We identified a total of 10 relevant US partnerships – 6 with CLTs, 1 with a ROC, and 3 with worker cooperatives, all of which agreed to participate in the study. For eight of the partnerships identified, the healthcare organization partner was a HAN member. Of the remaining partnerships with non-HAN members, one was identified by HAN and the other was identified in the gray literature. We conducted 29 interviews with a total of 38 key informants from a variety of roles and institutions. For every partnership, we interviewed at least one key informant from the healthcare organization and at least one key informant from the CWB organization partner, except for one CLT partnership for which we were unable to reach an appropriate representative from the healthcare organization. Table 1 summarizes the characteristics of the sample of partnerships and key informants.
Table 1 List of partnership cases and key informant affiliations
The healthcare organization partners were all non-profit entities that were themselves, or were affiliated with, larger “health systems” – regional or national networks of hospitals, clinics, and other care sites. The CWB organizations ranged from recently formed organizations exclusively focused on CLTs, ROCs, or worker cooperatives to more established, multi-faceted entities in which their CWB interventions were part of broader work in housing, community financing, or other areas. The CLT partners were themselves administrators of the CLTs while the ROC and worker cooperative partners were organizations that develop ROCs and worker cooperatives, which generally become separate entities. Nearly all of the CWB organizations were non-profits with the exception of Obran, which was organized as a private conglomerate of its worker cooperative members.
We found that CLT and ROC partnerships shared many similarities across the four domains. However, worker cooperative partnerships often had unique aspects. Therefore, we report our findings for each domain separately for CLTs/ROCs and worker cooperatives. Also, given that the aim of the study is to inform healthcare organizations interested in collaborating with CWB organizations, the results mainly focus on the partnership aspects most relevant to the healthcare organizations, incorporating perspectives from both healthcare organization and CWB organization key informants.
Informants described motivations for the partnerships as deriving from both community needs and healthcare organization needs. Informants from every healthcare organization interviewed described housing unaffordability and/or gentrification-related displacement as primary motivators for the partnership. In several cases, Community Health Needs Assessments (CHNAs) played an important role in identifying housing security as an investment priority. As one healthcare organization informant described their CHNA result: “access to health care or chronic disease wasn’t at the top; it was housing.”
In this context, healthcare organizations saw CLTs/ROCs as well-suited for addressing various aspects of housing insecurity. Several healthcare organizations were drawn to the permanent affordability created by the CLT/ROC model in contrast to time-limited rental subsidies or traditional homebuyer programs that only benefit the first purchaser. Healthcare organizations also saw the homeownership aspect of CLTs/ROCs as important for “turning neighborhoods around” while preventing displacement. Finally, some saw CLTs/ROCs as an important racial equity intervention, as several of the CLTs/ROCs primarily served minoritized communities disproportionately excluded from traditional homeownership. One CLT/ROC organization informant described this priority of the healthcare organization: “The biggest thing they’re interested in right now is we’re reaching out to underserved, and more importantly, minority households underserved by homeownership projects in the past.”
In addition to community needs, healthcare organizations were also motivated by their own needs, what one informant described as “enlightened self-interest.” One key health system need was preserving affordable housing for their own workforce, which was also facing displacement. While none of the CLT/ROC partnerships focused exclusively on workforce housing, several targeted areas where lower-income staff members lived. One healthcare organization informant noted, “workforce housing need was a high motivator in socializing this [CLT/ROC] concept.” Another healthcare organization need was for good relationships with the local community. In some cases, CLT/ROC partnerships provided healthcare organizations the opportunity to demonstrate a commitment to respond to local problems like the housing affordability crisis. A healthcare organization informant observed an important motivator for the healthcare organization was, “seeing potential to improve the health of kids but also to build better relationships with the neighborhood.”
Worker cooperative partnerships
Worker cooperative partnerships were also motivated by community needs and healthcare organization interests. High rates of poverty and what one worker cooperative informant described as “a dire need for jobs and economic inclusion” were key community factors motivating worker cooperative partnerships. Worker cooperatives not only provided living wage jobs but also wealth-building opportunities as worker-owners share the firms’ profits. Two of the worker cooperative partnerships also explicitly sought to address racial wealth inequity by focusing cooperative efforts in minoritized communities.
