begins with developing a strong long-term partnership with Centers or other coalition partners  (e.g., community health center, sliding-scale health clinic, local health department). We  recognize that each Center faces a different set of obstacles in delivering care to its patients. Our  team of experts will help each Center identify local barriers and develop an evidence-based, tailored health care action plan to overcome these challenges. Our expertise will help centers  improve the quality of care their patients receive with the goal of ensuring their patients will  enjoy health outcomes at or above the average for the general population in Georgia. 

 

Our assistance to coalition partners can include: 

 

• Developing a tailored step-by-step health care delivery and education policy • Providing an educational seminar to the health care providers and staff at each partner  Center 

• Offering technical support through regular communications to provide guidance to  maintain policy implementation 

• Providing regular, on-site support to help alleviate understaffing  

• Development of educational resources targeting patients at these Centers including  awareness pamphlets, postcard reminders, wall posters and signage to be distributed at  each health center. 

 

Mission Statement 

 

The mission of UHRU is to improve the health and well-being of rural and underserved people  worldwide. 

 

For UHRU’s purposes, health is defined as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Well-being is defined as the experience  of health, happiness, and prosperity. It includes having good mental health, high life satisfaction,  a sense of meaning or purpose, and ability to manage stress. Underserved is defined as having  inadequate service; specifically, with regard to health services, underserved refers to populations  which are disadvantaged because of ability to pay, ability to access care, ability to access  comprehensive healthcare, or other disparities for reasons of race, religion, language group or  social status or geography.  

 

Goal 

 

UHRU’s goal is to ensure that the rural and underserved populations’ health care and health  outcomes are at or above the average for the perspective populations of Georgia (USA).  

 

These averages are developed by state-appropriate available data. This state was selected based  on these data:  

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• Georgia has 108 rural counties. 

• Poverty rates in rural counties exceed those in urban counties by 58%.

• Lower education levels found in rural counties contribute to poverty and are a barrier to individuals and families in making health decisions. 

• Rural counties have approximately half as many physicians and large shortages of nurses,  therapists, and nutritionists per capita as compared to metro counties. 

• The crude death rate is higher in rural areas than urban areas. 
  
  Source: Georgia Rural Health Facts (per Georgia Rural Health Association, 2019)

 

Strategy 

 

UHRU’s strategy is to be the leading provider of expertise to health centers serving the rural and underserved populations in Georgia, helping to identify local issues, barriers and resources, and develop evidence-based, tailored plans to overcome the challenges faced by the health care providers and their clients. 

 

The initial focus of UHRU was colorectal cancer initiatives in the state of Georgia. To reach the stated goals and, thus, to be the leading provider of expertise to the health centers serving rural and underserved communities in Georgia, UHRU will need to add other health initiatives critical to the center clients (e.g., diabetes, obesity, hypertension, etc.). To successfully do so, it will be  critical that UHRU, as it grows its programs, adds to its staff to accommodate that growth.  Critical issues to consider in those additional staff will be that: 

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• UHRU will have the leadership to initiate contact with coalition partners to create  awareness of programs and services  

• UHRU will have leadership to coordinate community collaborations  

• UHRU will have the staff in place to support program implementation  

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There is an urgent need for what UHRU promises to do for the underserved. Therefore, UHRU  must grow rapidly and sustainably. Its growth must be in three directions.  

 

1. It must grow the width of its services so that services are available to all parts of the state.

2. It must broaden its services to cover a growing list of medical conditions.

3. It must add depth to its services so that all aspects of a medical condition are covered  (prevention, detection, treatment, and cure). 

 

Implicit in its growth plans is the need for its fundraising to grow faster than the organizational  growth. Therefore, UHRU needs a carefully constructed funding strategy that sets specific goals  for the sources of funds (donors, events, grants, etc.) and ties the funds to uses (venture capital,  operational expenses, reserves, capital expenditures, etc.). In addition, financial discipline and  accurate cash flow projections will be critical.  

