How Did Changes Occur?

This evaluation identified five core strategies leveraged by the Foundation, that helped enable positive outcomes, including signaling urgency, cultivating partnerships, offering capacity building support, modeling engaged strategic philanthropy, and adopting a systems approach.

In this section:

Adopted a systems approach to impact

The Foundation strategically and intentionally invested in efforts across various levels of the oral health system, acknowledging that solving complex problems, like equitable access to affordable and quality oral health care, requires more than just delivering services. It is also about understanding the conditions that perpetuate issues and multi-faceted strategies to shift them.

Over the past decade, the Foundation intentionally took actions across multiple levels of the system, which resulted in an increase in sustainable oral health outcomes.

This multi-level systems approach included bolstering clinical infrastructure, supplementing the oral health system (and increased access points) with care coordination and other tangible supports, increasing access to care for key population groups, strengthening ecosystem-wide partnerships to ensure coordinated efforts, affecting policy change, and enabling system-wide improvements.

The Foundation also embodied principles of systems change in its own functions as a funder – through deliberate thought partnership with grantees, respect for community needs and voices, and through moving towards equitable grantmaking practices.

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Signaled urgency

The Foundation signaled the importance and urgency of addressing oral health in the state of North Carolina, which garnered support from other funders and ultimately increased resources necessary to sustain the work. These signals came to bear in three major ways: early investments, strategic inclusion of peer funders, and ongoing presence in the oral health space.

Leading edge investments

In 2009, the Foundation entered this space when few peer funders were investing in oral health in NC. While there were great examples from other states, of oral health progress being realized through strategic investments, there wasn’t much momentum in NC. This situated the Foundation on the leading edge of funding place-based oral health initiatives in North Carolina. These early investments fostered credibility for the oral health work of organizations on the ground as well as for the importance of the overall movement to other funders.

“I felt like [the Foundation] was trying to push this big, huge boulder up a mountain. Then they got a few folks on board to help push it up… And then it got to the top, and now it feels like there’s just this massive amount of momentum and energy.”.

Ecosystem partner

Strategic inclusion of peer funders

Not only was the Foundation leading the oral health work with their own dollars, they also raised awareness of these issues among peer funders in the oral health space.

“I think the foundation played a role in really garnering the support of other funders to see the value in oral health and start to add that to their grantmaking strategies. …the reason [another funder] committed $20+ million to build school-based oral health programs is because of them.”

Blue Cross NC Foundation grantee

Consistent ongoing presence

Aside from influencing financial resource flows, the Foundation’s leadership presence in the oral health discourse added visibility and created urgency. The Foundation continued to build steady momentum by ‘showing up’ in a spirit of curiosity and insisting that there are “other paths.” This persistence by the Foundation further built trust, modeled commitment, and increased visibility for oral health issues.

“I remember the first day [Foundation staff] showed up at one of our dental director council meetings in Raleigh… She was there and she kept coming, year after year. And then eventually it was the intangible (impact) of pulling us together and setting up a meeting to where there’d be some CEs and we would meet everybody and we would spend the day together.

Blue Cross NC Foundation grantee

Cultivated partnerships and seeded collaboration

The Foundation strategically co-created mechanisms and offered support for grantees to deepen partnerships with other actors in the ecosystem. These partnerships were critical for grantee partners to identify shared opportunities, coordinate efforts, spur shared learning, and access additional resources.

A key driver of oral health advancements in North Carolina was the Foundation’s intentional cultivation of partnerships and efforts to seed collaboration among various actors within the ecosystem. Over time, the strengthened ecosystem enabled actors to start finding common ground across a diversity of perspectives (including with policymakers), which ultimately contributed to policy wins.

Of the 35 grantees surveyed as a part of this evaluation, 29 received networking support.

In 2016, the Foundation worked alongside key partners to develop a plan to establish the North Carolina Oral Health Collaborative (NCOHC), which was first funded by the DentaQuest Foundation (now CareQuest Institute for Oral Health). The Foundation and the Duke Endowment, subsequently supplemented this funding as the Collaborative built capacity, clarified direction, and developed key bodies of early work. The Collaborative is now an organization that seeks to resolve consumer-level and systemic barriers to good oral health and accelerate the implementation of policies that reduce oral health disparities across North Carolina. This served as another key mechanism intended to deepen and sustain partnerships among actors in the ecosystem.

