ncalhd blueprint final6!|page!! executive summary purpose!...

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A Blueprint of the Future for Local Public

Health Departments in North Carolina

2013 Statewide Public Health Incubator

Summary Report & Recommendations

North Carolina Association of Local Health Directors

Public Health Task Force In collaboration with the North Carolina Institute for Public

Health

June 2013

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NCALHD Public Health Task Force Chair Gibbie Harris Buncombe County NCALHD Public Health Task Force Members Bob Blackburn National Association of Local Boards of Health Colleen Bridger Orange County Jim Bruckner Macon County Laura Gerald NC State Health Director Gayle Harris Durham County Chris Hoke NC Division of Public Health Roxanne Holloman Beaufort County Sue Lynn Ledford Wake County Beth Lovette Appalachian Health District Gene Matthews NC Institute for Public Health Davin Madden Wayne County Kellan Moore Care Share Health Alliance John Morrow Pitt County Lloyd Novick East Carolina University Jerry Parks Albemarle Health District Marilyn Pearson Johnston County Phred Pilkington Cabarrus County Greg Randolph Center for Public Health Quality Wayne Raynor Scotland County John Rouse Harnett County Anna Schenck UNC Gillings School of Global Public Health Pam Silberman NC Institute of Medicine Danny Staley NC Division of Public Health Chris Szwagiel Franklin County Anne Thomas Dare County Lynette Tolson NC Public Health Association Doug Urland Catawba County Buck Wilson Cumberland County Nancy Winterbauer East Carolina University

NCIPH Staff

John Graham Heather Gates Jessye Brick Talene Ghazarian Taylor Snyder

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Table of Contents

Acronyms and Abbreviations .................................................................................................. 4

Executive Summary ................................................................................................................ 6

I. Overview of the Project ..................................................................................................... 17 Background .................................................................................................................................... 17 Project Purpose and Objectives ...................................................................................................... 18 Project Methods ............................................................................................................................. 18

II. Current Status of Local Health Departments in North Carolina .......................................... 21 Current Landscape ......................................................................................................................... 21 Funding .......................................................................................................................................... 22 Workforce……………………………………………………………………………………………………………………………………..24 Mix of Services Provided by North Carolina’s Local Health Departments ........................................ 25 Accreditation ................................................................................................................................. 29

III. Contextual Changes Affecting Local Health Departments ................................................. 32 Health System Changes .................................................................................................................. 32 Delivery of Clinical & Preventive Care ............................................................................................. 37 Community Health ......................................................................................................................... 40

IV. Opportunities .................................................................................................................. 48

V. Recommendations ........................................................................................................... 56

VI. Next Steps ....................................................................................................................... 78 Developing foundational capabilities ............................................................................................. 80

Appendix A: Definitions of Foundational Capabilities ........................................................... 84

Appendix B: Glossary of Terms ............................................................................................. 87

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Acronyms and Abbreviations ACA Affordable Care Act, 2010

ACO Accountable Care Organization

AHRQ Agency for Healthcare Research and Quality

ARRA American Recovery and Reinvestment Act

ASTHO Association of State and Territorial Health Officials

BRFSS Behavioral Risk Factor Surveillance System

CCNC Community Care of North Carolina

CDC Centers for Disease Control and Prevention

CHA Community Health Assessment

CHIP Community Health Improvement Plan

CHNA Community Health Needs Assessment

CMMI Center for Medicare and Medicaid Innovation

CMS Centers for Medicare and Medicaid Services

CTG Community Transformation Grants

DPH North Carolina Division of Public Health

EHR Electronic Health Record

EPA Environmental Protection Agency

FDA U.S. Food and Drug Administration

FQHC Federally Qualified Health Center

GAO Government Accountability Office

HERO Health Extension Rural Office

HHS U.S. Department of Health and Human Services

HiAP Health in All Policies

HIE Health Information Exchange

HIT Health Information Technology

HITECH Health Information Technology for Economic and Clinical Health

HRSA Health Resources and Services Administration

IOM Institute of Medicine

LHD Local Health Department

MU Meaningful Use

MUA Medically Underserved Area

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NACCHO National Association of County and City Health Officials

NCALHD North Carolina Association of Local Health Directors

NCHS National Center for Health Statistics

NCIPH North Carolina Institute for Public Health

NCIOM North Carolina Institute of Medicine

NCPHA North Carolina Public Health Association

NIH National Institutes of Health

NHSC National Health Service Corps

PCEP Primary Care Extension Program

PCMH Patient Centered Medical Home

PHAB Public Health Accreditation Board

PPACA Patient Protection and Affordable Care Act, 2010

PPHF Prevention and Public Health Fund

PPP Public-‐Private Partnership

QI Quality Improvement

REACH Regional Electronic Adoption Center for Health

SOG UNC School of Government

TFAH Trust for America’s Health

USPSTF U.S. Preventive Services Task Force

WIC The Special Supplemental Nutrition Program for Women, Infants,

and Children

WHO World Health Organization

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Executive Summary

Purpose

Public health is currently facing changes in policy, context, and funding which will significantly impact the work of local health departments (LHDs) across North Carolina and the United States. The healthcare system is facing new challenges stemming from an epidemic of chronic diseases and increased healthcare costs.1 Changing demographics, including an aging population, immigration, and increasing socioeconomic polarization, present another challenge. The Affordable Care Act has changed the healthcare and public health landscape by expanding access to care, emphasizing quality of care, and making a landmark investment through the Prevention and Public Health Fund.2,3 At the same time, the economic downturn and changes in the political climate have led to progressive cuts in funding and increased emphasis on outcomes.3,4 Finally, the evolution and adoption of health information technology and application of quality improvement techniques have accelerated over the last decade, enhancing the capacity of healthcare providers and public health practitioners to provide, evaluate, and improve services.5 These dramatic changes all have material implications for the work of LHDs in North Carolina. The following report strives to familiarize local health departments with relevant contextual changes and emerging opportunities and guide their response to these developments. LHDs must be proactive if they are to persist and flourish in health promotion and disease prevention efforts.

Objectives

This project provides resources and information to increase LHD capacity, improve LHD performance, and promote greater LHD sustainability in response to this changing context.

The objectives of this project are to:

1) Identify and describe important, strategic changes in North Carolina’s local health department context.

2) Assess the meaning of these changes for North Carolina’s local health departments (i.e. identify the significant opportunities associated with these changes).

3) Suggest a core set of foundational and programmatic services that should be provided by any health department to promote a healthy community.

4) Suggest new services or changes to existing services in response to identified opportunities.

5) Review and recommend practices to strengthen the capacity of North Carolina’s LHDs.

