CCHI worked with an existing coalition of representatives from the hospital, health department, and local agencies. There was strong collaboration, but membership was limited in scope. Despite recruitment efforts, there were few African American participants and there was limited participation from the local school system and local community health center. Planning was more reactive than proactive because local needs were often overwhelming, but participants maintained a high level of pride, energy, and involvement. One influential leader played a dominant role within the coalition, partly because of repeated turnover in health department leadership during the course of the project. The results of the CCHI community assessment were not highly utilized, and controversy took place over some funding decisions. Much of this stemmed from a perception of CCHI staff as outsiders and a strong concern about preserving local autonomy in decision making. Coalition members felt that the county should determine CCHI funding because it was acutely aware of local needs and had specific programs that needed funding.

Of the four study sites, this county had the most negative perception of CCHI and maintained a perception of CCHI as "Big Brother." Respondents were less likely to report that the project resulted in improved coalition building, was responsive to local needs, used a flexible approach, or had improved the image of CHS. Respondents indicated that CCHI and county priorities were not in agreement. One stakeholder commented, "I think CCHI needs to rely more on the [coalition]. . . . [T]here was some controversy because decisions were made about grants in Charlotte rather than in [our county]."

However, the majority of respondents indicated that the system of health care was better as a result of CCHI interventions and that the director of CCHI was highly respected. Resources and expertise were the most frequently cited benefits provided by CCHI, with funding for local initiatives clearly identified as the most important aspect. One respondent said, "[The] county is a poor rural county and there are just not that [many] resources here, but CCHI has helped the [group] find resources that [we] did not think [we] could find."

CCHI worked with a preexisting local coalition comprised of leaders of the major health and human service organizations who had considerable experience working together to assess community health needs and implement health improvement initiatives. While they were eager to work with CCHI, they clearly wanted their planning and organizational efforts to drive the process and were concerned that CCHI would duplicate local energies. To address this concern, efforts were made to augment and enhance existing assessments with previously unused data and integration of geographic information system mapping technology. Members of the coalition were also concerned about how data would be used, and there was initial difficulty gaining access to state and local health department data. An agreement was reached whereby available funds would primarily support activities specified in the coalition's action plan. This would allow coalition members to expand existing efforts and build a greater community presence.

Interviews indicated an overall positive perception of the CCHI project. CCHI was described as a facilitator and partner, and respondents in the county were outspoken about CCHI having worked with the county and used a flexible approach. Critical to the success of CCHI was the perception that local autonomy had been preserved, and the community was empowered by CCHI to develop a better health care system. One participant commented, "[CCHI has] empowered us not only with resources, but the ability to choose how to use them. . . . CCHI understands our strengths and has allowed us to use those strengths."

The majority of respondents described staff support as a significant benefit of CCHI and reported increased coordination within the county. However, many felt that the needs assessment duplicated existing efforts. Availability of funding for local interventions was the most commonly stated benefit. For example, one respondent offered this statement: "CCHI has helped us go from a virtual organization . . . to a more permanent organization because of our ability to access funding through CCHI and our ability to have a coordinator."

This project was unique among the four projects because it built on a community-oriented primary care effort — a coalition of local community residents and health care providers who had begun to define and address community health issues. However, initial distrust of the health care system was a significant challenge for CCHI staff. Residents had questions about the intent of the project and were highly suspicious of CCHI's long-term commitment to continued support of community-based initiatives. Community groups were highly independent and were often distrustful of so-called data-driven issues or needs. There were significant conflicts over how funds would be distributed to the community. However, community organizations were perceived by CCHI as being loosely organized, and there were concerns about their capacity to take on additional responsibilities without significant support. Some of these conflicts improved as the coalition gained experience working collaboratively on the community assessment and interventions.

Interviews with CCHI stakeholders revealed a surprisingly positive view of CCHI. Issues of trust and independence were a common theme, but it was clear that CCHI had made progress in overcoming the community's original image of the health care system. One stakeholder said, "There was significant community distrust about Carolinas HealthCare Systems' lack of responsiveness to the community needs. I think while some of that is still there, much of it has dissipated based on getting to know one another and discussing some things. I think [CCHI] may have changed the community attitude."

Respondents in this community were the most likely of all sites to feel that CCHI had a direct impact on coalition building and overcoming existing disputes over priorities within the county. The respondents felt that the CCHI model had helped produce community-based care and had provided coalition-building efforts. One commented, "One of the benefits is that CCHI brings another resource to the table, not only in the terms of funding but also in terms of involving community members at the neighborhood level, and getting input, . . . involvement, . . . and creating a sense of ownership for the folks at that level."

This county was furthest behind in implementing the CCHI model and struggled to develop a coalition. Some community health leaders questioned the need for a coalition. Among those who saw potential benefit, there was concern about sustainability and commitment. A fiscally conservative political atmosphere had limited collaboration among service organizations to small projects. Because initial attempts to develop an active coalition were not successful, initiatives and projects were developed and produced almost solely by the coordinator. To revitalize the process, a chairperson with local name recognition was identified and a coalition slowly began to form. Based on the findings of the health needs assessment, several community health interventions were developed and funded.

Similar to the other sites, respondents were positive in their evaluation of CCHI. The majority felt that CCHI had provided needed resources and reported increased collaboration with CCHI. Funding was the most commonly stated benefit. A respondent said, "This past year they allocated about one hundred thousand dollars for grants. . . . There are some new programs and new things that got started because of that funding."

Most respondents felt that CCHI had played a major role in developing coalitions, although some were critical of the coordinator for not facilitating further collaboration. Uncertainty and understanding of the coordinator's role was identified as a particular challenge to the process. Several respondents reported that the coordinator role faced positional challenges: "She has been strained in many ways. It's been a one-man operation. . . . She's been by herself . . . and had very little assistance . . . and hasn't had a lot of resources."