Jewish Healthcare Foundation Alan L. Otten

 

Tzedakah is a word that turns up frequently in the reports and other publications of the Jewish Healthcare Foundation. Tzedakah, the Foundation explains, is a Hebrew word that roughly translates as social justice––the deep moral obligation that the more fortunate have to reach out and help those who are less fortunate. And Tzedakah is a key to the Foundation's past, present, and future.

This sense of obligation was part of the reason for the creation of Pittsburgh's Montefiore Hospital, the hospital whose sale to Presbyterian University Hospital in 1990 produced the money that gave birth to the Foundation. It is the force that seems to motivate the Foundation's very large board of leading Jewish (and a few non-Jewish) Pittsburghers as they launch program after program to provide more or better health care for the frail elderly and the disabled, for children at risk and for women with health problems, for the indigent and underserved––and not just in the Jewish community but also in the broader community of southwestern Pennsylvania. And it is certainly one of the factors that persuaded the board to choose Karen Wolk Feinstein, a shrewd, politically astute and determinedly activist woman, as the Foundation's first and thus far only president; in choosing her, the board was making a further statement about the kind of foundation it wanted.

Though the Foundation was created in 1990, its history goes back exactly 100 years. In 1898, a small group of Pittsburgh's Jewish women met to consider ways to improve medical care for their fellow Jews, most of them comparatively recent immigrants from eastern Europe.

Over the next few years, this Hebrew Ladies Hospital Aid Society underwrote hospital care for impoverished members of the Jewish community and visited and cared for the poor and sick among their neighbors. Before long, however, they and other Jewish leaders came to feel that the growing Jewish community needed a hospital of its own. At that time and for several decades thereafter, most area hospitals either did not take Jewish patients at all or did not provide the kosher food, prayer meetings, and other special services Jewish patients wanted; moreover, Jewish doctors rarely were able to train or practice at these hospitals. After considerable community debate, an intense fund-raising effort was launched and the Montefiore Hospital Association was chartered. In May 1908, a hospital––named after British philanthropist Sir Moses Montefiore––opened its doors in a thoroughly remodeled old mansion about two miles east of the then-downtown area.

In the ensuing years, the hospital prospered and grew. Another major fund raising effort resulted in the opening of a new 13-story, 190-bed building in July 1929; it was, of course, just before the crash and the Great Depression, but the hospital struggled through and eventually prospered again. From the end of World War II through the 1970s, new wings and buildings were steadily added.

Throughout this period, Montefiore Hospital expanded not only physically but also in its range of services. Beyond providing hospital care, it was the first area hospital to set up community health clinics and offer home care. It trained black nurses and doctors and was the first area hospital to have black doctors on its staff. It opened the area's first outpatient surgery center and its first hospital-based research laboratory. It led in bone marrow transplants, the removal of brain tumors, and the use of laser surgery and chemical therapy. It did trailblazing research in geriatrics. Ultimately, it became a full-fledged teaching hospital, known for its excellent physicians, first-rate medical care, outstanding teaching skills, and pioneering research.

Throughout its history, Montefiore's board of directors, its staff, and the entire Jewish community consciously thought of Montefiore not simply as a Jewish hospital but as a hospital there to serve the entire Pittsburgh area––and they took satisfaction and pride in their contribution to the larger community. In its middle and later years, more of Montefiore's patients were non-Jewish than were Jewish, and its home care and other services extended throughout the city, into non-Jewish as well as Jewish neighborhoods.

Over the years, however, other Pittsburgh-area hospitals gradually dropped their anti-Semitic barriers and began to welcome both Jewish doctors and Jewish patients; a freestanding Jewish hospital was becoming less necessary to the Jewish community. In 1969, though still independently financed and governed, Montefiore formed a loose affiliation with the University of Pittsburgh Health Center, so that patients in either system had access to doctors, specialists, and treatments in the other. In succeeding years, this affiliation became steadily closer.

Then, in the 1980s, explosive changes began taking place in the health care world, both nationally and locally. New technology and procedures, powerful new drugs, swelling numbers of uninsured, and the beginnings of managed care were changing the health system everywhere. The switch to outpatient rather than inpatient treatment picked up steam, and Pittsburgh, like other areas across the country, began to develop a surplus of hospital beds.

Competition intensified among Pittsburgh-area hospitals, and particularly between Montefiore and the nearby Presbyterian University Hospital, by then a closely integrated part of the expanding University of Pittsburgh's Medical and Health Care Division. Montefiore was losing many of its most talented doctors and researchers to large academic centers, much of its physical plant was showing its age, and its occupancy rate was slowly declining. By the late 1980s, it was filling only about half of its 520-bed capacity, and its surplus in the year ending June 30, 1989, was a meager 1 percent of revenue.

Meanwhile, Presbyterian University, as part of the University of Pittsburgh medical system, seemed to thrive. Just across the street from Montefiore (ultimately, after they merged, the two would actually be connected by a walkway), it was planning a large new $180 million, 16-story tower. Presbyterian and the rest of the University system became less and less cooperative with Montefiore––resisting new programs at Montefiore, for example, and refusing to give University faculty appointments to doctors Montefiore was seeking to recruit.

The Montefiore board found itself faced with unpleasant choices. One possibility involved an ambitious attempt to modernize its plant, which would require a fund-raising effort of $50 million or more. Such a drive would probably have to take place largely within the Jewish community and would inevitably compete with the fund-raising efforts of other Jewish service groups including, most important, the United Jewish Federation (UJF), the umbrella Jewish charity organization. Many members of Montefiore's board were also prominent in the Federation and didn't particularly relish that sort of competition.

The alternative would be to attempt to work out an even closer relationship with the University medical system, which, given recent history, might be difficult. It seemed clear that the University had begun to feel that it could not have two University-affiliated medical-surgical hospitals competing with each other, one completely controlled by the University (Presbyterian) and the other only partly under its control (Montefiore). In such a situation, the University would always favor Presbyterian, which the University had come to regard as its flagship hospital.

Montefiore had from time to time received offers of purchase but had always rejected them out of hand. Now, though, several board members began to note that Jewish hospitals in other communities were having financial difficulties. With the health care system beginning to experience major upheaval, might not Montefiore soon be in the same boat? Might it not be wise to sell out while Montefiore was still a valuable asset?

Meetings between top University officials and key Montefiore officers had been going on for several months in 1989 in Montefiore's continuing efforts to solve the problems it was having with the University. Finally, at one such meeting, Montefiore Board Chairman Stanley R. Gumberg, a prominent local real estate developer, suggested that if the University didn't want the kind of relationship Montefiore was seeking, why didn't it just buy the hospital? The University promptly accepted the offer, and negotiations over price began. If the Jewish community was to give up its hospital, it would certainly expect to get something back, something in return for all the money and energy it had spent building Montefiore over 80 years.

Gradually, the outlines of the deal took shape in meetings kept highly secret for fear that the Montefiore medical staff and the entire Jewish community would mount a successful protest––better to have a done deal before letting the plans become public. The negotiators for the two sides agreed that ownership of Montefiore would be transferred to Presbyterian University Hospital, thus joining the University of Pittsburgh Medical Center (UPMC) system. Montefiore would continue to operate with its Jewish traditions and offer services for any special needs of Jewish patients.

Presbyterian had already begun excavation work on its proposed $180 million tower, but the acquisition of Montefiore would remove the need for the new building and thus save it from spending most of that amount. Montefiore had outstanding debt of about $65 million and would have to raise an additional $50 million to modernize, a total of $115 million on the Montefiore side of the ledger. So what if the University took over Montefiore's outstanding $65 million debt and gave the Jewish community cash for the difference between the $180 million the University would save by not building the tower and the $115 million Montefiore would save by having its existing debt paid off and not having to undertake a major fund-raising campaign?