Worker cooperative partnerships also addressed healthcare organization needs. In some cases, cooperatives provided local, reliable, and environmentally sustainable services not otherwise available within the hospital’s supply chain, such as energy-efficient laundry services. One healthcare organization informant described the worker cooperative partnership model as “local residents working at a local business providing a vital service we need for healthcare and building at the same time wealth for them.” Like CLT/ROC partnerships, worker cooperative partnerships also provided a means for the healthcare organization to strengthen its reputation in the community by channeling its purchasing power into local economic development and wealth-building.
While there were sometimes pre-existing collaborations between the healthcare organization and CLT/ROC organization on a non-CLT/ROC project, the formal initiation of the CWB partnership was generally catalyzed by a funding or investment opportunity initiated by the healthcare organization. Informants emphasized two major aspects of this initiation process for the healthcare organization: identifying partners outside the healthcare organization and obtaining “buy-in” within the healthcare organization.
In identifying community partners for their funding and investment opportunities, healthcare organizations sometimes specifically sought out CLTs/ROCs given their unique benefits. In other cases, healthcare organizations sought to partner with a particular community organization and only later learned of the CLT/ROC aspect of their work. In order to partner effectively with CLTs/ROCs, healthcare organizations often realized they also needed to involve additional community partners. These varied depending on the CLT/ROC’s internal capacities but sometimes included “underwriting partners” like community development financial institutions (CDFIs) as well as neighborhood associations or city housing departments to provide additional financing expertise, community involvement, or public resources and support.
In addition to identifying partners outside the healthcare organization, initiating the partnership also required obtaining buy-in within the healthcare organization. Most CLT/ROC partnerships were initiated by the healthcare organization’s community health leadership who then sought buy-in from the executive and/or finance team. Two main strategies were used to obtain buy-in: education and “risk mitigation.” Because CLTs/ROCs are relatively uncommon, educational meetings were set up between CLTs/ROCs and healthcare organization leadership to explain the benefits of the models and answer any questions. As one healthcare organization informant described, their process involved a “six-month period to understand what is a land trust,” in which the healthcare organization board, “had land trust folks come to a meeting to explain what a CLT is.” The uniqueness of the CLT/ROC models also raised concerns about risk, especially since almost none of the healthcare organizations knew of other healthcare organizations investing in CLTs/ROCs. One risk mitigation approach healthcare organizations took was making small, incremental investments and utilizing both grants and loans based on the community partner’s needs and capacity. Another risk mitigation approach was developing long-term relationships with CLT/ROC organizations, including having a healthcare organization representative on their board, to develop deeper trust and knowledge of their business operations.
Worker cooperative partnerships
As for the CLTs/ROCs partnerships, worker cooperative partnership informants also emphasized the importance of securing external partners and internal buy-in for initiating the partnership. The key external partner for worker cooperative partnerships was the worker cooperative developer organization, which could develop a new cooperative or connect the healthcare organization to an existing cooperative to meet a healthcare organization purchasing need.
As with CLT/ROC partnerships, worker cooperative partnerships also sought healthcare organization buy-in through education and risk mitigation strategies. In terms of education, informants from all three partnerships emphasized the crucial role visits with successful worker cooperatives played in getting buy-in, with one noting “a tour over two to three days is worth a year of talking.” Members of the more recent worker cooperative partnerships had the advantage of being able to visit the first worker cooperative partnership (University Hospitals and Cleveland Clinic with Evergreen Cooperatives), but given the novelty of their contexts and approaches, risk mitigation was still a priority. Informants described several risk mitigation strategies, including having a healthcare organization representative on the cooperative advisory board and converting existing businesses into worker cooperatives rather than starting a new business. In addition to these strategies, informants also emphasized the importance of specifically obtaining buy-in from the healthcare organization’s middle managers, who directly control purchasing decisions, in order to facilitate purchasing from the worker cooperatives. One worker cooperative informant explained, “just because the CEO says it doesn’t mean Joe in procurement will do it…part of the organizing strategy is organizing the C-suite leadership and also the procurement people.”
