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Am J Manag Care. 2016 Aug;22(12 Suppl):s393-402.

Improving care delivery at the community level: an examination of the AF4Q legacy.

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Aligning Forces for Quality (AF4Q) was the Robert Wood Johnson Foundation's nearly 10-year, multicomponent initiative to create meaningful and sustainable change in 16 communities. Our purpose was to describe the likely legacy of the care delivery component of AF4Q among participating communities and the factors that influenced the legacy.


We used a multiple-case study approach. Our analysis relied on 3 key documents for each community, based on key informant interviews conducted between 2006 and 2015: (1) a summary of the community's care delivery activities under AF4Q, (2) a summary of the community's experience in the AF4Q program, and (3) a summary of the characteristics of each community and the multi-stakeholder alliance that led local efforts under AF4Q. We used a team-based consensual approach to analysis.


We identified 3 types of legacies: (1) in 3 communities, there appear to be sustained infrastructures or wide-reaching activities attributable to AF4Q; (2) in 5 communities, AF4Q participation was used to advance preexisting activities; and (3) in 8 communities, the care delivery legacy is likely to be limited, because the local alliance focused on performance measurement instead of care delivery or the care delivery activities had limited reach and sustainability. Community contextual factors (eg, availability of other grant support) and alliance characteristics (eg, areas of expertise) greatly influenced the AF4Q care delivery legacy.


AF4Q appears to have created meaningful and sustained change in care delivery in half of the participating communities. Among the other communities, the considerable financial support and technical assistance provided by RWJF was not enough to overcome some of the contextual barriers that often hamper quality-improvement efforts.

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