Project Methods

The Public Health Task Force of the NC Association of Local Health Directors targeted this project as a priority for LHDs in North Carolina. In turn they requested support from the NC Public Health Incubator

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Collaboratives. The oversight body of the Collaboratives, the Incubator Steering Committee, reviewed this request, along with others, and chose to support this project. With guidance from the Task Force and the Steering Committee, the North Carolina Institute for Public Health (NCIPH) at the UNC-‐CH Gillings School of Global Public Health conducted research and facilitated a collaborative process among Public Health Task Force members to gather and collate pertinent information. The methods consisted of:

1) An extensive literature review covering the current landscape of local health departments in North Carolina, laws and policy changes affecting LHDs, and changes in the health system landscape, the economy, and the political climate.

2) Key Informant Interviews with the state’s healthcare leaders and local health directors; nineteen interviews were conducted to validate literature review findings, identify existing gaps in services, and discuss potentially promising LHD opportunities and examples.

3) The Task Force itself convened twice during the data collection and reporting phases to review and prioritize contextual changes, discuss the emerging opportunities and strategic options, and confirm a short list of main recommendations.

Current Status of North Carolina’s Local Health Departments

Ø Structure and Governance Public health services in North Carolina are decentralized and administered by each county. There are a total of 85 local health agencies in North Carolina, serving 100 counties. The majority of these agencies (68) can be classified as county health departments, which serve a single county. The remaining health departments are either district health departments, covering multiple counties (6); public health authorities (1); public hospital authorities (1); or consolidated human services agencies (9). The population size of these agencies’ jurisdictions ranges from 5,800 to over 900,000.6

Ø Accreditation North Carolina requires that health departments pursue accreditation with the North Carolina Local Health Department Accreditation (NCLHDA) Program. Accreditation ensures that health departments are able to perform the three core functions of assessment, assurance, and policy development and provide the Ten Essential Public Health Services. Currently, 78 health departments have received accreditation status.

Ø Funding In a comparison of FY 2012 state budgets and appropriations for the agency in charge of public health services, TFAH found that North Carolina ranked 44th in state funding for public health. North Carolina spent an average of $14.16 per person compared to the national median of $30.61.8 The expenditures per capita by North Carolina local health departments range from $37 per capita for some agencies serving larger populations to $282 per capita for smaller agencies. Sources of revenue for LHDs include county appropriations, Medicaid, state and federal dollars, and other revenues.6

Ø Workforce Staffing varies by local health department; however, staffing must be sufficient to ensure that required services are available throughout the agency’s jurisdiction. Local health agencies employ between 0.6 and 2.8 FTEs per 1,000 population. Agencies serving larger

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populations tend to employ fewer FTEs per 1,000 population. Almost all types of agencies have reduced their FTE to population ratio since 2005.6

Contextual Changes

In order to inform the identification of opportunities and strategic options, NCIPH conducted an in-‐depth literature review of changes in the public health context as well as 19 key informant interviews. Several themes regarding the most important changes were revealed:

Ø Structure: Recent North Carolina legislation has introduced organizational/structural options heretofore unavailable to most of North Carolina’s LHDs. House Bill 438, which became law in June 2012, extends to all counties the options to: 1) abolish local board(s) of health and transfer their powers and duties to the Board of County Commissioners; 2) create a consolidated human services agency (CHSA) governed either by a consolidated board or by the County Commissioners.6 Between June 2012 and May 2013, 7 county health departments became CHSAs.

Ø Access to Care The Affordable Care Act (ACA) promulgates several new health insurance regulations intended to promote access to care.7

Ø Funding for Public Health The economic downturn has resulted in damaging budget cuts for local health departments and has reduced the capacity of local agencies to provide public health services.8,9 Although the ACA authorized $18.75 billion between 2010 and 2022 for the Prevention and Public Health fund, these funds are already facing federal cuts.

Ø Health Information Technology (HIT) The widespread adoption of HIT has led to a dramatic increase in the availability, sharing, and reporting of digital patient information.

Ø Quality Improvement Much focus has been placed on efforts to improve the quality of care and services, as exemplified by the National Strategy for Quality Improvement in Health Care (NQS). The NQS is aligned with the Triple Aim approach of improving quality of care, improving population health, and reducing costs.10

Ø Outcomes -‐ Based Reimbursement The ACA encourages innovative restructuring of healthcare practices, investing in integrated approaches that reward practices for improving health outcomes, rather than merely adhering to guidelines.11

Ø Prevalence of and Costs Associated with Chronic Diseases Chronic diseases have become a critical public health concern in the United States. In 2005, 133 million Americans had at least one chronic condition and this number is expected to continue to rise.12

Ø Community Health Improvement Processes & Collaborations Collaborations between nonprofit hospitals, LHDs, and community organizations are an important opportunity to enhance effectiveness and efficiency, especially given the requirement for nonprofit hospitals to conduct Community Health Needs Assessments and the Triple Aim’s focus on population health improvement.

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Opportunities

The review of contextual changes suggests a very dynamic and complex environment that North Carolina’s LHDs must navigate. While there are many material changes, a number of themes and related opportunities do emerge:

Ø Provision and Assurance of Clinical Care The ACA will require all insurers to provide preventive care services and chronic disease management. Many health departments are already providing these services in their communities. Primary care providers are not likely to offer these services as they will be trying to meet the increased demand for primary care services. LHDs may need to expand their capacity in this area. LHDs can act as sources of referrals, case managers, or “prevention services navigators.” Furthermore, given the NC legislature’s decision to opt out of Medicaid expansion, roughly 500,000 people who would have been covered by Medicaid will not be, and many will need a safety net provider.13 If North Carolina were to expand Medicaid in the future, there would be a drastic increase in demand for reimbursable services. Thus, regardless of the state of Medicaid expansion, there will likely be a growing need for LHDs to provide direct services. Agencies may also make care more accessible by contracting with local healthcare providers to supply low-‐cost or free services through clinics at LHDs.

Ø Coordination of Care Healthcare providers, third party payers, and government at all levels are under unprecedented pressure to control healthcare costs and to improve the quality of care. In response they are exploring alternative models of care. Many of the models rely on performance-‐based reimbursement, which compensates outcomes rather than the number of procedures performed.10,11 Providers will find that it is becoming more profitable to prevent illness than to simply reward health. Improving outcomes will require a coordinated approach and providers may be interested in contracting with health departments in pursuit of superior care coordination.12 The traditional role of LHDs in the provision and coordination of population health interventions could be leveraged, with the LHD playing a key role in formally linking prevention, acute care, disease management, and other wrap-‐around services for patients at risk of a chronic disease or of chronic disease complications.

Ø Sustaining Communicable Disease Surveillance LHDs fill a critical health “gap” in a community’s health system by providing communicable disease control and surveillance.5 The importance of this role should be emphasized as LHDs communicate and negotiate their larger contribution as a partner in the health system.

