18 westernmost counties of North Carolina, each with population numbers noted
A county-by-county map of western NC with population numbers. There are just eight hospitals with labor and delivery units for this 18 county region. Image credit: Dogwood Health Trust

By Mark Tosczak

If all goes as planned, a newly formed foundation, the Dogwood Health Trust, will receive the proceeds of Mission Health’s sale to for-profit hospital operator HCA sometime later this year or in early 2019.

shows a group o fpeople in a conference room at tables
Dozens of nonprofit leaders and other residents from western counties attended a forum on the creation of a conversion foundation formed from the sale of Mission Health to for-profit hospital chain HCA. Photo credit: Mark Tosczak

That money, as much as $2 billion, will be used to fund $50 million to $100 million in annual spending to address the social issues affecting the health and well-being of residents throughout Mission’s western North Carolina service area.

But Dogwood leaders and staff, experts say, will have to be smart and strategic if they hope to have a truly transformative effect on the region.

“You have to pick something to focus on or few things to focus on,” said Karen McNeil-Miller, president and CEO of The Colorado Health Foundation, a $2 billion-plus statewide foundation formed when the not-for-profit Denver-based HealthONE hospital merged with for-profit HCA in 1995. She also suggested focusing on a specific population.

But focusing effectively across western North Carolina will come with challenges.

Diverse region

North Carolina’s 18 westernmost counties are home to just over 900,000 people — fewer than the population of Wake County — who are spread across a mountainous, mostly rural area larger than Connecticut. There are considerable cultural, economic and political differences across the region.

“There is a fundamental tension between greater Asheville and the rest of that region that is as challenging as any other place in the country that I’ve experienced,” said Karl Stauber, CEO of Danville Regional Foundation, a hospital conversion foundation in Virginia.

The latest in the Mission-HCA sale process

What happened last week

  • Mission announces up to $90 million in gifts to six hospital/health care foundations as part of the deal. Each of the six foundations will receive $5 million per year over the next three years. Five of the foundations already exist, but as part of the gift the Angel Medical Center Foundation will be created. More information: http://blog.mission-health.org/2018/08/20/rural-communities-proceeds-hca/
  • Eight additional Dogwood Health Trust board members have now been named publicly. The board includes several current or former Mission Health board members; three of its nine members are from outside Buncombe County. These nine members will elect the remaining 3-6 members of the Dogwood board. More information: https://dogwoodhealthtrust.org/blog/additions-to-board-of-directors/
  • Mission chair John Ball told Business North Carolina magazine that a final deal between Mission and HCA is being negotiated, which will then trigger a 60-90 day period where the N.C. attorney general will review the deal. Ball said he expects the sale to be complete sometime in December. “There’s been nothing in the way of going in a different direction.” More information: http://businessnc.com/mission-is-full-speed-ahead-on-hca-sale-board-chair-says/

Stauber, a North Carolina native, spoke to a dozen or so people familiar with western North Carolina before giving a talk at an Asheville forum in early August focused on the Dogwood Health Trust.

Buncombe County is home to nearly a quarter of a million people and is a thriving retirement and tourism destination. It has a median household income of $46,902 and 36 percent of the population have bachelor’s degrees. Only 11 percent of people lack health insurance.

By contrast, tiny Graham County, a county further west, is home to fewer than 9,000 people, has an unemployment rate that’s higher than the state average. Median household income is $34,778 and only 14 percent of residents have earned a bachelor’s degree or higher. Close to 17 percent of the residents lack health insurance.

At that forum, which drew dozens of nonprofit leaders, government officials and activists, Graham County Economic Development Director Sophia Paulos asked Mission Board chair John Ball, how the foundation would handle regional differences.

“What is this current board doing to get the broader regional perspective?” she asked. “What are you guys doing now to ensure that you’re getting the perspective of those 18 counties?”

Board representation

Ball, who is one of Dogwood’s founding board members in addition to his role with Mission, said the group was seeking representation from across the region, while also being mindful of the skills they needed and reflecting the population’s diversity.

older white man stands at a podium speaking
Mission Health board chair John Ball speaks to an August forum on the new Dogwood Health Trust. Photo credit: Mark Tosczak

At the time of the forum only Dogwood’s founding board chair, Janice Brumit, had been publicly identified.

Last week — almost three weeks after the forum — Dogwood announced the name of eight additional board members (see box, bottom). Three of the nine members are from outside Buncombe County. The foundation is accepting nominations for board members now and, according to a news release, plans to eventually have 12-15 members.

At the forum, Ball told North Carolina Health News that the office of N.C. Attorney General Josh Stein insisted that the new foundation demonstrate its commitment to the whole region by including people from outside Buncombe County on its charter board.

But merely having board members from several counties won’t be enough to ensure the foundation can effectively serve the region, experts say.

Listening to people

Dogwood leaders have said the foundation will focus on “social determinants of health,” which include housing, education, the environment, jobs and other factors that contribute to health and well being. Research has shown that these social factors can be more important to achieving and maintaining health than simply providing medical services.

