Editors' Introduction      By Stephen L. Isaacs and James R. Knickman

As we approach the last year of the twentieth century, market forces increasingly dictate the way in which health services are delivered; government can no longer be counted on to provide services for its neediest citizens; and an aging population, with its attendant chronic conditions, threatens to strain a health care system attuned to treating acute illnesses. Moreover, as addictions and unhealthy behaviors cut short the lives of too many Americans, the need to confront directly the behavioral factors that influence health becomes increasingly clear. These are monumental challenges--the kinds that The Robert Wood Johnson Foundation has been addressing since 1972 through its program investments.

These investments reflect the Foundation's mission of improving the health and health care of all Americans. Through the demonstration, research, training, and communications programs it funds, it attempts to advance one or more of its three goals: to improve access to basic health care for Americans of all ages; to improve services for people with chronic illnesses; and to reduce the harm caused by substance abuse. Both the goals and the investments are substantial. In 1997 alone, the Foundation awarded $331 million to carry out more than one thousand grants.

This book, the second in The Robert Wood Johnson Foundation Anthology series, has three purposes. First, to demystify the world of philanthropy--at least as seen from the Foundation's vantage point. Second, to provide a public accounting of the Foundation's program investments. Third and finally, to offer useful lessons gained from more than a quarter century of grant making.

To accomplish these purposes, we invited the authors--some of whom work for the Foundation, others of whom come from institutions that manage or evaluate Foundation-funded programs, and two of whom are professional journalists--to discuss as candidly as possible why programs were launched, what happened under them, and what lessons were gained from them. We selected programs that were mature, had the potential to provide important lessons, and represented a range of the Foundation's interests.

FOREWORD

Programs do not appear in a vacuum--either politically, economically, or philosophically. In the Foreword, Steven Schroeder, president of The Robert Wood Johnson Foundation, articulates the core values that frame the Foundation's investment choices and shape its culture. Adapted from a presentation he made to the board of trustees in July 1997, Dr. Schroeder's message seeks to identify the fundamental principles that characterize the Foundation.

COMBATING SUBSTANCE ABUSE

In 1991, the Foundation broke new ground by adopting a new goal: to reduce the harm caused by substance abuse. In the first chapter, Robert Hughes, a Foundation vice president, discusses why and how the organization became involved in substance abuse in the first place. Looking at both the people involved and the institutional processes, he reflects on the significance of goal setting for philanthropy and offers an insider's guide to the workings of a major foundation.

Once the Foundation embraced the substance abuse goal, it then developed a number of strategies to reach it. One of them was to seed the new field of tobacco policy research. In Chapter Two, Marjorie Gutman, David Altman, and Robert Rabin--each of whom has played a key part in developing this new field--write about two national tobacco policy research initiatives launched by the Foundation and the significance of the research they produced. The chapter demonstrates the potentially important role that such research can play in transforming public policy.

Chapter Three describes a very different approach to combating substance abuse. The chapter focuses on the single-minded effort of one committed individual to affect change through a particularly American subculture--baseball. Sportswriter Leonard Koppett captures the passion and personality of Joe Garagiola, a former major league star turned activist in his quest to combat the use of spit tobacco. It is the story of his campaign and the creation (told almost parenthetically) of the National Spit Tobacco Education Program that he helped establish with Foundation support. It is a powerful reminder of the impact one committed individual, with philanthropic support, can have.

The landscape changes from the ballpark to the office park in Chapter Four. Thomas Mangione, Jonathan Howland, and Marianne Lee, three Boston-based researchers, report the results of their survey on drinking and the workplace. After studying seven Fortune 500 companies and surveying nearly fourteen thousand managers, they find that corporate drinking policies are misdirected. By targeting problem drinkers, who are relatively few in number, company policies ignore moderate-to-light drinkers, who, by dint of their far larger numbers in the workplace, cause many more job-related performance problems. The authors reveal a number of myths that, if recognized and acted upon, could change the way American corporations address alcohol and the workplace.

INCREASING ACCESS TO CARE

Since it became a national philanthropy in 1972, the Foundation has had a goal of increasing people's access to health care services. Chapters Five and Six discuss two of the approaches the Foundation has used to reach that goal. The first tries to improve medical education, in the expectation that appropriately trained physicians will be more responsive to people's needs; the second approach tries to improve the nursing profession, so that patients will receive better care.