Ø Promotion, implementation, and evaluation of community-‐based health promotion and disease prevention Given the epidemic of chronic disease and the population-‐related components of healthcare reform like the Community Health Needs Assessments required of nonprofit hospitals, health promotion and disease prevention will be central to an effective, integrated system of care. Most hospitals and other healthcare providers have limited capacity to undertake community-‐based assessments and prevention interventions, whereas prevention falls under the traditional purview of LHDs.14

Ø Enhancing capacity through resource sharing, leveraging technology, and the provision, evaluation, and communication of value to health system partners and other key stakeholders

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Health departments have long struggled to secure adequate funding and the challenge continues as many have been forced to reduce staff and cut programs.9 Under these circumstances it is more important than ever that local health departments work more effectively and efficiently. Sharing resources and leveraging technology are two strategies to improve efficiency and quality of services.15 Furthermore, LHDs must be able to justify their role in newly developed healthcare models, such as Accountable Care Organizations, by tracking outcomes of interventions, targeting health interventions, and pursuing data-‐driven QI activities.

Recommendations

While presented as separate recommendations, both the overarching recommendations and the more specific recommendations are frequently inter-‐related where the success of one may be dependent on the execution of another. In addition, the LHD leadership must play a central role in the initiation and oversight of many of these initiatives if they are to succeed.

Option 1: Take a leadership role in the promotion, implementation, and evaluation of community-‐based health promotion and disease prevention.

Health promotion and disease prevention are central to an effective health system that provides high-‐quality integrated care at a reasonable cost. Prevention has always been a predominant concern for LHDs, who will be able to contribute their expertise in this area to their community’s health system.

Ø Collaborate with area nonprofit hospitals and other community-‐based organizations to develop CHNAs and CHIPs that include evidence-‐based strategies and robust evaluations. LHDs have expertise in these areas and may supplement hospital efforts. They should be involved in all aspects of the assessment and improvement plan, including health planning, implementation of action plans, quality improvement, and evaluation of interventions. This role represents a key opportunity to become the ongoing “convener” for community health-‐related issues and initiatives in the LHD’s community health system. The NC Center for Public Health Quality offers training in QI methods for all health professionals and may be a resource for LHDs interested in conducting such work.

Ø Become the community health system’s resource on evidence-‐based best practices (EBSs). If LHDs are to be effective as leaders in community health promotion and prevention activities, they will need to adopt, adapt, and evaluate EBSs. In collaboration with the Division of Public Health, the Center for Healthy North Carolina has been tasked with providing training and technical assistance to help LHDs develop the capacity to effectively adopt EBSs in their communities.19 The NC Institute for Public Health and the CDC’s Prevention Research Centers may offer additional training resources.

Ø Become the community health system’s resource for population health interventions outcomes evaluation. Successful health promotion will leverage the availability of digital patient information and background in epidemiology to precisely target the areas of greatest need with

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the potential for greatest impact. LHDs will also be able to assess the efficacy of interventions, refine interventions, and add to the EBS body of knowledge.

Option 2: Play an integral role in the reform of your community’s health system.

With new emphasis on outcomes-‐based compensation and care coordination, it is critical that local health departments identify the role they will play in these new systems. While interviewees noted that the shift to outcomes-‐based compensation should theoretically drive healthcare providers to work with LHDs, they also expressed concern that health systems would overlook health departments. Given these circumstances, LHDs need to be proactive about claiming a role, including compensation for this role, and reaching out to providers. LHDs have expertise in community engagement, controlling communicable diseases, and population health promotion and disease prevention. They can play an important part in efforts to integrate health work in the clinic and the community.5,16 However, it will be necessary for LHDs to prove their value by documenting and sharing early wins and analyzing the return on investment (ROI) of partnership efforts.

Ø Collaboratively identify clinical services that your LHD will provide directly. Key informants had differing perspectives regarding whether LHDs should provide clinical services but most agreed that the decision should be based on the needs and capacities of the community. LHDs should collaborate with partners in their community’s health system to identify service gaps and define their respective roles in the provision of clinical services.

Ø More systematically integrate the goals/priorities, tasks, and staff of LHDs and those of community primary care providers and hospitals. LHDs can partner with providers to identify and address gaps in services. Partnering may require the alignment of organizational goals and strategies, assignment of tasks, and sharing of staff.

Ø Explore and become experts in outcomes-‐based reimbursement models and play a leadership role in planning discussions. An integrated approach to care requires a team to provide different but coordinated services to individuals and populations. LHDs could play several roles in outcomes-‐based models, including health planning, dynamic systems modeling, community outreach, and evaluation. LHDs may also serve as a community-‐based “risk manager” in the pursuit and strengthening of their communicable disease prevention efforts (e.g. immunization, promoting appropriate use of antibiotics, restaurant inspection), surveillance, and response roles.

Ø Address root causes contributing to poor health status and implement evidence-‐based approaches to intervene at social and economic leverage points for improved health equity.

Option 3: Develop foundational capacity to sustain core public health services and to embrace emerging opportunities.

With the future of public health funding uncertain, LHDs must be able to demonstrate their value to community partners and policymakers while continuing to strive toward increased efficiency and financial sustainability.

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Ø Explore the cross-‐jurisdictional sharing of foundational functions. Many LHDs struggle to sustain and expand services and capacity. Sharing arrangements such as shared services, shared staffing, or consolidation can help enhance services.15

Ø Secure grant scanning and grant making capacity. Health departments often rely extensively on grant funding to support a number of programs, especially those related to prevention. Enhancing capacity to find relevant grant opportunities and write effective proposals will help ensure the sustainability of local agencies.

Ø Provide fee-‐based services. The ACA requires that new insurance plans cover many preventive services and screenings without cost sharing. LHDs might consider providing clinical services that can be reimbursed, such as dental, pediatric, behavioral health, and home health services. Worksite wellness programs are another option as businesses become more aware of the high cost of an unhealthy workforce and the value of prevention.

Ø Leverage telehealth tools. In rural areas in particular, leveraging telehealth tools can improve access to primary care and specialty services. Home monitoring and telepsychiatry programs have recently expanded in North Carolina.

Ø Explore collaborations with other human service agencies. RWJF, CDC, and WHO encourage the use of policy interventions to impact social determinants of health. Implementing health in all policies will require close collaboration with other agencies.17

Ø Identify new sources of revenue for health investment. LHDs should reach out to sectors that invest in community development, such as banks and nonprofit hospitals and provide education on how improving health improves business.

Option 4: Become a community health system expert in clinical and population health data collection and analysis, including ROI analysis. Leverage these skills to demonstrate the value of public health.

