community of practice for public health improvement: open forum 2013 marthe r. gold, md, mph logan...

Community of Practice for Public Health Improvement: Open Forum 2013 Marthe R. Gold, MD, MPH Logan Professor of Community Health and Social Medicine City College of New York For the Publics Health: A whirlwind tour through 3 reports from the IOM Committee on Public Health Strategies on Measurement Law and Policy Funding

The Institute of Medicine (IOM) is the health arm of the National Academy of Sciences and was founded in 1970. The National Academy of Sciences was established by Congressional charter in 1863. IOM serves as adviser to the nation to improve health. About the Institute of Medicine

Study overview SponsorThe Robert Wood Johnson Foundation Duration November 2009 April 2012 Products3 reports responding to 3 tasks Committee 18 members with a range of expertise

The U.S. return on its health investment

Achieving better value The US lags its peers in health status while leading the world in cost Large expenditures on health (care) means less money for education, social goods, business development, and other systems that keep nations globally competitive The US must stretch its health dollar by: Eliminating inappropriate and unnecessary care Limiting administrative costs Achieving universal access Implementing population-based prevention strategies (NOTE: health care accounts for 20% or less of what creates good health, so improvements to the quality and efficiency of health care can only do so much.)

A Collaborative Health System Governmental Public health Infrastructure Employers and Business Education sector Government agencies (other than public health) The Media Clinical- care delivery system Community Assuring the Conditions for Population Health Employers and Business Academia Governmental public health infrastructure The Media Health care delivery system Community The Public Health System (IOM, 2003) The Health System (current report)

7 10 Essential Public Health Services 1.Monitor health status to identify and solve community health problems. 2.Diagnose and investigate health problems and health hazards in the community. 3.Inform, educate, and empower people about health issues. 4.Mobilize community partnerships and action to identify and solve health problems. 5.Develop policies and plans that support individual and community health efforts. 6.Enforce laws and regulations that protect health and ensure safety. 7.Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8.Assure a competent public and personal health care workforce. 9.Evaluate effectiveness, accessibility, and quality of personal and population-based health services. 10.Research for new insights and innovative solutions to health problems.

8 Capacity to meet community needs Not all state public health statutes require the full breadth of public health activities All communities need access to a public health agency that meets a uniform level of capacity The committee recommends that States: Enact legislation with appropriate funding to ensure that all public health agencies have the mandate and the capacity to effectively deliver the Ten Essential Public Health Services. Revise laws to require accreditation through PHAB

The Minimum Package A minimum package of foundational and programmatic public health services will: Protect and promote the health of populations Serve as a framework for program management, performance evaluation and accountability Permit linkage of financial data to capacities to processes, to program and policy development, and ultimately, to outcomes.

The Minimum Package Basic Programs Foundational Capabilities Information systems Policy decision support Communication Partnership development And many others Health planning And many others Environmental health Mental health & substance use Injury Control Communicable disease Chronic disease Maternal & child health Research and evaluation Minimum package of public health services

11 The Minimum Package (contd)) There is no standardized method for collecting and reporting information about funding streams and costs of program delivery by public health departments. A chart of accounts used by all public health departments would: permit apples to apples comparisons of public health departments support the development of better aggregated information about the revenues and expenditures of public health departments across the nation

Tools to record financial information The committee recommended that a model chart of accounts be developed for all public health agencies to track funding on programs and outcomes across agencies.

Needed: Investment in research The committee recommended that Congress direct DHHS to develop a robust research infrastructure for establishing the effectiveness and value of public health and prevention strategies, mechanisms for effective implementation of population-based strategies, the health and economic outcomes derived from this investment, and the comparative effectiveness and impact of this investment..

Needed: Stronger collaborations between Public health and Clinical care The social and environmental determinants of health are well understood and the relationships between them and health outcomes are well established. Need to position rich data available in the medical care delivery realm to provide a fuller understanding of population health The measurement report recommended the sharing of information between governmental public health and medical care to: Develop an understanding of the prevalence of conditions/illnesses locally Develop an understanding of the distribution of risk factors within sub- populations Heighten public awareness of underuse/overuse/quality/efficiency of health systems

Public health Agencies and Clinical Care Health care reform is intended to substantially extend insurance coverage. When coverage increases, the need for direct clinical service provision by public health departments will diminish. Although the assurance function may in some instances continue to require direct care provision by public health agencies, the primary activities of health departments are better directed at critical population- based activities that they are uniquely positioned to provide.