"The difference was $65 million and we eventually worked it up to $75 million," one of the Montefiore negotiators recalls. However arrived at, that finally was the agreed price, except that the University would pay only $45 million in cash on settlement, with the remaining $30 million owed in interest-free notes to be paid off $5 million a year for six years. Committees were set up to work out nonmonetary details such as the composition of the two hospitals' boards.

But what was to be done with the $75 million the Jewish community was getting for Montefiore? Someone had heard that the Chicago Jewish community was thinking of setting up a charitable foundation with the proceeds from Humana's proposed purchase there of Michael Reese Hospital, and the Montefiore negotiators promptly decided that was the road they wanted to take too. The money would go to a newly created Montefiore Foundation, a private foundation that would be tax-exempt under the federal Internal Revenue Service code.

"As chairman of Montefiore, I felt I had a responsibility to preserve the value of this asset and that the best way to do that was to get rid of it and get some money out of the sale," Gumberg recalls. "It was time to dispose of an asset while it was still an asset." Declares Thomas Detre, now retired senior vice chancellor of health sciences at the University of Pittsburgh and at the time of the Montefiore takeover, president of the University's Medical and Health Care Division and one of the University's negotiators: "We felt we should be especially gentle and sympathetic in the negotiations. It was really a very friendly negotiation." Alvin Rogal, an insurance executive who had been a previous chairman of the Montefiore board and was to become the first chairman of the new foundation, sums up realistically: "The negotiations were not long and arduous. They wanted us, and we wanted to sell. But first we needed to agree on the price."

The actual agreement, termed a "major restructuring" that would maintain the two hospitals as separate entities but with overlapping boards and integrated management, was announced November 15, 1989, though the formal written offer from Presbyterian University was actually dated November 9, 1989. On November 29, the executive committee of the Montefiore Hospital board of trustees agreed to the terms in that letter, and on February 9, 1990, the full Montefiore board accepted––with Gumberg leading a hard-driving push for adoption.

Before this vote and continuing long after it, strong opposition was expressed within the Montefiore Hospital board and the Jewish community generally. Many Pittsburgh Jews had been born at Montefiore or had children born there; they and their families had been treated there; they had made donations and bequests to the hospital, and hospital plaques honored them or their parents. There was widespread shock that a separate Jewish hospital would no longer exist in Pittsburgh.

The Ladies Hospital Aid Society worried what its role would be under the new setup. Despite the fact that representatives of the medical staff had participated in the latter stages of the negotiations, many Montefiore doctors wanted to know how much operating room time they would now get, who would head the combined departments, who would allocate office space. A number of doctors formed a committee to see whether anything could be done to block the sale and concluded there wasn't. Many community leaders argued that rather than sell the hospital, the board should try to raise the money to modernize it and keep it in existence.

Two outside consulting firms were hired and gave as their opinion that, considering "current day events in the health care field," the proposed arrangement was a "fair and attractive way for the Jewish community to continue a health care mission." Says principal consultant Raymond S. Alexander: "We told them it was probably the right thing to do, at a time they still had options. Their backs weren't yet against the wall."

Detre held several meetings with Montefiore doctors, members of the Ladies Hospital Aid Society, and other community groups to ease their concerns. A separate agreement between Montefiore and Presbyterian––with the new foundation as a third party to the agreement––guaranteed the appointments and privileges of the Montefiore doctors.

Ultimately, the hard facts of the hospital's financial situation and the new foundation's potential for continuing the Montefiore tradition helped reduce the opposition of many in the Jewish community. Gumberg and other backers of the sale argued that the foundation would in effect let the Jewish community have its cake and eat it too: Jewish patients would still be served by a hospital sensitive to their special needs, while the foundation, with its $75 million, would give the community a new vehicle for serving both its own health needs and those of the larger Pittsburgh community.

On April 8, 1990, the Allegheny County Court of Common Pleas accepted the plan to separate the Montefiore Foundation, a newly created corporate entity, from Montefiore Hospital, and to permit Presbyterian to take control of Montefiore, to be renamed Montefiore University Hospital. Ten days later, all this was carried out. Under the agreement finally worked out, the board of the new foundation would consist of the entire large board of the old Montefiore Hospital. Two-thirds of the new Montefiore University Hospital board of trustees would be appointed by Presbyterian University Hospital's board (half of whom were appointed by the University of Pittsburgh), and one-third would be chosen by the board of the new foundation (which would also name three people to the Presbyterian University Hospital board). The chairman of the new Montefiore University Hospital board was to be Jewish, and the vice chairman was to be appointed by the foundation representatives on the Hospital board and presumably would also be Jewish. Montefiore would continue under the new name with its Jewish traditions and with kosher food and other special services for Jewish patients. (A few years later, though, everyone agreed that separate hospitals no longer made much sense, and in July 1993, Montefiore University Hospital was legally merged into Presbyterian University Hospital.)

Financial and governance relationships between the new foundation on the one hand and Montefiore University Hospital and other parts of the University of Pittsburgh's medical system on the other hand gradually diminished, and now there are none except for the Foundation- nominated trustees on the two hospital boards. The Jewish Healthcare Foundation does make grants to specific projects at the University of Pittsburgh, but these are a relatively small part of the Foundation's total grants, and both University and Foundation officials insist that University researchers get no special consideration. UPMC Health Systems President Jeffrey A. Romoff, who was executive vice president of the University's Medical and Health Division and one of the University negotiators at the time of the Montefiore sale, actually complains about the scarcity of Jewish Healthcare Foundation grants to the University. Feinstein replies that "we fund many grants there––medical education, research, health care innovations. We want to work with the best and brightest, and they have a lot of the best and brightest. But we also turn down their grant applications all the time."

Though there are still voices in the Jewish community who believe that the decision to sell the hospital was wrong and a betrayal, most of the community has come around to the belief that the decision was probably a wise one. Daniel A. Kane, a veteran hospital administrator who had become president of Montefiore at the beginning of 1989 and is now chief executive officer of Englewood Hospital in New Jersey, says he believes his current feeling may be typical of many in the Jewish community. "When the sale took place, I wasn't convinced it was necessary," he says. "Now, based on everything that has happened since then in health care, it's clear to me that it was inevitable and that Montefiore could not have continued to exist very long as a freestanding entity."

From the other side of the bargaining table, Romoff argues that Montefiore got a good deal selling when it did. "Now, in the present environment, the urge for a freestanding hospital to merge is so strong that the acquirer doesn't have to set up a foundation," he says. "We might decide to do it for political reasons, but it's no longer essential."

The New Foundation Takes Shape

Once the sale agreement was approved, the board of the newly created Montefiore Foundation––the full board of the former Montefiore Hospital––quickly set about its business under the leadership of Rogal; as a past president of both the United Jewish Federation and the board of Montefiore Hospital, he was considered likely to calm some of the hostility felt toward the deal in the Jewish community. A committee of leading board members––mostly past presidents of the hospital and also of the UJF––conducted long intensive meetings and, helped by a consultant who had worked with other charitable organizations, drew up proposed bylaws and a proposed mission statement. These were circulated for comment, revised slightly, and then adopted by the full Foundation board––the bylaws first, the mission statement a few months later.

The key decision was to maintain the two essential aspects of the old Montefiore Hospital: The new foundation would work in the health care field, as Montefiore had done––though health care was to be and has been broadly interpreted––and, like Montefiore, the new foundation would service both the Jewish community and the broader community of southwestern Pennsylvania.