Key informants and Task Force members consistently emphasized the need to communicate the value of public health work. Throughout key informant interviews, the experts indicated that LHDs do not package their ‘sales pitch’ well. Hospitals and other partners do not always perceive local health departments as efficient or effective and may ignore the expertise of public health professionals. They emphasized the need to select outcome metrics, meet those metrics, and report results with an eye to the financial return on investment in public health services. Doing so will be essential for successful collaboration and sustainability.

Ø Adopt and become conversant in available health information technology. HIT can be leveraged by LHDs in several ways. As providers of clinical services, LHDs can collect and analyze patient and workflow data to undertake data-‐driven QI initiatives and enhance operational efficiency in clinics. They can also share patient information with other community healthcare providers and pharmacists to avoid redundant tests and imaging, to coordinate medications, and to assure greater continuity of care, promoting better outcomes and lower costs. New assessment tools and access to patient data will enable LHDs to better target and evaluate community-‐based prevention interventions. In pursuit of these strategies, LHDs should:

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o Adopt an electronic health record (EHR)/promote Health Information System (HIS) enhancements to enable flexible clinic reporting and analysis.

o Adopt and advocate for NC Direct with community providers. NC Direct enables the secure exchange of patient information and other clinical messaging between participating providers.

o Connect to the NC Health Information Exchange through the CCNC Informatics Center or the DHHS Qualified Organization.

o Subscribe to a high-‐speed, reliable broadband network like the North Carolina Telehealth Network.

o Adopt telehealth technologies to expand capacity and extend clinical reach. o Develop Informatics capacity.

Ø Improve ability to communicate effectively with community health system partners and public policymakers. To enhance this capability, the Public Health Task Force developed a “Communications Toolkit” that includes communications “tips and tools,” “talking points materials,” and “messaging” recommendations. These materials should be supplemented with communications strategies that incorporate regular public health reporting on outcomes and the value of the local public health agency to its community to foster effective relationships.18

Ø Calculate and leverage ROI analyses with external stakeholders. Effective communication will be enhanced by the inclusion of both personal, qualitative accounts of success as well as quantitative data and ROI analyses. In the end, important community health system partners want to know what the impact of LHD activities are on their bottom line. Thus, LHDs will need to improve their capacity to leverage data and calculate ROI.

Implications for North Carolina’s Local Health Departments

The Public Health Task Force identified three priority next steps based on discussion of the recommended strategic options:

1. Identify priority roles for LHDs in community care coordination. The Task Force recommends that LHDs focus on and enhance communicable disease prevention, and in particular, on the provision of immunizations as an initial service to provide as a partner in coordinated care.

2. Explore and encourage models for cross-‐jurisdictional sharing. LHDs should track and evaluate collaborative efforts and reference steps in Strategic Option 2 to identify and inform potential cross-‐jurisdictional sharing initiatives.

3. Build capacity to effectively identify LHD roles and communicate the value of local public health. As a first step, selected LHD staff should become conversant in the “language” of the community health system partners, develop and familiarize themselves with internal and external performance measures, and gain a foundational understanding of key health informatics subject areas and terminology.

In order to pursue the recommended strategic options, local health departments will have to invest in the following foundational capabilities (organized by the foundational capabilities categories identified by the IOM.) Foundational capabilities refer to the skills and infrastructure that are required for the

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successful execution of basic public health programs (including those programs required by health system partners.)20

Ø Information systems and resources, including surveillance and epidemiology. Cultivate the ability to collect, analyze, and report internal operational and external health-‐related performance data. Identify and improve sources of local data to address current gaps in available data.

Ø Health planning, including community health improvement planning. Strengthen existing health planning skills including the capacity to assess a community’s strengths, weaknesses, needs, identify related challenges and opportunities, and produce health plans and community-‐based interventions.

Ø Partnership development and community mobilization. Enhance the capacity to effectively identify, cultivate, and enroll health system individuals/partners and to craft and negotiate LHD partnership roles.

Ø Policy development, analysis and decision support. Become the policy-‐related EBS expert in the LHD community health system.

Ø Communication, including health literacy and cultural competence. Improve staff capacity to engage in “value-‐related” communications, such as ROI, with key health system and other community stakeholders.

Ø Public health research, evaluation and quality improvement. Enhance staff capacity to secure grant-‐based funding and to conduct rigorous program evaluations.

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References

1. Institute of Medicine (US). The future of the public’s health in the 21st century. Washington, DC: The National Academies Press. 2002.

2. Shearer G. Prevention provisions in the Affordable Care Act. American Public Health Association. American Public Health Association Issue Brief. October 2010.

3. Silberman P, Liao CE, Ricketts TC, 3rd. Understanding health reform: A work in progress. N C Med J. 2010;71(3):215-‐231.

4. Meyer J, Weiselberg L. County and city health departments: The need for sustainable funding through health reform. Washington, DC: Health Management Associates. 2009.

5. Institute of Medicine (US). Primary care and public health: Exploring integration to improve population health. Washington, DC: The National Academies Press. 2012. 6. University of North Carolina School of Government. Comparing North Carolina’s Local Public Health Agencies: The Legal Landscape, the Perspectives, and the Numbers. May 2013. Available at: http://www.sog.unc.edu/sites/www.sog.unc.edu/files/Comparing%20Public%20Health%20Agencies%20FINAL%20May%202013.pdf.

7. Silberman P, Liao CE, Ricketts TC,3rd. Understanding health reform: A work in progress. N C Med J. 2010;71(3):215-‐231.

8. Trust for America’s Health. Investing in America’s Health: A State-‐by-‐State Look at Public Health Funding and Key Health Facts. April 2013. Available at: http://healthyamericans.org/assets/files/TFAH2013InvstgAmrcsHlth05%20FINAL.pdf

9. National Association of County and City Health Officials. Local Health Department Job Losses and Program Cuts: State-‐Level Tables from January/February 2012 Survey. April 2012. Available at: http://www.naccho.org/topics/infrastructure/lhdbudget/upload/State-‐level-‐tables-‐Final.pdf.

10. U.S. Department of Health & Human Services. 2012 Annual Progress Report to Congress. National Strategy for Quality Improvement in Health Care. April 2012.

11. McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Affairs. 2010; 29(5): 982-‐990.

12. Bodenheimer T, Chen E, Bennet HD. Confronting the growing burden of chronic disease: Can the U.S. healthcare workforce do the job? Health Affairs. 2009; 28(1): 64-‐74.

13. Fitzsimon, C. Medicaid, unrealistic budget cuts, and denying healthcare to 500,000. February 19, 2013. Available at: http://www.ncpolicywatch.com/2013/02/19/medicaid-‐unrealistic-‐budget-‐cuts-‐and-‐denying-‐health-‐care-‐to-‐500000/. 14. National Association of County and City Health Officials. Statement of policy: Role of local health departments in community health needs assessments. March 2012. Available at: http://www.naccho.org/advocacy/positions/upload/12-‐05-‐Role-‐of-‐LHDs-‐in-‐CHNA.pdf. Accessed October 21, 2012.