Clinical care and Public Health Agencies The committee recommended that Health departments to work with clinical care providers to develop adequate alternative capacity for clinical care services (i.e., outside health departments)

Funding And now about the money

Setting a goal for better value The committee recommended that... The Secretary of HHS set national goals on life expectancy and per capita health expenditures that by 2030 bring the US to average levels among other wealthy countries.

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ The Public Health Department of today

20 Funding: Flexible, Sufficient, Stable and Sustainable In 2011 governmental public health funding was 3.1% or $77.2 billion of $2.5 trillion health spend Per capita expenditures on health: $251 PH $8,086 Medical Care Federal contribution to PH - 15% (State and local make up the rest) Public health funding streams have been unpredictable, inadequate and inflexible

Changes in State and local funding Local and state government funds are used to pay for clinical services delivered by health departments. As health care reforms lead to improvements in coverage, local and state funds could be liberated.

Changes in federal funding mechanisms DHHS is asked to create greater state and local flexibility in the use of grant funds, consistent with local population needs Recognize cross-cutting foundational requirements of PH Agencies Congress is called on to institute legislative changes to increase flexibility of government funding streams Federal public health agencies are asked to incentivize coordination among PH stakeholders

Federal funding for the minimum package However, current federal funding levels for public health departments fall well short of what is needed to allow departments to function smoothly in fulfilling their duties. Governmental public health needs adequate funding to enable it to deliver the minimum package of public health services

New mechanisms to fund public health Best options for revenue generating meet these criteria: Have a meaningful connection to population health Raise sufficient funds Do not have significant deleterious economic consequences

New federal funds will be needed The committee recommended that 1. Congress authorize a dedicated, stable, and long-term financing structure to generate the enhanced federal revenue required to deliver the minimum package of public health services in every community. 2. Congress establish a new funding source by enacting a national tax on all medical care transactions

New federal money: How much is needed, and where? Necessary steps: Better financial data Strengthened public health research enterprise Convene expert panels to: develop and cost out the minimum package determine the proportions of national health spending to be invested in the medical care and public health systems

A starting point for how much? The information needed to make an accurate estimate of the financial needs to support the public health system is limited. Several ways to use the available information to arrive at a conservative initial estimate A $24 billion investment by the federal government (roughly doubling of the current $11.6 billion federal portion spent on governmental public health activity as defined by the National Health Expenditure Accounts )

$ $ $ $ $ $ $ $ $ $ $ $ $$ $ Tomorrows Public Health Department $ $

Envisioning PH Agencies of tomorrow Leaner no clinical care delivery More policy oriented Different array of capacities (strengthen some existing, add new ones) Greater accountability More collaborative Fewer, but larger local health departments Adequately and sustainably supported by flexible, coordinated, and evidence-based funding

For more information about the three reports, visit www.iom.edu/PHstrategieswww.iom.edu/PHstrategies

Making Sausage The politics of developing a Core Package of Public Health Services in Ohio

Overview Provide an overview of Ohios decentralized public health system and the contextual factors that lead to the development of the Public Health Futures Review the methods used to build a consensus around a Core Package of Public Health Services Examine the impacts of developing a Core Package

Context What factors influenced the decision to develop a Core Package?

OHIOS LHD PROFILE In Ohio, all 88 counties have a General Health District, but Any incorporated area that reaches a population of 5,000 on a decennial census becomes a city and is required to be served by a health department either through creating a new LHD, contracting with an existing, or combining with a another health district. (ORC 3709.07). 88 County (or Combined) 37 City

Figure 2. Jurisdictions by Size Adapted from: Association of Ohio Health Commissioners. (2012). Public Health Futures: Considerations for a New Framework for Local Public Health in Ohio. Columbus, Ohio: author.