"We wanted the Foundation to serve the same purposes as Montefiore Hospital (MH) had served––to be a Jewish community contribution to the greater community and to be devoted to health," Rogal says. "But I wanted a 'Jewish' identity in the name." To achieve that and also to avoid continuing confusion between the new Montefiore University Hospital and the new Montefiore Foundation––some early applications for foundation grants had been going to the hospital and other snafus were occurring––the Foundation board in December 1990 voted to rename the new foundation the Jewish Healthcare Foundation of Pittsburgh (JHF) and published the mission statement, which it had taken "time and great care" to draft. This important statement, the Foundation board said, "gives the Foundation a mandate to fulfill Jewish values with programs for the underserved and vulnerable . . . and to search for wisdom and understanding that define the Jewish meaning of service to God."

"JHF shall support and foster the provision of health care services, health care education, and, when reasonable and appropriate, medical and scientific research," the mission statement said, "and it shall respond to the medical, custodial, and other health-related needs of elderly, underprivileged, indigent and underserved persons in both the Jewish and general community throughout western Pennsylvania.

"JHF, just as its predecessor MH, will attempt to enhance and provide a new perspective to health care and health-related problems and, where appropriate, will seek to provide leadership in identifying problems and in seeing that such problems are studied. Further, it will seek collaboration not only in the study of problems but in proposing solutions and in the funding of programs dealing with these solutions. JHF will reach out to other Jewish and general community organizations and institutions to give not only leadership but also to work with and cooperate on common concerns and undertakings. . . ."

The statement affirmed the new foundation's "special relationship to the Jewish community and its institutions" but noted its determination to also serve "the general community of Western Pennsylvania."

"JHF is cognizant," the statement concluded, "of the long and successful history of the Jewish community institutions of Western Pennsylvania in dealing with health and health-related concerns. It sees its mission as that of a new creative and quality voice to join with others in fulfilling its Jewish heritage and obligations."

In early 1991, after a thorough search process, the JHF board named Feinstein as president. Though born in Des Moines, Feinstein grew up in Pittsburgh, and her family had deep roots there. A graduate of Brown University, she received a Ph.D. in labor economics from the Heller School at Brandeis University and taught social planning at Boston College. In 1984, she returned to Pittsburgh to teach at Carnegie Mellon's School of Urban and Public Affairs. She also consulted with the United Way of Allegheny County, ultimately becoming senior vice president in charge of allocations and community initiatives. The Jewish Healthcare Foundation board liked the way she had come up with new ideas at the United Way and had enhanced the organization's presence in the Pittsburgh area. Moreover, it wanted a relatively young person for the job; she was then 45.

"My instructions were to be creative and proactive," Feinstein says. "To find out what needs the community had, to do what I could to meet them, and to develop a unique identity for the Foundation."

In its early publications, the Foundation set forth as its priority concerns the elderly and chronically ill, at-risk children, women's health, the indigent and underserved, and AIDS patients. These are still essentially the groups and issues the Foundation targets, though it now prefers to express its priorities in terms of "visions" or "outcomes": to prevent disease and disability, to give children the physical and mental health they need to develop and succeed, to create healthy neighborhoods and communities, and to build better health systems and health policies, especially for the most vulnerable.

Feinstein knows that to keep her board happy, she must attend to all these goals and to the special needs of the Jewish community, but it is really the last of those "outcomes"––better health systems and policies––that seems to hold the most interest for her. "I want to use our ability to convene, to do policy analysis, to educate legislators––all these to work toward systems change," she says.

The Foundation's 1995 report points out that two unique circumstances of the Foundation's birth have shaped its agenda and grant-making activities: one is that it evolved from the sale of a Jewish institution founded on Jewish religious values and traditions; the other is that it was "born out of and into an era of tremendous upheaval and restructuring of our nation's health system."

"This is still an evolving organization," says current board Chairman Leon L. Netzer, a Pittsburgh industrialist and longtime Jewish community leader. "When we started, no one had a really clear vision beyond carrying on the traditions of Montefiore Hospital. Originally, we were involved with women, children, aging. Those were safe bets. Now we are dipping our foot into systemic changes."

Vital Facts and Figures

Before looking at the Foundation's specific programs, though, it might be well to take a snapshot of its financial situation and other vital figures and facts. Aided largely by the stock market surge of the 1990s, the Foundation's assets have increased steadily (every year but one) from the $45 million it received initially from the University to more than $137 million as of June 1998. The Foundation does no fund-raising; other than earnings on its investments, its only income has been a few small donations and bequests––less than $500,000 all together. (It is the financial agent in western Pennsylvania for the state's AIDS program and, as such, receives federal, state, and local dollars earmarked for AIDS programs, but the Foundation merely receives the money and then makes allocations to specific programs chosen through a regional AIDS planning process.)

Foundation funds are invested in the usual highly diversified way. Roughly 70 percent is in stocks or stock funds and about 30 percent in bonds or bond funds; about 3 percent of the portfolio is invested in Israeli bonds. Between five and 10 investment firms do the day-to-day trading under the general direction of a 14-member Foundation board committee. That committee meets annually to set general investment policy (which is then subject to approval by the entire board) and also meets quarterly to review results and make any needed adjustments in policy. Each investment firm handles between $2 million and $15 million of Foundation funds. For many years, there were no investment restrictions on social grounds, but this year, the board voted to ban investments in tobacco stocks.

The Foundation's annual grants have risen from $3,125,000 in 1992, the first full year of grantmaking, to an expected $5,710,000 in calendar year 1998. Grant management and administrative expenses are expected to total $790,000 this year, compared to $628,000 in 1992.

The Foundation occupies modest office space––though one with an impressive view over the Allegheny River––on the twenty-third floor of a downtown office building. The eight-member staff consists of Feinstein, two senior program officers, a financial and administrative officer, four clerical assistants, and an ever-changing stream of paid and unpaid interns. A policy-planning and research director will probably be added to the staff this year. The Foundation's offices include space for an AIDS coordinator (paid by the state); for a lawyer working for the Pennsylvania Health Law Project, a Philadelphia-based nonprofit organization; and for the Consumer Health Coalition, a Foundation-sponsored consumer advocacy group.

There is no local regulation of the Foundation, and the only state regulation is a recent requirement that it file with the state the same detailed financial information that it must file under federal law with the Internal Revenue Service in order to avoid excess tax liability. Federal law also requires the Foundation, in order to maintain its tax exemption, to distribute at least 5 percent of its endowment each year, and the Foundation tries to come out just a little above that percentage. The Foundation widely distributes its annual reports and a raft of other publications.

"We are a very open foundation," Feinstein says. "We tell everyone what we are doing, what we are taking on, where we want to land. We want them to know."

The Foundation is definitely, to use the accepted jargon, proactive. It does accept grant applications and approves a number of them, but it also thinks up programs it believes should be tested and then seeks out and finances organizations to carry them out. Every once in a while, it issues requests for proposals for this sort of testing, but more often, it will go to an organization and say, "We know of a problem to be solved and you have had experience with this sort of thing. Would you like to take it on? What would you do? How would you go about it?" On grant proposals, it works frequently with the petitioning organization to reshape the proposal and then assists it in putting the program into effect.

"We don't usually make capital grants or operating grants," says senior program officer Nancy D. Zionts. "We don't want situations where, when the money runs out, we're back to where we started. We want to fix glitches in the system, make lasting changes." The Foundation does not fund strictly clinical laboratory research, but it does fund demonstration projects that apply research.

Foundation reports and announcements say that grant proposals will receive special attention "if they provide opportunities for new information and fresh perspectives about health problems; improve health care systems or utilization of health care; and build partnerships among community institutions and/or contain a community education component." The Foundation says it selects grants that are "the best investments in meaningful systems change."