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15. Libbey P. Cross Jurisdictional Sharing of Services and Resources [PowerPoint slides]. May 23, 2012. Available at: http://nnphi.org/CMSuploads/Libby%20-‐NNPHI%20May%202012.pdf.

16. National Association of City and County Health Officials. Implementation of the Patient Protection and Affordable Care Act. June 2011. Available at: http://www.naccho.org/advocacy/healthreform/upload/ACA-‐white-‐paper-‐final.pdf. Accessed October 9, 2012.

17. World Health Organization. Social determinants of health. 2012. Available at: http://www.who.int/social_determinants/en/. Accessed September 25, 2012.

18. North Carolina Public Health Incubator Collaboratives. Public Health Taskforce communications toolkit. 2012. Available at: http://nciph.sph.unc.edu/incubator/taskforce_comm_toolkit/index.html. Accessed May 31, 2013.

19. North Carolina Institute of Medicine. Improving North Carolina’s Health: Applying Evidence for Success. September 2012. Available at: http://www.nciom.org/wp-‐content/uploads/2012/10/EvidenceBased_100912web.pdf.

20. Institute of Medicine (US). For the public’s health: Investing in a healthier future. Washington, DC: The National Academies Press. 2012.

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I. Overview of the Project

Background

Public health is currently facing changes in policy, context, and funding which will significantly impact the work of local health departments (LHDs) across North Carolina and the United States. The healthcare system is facing new challenges stemming from an epidemic of chronic diseases and increased healthcare costs.1 Changing demographics, including an aging population, immigration, and increasing socioeconomic polarization, present another challenge. The Affordable Care Act has changed the healthcare and public health landscape by expanding access to care, emphasizing quality of care, and making a landmark investment through the Prevention and Public Health Fund.2,3 At the same time, the economic downturn and changes in the political climate have led to progressive cuts in funding and increased emphasis on outcomes.3,4 Finally, the evolution and adoption of health information technology and application of quality improvement methods have accelerated over the last decade, enhancing the capacity of healthcare providers and public health practitioners to provide, evaluate, and improve services.5 These dramatic changes all have material implications for the work of local health departments in North Carolina. LHDs must be proactive in their response to these changes if they are to persist and flourish in health promotion and disease prevention efforts.

With this in mind, the NC Association of Local Health Directors established a Task Force to examine what these changes mean for local public health departments. The Task Force requested staffing support from the North Carolina Public Health Incubator Collaboratives, suggesting that the work be prioritized as a statewide Incubator project, and the Incubator Steering Committee agreed.a The following report will familiarize local health departments with relevant contextual changes and emerging opportunities and provide guidance as LHDs respond to these developments.

a The “Incubators” are teams of local health departments working together voluntarily to address pressing public health issues. Their statewide governing body is the Incubator Steering Committee.

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Project Purpose and Objectives

This project provides resources and information to increase LHD capacity, improve LHD performance, and promote greater LHD sustainability in response to this changing context.

The objectives of the project were to:

1) Identify important strategic changes in North Carolina’s LHD context.

2) Assess the meaning of these changes for North Carolina’s LHDs and identify significant opportunities associated with these changes.

3) Suggest a core set of programmatic services that should be provided by any health department to promote a healthy community.

4) Suggest changes to existing services or new services in response to identified opportunities.

a. Recommend possible changes in LHD roles and in the roles of their health system partners.

b. Identify foundational capabilities required to support changing programmatic services.

5) Review and recommend practices to strengthen the capacity of North Carolina’s LHDs, including:

a. Regional collaborations (i.e., cross jurisdictional sharing), and

b. Transitional and sustainable funding alternatives.

Project Methods

The Public Health Task Force of the NC Association of Local Health Directors targeted this project as a priority for LHDs in North Carolina. In turn they requested support from the NC Public Health Incubator Collaboratives. The oversight body of the Collaboratives, the Incubator Steering Committee, reviewed this request, along with others, and chose to support this project. With guidance from the Task Force and the Steering Committee, the North Carolina Institute for Public Health (NCIPH) at the UNC-‐CH Gillings School of Global Public Health conducted research and facilitated a collaborative process among Public Health Task Force members and other key informants to gather and collate pertinent information. The methods consisted of:

1) An extensive literature review covered the current landscape of local health departments in North Carolina, laws and policy changes affecting LHDs, changes in the health system landscape, and changes in North Carolina’s economic and political climate.

2) Key informant interviews were conducted with 15 of the state’s healthcare leaders either in person or via telephone; interviews lasted approximately 60 minutes. During the interviews,

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informants were asked to validate literature review findings, identify existing gaps in services, and discuss potentially promising LHD opportunities and partnerships.

3) Key Informant Interviews were conducted with four local health directors to follow up on findings from the literature and key informant interviews. Health directors were asked to comment on these findings and validate identified contextual changes, gaps, and opportunities. In addition, they were asked to provide examples of services and capacities that might be pursued in response to identified opportunities.

4) The Task Force itself convened twice during the data collection and reporting phases. During the initial meeting, important contextual changes were reviewed and Task Force members were invited to discuss and prioritize these changes. During the second meeting, Task Force members discussed opportunities and strategic options that emerged from the contextual changes. The Task Force also developed a short list of major recommendations.

This final report describes the current status of local health departments in North Carolina, summarizes the contextual changes and the challenges and opportunities facing local public health departments, and provides strategic options for effectively dealing with these challenges and opportunities.

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References



3. Silberman P, Liao CE, Ricketts TC, 3rd. Understanding health reform: A work in progress. N C Med J. 2010;71(3):215-‐231.


5. Institute of Medicine (US). Primary care and public health: Exploring integration to improve population health. Washington, DC: The National Academies Press. 2012.