Figure 3. Governance of Ohios Decentralized Public Health System Constituents (General Shareholders) Elected District Advisory Council (Preferred Stockholders) Appointed Board of Health (Board of Directors) Health Department Staff Appointed District Licensing Council (Preferred Stockholders) Elected Mayor / City (Preferred Stockholders) Health Commissioner (CEO) Medical Director

Figure 4. County Government & the LHD County Commissioners Boards/OfficesElectionsDev. DisabilitiesJobs and FamilySheriffAuditorTreasurerEngineerCourtsCoroner LHD Separate Political Subdivision of the State (& funded separately) CC fund the offices of the elected officials Political Subdivision

Environmental Factors Changes occurring in the broader health care delivery system (in part due to the Affordable Care Act) National accreditation standards for state and local public health Reductions in available state and local government funding and the need to produce better value by optimizing shrinking resources Political pressure from the newly elected Gov. Kasich & the Office of Health Transformation LHD

Governors Office likes to use a little word called,

Figure 5. Critical Incident Timeline Greg Moody, Director--Office of Health Transformation, is key note speaker at AOHC fall conference; he indicates PH will be reformed (Fall 2011) Governors Office begins drafting 2014-15 biennial budget; Core Package is part of discussion though no specific requirement AOHC forms Public Health Futures Committee (Fall 2011) AOHC leadership meets with OHT to deflect policy changes until Futures Committee completes its work (Winter 2011) Legislature passes HB 487 creating a Subcommittee to study the Futures Report and recommend legislative changes; sparked by disaffected member of the Futures committee Futures report released (Summer 2012) Legislative Committee adopts Core Package but only recommends accreditation Am. Sub. HB 59 (Biennial Budget) Signed by Gov. Kasich: Among its provisions, requirement that all LHD be accredited by 2018 & State create a dashboard report of LHDs. Dashboard is guided by the Core package & Outcome IOM (2012) PHAB (2011)

Vision for the Future of Local Public Health in OhioThe Public Health Futures Committee The Association of Ohio Health Commissioners (AOHC) envisions a future where ALL O HIOANS ARE ASSURED BASIC PUBLIC HEALTH PROTECTIONS, regardless of where they live, and where local public health continues to be a vital leader in improving Ohios health outcomes. We envision a network of local health departments that: Are rooted in strong engagement with local communities; Are supported by adequate resources and capabilities that align with community need and public health science; and Deliver high quality services, demonstrate accountability and outcomes, and maximize efficiency.

Goals of the project 1.Describe the current status of Ohios local public health departments (LHDs), including structure, governance, funding, and current collaboration. 2.Identify rules, policies, and standards that may impact the future of local public health (including statutory mandates, national public health accreditation standards, and policy changes affecting health care, such as the Affordable Care Act). 3.Identify stakeholder interests and concerns and develop set of criteria for assessing new models of collaboration or consolidation. 4.Identify and assess potential models of collaboration and consolidation and the factors that would contribute to successful implementation of those models. 5.Foster consensus among LHDs to prioritize a small number of preferred frameworks. 6.Create a decision-making guide for LHDs to use when moving forward with model selection. Structure & Money

Additional questions Role and functions of public health What should the minimum capacity of public health look like in the future? What do Ohio residents need and deserve from the public health system? What are the potential impacts of various models of shared services and consolidation on LHDs ability to deliver the essential functions of public health? Addressing concerns about the current system Is the current system sustainable? How should the local public health system address longstanding (but now more intense) and fundamental funding shortfalls and fragmentation? How can local public health become more proactive and driven by evidence about what works and what is most needed, rather than re-active and driven by chasing after available funding streams? Considerations for new approaches Are there changes in policy or law that are necessary and ought to be considered? What models or business practices are available that will help LHDs to go beyond talk and relationship-based collaboration to more efficient and standardized collaboration? What models or business practices are available that will help LHDs to improve quality and outcomes?