The bylaws do allow money to be spent outside the southwestern Pennsylvania area, but only by a two-thirds vote of the board––a provision that was included in case an emergency might require, for instance, the provision of money to aid Jews abroad. So far, the exception has been used only once––a 1991 grant of $1 million, to be spread over five years, to help Soviet Jews resettling in the Pittsburgh area.

The Foundation's unusually large board both sets general guidelines for Foundation activities and directly reviews staff recommendations for specific programs and the execution of those programs. The board is essentially self-perpetuating, consisting of 37 elected trustees––one-third nominated and elected each year for a three-year term––plus 19 lifetime trustees, men and women who were life trustees on the Montefiore Hospital board at the time of sale. Originally, there were several more life trustees, but the years have taken their usual toll.

The Foundation officers––chairman, vice chairman, secretary, treasurer, and sometimes additional vice chairmen and an assistant secretary and assistant treasurer––are nominated by a broad-based committee that consists of members of the Jewish community. They must then be elected by the full board, and must themselves be board members; the Foundation president is an ex-officio board member. Officers serve a one-year term and cannot serve for more than three. At least three board members must be doctors. Board members are nominated by a different board nominating committee for three-year terms, with the right to one succeeding term. Technically, only the 37 elected trustees can vote, but most matters are decided by consensus, including the lifetime trustees.

Board members are unpaid––the by-laws specify this––and while the bylaws also provide reimbursement of board members for actual expenses, Financial/Administrative Officer Robert J. Feidner says he can't remember ever receiving an expense account from any board member; board service is seen as an honor.

It's an active board too: it meets three times a year, with an occasional extra meeting, and every board member serves on one or more of the six standing committees and four "grant assessment" teams.

Besides the separate nominating committees for officers and board members, the committee list includes an infrequently used executive committee, an investment committee, a finance and audit committee that meets two or three times a year, and a distribution (or grants) committee that meets just in advance of each board meeting to review staff-proposed grants before putting them before the full board. About three years ago, the board created three (now increased to four) assessment teams in order to become intimately acquainted with program activities in specific areas. They work with the staff on new ideas, go with them on site visits, and do their own independent investigating––thus getting to know the grants quite well.

Now the Foundation has set up an evaluation committee to do an in-depth review and assessment of what the Foundation's money has been buying in terms of results and to suggest what to do for the future. "We're now in our seventh year of grantmaking," Chairman Netzer says, "and have reached the point where we should be evaluating what we've done and what we've accomplished. And develop some sense of where we ought to be going." Moreover, he says, "in the foundation world, we're really pretty small potatoes, so we have to be a boutique––pick our special things. This year we will put out about $6 million. That doesn't go very far, so we need a lot of bang for each buck."

The Foundation bylaws do include rules on conflicts of interest, requiring trustees to disclose publicly any possible conflict between their personal interests and the Foundation's business, and the board can bar voting on a particular item by any member who the board thinks has a conflict.

The Foundation Begins Grantmaking

The Foundation's first round of grants was announced in June 1991, only a few months after Feinstein became president, and much of the early money went to the United Jewish Federation, community health centers, and other established health service agencies. She did move quickly, however, to involve the Foundation in a few high-profile activities.

For example: In 1990, Pennsylvania had suffered a bad outbreak of measles, and the state government had urged local public-private efforts to educate the public on the importance of immunization and the need to increase the availability and actual use of vaccines. The following September, the Foundation––joined by the Rotary Club and several area hospitals––staged Operation KidShot, a volunteer-led countywide immunization drive that in one week inoculated 1,336 children in Allegheny County and endeavored to educate their families on the need for early immunization. That drive––and a 10-page spiral manual entitled "How to Conduct a Community Immunization Drive," which included a description of the clinics used, the materials available, the incentives offered and other details––won the Foundation widespread attention and a large number of awards. The following August, it repeated the drive in nine southwestern Pennsylvania counties, reaching 4,447 children. "It was our way of saying, 'Look, we're here, we're a new resource,''' Feinstein recalls. The project was credited with helping to enact a state law requiring all private insurers to fund immunizations.

A second example: In 1991, the Foundation undertook a study of the high death rates among black infants in Pittsburgh––interviewing black teen mothers and their mothers, studying past community efforts to reduce the rate, and reviewing research on the subject. An account of the study was subsequently published by the Foundation as "Ear to the Ground––A Study of Black Infant Mortality" and received wide publicity.

A third example: In 1992, the Foundation began working with a number of Pittsburgh public schools to set up "wellness centers" in each school, offices that would go considerably beyond the usual nurse's office in the kind of medical care, health education, and counseling they could offer. Then it teamed each school with a local hospital or community health center to help staff the wellness centers, and the doctors and nurses from the hospital or health center worked to figure out what additional health services the school needed and then helped to provide those services. Two dozen of these partnerships were formed in southwestern Pennsylvania.

And example four: In August 1992, the Foundation released a lengthy staff report––"Lead and Kids: Bad Chemistry"––reviewing what Pittsburgh and Allegheny County were already doing to reduce lead poisoning in children, making a series of recommendations to improve the local effort, and laying out a model program for other communities seeking to deal with lead poisoning. Foundation staffers were asked to testify before the Pittsburgh City Council and to address a nationwide conference staged by the federal Centers for Disease Control.

Several approaches have become JHF hallmarks. "I am not enamored with traditional philanthropy," Feinstein says. "It's very distant. I do not want the Foundation to be just an R and D incubator. I want to be engaged. We are activists."

For one thing, she believes in what she calls "environmental scans"––a device she used at the United Way and imported to the Foundation. A scan is a broad panoramic survey of an issue or a community before moving on to action; it's both a legitimate approach to many problems and again a valuable publicity tool. "I believe you don't jump into a problem," Feinstein says. "You want the demographics, what the problems are, what other players there are and what they're doing. Issues don't exist in a vacuum."

At the Foundation, these scans are carried out either by staffers or by consultants, and the scans usually end up providing a blueprint or agenda for future Foundation efforts.

A favorite tactic closely allied to the scans for discovering the feelings of a particular constituency or community is the use of small focus groups. In October 1993, the Foundation sponsored a Children's Health Summit at which policymakers and health experts from across the state discussed current state health programs for children and ways to improve them. But first the Foundation had conducted focus groups in three separate communities to discuss the subject and to discover which particular topics would make for profitable discussion at the Summit.

The Foundation is also always more than happy to act as a convenor of meetings to enable local leaders, state officials, foundation executives, and other community leaders to kick around a hot issue, see what ideas there are for dealing with it, and find out who's willing to put up money. In 1993, after the state enacted a program to provide health insurance for low-income children who did not qualify for Medicaid, the Foundation convened more than 100 local health providers from around the state to meet with state officials and discuss ways to implement the plan. Then it staged three retreats for state and county officials to work more privately on details.

Almost every major Foundation grant, meeting, or other activity is either preceded or followed by a Foundation report or Foundation study, which is then widely distributed. The advance reports usually survey the problem and provide examples of what other communities are doing on the subject; the reports that follow a meeting or other activity sum up what happened, make recommendations, and offer examples to be followed. Four or five times a year, the Foundation publishes Branches, an attractive, four-page newsletter. Each issue discusses in half a dozen simply written articles one particular broad health topic: recent advances in genetics and genetic testing, children's health coverage in Pennsylvania, the quest for quality in a managed care world. Each issue also contains ideas for dealing with new developments on the subject being addressed, phone numbers to call for information and help, and suggestions about what communities can do to educate their citizens on the subject. About 2,500 academics, journalists, business and union leaders, foundation executives, and state officials are on the mailing list. A foundation Web site (www.jhf.org) made its debut early in 1999.