In Chapter Five, Lewis Sandy, the Foundation's executive vice president, and Richard Reynolds, his predecessor in the position, write about the Foundation's long relationship with those huge medical conglomerates known as academic health centers. Beginning in the 1970s, when academic health centers were viewed as "the center of the health and health care universe," and concluding in the 1990s, when academic health centers' place at the center of power had eroded, they trace the Foundation's efforts to open these institutions to new ideas, particularly the idea of training more generalist physicians.

In Chapter Six, Thomas Rundall, David Starkweather, and Barbara Norrish--from the School of Public Health of the University of California, Berkeley--report on their evaluation of the Strengthening Hospital Nursing program. A joint endeavor of the Pew Charitable Trusts and The Robert Wood Johnson Foundation, it was a large demonstration project whose purpose was to improve patient care by restructuring hospital services around nursing. The struggle to reorganize hospital services in the midst of the massive changes occurring throughout the entire health care system permeates the chapter. Although overtaken by managed care and the subsequent weakening of hospital nursing, the authors find that the Strengthening Hospital Nursing Program did make some lasting improvements in patient care in the sites they studied.

IMPROVING SERVICES FOR PEOPLE WITH CHRONIC ILLNESS

To a great extent, patient care has moved from the hospital to the community. This shift is due largely to the greater number of people with chronic conditions that do not necessarily require hospitalization and to the economics of managed care. As the chapter on Springfield, Massachusetts, in last year's Anthology revealed, community and home-based services for the chronically ill tend to be disorganized, underfunded, and inadequate. Three chapters in this year's Anthology examine Foundation-funded programs aimed at improving services for chronically ill individuals.

The Faith in Action program, like the Reach Out program reported in last year's Anthology, attempts to tap the spring of voluntarism--in this case by funding coalitions of religious organizations whose members volunteer to serve the homebound and other chronically ill individuals. In Chapter Seven, Paul Jellinek, Terri Gibbs Appel, and Terrance Keenan--current and former staff members who played key roles in the program's development--offer an inside perspective on the thinking behind the program, the people who made it happen, and its potential influence in an era when more and more social services are expected to be provided by volunteers.

In Chapter Eight, Lisa Lopez, a journalist who specializes in health issues, goes to the heart of services for the chronically ill: how they are provided in health maintenance organizations, or HMOs, and how they are organized in the community. She reports on two demonstration programs that test new approaches to improving services. The first provides funds to HMOs that restructure the way care is given to chronically ill individuals, and the second attempts to coordinate services offered in the community by nursing homes, physicians, home health organizations, and social services agencies.

In Chapter Nine, Leonard Saxe and Theodore Cross, professors in the Family and Children's policy Center at the Heller School at Brandeis University, report on the Mental Health Services Program for Youth, which supported the coordination of community-based services for children with severe mental disabilities. They found that this approach offered the children more access to care and permitted them to live outside of mental institutions. The limited scope of the evaluation did not, however, enable them to determine whether the program improved the mental health of the young people it served.

COMMUNICATIONS

Many people know of The Robert Wood Johnson Foundation by hearing the name mentioned on National Public Radio. What they may not realize is that the Foundation's support of public radio, brought about by a recognition of the public's need for reliable information, is part of a much broader communications strategy. The Foundation was one of the early philanthropic supporters of public broadcasting on health care issues and, since then, it has greatly expanded its work with the media. In Chapter Ten, Victoria Weisfeld, a senior communications officer at the Foundation, discusses how decisions about funding radio and television projects are made and chronicles the hits, misses, and near-misses of the Foundation's work with these media.

A LOOK BACK

Although it is not widely known, in the 1970s the Foundation played a pivotal role in establishing physician assistants and nurse practitioners as viable health professions. In the final chapter, Terrance Keenan, one of the Foundation's first staff members, offers a personal and evocative memoir of this work. His recollections include physicians who flew their own planes to supervise nurse practitioners in remote areas of Utah and nurse practitioners riding the circuit in rural Alabama in a van outfitted as a mobile medical office. It's a time and history that should not be lost.

STEPHEN L. ISAACS
JAMES R. KNICKMAN

Princeton, New Jersey
May 1998