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II. Current Status of Local Health Departments in North Carolina

Current Landscape

There are a total of 85 local health agencies in North Carolina, covering 100 counties. They can be classified into five types of agencies. The great majority (68) are county health departments that serve a single county. Six are district health departments that cover multiple counties. These agencies cover 21 counties in total. One county (Hertford) is a public health authority, and another (Cabarrus) is a public hospital authority that provides public health services. Finally, nine counties are served by consolidated human services agencies, which provide public health, social services, mental health, developmental disabilities, and substance abuse services. North Carolina also allows counties to contract with the state for public health services, but no county has chosen this option.1

Until 2012, under North Carolina law, only counties with populations over 425,000 were eligible to create a consolidated human services agency. This meant that only Mecklenburg, Wake, and Guilford were eligible. House Bill 438, passed in June 2012, removed this population cap.2 With this change in legislation, several counties have transitioned or are considering transitioning to a consolidated human services agency. Between June 2012 and May 2013, the number of consolidated human services agencies increased from two to nine. The counties that have consolidated since 2012 range in jurisdictional size from 28,000 (Montgomery) to 238,000 (Buncombe). Figure 1 shows the locations of the different types of local public health agencies across the state.1p11

Figure 1: North Carolina Agencies Map

Hospital authority

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Local health agencies in North Carolina serve populations ranging in size from 5,800 (Hyde) to over 900,000 (Mecklenburg and Wake). Figure 2 shows the distribution of population size by type of agency.1p39 North Carolina is primarily rural; only 15 counties have a population greater than 250 residents per square mile and are classified as urban. Eleven of these 15 urban counties have county health departments. Of the nine counties with consolidated human services agencies, three are in urban counties and six are rural. Cabarrus County, with its hospital authority, is also urban. All 21 counties that are part of a regional district health department are rural.3

Table: 1 Population Size by Agency

Type of Agency Number Population Served

CHD-‐High Pop County health department/High population 21 100,000-‐500,000

CHD-‐Med Pop County health department/Medium population 22 50,000-‐99,000

CHD-‐Low Pop County health department/Low population 25 Under 50,000

DHD District health department 6 42,140-‐135,913 PHA Public health authority 1 24,010 HA Hospital Authority 1 178,011

CHSA Consolidated human services agency 9 28,000-‐919,628

*Abbreviations: CHD: county health department; DHD: district health department; PHA: public health authority; HA: hospital authority; CHSA: consolidated human services agency.

Funding

In a comparison of FY 2012 state budgets and appropriations for the agency in charge of public health services, Trust for America’s Health (TFAH) found that North Carolina ranked 44th in state funding for public health. North Carolina spent an average of $14.16 per person, compared to the national median of $30.61.4 The expenditures per capita by local health departments vary by agency type and by population served, ranging from $37 per capita for some agencies serving larger populations to $282 per capita for some smaller agencies.1

Local health departments in North Carolina receive revenue from a variety of sources including county appropriations (local ad valorem taxes), Medicaid reimbursements, and state and federal funds. North Carolina receives $18.02 per person in funding from the Centers for Disease Control and Prevention (CDC) (36th in the country) and $18.86 per person from the Health Resources and Services Administration (HRSA) (39th).4 State and federal funds include general aid, state environmental health funding, and state and federal grants. Health departments may also receive funding from private foundations, fees from environmental health services, Medicare reimbursements for home health and diabetes care, fees for women’s health services that have mandatory sliding fee scales, and contracts for services.1

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The funding mix varies by type of public health agency. County health departments and consolidated human services agencies receive a larger percentage of their revenue from county appropriations, while health authorities, district health departments, and public hospital authorities receive a greater percentage of their revenue from other sources. Figure 2 shows the variety in funding sources by agency type.1p40

Figure 2: NC Local Health Department Funding Sources (FY 2010 and FY 2012)

*Percentages do not total 100 percent because median, not mean, figures were used.

*Counties that established CHSAs since 2012 are shown here under their previous agency type (CHD—Low, Medium, or High Population).

Source: NC DHHS Public Health Revenue Source Book, FY 2010 and FY 2012

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Workforce

Local health departments are required to have a minimum of four full-‐time positions: a health director, a public health nurse, an environmental health specialist, and a secretary. However, agencies are allowed to share health directors.1 Staffing varies by local health department, but staffing must be sufficient to ensure that required services are available throughout the agency’s jurisdiction. Local health agencies employ between 0.6 and 2.8 FTEs per 1,000 population. Agencies serving larger populations tend to employ fewer FTEs per 1,000 population.1 Almost all types of agencies have reduced their FTE to population ratio since 2005 except for district health departments, where FTEs have increased, from 1.2 per 1,000 population in 2005 to 1.7 FTE per 1,000 population in 2011. The ratio varies more widely within agency types than between agency types. For example, small county health departments employ anywhere from .8 to 3.5 FTEs per 1,000 population.1

Figure 3 shows the percentage of FTEs in North Carolina by occupational area. Nurses comprise the largest proportion of personnel (27%). Management support staff make up 24% of employees. Health educators, nutritionists, social workers, aides, and environmental health professionals range between 3 and 9% of the workforce.5 Of note is that this mix of staffing suggests a focus on services provided at the LHD, with a preponderance of nurses and management support and only 3% of the workforce being designated as health educators whose focus is community-‐based.

Figure 3. FTE Employees by Occupation (2011)

Nurses 27%

Mgmt. Support 24% Other

22%

Environmental Health

Specialists 9%

Aides 5%

Social Workers 5%

Nutrisonists 5%

Health Educators

3%

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Mix of Services Provided by North Carolina’s Local Health Departments

In 2012, the Institute of Medicine (IOM) published For the Public's Health: Investing in a Healthier Future with a set of basic programs i.e. services expected to be provided by all local health departments, and foundational capabilities which are important, cross-‐cutting capabilities required by most public health programs.6 The basic programs are in line with the Ten Essential Services, outlining a minimum package of health services. We will use this IOM framework to organize the listing and mix of North Carolina LHD services and in later sections, to discuss possible roles and capabilities or capacities associated with recommended strategic options. Table 2 enumerates the services that local health agencies in North Carolina currently provide, how these services align with the IOM’s basic programs, and the percentage of LHDs in the state that currently provide that service.5 Table 2: Services Provided by LHDs in North Carolina

Services Offered by North Carolina Health Departments

Percent of LHDs Offering Service

IOM Basic Programs

Maternal and Child Health

Pregnancy Care Management 100%

Contraceptive Care 100%

Pregnancy Prevention-‐-‐Adolescent 97.6%

WIC Services—Mother 96.5%

Preconception Counseling 96.5%

Care Coordination for Children (CC4C) 96.5%

WIC Services-‐-‐Children 95.3%

SIDS Counseling 94.1%

Child Health 89.4%

Prenatal and Postpartum Care 89.4%

Well-‐Child Services 83.5%

Newborn Home Visiting Services 80%

Pediatric Primary Care 54.1%

Fertility Services 45.9%

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School Nursing Services 41.2%

Services to Children with Developmental Disabilities 37.6%

Postnatal Home Visits 27.1%

Pregnancy Medical Home 25.9%

Genetic Services 23.5%

Injury Control

Injury Control 47.1%

Communicable Disease Control

Communicable Disease Control 100%

Tuberculosis Control 100%

STD Community Level Surveillance, Investigation, Prevention and Control

100%

Immunizations 98.8%

Hepatitis A and B Immunizations 97.6%

Rabies Control: When People are Bitten by Dogs or Cats 96.5%

Communicable Disease Surveillance 94.1%

Rabies Control: When People are Exposed to Rabies Vector Species (Bats, Terrestrial Carnivores)