In all their activities, the Foundation board and the Foundation staff consciously seek to follow through on the old Montefiore principles of service to both the Jewish community and the larger Pittsburgh area. The following represent the major efforts of the Foundation during its first seven years of grantmaking.

The Foundation and the Aged and Chronically Ill

Pittsburgh is a city with an unusually high proportion of old people. Nationally, Allegheny County ranks second only to Broward County, Florida, in the proportion of the population 65 years of age and older (18 percent)––and the Jewish community has a particularly large percentage of elderly, so this was a natural target group for the Foundation.

From the beginning, the JHF has sought to increase the number and effectiveness of volunteers working with the frail elderly and the chronically disabled. Among its first grants were those to help several local service organizations recruit and train 300 to 500 new volunteers. Year after year, it has been a major supporter of the Interfaith Volunteer Caregivers, an organization that encourages churches, synagogues, and other places of worship to work together on training volunteers and coordinating volunteer activities in each neighborhood.

In 1994, the Foundation contracted with the Washington-based Alliance for Aging Research to put together a basic sourcebook that caregivers could use. The pamphlet, "Moderating the Effects of Aging––A Caregiver's Manual," has been reprinted three times since, with more than 20,000 copies distributed to date. It sets forth in clear language the most up-to-date information a caregiver might need––about geriatric assessment, managing medications, nutrition, preventing falls, treating chronic wounds. Sources of help are also listed. The manual, a foreword says, is meant "to supplement, not supplant," the information and help provided by regular health care providers.

In 1994, the Foundation also helped set up the Southwestern Pennsylvania Partnership for Aging (SWPPA) as an advocacy group for the elderly. The Partnership includes representatives of nursing homes, hospitals, social service agencies, and other organizations involved with the elderly in 10 counties in southwestern Pennsylvania. "The Jewish Healthcare Foundation was not only willing to help with money," says Mary Anne Kelly, the Partnership's executive director, "but it also suggested what organizations to involve, what subjects to cover. It's a willing convenor, a willing participant, an organization willing to ask the tough questions."

In the fall of 1995, JHF joined with the United Way and SWPPA to carry out the Aging Environmental Scan, an effort to discover new ways to help older residents achieve better health and greater independence. The scan gathered facts on the numbers and types of elderly in the Pittsburgh area, the problems they were facing, the resources available to help them, and possible ways to employ these and other resources more effectively.

A number of Foundation projects resulted from the Aging Scan. For instance, the scan showed that many people felt uneasy about their caregivers––the caregivers weren't properly trained, they weren't dependable, they cheated or were threatening or even abusive. But the elderly men and women were reluctant or afraid to report them. The Foundation embarked on several programs to provide better training for caregivers and potential caregivers, including a grant to four local service organizations to develop a training program at the Community College of Allegheny County for caregivers or people likely to become caregivers.

The Aging Scan also served to make the Foundation newly conscious of the need to moderate the debilitating effects of aging and keep aging people strong and active. More money was put into home-delivered meals and disseminating information about good nutrition. A new program at various locations offered information and training to the elderly and their caregivers about how to take care of sores and wounds so they wouldn't develop to the point where individuals became bedridden or required institutionalization.

Another grant created the Community University Partnership for Successful Aging, an attempt to get local universities working to practically apply some of their research findings. For example, considerable academic research indicated that daily physical exercise was a better prescription than bed rest for many homebound or hospitalized elderly. Demonstration projects were set up at eight sites––nursing homes, high-rises, day care centers, and assisted-living residences––to teach proper walking posture, good walking habits, leg lifts and other exercises.

"You take something very practical, low cost, and transfer it from research to practice," says Charles W. Pruitt, Jr., president of Presbyterian Senior Care. "It doesn't look like a big high-benefit project, but if you get a lot of bedridden old folks up and walking again, that's pretty good."

The Foundation has begun working with nursing schools to give student nurses more training in how to identify the signs of increasing debility and what to do about it. When the MacArthur and Hartford Foundations sponsored a five-site test to learn how primary care personnel might do a better job of recognizing and treating depression in the aged, the Jewish Healthcare Foundation became the manager and partial funder of the Pittsburgh test site, working with the Western Psychiatric Institute and Clinic.

Pruitt also tells about Woodside Place, a residential facility his organization runs for people with Alzheimer's disease. The JHF suggested that Woodside Place test the idea of adding six to eight day patients with Alzheimer's, and it put up $75,000 to get the project under way and then evaluate it. "Now we have a regular day care center, where half a dozen people with Alzheimer's come for four or six or eight or 10 hours a day," he says. "We had this as one of our original goals but couldn't afford it. The Foundation heard about our plan and offered to help us test it. Now we have 36 residential beds and six or eight day patients who fit easily into the dining areas or recreation programs. And this approach can easily be replicated."

Last year, just as Philadelphia was hosting a highly publicized presidential summit on volunteer help for young people, the JHF was in the process of releasing a study of volunteer programs serving homebound seniors, and wrote into its recommendations the suggestion that a similar event be held for volunteers to help the elderly.

That prompted a host of "right on" comments from many groups, and the Foundation decided to organize a National Senior Volunteers Summit that in June of 1998 attracted more than 500 people from as far away as Hawaii––social service agency officials, health workers, religious leaders, and state and local government officials. The conference discussed innovative programs to provide better volunteer services to the infirm elderly and to involve active elderly men and women as volunteers themselves. In advance of the meeting, the Foundation staff prepared a compendium of programs from organizations all across the country––how the program worked, who was involved, what it cost, what the organization's plans were for the program's future––and then distributed this volume to everyone at the Summit.

The Foundation and At-Risk Children

The Foundation has been a vocal leader in efforts to provide health coverage for all Pennsylvania children. It has repeatedly pushed for expansion of CHIP, the state's Child Health Insurance Program that provides subsidized health insurance for children from families that are very poor but are still above the income cutoffs for Medicaid benefits.

In the fall of 1996, the Jewish Healthcare Foundation gave Pennsylvania Partnerships for Children, a Harrisburg-based advocacy group, money to distribute a study of the numbers of uninsured and underserved children––who they were, where they were, what coverage was being provided by various health plans. That study, which essentially showed that the Pennsylvania program had been effective but that more was needed, became the basic reference document for all subsequent debate. For example, the study showed that almost one-third of Pennsylvania children without health insurance were actually eligible for coverage under the Medicaid program but somehow weren't participating––close to 94,000 children. Starting in January 1997, the Foundation convened a series of four closed-door, off-the-record sessions at which small groups of 20 to 25 state officials, business leaders, health providers, and representatives of advocacy organizations could learn about and discuss the issues that had to be faced––how much was being spent on children and was it enough, what kind of care they were getting, and whether the state was getting what it paid for.

Also in early 1997, to focus more concentrated effort on the same problems in its home county, the Foundation joined with the Consumer Health Coalition, an advocacy group, to convene a working group of local officials and representatives of hospitals and other health providers to consider the fact that 18,000 local children were eligible for Medicaid or CHIP but weren't enrolled in either program. The group sought to understand how this could be and what could be done about it and made a series of recommendations to bring many of these children under health care coverage. The group also designed and implemented an enrollment campaign, which, in two months, counseled the families of more than 1,000 eligible but uninsured children and stands to be adopted as a model for Pennsylvania's approach statewide.

The Jewish Healthcare Foundation is the lead organization for the Pittsburgh test of the Healthy Steps program, a nationwide Commonwealth Fund initiative designed to make pediatric care more effective by broadening the pediatric team to include one or two professionals trained in child development. Pittsburgh is one of the original 15 sites involved in the program across the country. The idea is to use the regular pediatric checkup or other visit to the doctor as an occasion for discussing with young parents whatever behavioral or developmental problems the child might be having and to follow up with home visits for further discussion and guidance.