The implementation domain describes the “what” of the partnership, and informants specifically described what resources healthcare organizations provided in the partnerships and what roles they played. In terms of financial resources, healthcare organizations used grants and/or impact investments to support CLTs/ROCs. Table 2 provides a general description of the resources provided by healthcare organizations within each partnership.
Table 2 Characteristics of community wealth-building partnerships
In terms of the overall roles healthcare organizations played in supporting CLTs/ROCs, a typology of three basic roles emerged among informants. Healthcare organizations acting as contributors provided financial capital to the CLT/ROC in the form of grants or loans. All the healthcare organizations studied acted as contributors. In most cases, healthcare organizations were the first major financial contributors to the CLT/ROC, which one CLT/ROC informant described as, “foundational for other investments.”
Some healthcare organizations also acted as conveners, using their social capital to bring together resources to support a CLT/ROC. A CLT/ROC informant noted their healthcare organization partner, “has a strong pull and when they come to a project they bring a lot of partners with them.” One healthcare organization led a broad fundraising effort for a CLT/ROC while another connected a CLT/ROC with partners to apply for tax credit funding.
Finally, one healthcare organization focused primarily on their role as a capacity builder, providing technical assistance, strategic planning resources, and other supports to help a CLT/ROC develop. One healthcare organization informant explained “I was able to get the hospital to fund strategic planning for the group and they need to figure out where they need to go.” This role can be especially important with a new or developing CLT/ROC.
Worker cooperative partnerships
Healthcare organizations supported worker cooperative partnerships primarily through purchasing from the worker cooperative (e.g. laundry services, solar installation, furniture upholstery) and also through grants aimed at cooperative capacity-building. Partnerships took one of two approaches to supporting worker cooperatives. Two healthcare organizations took outside-in approaches, which focused on bringing existing worker cooperatives into their supply chains. One healthcare organization took an inside-out approach, which focused on identifying businesses in its current supply chain to convert into worker-owned cooperatives. This healthcare organization helped fund two organizations with expertise in cooperative conversions to identify businesses interested in converting and support them through the conversion process.
While informants referenced the established health benefits of housing stability, affordability, and wealth-building as important impacts of the partnerships, they also noted that capturing these impacts through return-on-investment (ROI) calculations or health outcome metrics would be challenging for two reasons. First, the impacts of wealth-building and neighborhood stability can take years or even decades to be fully realized, limiting the utility of shorter-term assessments. Second, many of the benefits of the CLT/ROC may go to people who are not healthcare organization patients or may improve patients’ health and well-being in ways that don’t primarily impact healthcare utilization. One informant contrasted the broad impacts of CLT investments with “surgical investments” aimed at reducing asthma emergency room admissions through interventions like mold abatement, which can show a positive return on investment. While acknowledging the value of both approaches, he stated, “we’re not approaching this from an ROI perspective. We’re doing neighborhood change.”
Rather than relying on health outcome measures, informants described the use of process measures to assess whether health-enhancing neighborhood changes were occurring. These include the scale of the project (e.g. number of CLT/ROC units), affordability (e.g. median home price, income of residents), neighborhood metrics (e.g. neighborhood vacancy rates), and wealth-building (e.g. net equity for sellers). Some partnerships are also tracking racial equity measures, including the racial demographics of the CLT/ROC and of the surrounding neighborhood. One health system reported a longer-term approach by measuring changes in the social vulnerability index over the next five to ten years in neighborhoods with CLTs and other healthcare organization investments.
Worker cooperative partnerships
Worker cooperative partnerships noted similar impact measurement limitations and also focused primarily on health-associated process measures. Those include scale (e.g. number of cooperatives and cooperative members), compensation (e.g. wages and benefits), wealth-building (e.g. dividends from cooperatives), and racial equity (e.g. racial demographics of cooperative members).