94.1%

AIDS/HIV Community Level Surveillance, Investigation, Prevention and Control

92.9%

Reportable disease 90.6%

Rabies Control: Services for Domestic Animals That Are Reasonably Suspected of Being Exposed

68.2%

Chronic Disease Prevention, Including Tobacco Control

Comprehensive Community Health Assessment 97.6%

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Chronic Disease Control: Early Detection and Referral 95.3%

Community Health Education 92.9%

Chronic Disease Control: Patient Education 87.1%

Nutrition Counseling 83.5%

Tobacco Cessation 80%

Health Planning 77.6%

Chronic Disease Surveillance 57.6%

Behavioral Risk Assessment 50.6%

Chronic Disease Monitoring and Treatment 42.4%

Environmental health

Bioterrorism/Other Emergency Preparedness 98.8%

Restaurant/Lodging/Institutions Sanitation and Inspections

97.6%

On-‐Site Sewage and Wastewater Disposal 97.6%

Lead Poisoning Services 91.8%

Water Sanitation and Safety 83.5%

Lead Abatement 74.1%

Environmental Risk Assessment 70.6%

Health Code Development and Enforcement 70.6%

Pest Management 29.4%

Pesticide Poisoning 18.8%

Bedding Control 14.1%

Mental health and substance abuse

Behavioral Health Services 17.6%

Clinical Services (not endorsed by the IOM)

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Most services provided by LHDs in North Carolina can be categorized into four of the IOM’s basic programs and clinical services (not endorsed by the IOM.): 1) MCH (18 services); 2) Communicable Disease Control (11 services); 3) Environmental Health Services (11 services); 4) Chronic Disease Control (10 Services); 5) Clinical Services (8 services). Remaining IOM basic programs include: 1) Injury Control (1 service) and; 2) Behavioral Health Services (1 service).

Further, we see for those basic programs with the largest number of services, many of their services are performed by the majority of North Carolina health departments. If we list the number of services for each basic program provided by ninety or more percent of North Carolina’s local health departments, we find that 10 of 11 communicable disease control services are provided by 90% of LHDs, and 8 of 18 MCH services are provided by 90% of LHDs.

Other widely provided services include: Comprehensive Community Health Assessment (98%); Chronic Disease Control: Early Detection and Referral (95.3%); Community Health Education (93%); Restaurant/Lodging/Institutions Sanitation and Inspections (98%); On-‐Site Sewage and Wastewater Disposal (98%); Lead Poisoning Services (92%) and; Dental Health (87%). The widespread practice of many services across North Carolina’s LHDs suggests a relatively high congruence of opinion among public health leaders and policy makers about the need to provide these services. In addition, many of these widely practiced services could be formally coordinated with more traditional healthcare services as a means of distinguishing a role for LHDs in new models of coordinated care. At the same time, when providing these services as part of a coordinated community care system, LHDs must develop the capacity to measure their performance and to engage in regular, effective quality improvement (QI) activities.

Dental Health 87.1%

Public Health Nurse Pharmacy Dispensing 69.4%

Adolescent Health Services 69.4%

Other Pharmacy Services 47.1%

Adult Primary Care 43.5%

Home Health Services 36.5%

Refugee Health 24.7%

Migrant Health 17.6%

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Accreditation

With funding from the CDC and RWJF, the Public Health Accreditation Board (PHAB) launched a national accreditation program for local, state, territorial, and tribal health departments in September 2011. PHAB has established national standards with the intent of strengthening public health services and programs, improving infrastructure, and increasing accountability. In order to become accredited, a health department must complete three prerequisite requirements: a community health assessment, a community health improvement plan, and an organizational strategic plan.7 PHAB defined twelve domains of services, which are based on the Ten Essential Public Health Services. The domains are as follows:8

1. Conduct and disseminate assessments focused on population health status and public health issues facing the community.

2. Investigate health problems and environmental public health hazards to protect the community. 3. Inform and educate about public health issues and functions. 4. Engage with the community to identify and address health problems. 5. Develop public health policies and plans. 6. Enforce public health laws. 7. Promote strategies to improve access to healthcare services. 8. Maintain a competent public health workforce. 9. Evaluate and continuously improve health department processes, programs, and interventions. 10. Contribute to and apply the evidence base of public health. 11. Maintain administrative and management capacity. 12. Maintain capacity to engage the public health governing entity.

PHAB emphasizes that the purpose of accreditation is not accreditation itself but to continuously improve services to better serve the community. Each domain is comprised of a set of standards and measures that dictate the level of achievement that health departments must reach and means of demonstrating such achievement. Yet PHAB recognizes the immense diversity in health departments and communities across the country. Therefore, the Board focuses on how a health department provides its services, rather than what services are provided in particular.9

Cabarrus County in North Carolina was among the first eleven health departments nationally to receive accreditation in February 2013. Three additional health departments were awarded national accreditation status on May 30, 2013. Over 130 health departments nationwide are currently preparing actively for accreditation consideration.10

North Carolina health departments are in a strong position to receive national accreditation given that the North Carolina Division of Public Health and the North Carolina Association of Local Health Directors first began developing a statewide accreditation system in 2002. State rules were finalized in 2006. The national accreditation program was developed based on the North Carolina accreditation experience. While the national accreditation program is voluntary, health departments in North Carolina are mandated to pursue accreditation through the North Carolina Local Health Department Accreditation

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(NCLHDA) program. The goals of the program are to improve capacity, accountability, and consistency of LHD services, programs, and policies across the state.11 All LHDs will be reviewed by the Board by 2014. In order to achieve NC accreditation, a local health department must conduct a self-‐assessment of 41 benchmarks and 148 activities and participate in a three-‐day site visit. Upon completion of these activities, the North Carolina Local Health Department Accreditation Board will determine accreditation status.11 A comparison of PHAB and NCLHDA standards revealed 95% overlap of the content.11 In addition, LHDs are required to conduct a community health assessment, one of the prerequisites for national accreditation. As of June 21, 2013, 78 of 85 health departments had been accredited.12

One major concern of both PHAB and NCLHDA is that accreditation status will be viewed as the end goal, rather than a tool to drive continuous quality improvement and investment in public health. A survey of accredited LHDs in North Carolina, however, found that the majority (67%) pursued quality improvement activities after becoming accredited.11 This finding indicates that pursuing accreditation is a promising means of continuously enhancing public health services.

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References

1. University of North Carolina School of Government. Comparing North Carolina’s Local Public Health Agencies: The Legal Landscape, the Perspectives, and the Numbers. May 2013. Available at: http://www.sog.unc.edu/sites/www.sog.unc.edu/files/Comparing%20Public%20Health%20Agencies%20FINAL%20May%202013.pdf.