"The JHF not only helped fund the program but Karen went out and created a task force of a number of local organizations to discuss how we could take greater advantage of the program," says Gayle Tissue-Kaloyeropoulos, then chief operating officer of Children's Hospital of Pittsburgh. "How could we publicize it better, get it into people's homes, influence public policy? She had a meeting of 20-plus people to come up with ideas. The Jewish Healthcare Foundation takes a project way beyond simply funding it. They maximize the dollars they put into it."

A recent project seeks to improve the quality of diagnosis and treatment for children with attention deficit/hyperactivity disorder (AD/HD). Foundation officials had begun hearing anecdotes about the growing number of kids coming to school Ritalin-treated, and it commissioned two specialists to search the literature and interview experts on the appropriate use of Ritalin. They discovered that local practice in some areas varied widely from acceptable standards for diagnosis and management of AD/HD.

A Foundation-convened conference of pediatricians, psychiatrists, school officials, community leaders, and other concerned men and women came up with a number of ideas for addressing the problem. One was to set up a group to formulate an accepted process for diagnosis and treatment. Another was to work with employers and insurers to expand health insurance coverage to include behavioral therapy for both children with AD/HD and their parents. For the conference, the Foundation staff had prepared two papers––a study of trends in Ritalin use and treatment among different groups of children and a survey of the best local practices. Pennsylvania media gave these reports extensive coverage.

Since its inception, the Foundation has made repeated efforts to increase community action against youth violence. In 1992, for example, it provided money and worked with the Pittsburgh public schools, Western Psychiatric Institute and Clinic, and other groups to draft a comprehensive blueprint suggesting how school officials and representatives of the police and community agencies could work together more effectively to reduce violence in the schools. In 1994, after gang-inspired racial and ethnic violence at the city's Taylor Allerdice High School in the heart of the Jewish community, a Foundation grant enabled the American Jewish Committee to bring its "Hands Across the Campus" curriculum to the school, and the effort was successful enough in easing tensions that the Pittsburgh school system ordered every high school to provide a similar educational program on tolerance.

More recently, youth violence has been a heightened focus of Foundation activities. At the request of the U.S. Attorney for Western Pennsylvania, Allegheny County set up a Youth Crime Prevention Council, a coalition of community groups. Feinstein chairs one of the Council's three subcommittees, the subcommittee on community mobilization. Early in 1997, in cooperation with the United Way and Blue Cross of Western Pennsylvania, Foundation staff prepared and published a report for the Council entitled, "The Child and Youth Injury Environmental Scan: A Benchmark for Violence Prevention in Allegheny County." The statistic-jammed scan reported trends and patterns in injury and violence among children and youth, the factors that seemed to be behind these trends, model programs of prevention, and local resources that communities could call on for help.

When the Council decided to sponsor a series of media ads and community workshops aimed at reducing youth violence, the Foundation staff canvassed programs around the country and suggested that Hands Without Guns be the model for the campaign. More than 200 local leaders met over a three-day period––social workers, law enforcement people, businessmen, university researchers. They were addressed by an official of the Washington-based Center to Prevent Handgun Violence, the creator of Hands Without Guns. Then the Foundation put the idea to a focus group of young people from high-violence communities. The upshot––a program that includes school discussion of gun use, classroom teaching of conflict avoidance techniques, and community attempts to build and apply peer pressure––was launched in one Pittsburgh neighborhood in September of 1998, under the sponsorship of the United Way and with funds from the state, JHF, and other local foundations, and was scheduled to be extended to a second neighborhood by the end of 1998.

One of the Foundation's many publications is "First Steps––An Overview of Key Services and Benefits for Children with Special Needs in Allegheny County." As its name indicates, it's a directory that provides information to families of children with disabilities.

The Foundation and Women's Health

The Foundation has repeatedly said it wants to make Pittsburgh a national center for research and education on women's health problems. Breast cancer was an obvious target, since rates are especially high among Jewish women. Early on, the Foundation sponsored and produced in cooperation with local television station WQED-TV an hour-long film, "The Breast Test," which graphically explains the methods used to screen for breast cancer, the importance of early detection, and the possible treatments and their results. The film was televised locally and then statewide and nationally, winning many major awards.

The JHF has funded two major breast cancer studies by the Pittsburgh Health Research Institute. The first study aimed at discovering whether women with stage one breast cancer were getting adequate information on the relative merits of lumpectomy versus mastectomy. The study revealed that Pittsburgh-area women were informed of their options at a higher rate than the national average and that they chose lumpectomy more often, although women covered under Medicaid were much less likely to be offered the lumpectomy option than those covered under private insurance. But the study also found that many Pittsburgh women choosing lumpectomy––especially those on Medicaid––weren't getting the necessary follow-up radiation. The second study sought to find out why and discovered that the main reason was that the women's doctors hadn't sufficiently stressed the need to have the radiation after lumpectomy.

To provide better information systems for women with breast cancer, the Foundation in 1996 gave the University of Pittsburgh Cancer Institute money to produce a Computerized Breast Cancer Patient Notebook, which combines the individual woman's medical history and treatment course with the latest relevant background material on breast cancer. Another outreach effort resulting from the breast cancer studies is a new Foundation-financed Web site maintained by the local chapter of the National Council for Jewish Women. The site offers extensive information about breast cancer and a listing of both local and national sources for additional information and help.

A more recent grant helped the University of Pittsburgh's Genetics Education and Counseling Program publish a guide explaining genetics and what genetic testing can and can't reveal. The grant also finances an outreach program under which genetics specialists from the University visit community groups to explain genetics and to stress the availability of counseling to help people make the hard decisions about the conditions that genetic tests may reveal.

To help women and children threatened by family violence, the Foundation has supported the Safe Families Project––a joint program of the Children's Hospital and the Women's Center and Shelter––to teach emergency room doctors and nurses to recognize and refer women and children victimized by family violence and abuse.

Most recently, the Foundation has begun to explore whether something can be done to provide better support for women whose doctors have suggested hormone replacement therapy. Research indicates that high proportions of women whose doctors prescribe the therapy aren't given a thorough enough review of their options, taking personal and lifestyle considerations into account, and therefore don't fill their prescriptions and take the medication. A JHF grant will enable Magee-Women's Hospital to try to find out whether involving the woman more in the initial discussion will improve compliance without unduly lengthening the time the doctor must spend with each patient. First-year results, the researchers say, indicate that only a few extra minutes of discussion result in dramatically improved compliance.

The Foundation and the Underserved

Montefiore Hospital's long-time involvement with community care "is always in the back of our minds when we work with low-income groups, with the indigent," says Foundation senior program officer Kenneth T. Segel. "The (Foundation) board feels it, the staff feels it."

One of the earliest Foundation publications, in 1992, was "A Guide to Primary Health Care," a listing of all the Allegheny County-area programs and agencies that could assist people in locating affordable health care. Published in conjunction with the United Way of Allegheny County, it gave the names, addresses, phone numbers, hours of service, fees, and other information about hospitals, community health centers, service agencies, and other places that offered free care or reduced-cost care or could direct people to it. The targeted audience included low-income people, the homeless, people with AIDS, and battered women. "It was issued at a time many people were losing their medical insurance or Medicaid benefits," says Feinstein, "and this was to show that there were a lot of other options. Caseworkers used it and loved it." It has been reprinted many times, and an updated edition was issued in 1996.

The Foundation has supplied seed money and other help to start the Consumer Health Coalition, which works for better health care for such vulnerable groups as the chronically ill and disabled, the elderly, minorities, and low-income adults and children. Members of the Coalition include service organizations, unions, and community health agencies. Not only did the Foundation supply $60,000 to support the Coalition over its first three years of life but it has also given the Coalition office space and other services. Currently, the Coalition is working with the Pennsylvania Health Law Project, another Foundation-sponsored advocacy group, to educate the public about HealthChoices, the state's mandatory managed care program that went into effect January 1, 1999, for Medicaid recipients.