Methods The forced evolution of a Minimum Package

Project Structure Table 1. Input & Involvement in the Process from the Field NamePersonsRole Steering Committee 17 AOHC members (of a possible 125) from a wide variety of LHDs (urban/rural, city/county departments, all regions of the state) Guide the collection and interpretation of data, information and opinions on the current status and potential for LHDs in Ohio Sub- Committees Drawn from steering committee Finance, Core Package, Structure/ Collaboration, ad hoc Research Team Health Policy Institute of Ohio & Patrick Lanahan Health Policy Institute of Ohio (HPIO) to conduct research, facilitate a consensus-building process, and issue the final report

Methods Part 1. The Current Status of Ohios Local Health Departments Part 2. Stakeholder Considerations, Lessons Learned, and Guiding Concepts Part 3. Consensus and Recommendations There is broad agreement that the new model should define a minimum standard of health protection. Most informants believe that the new model needs to address ways of organizing, funding, and providing capacity to support such a standard as a high priority.

Methods Part 1.The Current Status of Ohios Local Health Departments Review of descriptive information about Ohio LHDs State-level regulatory scan and review of relevant standards and policies (e.g., Public Health Accreditation Board standards, Affordable Care Act, State Health Improvement Plan) Online survey of AOHC members regarding current collaboration

Methods Part 2. Stakeholder Considerations, Lessons Learned, and Guiding Concepts HPIO conducted 25, 60 min. key-informant interviews in January and February 2012 Targeted review of research literature related to public health systems, local government reform, and models for collaboration and consolidation Subcommittees to explore specific topics in-depth & generate recommendations

Methods: Key Informant Interviews The Local Public Health Group (N=18): All of the Public Health Futures Steering Committee members and its staff (Executive Director, AOHC). The Committee members were appointed by the AOHC Board of Directors, and represented all geographic areas of Ohio and local district sizes. The Statewide Policy Group (N=7): Senior officials from the Ohio Department of Health and the Governors Office of Health Transformation were pre-selected by the Steering Committee (n=5). HPIO also identified additional informants with relevant knowledge and experience with leaner government and shared services (n=2).

Methods Part 3. Consensus and Recommendations Series of consensus-building meetings: AOHC all- members meeting in March 2012, five regional district meetings in April 2012, and Steering Committee meetings in May and June 2012 Steering Committee development and approval of recommendations in June 2012 Process driven by practitioners (LHO)

The project focused significantly on funding Local Public Health Financing of Public Health OtherFoundationalCore People clamored for more $$ from the outset, but You cant fund something when you dont actually know what it isa Minimum Services package was the missing link.

Result All the consensus building workshops had access to the environmental scans and demographic data. What is the inevitable conclusion based on all these hints?

53 Source : 2010 National Profile of Local Health Departments, NACCHO, 2011 Figure 6. Percent of total annual health district revenue, US & Ohio Excerpt from Public Health Futures Summary Presentation, AOHC 2012 >1% of my budget is state GRF

Excerpt from Public Health Futures Summary Presentation, AOHC 2012

19 Recommendations Issued 7 of 19 focused on local public health capacity, services, and quality 1.All Ohioans, regardless of where they live, should have access to the Core Public Health Services described in the Ohio Minimum Package of Local Public Health Services 2.All local health departments (LHDs) should have access to the skills and resources that make up the Foundational Capabilities in order to effectively support the core services. 3.The Ohio Minimum Package of Local Public Health Services should be used to guide any future changes in funding, governance, capacity building, and quality improvement 4.All LHDs should become eligible for accreditation through the Public Health Accreditation Board (PHAB). 5.LHDs that meet Minimum Public Health Package standards should be prioritized for grant funding in their jurisdiction. 6.The biennial LHD Health Improvement Standards reported to the Ohio Department of Health via the Ohio Profile Performance Database should serve as the platform for assessing LHD provision of the Minimum Package. The Profile Performance Database may need to be updated periodically to capture the Core Public Health Services and Foundational Capabilities. 7.The Association of Ohio Health Commissioners (AOHC) supports a review of current laws and regulations to determine where mandates may need to be revised or eliminated and should advocate for elimination of mandates that do not align with the Minimum Package of Public Health Services. All LHDs should become eligible for accreditation through the Public Health Accreditation Board (PHAB).