I don’t think there would have been a Collaborative if Blue Cross hadn’t been interested in that.

Blue Cross NC Foundation grantee

Blue Cross Blue Shield really connected us with the Collaborative and helped us become really intentional partners, and I think they really wanted us to think about our work in a holistic way, and they funded both of us, and I think that was really a helpful approach.

Blue Cross NC Foundation grantee

They were able to bridge the gap between dentists, the board, and the Collaborative, to bring all three of those partners together.

[The NCOHC leadership] was instrumental in bringing those key players, those key stakeholders together so that they could talk and move oral health forward, in North Carolina.

Blue Cross NC Foundation grantee

And so I think that that Oral Health Collaborative has helped to highlight, here’s who you need to talk to or here’s who needs to hear about this.

Blue Cross NC Foundation grantee

Curated capacity building support

A variety of capacity building supports (e.g., technical assistance, needs assessments, and equipment grants) were paired with responsive grantmaking to facilitate positive outcomes for grantees.

Over half of the 35 grantees surveyed received capacity building support from the Foundation.

Grantees shared illustrative examples of how the capacity-building support positively affected their organizations. By and large, grantees highlighted how the capacity-building support was instrumental in increasing organizational effectiveness and efficiency, as well as boosting their ability to share knowledge with others in the ecosystem.

We found so many ways we could do things better, more efficiently, see more patients at less cost per appointment, and still provide and expand our services. And that was one of the best things that they’ve ever done, and [Foundation staff] was spearheading that.

Blue Cross NC Foundation grantee

They’ve helped us look at evaluation and really strengthen the way we do our project design and measurement across all our platforms, not just oral health.

Blue Cross NC Foundation grantee

“…Access to learning, training, and expertise and supporting opportunities for our staff to grow their technical expertise in bidirectional ways… There were real opportunities to learn and share with one another.

The Foundation really supported that.”

Blue Cross NC Foundation grantee

Modeled engaged strategic philanthropy

The Foundation identified and supported solutions through an approach that the Foundation calls Engaged Strategic Philanthropy. Through this approach, strategy was generated and informed by engagement with communities, subject matter experts, and other stakeholders and adapted through a process of mutual learning between grantee partners and the Foundation. This bi-directional engagement promoted information flows, transparency, feedback, and accountability.

Central to the Foundation’s engaged strategic philanthropy approach, and more importantly, the effectiveness in the oral health ecosystem, was the intentional and humble efforts to listen, learn, and interact with diverse ecosystem actors and experts. The Foundation gathered and connected people around shared information and ideas, further deepening its own contextual knowledge along the way. This deep knowledge equipped the Foundation to see things systemically and better understand the ecosystem.

I think those responsive grants shaped the initiative…

It taught us not to jump off and run with something, and to really take the time to understand all the different things that are happening out in the field.

And that’s why I think this program has been so successful. We learned from the responsive grants and it shaped the model going forward and the level of technical assistance needed and what components.

Blue Cross NC Foundation grantee

There was a grant that was not moving as well as the foundation thought it should move.

So they just asked us, ‘What do you need?’

And then the foundation supplied us with additional funding that we could apply for to get just a little bit more of what we needed to make it successful.

So they don’t just give you the money and then drop you. They actually nurture the relationship and they add value.

Ecosystem partner

the bulk of the time [the foundation staff] have been our program person she has been such an amazing partner in being like, “Think creative, think big, what are some new things that you wanna do? And how can we support you in doing so?”

Blue Cross NC Foundation grantee

Relatedly, the Foundation also leaned into trust-based approaches. For example, the Foundation offered flexible funding that allowed grantees to quickly respond to opportunities as they emerged. Further, the Foundation worked with grantees to identify funding opportunities and streamline reporting processes to lighten the burden. As a thought partner to grantees, the Foundation helped brainstorm targets and achieve success with their organizational goals. Grantees felt that this type of partnership enabled them to scale their efforts in a sustainable way.

“Thinking about grantee success and creating opportunities to talk through our goals and target outcomes in a way that made our success achievable.

So we were able to grow incrementally and grow our capacity in really thoughtful ways without trying to bite off more than we could chew too quickly.”

Blue Cross NC Foundation Grantee

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