Last year, the Coalition led an ultimately successful campaign to ban managed care companies from carrying on door-to-door marketing to Medicaid recipients, a practice that was felt to take unfair advantage of vulnerable individuals. The Coalition also has worked to achieve expansion of the state's CHIP program and to use all available federal funds to cover additional children.

"JHF was also instrumental in getting us money from other foundations," says the Coalition's first director, William England. "Being associated with the JHF gave us recognition from the start; it opened doors for us. Without their generosity, we wouldn't be here and probably no one would be here to represent the consumer in facing all these changes in the health care system."

The Foundation also has been the key sponsor of the Coordinated Care Network, which links 20 neighborhood-based health centers and social service agencies that not only provide all types of health care (medical, mental, dental) to uninsured or underinsured men and women but also offer a range of other services such as day care, Meals-on-Wheels, and, very importantly, spiritual counseling. Each center has one or more satellites. The network's clientele includes not only the indigent and homeless but also addicts, single mothers, and the elderly. The three-year-old network is nondenominational and interfaith, and while most centers are run by Jewish, Catholic, or Protestant groups, one is run by evangelicals and another caters to Muslims. The network is now bargaining with HMOs to provide primary care for the more than 50,000 people served by these community centers, according to Director Jeffrey S. Palmer, who had previously been executive director of one of the community centers.

The Jewish Healthcare Foundation gave $150,000 to help get the network established and twice convened meetings of other Pittsburgh foundations to urge them to pitch in.

The Foundation has actively encouraged another effort to combine purchasing power to bargain more effectively with health care providers and insurers. The Three Rivers Labor-Management Committee is an outgrowth of a labor-management committee originally formed to work on the more traditional workplace disputes, and at some point, it created a disability pool and found it highly successful. Helped by the JHF and the Heinz Family Foundation, the group is trying to assemble a health care purchasing collective that includes more than 100,000 workers, retirees, and their dependents––largely school employees, firefighters, and other city and county employees. Bids have been solicited from five health care insurers.

Foundation staffers worked long hours last summer, meeting with all the possible groups and helping them understand health care purchasing. To advise the local business and union leaders on just how to go about forming the collective, the Foundation flew in several people who had formed similar groups in other areas.

"The board expects a Jewish organization to speak up for the underdog and the consumer," Feinstein says. "Working to distribute our health resources more equitably is the only way a Jewish organization could go."

The Foundation and the Jewish Community

"From the start, there's been a continuing, conscious effort not to give more than two-thirds of our disbursements to the Jewish community," Board Chairman Netzer says, and the actual amount tends to vary between about 55 percent and 60 percent each year. Estimates put the Jewish population of the greater Pittsburgh area at about 45,000, with most Jews living in the city proper and a large percentage of those in the so-called Squirrel Hill area.

Until last year, the United Jewish Federation received $750,000 annually from the Foundation for distribution to specific health-related agencies in the Jewish community, but the amount was raised in July 1997 to $900,000 a year. The Federation has received additional grants most years for specific programs that it operates itself, and substantial amounts also have gone each year directly to specific health-service agencies in the Jewish community.

In 1992, the Foundation helped establish the Jewish Association on Aging to guarantee a "continuum of care" for elderly Jews––to make sure that they would continue to receive care whether they were living in their own homes, with relatives, or in assisted-living quarters, nursing homes, or other institutions. The Foundation has each year awarded the Association major grants to carry out this commitment. When the United Jewish Federation launched a $50 million-plus drive to update various Squirrel Hill community facilities––including the community center, the nursing home, the day care center, and Jewish day schools––the Foundation pledged $25 million over 30 years but earmarked it for rebuilding the antiquated nursing home, the Riverview Center for Jewish Seniors, and for assisted-living apartments and home health care services.

One of the Foundation's most important efforts in the Jewish community has been what it called the Healthy Jewish Community Project, an extensive attempt to identify health care needs not being met by existing programs. In early 1994, the Foundation involved 80 community leaders in shaping the project. It then interviewed 20 rabbis and 75 health professionals for their views and conducted 15 different focus groups involving 100 randomly selected men and women of varying ages. Finally, 1,178 randomly selected Jewish households were surveyed, with lengthy 25-minute questionnaires that asked about hunger, poverty, health, schooling, family violence, and substance abuse. The idea, the Foundation said, was to let the entire community suggest directions for future Foundation attention.

"It was an excellent exercise in listening and building community contacts, but it was also an excellent opportunity for the Foundation to get its name out there in the community," Zionts says.

In 1995, the Foundation published the results in "A Community Health Assessment and Action Plan for the Greater Pittsburgh Jewish Community." The assessment highlighted the extent to which elderly people felt the need for more help and the stress their children and other caregivers felt in trying to fill this need, high concern about family cohesion, the need for more health education and prevention services, and increasing difficulties with health insurance coverage. From these results, the Foundation shaped a restatement of the obligations of a Jewish community to try to prevent illness and injury, support those who are sick, and maintain strong multigenerational families.

One surprising finding was the large number of Jewish poor and hungry. A three-year Foundation grant will finance in the Squirrel Hill area a new Kosher SuperPantry where low-income residents can obtain free supplies of guaranteed-kosher nonperishable staples; other Pittsburgh food pantries include foods that aren't kosher. The SuperPantry opened in September 1998, with twice-a-month service for more than 100 Jewish families, and Foundation officials say that ultimately it will be servicing close to 200 families.

The survey revealed an unexpected level of concern about family violence. This led the Foundation to develop educational materials about spousal abuse and other forms of family violence and to launch an outreach program to alert doctors, lawyers, teachers, and other community leaders to the fact that the Jewish community is not immune to this type of problem. The Jewish Family and Children's Service was given funds to develop a network of "safe houses" for the victims of family violence.

Also as a result of the survey, the Foundation has been making renewed efforts to increase both the number and the efficient use of volunteer workers in the Jewish community––to help the elderly, single parents, children and teens, and abused women. A new Jewish Volunteer Resource Center was set up to work with the United Way to build a community database of volunteers and to train volunteer coordinators and service agency officials in ways to use volunteers more efficiently. The Foundation issued a new edition of its "Guide to Primary Health Care" and published another volume, "There for You," which, as its subtitle indicates precisely, is "A Guide to Community Resources and Entitlement Programs for the Pittsburgh Jewish Community."

Still another problem area spotlighted by the Healthy Jewish Community survey was that of Jewish families with disabled children, who were experiencing difficulties in finding services and a feeling of exclusion by the rest of the community. The Foundation began working with the United Jewish Federation, Jewish social service agencies, and the University of Pittsburgh's Office of Child Development on various measures to rectify the situation. A new Jewish Care Coordination Project was organized to provide confidential one-to-one counseling for parents of disabled children and also to provide them with advice on special resources available to them and to the disabled child, his or her siblings, and other relatives. The Jewish Community Center was given funds to conduct a series of support groups for parents of disabled children and separate support groups for grandparents and siblings.

Just as there are those in the health field who grumble that the Foundation gives too much money to the Jewish community, there are those in the Jewish community who complain that the Foundation works too much on problems outside the Jewish community and that its focus on health problems keeps it from helping out with Jewish day schools and other non-health Jewish community needs. It is a grumble the Foundation has sought to meet by its large grants to the United Jewish Federation and by giving a health twist to programs that help school or other non-health causes. Recent grants, for instance, provide money to Jewish day schools to provide new services for children with disabilities.