The Big Reveal

Excerpt from Public Health Futures Summary Presentation, AOHC 2012

Table 2. Crosswalk of PHA to Ohios Minimum Package, Part 1 PHAB DomainCore Public Health ServicesOther ServicesFoundational Capabilities 1AssessEpidemiology Access to birth and death records Information management and analysis Community health assessment (Support and expertise for LHD community engagement strategies) 2InvestigateEnvironmental health services Communicable disease control Emergency preparedness Non-mandated environmental health services Laboratory capacity (environmental) 3Inform and Educate Health promotion and prevention Community engagement Specific maternal and child health programs 4Community Engagement Community engagement Health promotion and prevention Support and expertise for community engagement strategies

Table 2. Crosswalk of PHA to Ohios Minimum Package, Part 2 PHAB DomainCore Public Health Services Other ServicesFoundational Capabilities 5Policies and Plans Health promotion and prevention Emergency preparedness Policy development Community health improvement planning (Support and expertise for LHD community engagement strategies) 6Public Health Laws Environmental health services Legal support 7Access to CareLinking people to health services Clinical preventive and primary care services Specific maternal and child health programs Laboratory capacity (clinical)

Table 2. Crosswalk of PHA to Ohios Minimum Package, Part 3 PHAB DomainCore Public Health Services Other Services Foundational Capabilities 8Workforce Resource Development Resource development 9Quality Improvement Quality assurance Information management and analysis 10Evidence Based Practice Quality assurance Information management and analysis 11Administration & Management Resource development 12Governance

The Fallout Why no good deed goes unpunished3 Pockets of Angst

HC Uprisings Accusation that rogue HCs appointed themselves to the steering committee (process was closed and not representative) Outright effort to undermine the Minimum Packagecall to revisit the entire package again, and again, and again---just like Congress and OBAMACARE (ACA). Call for a new survey (not AOHC sponsored) to determine minimum package Member of the committee petitioned legislature for more actionFutures was going the wrong way

Directors of Nursing Indignation at the use of the term othereven the use of salmon color in the box was offensive Increased paranoiathey [HCs] are out to get us Pretty sure Ive been burned in effigy Humphrey Bogart as Cpt. Queeg in the Caine Mutinygive me my strawberries

Legislative Outcomes Bitter, protracted budget process that resulted in: Focus on consolidation Emphasis on regionalization of grants New reporting requirements (grade cards for LHD) Board of Health continuing education Cut in the state GRF to LHDs Mandatory-Voluntary Accreditation And Mandatory-Voluntary Accreditation

HB 457 Legislative Subcommittee Recommendation All local health districts shall meet PHAB eligibility within five years. Such documentation shall be independently verified. HB 59: SFY 2014-2015 biennial operating budget bill As a condition precedent to receiving funding from the department of health, the director of health may require [LHD] to apply for accreditation by July 1, 2018, and be accredited by July 1, 2020, by an accreditation body approved by the director. Public Health Futures Recommendation All Ohioans, regardless of where they live, should have access to the Core Public Health Services described in the Ohio Minimum Package of Local Public Health Services. All local health districts shall meet PHAB eligibility within five years. Such documentation shall be independently verified. Mandatory-Voluntary PHAB Accreditation Lost Minimum Package

Implications Into the Future Despite turmoil, most have accepted the need for the concept of minimum package & Core Services Being used in current development of the LHD grade card Emphasis on funding lead to a RWJ Quick Strike Grant Cost of Doing Business and subsequent participation in the Delivery and Cost Study (DACS)Core Package versus Other was/is key to both studies LHDs are focusing on PHAB (maybe to the exclusion of all else) LHDs are looking for ways to engage in CJS to meet PHAB One Office Project, consolidation of back office clinical functions under an LLC Health Officers in smaller jurisdictions are most concerned with meeting minimum package requirementssize matters

For more information, please contact Jason E. Orcena, Health Commissioner [email protected] 937-642-2053 x2044 For a copy of the Futures report, please go to www.aohc.net [email protected] Thank You.

community of practice for public health improvement: open forum 2013 marthe r. gold, md, mph logan...

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