But within that broad category of work, Dogwood leaders will have to decide what to focus on and where they can make the most difference. Part of that process, said McNeil-Miller, is listening.

“Find out what the issues are from all strata of people — not just community leaders, not just nonprofit leaders, not just elected officials,” she said. “If you’re interested in social determinants and you want to work on, let’s say, affordable housing, talk to people who are experiencing homelessness or who can’t afford housing.”

For example, once every three months, McNeil-Miller said, she’ll pick a 100- or 200-square-mile area somewhere in Colorado and spend a week there to better understand the needs of residents. She has pre-arranged meetings with local nonprofit and government leaders, but part of the time she also spends talking to individuals. That can involve setting up small, informal focus groups through public health departments, homeless shelters and the like. Other times, she simply strikes up conversations with people in laundromats or convenience stores or the maids in the hotel.


“I certainly don’t mean that you ignore data that’s already available,” she said. “But you supplement that data with the lived experience of people.”

McNeil-Miller said learning, for example, that the closest grocery store for someone in a sparsely populated county is a 40-minute drive from home, over a mountain pass that may be impassable for weeks at a time during the winter, adds insight that data alone can’t provide.

Finding partners

Once Dogwood Health Trust has established focus areas and a strategy, it won’t be as simple as writing checks to local nonprofits. For starters, in some smaller communities, there may be a dearth of such organizations.

“If you think about western North Carolina, you go all the way out to Cherokee, there’s not a lot of people out there, and there aren’t a lot of nonprofits,” said Kate Treanor, senior program director at Grantmakers in Health, a Washington-based organization that helps foundations and corporate giving programs improve health. “So there is a capacity issue there. I think that’s probably the largest challenge.”

Dogwood could also give grants to local government agencies, such as school systems or county health departments, but that too comes with challenges. Managers in those organizations may have little experience with the expectations of philanthropic funders.

And not only are there fewer nonprofits in smaller communities, but those that do exist may not be as well equipped to pursue grants and carry out programs.

“If [Dogwood staff] come out and say, ‘We’re going to do an RFP [request for proposal],’” Stauber said, “ … you have potentially an unintended bias toward organizations that have professional staff that can respond.”

Foundations serving rural areas can often fund capacity-building programs to strengthen local nonprofits. In Danville, Stauber said, the Danville Regional Foundation created a professional development program for nonprofit executives.

That seems to be on Dogwood’s to-do list already, based on comments Ball made during the Asheville forum.

Stauber warns that the way Dogwood issues its first grants will send a message.

“If a high percentage of the first grants are all in Buncombe County, it’s going to be really challenging,” he said.”If they are all to large organizations that are perceived as being affluent, whether they are or not, that’s going to be tougher.”

Uncharted territory

Also tough for Dogwood may be measuring success.

Philanthropic funders often like the idea of “evidence-based” programs — strategies that have already been proven effective elsewhere.

But Allen Smart, who directs the Office of Rural Philanthropic Analysis at Campbell University, says most evidence-based programs were designed for urban, not rural, areas.

“Funders who are supporting communities and nonprofits to do evidence-based work in rural [areas] are essentially saying ‘We’re going to make you do work that’s never been proven,’” Smart said.

To evaluate success in rural communities, Smart said, funders need input on what success or failure actually means — usually from members of the community itself.

That may mean that Dogwood will need more than one philanthropic strategy. Some foundations, Smart said, do this by designating different staff members to focus on either rural or urban areas, though this can create conflicts within the foundation.

Another approach, he said, would be to hire staff with specific expertise and who already have networks in rural western communities. Some foundation staff could live or have offices there to strengthen Dogwood’s knowledge of places outside Buncombe County.

“When you have the foundation of this size, you can have these special specialized people,” he said.

Mission Health leaders have been saying that they believe Dogwood, when measured on a per capita basis across the 900,000 or so people it will serve, is likely to be the largest such foundation in the country.

“There is a fantastic chance to be able to improve the health of our people. They are sicker, poorer and less insured than the rest of North Carolina and most of the rest of the country,”  Ball told the Asheville forum. “We’ve got a phenomenal opportunity here.”

A public “kick-off” event for Dogwood is scheduled for Sept. 30.

Dogwood Health Trust board

Janice Brumit, chair (Buncombe County)
Jack Cecil, vice chair (Buncombe County)
Dr. John R. Ball (Buncombe County)
Michell Hicks (Qualla Boundary)*
Sam Lupas (Jackson County)
George Renfro (Buncombe County)
Robert C. Roberts (Buncombe County)
Wyatt S. Stevens, JD (Buncombe County)
Martha Tyner (Yancey County)

* The Qualla Boundary is an area of land that includes parts of Swain, Jackson, Haywood, Graham and Cherokee counties and is home to the Eastern Band of Cherokee Indians.

Source: Dogwood Health Trust

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Mark Tosczak has worked as a writer and communications professional for more than 20 years, including stints as a newspaper reporter and editor, think tank communications director, marketing agency vice...