Despite its extensive investment in the Jewish community, even some board members concede that the Foundation is still probably better known in the general Pittsburgh community––in particular, the Pittsburgh foundation and health worlds––than in the Jewish community itself. "The Jewish community knows it's there but isn't sure exactly what it does," one board member says.

The Foundation's Impact

The Foundation's bylaws specifically state that "no substantial part of the activities of the Corporation or any recipient of its funds shall be to carry on propaganda or otherwise to attempt to influence legislation or to aid any political campaign on behalf of any candidate for public office." Occasionally, one or another board member does caution that the Foundation not get too close to stepping over the line between "education" and "lobbying."

For example, in December 1994, the Foundation issued a much-publicized 22-page report strongly urging the newly elected governor of Pennsylvania to take a series of specifically enumerated steps to rebuild and "reinvigorate" the state Department of Health, which, the report said, was held "in almost universally low regard in Harrisburg." Together with the United Way, the Foundation in January 1995 released the "Health Environmental Scan," which surveyed health trends in seven southwestern Pennsylvania counties, discussed the failures of the medical system to address many health problems, and urged a "new regional health assurance organization" to promote an integrated health system in the area.

Staffers travel frequently to Harrisburg to meet with state officials or to testify on current health policy issues. Foundation officials have taken part in many meetings with state and local officials to shape what Pennsylvania will do to bring poor children under managed care.

"We are very conscious of the problem" of avoiding lobbying and political activity, Feinstein says, "and if we weren't, the board or our counsel––who reviews our projects––would soon rein us in. But we study and testify. We provide a full and fair explanation of the issues for the public. We provide background material, alternative answers. We can be critical. We speak up. But we try to work collegially. We do not lobby or support candidates."

The Foundation's first round of grants were made in June 1991, and in the seven intervening years, it's widely agreed, the Foundation has become a major and innovative player in the health care field, both locally and statewide. Larger local foundations respect the Jewish Healthcare Foundation's perspective on health issues. One JHF grantee tells of going with his project to a large family foundation and being told by the foundation executive: "If it's health care in Pittsburgh, you need to be sure the Jewish Healthcare Foundation is involved. They're the experts. Go there, and if they decide to do something, come back here and we'll talk some more."

"An activist agenda is their trademark," says Beaufort Longest, director of the Health Policy Institute at the University of Pittsburgh. "Pittsburgh has a large body of foundations for a community its size, and on health issues the Jewish Healthcare Foundation is far out in front." Declares Claire Morrison, the executive director of the Allegheny County Welfare Department: "The Jewish Healthcare Foundation gets people to come to the table and then gets them to stay there."

"The Jewish Healthcare Foundation takes on issues other foundations aren't comfortable with," a state official says. "They don't put in huge amounts of money, but their impact is very large in achieving change." And an HMO official says that "they have a definite public health agenda and like to influence policy, but I have to admit they are innovative and creative and a lot of what they push makes good sense."

Lessons to Be Learned

So are there lessons to be learned from the sale of Montefiore and the creation of the Jewish Healthcare Foundation? The people involved offer a few thoughts, but not too many. By and large, they indicate, things have gone pretty much as people should have expected.

Several members of the small group that arranged the sale of Montefiore to the University of Pittsburgh suggest that secrecy is essential in this type of negotiation. "One of the lessons from all this is that it's best to conduct these negotiations in secrecy," says one participant. "If the terms had been known before we had concluded the agreement, it never would have come off." Agrees Rogal, the man who was to become the first president of the new foundation: "It had to be secretive or we would have lost the deal in the uproar."

And Farrell Rubenstein, who was one of the University's negotiators in the purchase of Montefiore Hospital and who now heads the Foundation's finance and audit committee, says, "Keep the number of people involved in the negotiations to a minimum. It should be done by competent people in a confidential way. And above all, keep the doctors out of it––they have zero eye for the bigger picture."

Former Montefiore President Daniel A. Kane offers several thoughts. "A decision like this," he says, "should have at its core some strategic plan and analysis––is there a need for the institution, can it survive independently, what will be its role in the new setup? Don't kid yourself about what's going to happen to the institution after you've sold it. The University of Pittsburgh took great pains to be solicitous, even overly solicitous, to the Montefiore staff. A year or two later, they were all gone."

And, he adds, "don't think you can take your money and still preserve the institution as it was. You can expect a lot of changes you won't like."

Feinstein has several conclusions from her experience so far. For one thing, she says, it's a good idea for a conversion foundation to have a large and frequently changing board. A small, long-serving board, she believes, can create a sense among board members that the foundation belongs to them, whereas a larger board, with constant turnover, emphasizes that the foundation belongs to and serves the community from which the board members are drawn. In addition, the large board multiplies the contacts and experience on which the foundation can draw.

"In a conversion foundation," Feinstein says, "the board is the custodian for the community. That creates a whole different set of circumstances and goals. We have no claim to privacy––we belong to the community. So we have this need for scrutiny, need for communication. We have no sense of entitlement, neither on the part of the board nor of the staff.

"Also, we are local. The connection with this community is very profound. We are here to shape systems that work here. We can't try out one idea and then leave. Some national people come in with the idea that the problem is the local establishment, and so they want projects that challenge the establishment. Our idea is to get the establishment to broaden its perspective. These are our friends and neighbors. We have to live here. We can't take our marbles and go play somewhere else."

Summary

The Jewish Healthcare Foundation of Pittsburgh was created in 1991 with the $75 million paid by Presbyterian University Hospital to take over Montefiore Hospital, a large teaching hospital that the city's Jewish community had built and supported for more than 80 years. The community, and particularly its leaders, took great pride in the hospital, seeing it as providing care not only for Pittsburgh's Jews but for all the citizens of the entire city and surrounding area, and it was almost a foregone conclusion that they would want the proceeds to go to an institution that would have health care as its mission and would seek to serve both the Jewish community and the larger area of southwestern Pennsylvania. Traditional Jewish concerns and a deep Jewish commitment to social justice dictated the priorities for the new foundation: problems of the aged and chronically ill, at-risk children, women, the medically underserved, and of course, the Jewish community itself.

The unusually large board of Montefiore Hospital––60 members at the time––approved the decision to set up the new foundation, but the dominant role on both its direction and structure was played by a small group of the board, longtime leaders on the hospital board and, perhaps even more important, longtime leaders of the Jewish community and particularly of the United Jewish Federation, the community's umbrella do-good organization. This leadership was able to overcome widespread unhappiness within the community over the sale of a valued community institution.

Approval by the Allegheny County Court of Pleas had to be obtained to pave the way for the sale of Montefiore, but no other special government approval––federal, state, or local––was needed, and except for the required annual foundation report to the Internal Revenue Service and a similar report to the state, the Foundation is subject to no government agency control or oversight. It has no financial relationship with Montefiore Hospital or the University of Pittsburgh; University researchers occasionally receive grants or are involved in Foundation projects, but the grants are strictly on the merits, with no favored treatment.

A key early decision by the Foundation's leaders was to choose as president a politically astute, activist woman named Karen Wolk Feinstein, who quickly established the Foundation as an important player in the Pittsburgh foundation world and in Pennsylvania health affairs. Though it continues to work diligently on all its original priorities, the Foundation increasingly seems to focus on changes in the health care system to provide better care of the indigent and underserved.

Those who took part in the sale of Montefiore Hospital back in 1990 and 1991 tend to believe that such negotiations should be kept private as long as possible––that premature disclosure may well scotch the transaction. Expect change, future sellers are warned; don't think you can sell and still keep the hospital the way it was. As for any new conversion foundation, a large and frequently changing board may help emphasize the foundation's ties and obligations to the community in which it works.