The dynamics of the type of growth UHRU must sustain implies it will have a robust funding  model, strong financial management, and excellent fiscal planning that span multiple years.  Sustaining the growth will be heavily dependent on its coalition partners. The UHRU partners  must be carefully chosen. 

 

The majority of the UHRU’s coalition partners will be nonprofits with limited resources, low  levels of resilience, and limited capacity to serve those who need their services most. Most of the  partners are expected to be fragile organizations. Therefore, UHRU needs to include in its  financial plan the provision of financial support for coalition partners when they are under stress.  UHRU also must monitor the condition of its partners (financial strength, leadership capabilities,  resilience, quality controls, efficiency, effectiveness, and funding capabilities) so that it can  predict, prepare for, and avert crises.

 

As funding becomes available to expand UHRU’s existing programs and add new health  initiatives, a process should be established whereby proposed new programs can be evaluated for  their potential to contribute to the mission of UHRU. Issues that should be considered when a  new program is considered should include, but not be limited to: 

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• Identifying local health care issues, barriers, and resources 

• Identifying potential collaborators in the health care community 

• Developing an evidence-based plan which can be modified appropriately based on  community needs and resources 

• Developing a monitoring system to determine effectiveness (vis a vis health care issues  identified, service/s provided, and success/cure rate) of health care provided.

• Developing funding required to implement the proposed new program and the UHRU  personnel to be responsibility for working with the coalition partner to implement and  monitor the plan 

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Critical to the implementation of a new program for a community will be the commitment by the  coalition partners to doing what is necessary to maximize the potential success of the new  program. Therefore, UHRU, as part of the process of evaluating a specific program for a coalition partner, should evaluate the following critical assumptions, ensuring that: 

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• the coalition partner wants to work with UHRU  

• the coalition partner will follow through with program recommendations

• the coalition partner will have the infrastructure in place to support the specific activities

• the coalition partner will have qualified staff for implementing the activities / programs

• the coalition partner must have a plan for the long-term sustainability of the program 

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Success Measures 

 

The ultimate success of UHRU depends on the long-term health outcomes of the patients served  by the UHRU coalition. Examples of outcomes UHRU expects its coalitions to achieve are  raising life expectancy, improved quality of life, decreased work time lost due to medical  conditions, and other outcomes related to specific medical conditions and improved access to  medications, care, diagnostics, and treatment facilities. The standard for determining success is  patient statistics that are the same as or better than those of the general population.  

 

Each of the efficiency, effectiveness, and outcome measures must be mutually agreed upon  between UHRU and the individual coalition partners. The expectations must be bilateral and  linked to identified outcomes. UHRU must know what is expected of it for the partner to achieve  success and understand how its ability to meet the expectations of the partner is likely to affect  the achievement of each measure. The partner must also know what UHRU expects from it and  how its ability to meet the expectations of the UHRU is likely to affect the achievement of each  measure. 

 

When operational (efficiency) and tactical (effectiveness) indicators are trending in the  appropriate direction, there is the potential that the patients will receive the health outcomes  promised by the UHRU mission statement, goal, and strategy. The year-on-year trends also suggest that the UHRU service models are producing the results, which will lead to the desired  health outcomes. 

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Recommendations 

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The following are crucial to reaching these success measures. Key to understanding these  recommendations is that many may be developed simultaneously and these may vary with  program and community:  

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• Develop a service model that can be used with the Center and coalition partners

• Develop a business model that support UHRU activities  

• Assess staff needs in light of the service and business models 

• Develop a ‘menu’ of support services 

• Develop a template for an evidence-based, tailored health care action plan

• Identify one region (area/Center) in the first year to pilot the new service plan

• Develop an evaluation plan to measure the success of UHRU’s activities

• Develop a funding and/or fundraising strategy to support UHRU and its programs.

• Develop a successor plan for key leadership positions