2. University of North Carolina School of Government. Summary of H 438, Third Edition. June 8, 2012. Available at: http://www.sog.unc.edu/sites/www.sog.unc.edu/files/Summary%20of%20H%20438-‐3d%20ed.pdf.

3. North Carolina Rural Economic Development Center. Rural Counties in North Carolina. 2012. Available at: http://www.ncruralcenter.org/index.php?option=com_content&view=article&id=75&Itemid=155.

4. Trust for America’s Health. Investing in America’s Health: A State-‐by-‐State Look at Public Health Funding and Key Health Facts. April 2013. Available at: http://healthyamericans.org/assets/files/TFAH2013InvstgAmrcsHlth05%20FINAL.pdf.

5. North Carolina Department of Health and Human Services Division of Public Health. State Center for Health Statistics. Local Health Department Staffing and Services Summary: Fiscal Year 2011. January 2012. Available at: http://www.schs.state.nc.us/schs/data/lhd/2011/FacStaff.pdf.


7. Centers for Disease Control and Prevention. National voluntary accreditation for public health departments. March 2013. Available at: http://www.cdc.gov/stltpublichealth/hop/pdfs/NVAPH_Factsheet.pdf.

8. Public Health Accreditation Board. Standards and measures version 1.0. March 2011. Available at: http://www.phaboard.org/wp-‐content/uploads/PHAB-‐Standards-‐and-‐Measures-‐Version-‐1.0.pdf.

9. Public Health Accreditation Board. PHAB accreditation online orientation module 1: A general overview of public health accreditation. Available at: http://www.cecentral.com/activity/3594.

10. Public Health Accreditation Board. Public Health Accreditation Board awards national accreditation to three public health departments. June 4, 2013. Available at: http://www.phaboard.org/general/public-‐health-‐accreditation-‐board-‐awards-‐national-‐accreditation-‐to-‐three-‐public-‐health-‐departments/. Accessed June 25, 2013.

11. Davis MV, Cannon MM, Stone, DO, Wood BW, Reed J, Baker EL. Informing the national public health accreditation movement: Lessons from North Carolina’s accredited local health departments. American Journal of Public Health. 2011; 101(9): 1543-‐1548.

12. North Carolina Institute for Public Health. North Carolina local health department accreditation. Available at: http://nciph.sph.unc.edu/accred/. Accessed June 25, 2013.

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III. Contextual Changes Affecting Local Health Departments

North Carolina’s local health departments, like many other healthcare organizations, are seeing dramatic changes in the world around them, and these changes can be expected to have a material impact on the role of local health departments and the services they provide. Thus, it is important to understand these changes and to consider them both individually and collectively. Below we briefly describe the changes that will present both the greatest challenges and opportunities for North Carolina’s LHDs. Other important changes, like climate change and the ongoing threat of bioterrorism, are certainly important but are not discussed here.

Health System Changes

The term health system refers to the community system of public, private, and nonprofit healthcare and public health partners, their roles, and their interactions. Recent changes in the health system include transformations in structure, funding (particularly as it relates to prevention), and the evolution and adoption of health information technology (HIT).

Structure

Recent North Carolina legislation has introduced organizational/structural options heretofore unavailable to most of North Carolina’s LHDs. As noted above, House Bill 438, which became law in June of 2012, extends to all counties several organizational options previously available only to large counties.1 Now, any county may elect to:

1. Assume direct control of certain local boards by adopting a resolution abolishing the board(s) and transferring powers and duties to the Board of County Commissioners.

2. Create a consolidated human services agency (CHSA) governed by a board appointed by the County Commissioners.

3. Create a CHSA governed directly by the County Commissioners.

The law also created the Public Health Improvement Incentive Program to provide monetary incentives for multi-‐county local public health agencies serving populations of over 75,000. However, while the purpose of the program is to provide incentives, they have not yet been implemented. HB 438 also rewrote North Carolina’s list of essential public health services and transferred responsibility for ensuring them from the state public health agency to local public health agencies.1

The structure of clinical care delivery is also changing. Over the last decade, the number of doctors employed by hospitals has more than doubled, both in the U.S. and North Carolina. Currently, roughly two thirds of North Carolina’s doctors are employed by hospitals and health systems.2 Several factors are driving this trend, including economic instability among physicians, the movement to performance-‐based reimbursement, the costs associated with health information technology adoption, and greater leverage in negotiations with payers.2

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Access to Care

The Affordable Care Act (ACA) includes several new health insurance regulations intended to promote access to care, particularly preventive care. New private plans as of September 23, 2010 are required to cover many preventive services without cost sharing. Plans must cover services that are rated A (strongly recommended) or B (recommended) by the U.S. Preventive Services Task Force (USPSTF), vaccinations endorsed by the Advisory Committee on Immunization Practices, and other services. Some examples of these services are screenings for breast cancer, cervical cancer, and colorectal cancer, tobacco-‐cessation, obesity screening and counseling, alcohol-‐misuse counseling, and depression screening. Women’s health services endorsed by HRSA, such as well-‐woman visits, contraceptive counseling, and breastfeeding support are also covered.47 In addition, Medicare began covering an annual wellness visit without cost sharing in 2011. The wellness visit includes a health risk assessment and customized prevention plan. Medicare will cover many of the USPSTF-‐recommended services and Medicaid programs that do so may receive enhanced federal matching funds.47

Other regulations improve access to these insurance plans. For example, children up to the age of 26 can continue on their parent’s insurance plan. Adults with pre-‐existing conditions are able to enroll in a high-‐risk insurance pool. In addition, insurers are no longer able to drop an individual’s coverage once they become sick, or vary premiums based on gender or use of health services. Premiums may only be adjusted for age, geographic area, family composition, and tobacco use. Furthermore, insurers are no longer allowed to set annual or lifetime limits on benefits.3,4 The ACA gives states the option to expand Medicaid coverage to all non-‐elderly low-‐income citizens and many lawfully present permanent residents with incomes below 138% of the federal poverty line. As of 2013, however, North Carolina has decided not to expand Medicaid coverage.3

Even so, starting in 2014, lawful North Carolina residents will have access to a federally managed health insurance marketplace. These marketplaces serve various functions: they will certify that the health plans meet federal requirements and offer standardized information on the quality and cost of the featured plans. In addition, they will automatically check an enrollee’s eligibility for Medicaid or federal insurance subsidies (138% FPL -‐ 200% FPL) and streamline the enrollment process. The creation of insurance marketplaces will coincide with the 2014 ACA requirement that most people be insured or pay a penalty.3 To meet the needs of the many individuals newly eligible for health insurance, the ACA requires marketplaces to establish a network of Navigators. These Navigators’ responsibilities include distributing fair and impartial information about enrollment and availability of tax credits, conducting public education to raise awareness of Qualified Health Plans,b and facilitating enrollment in such plans.5

Of course, greater coverage will increase the demand for healthcare services. This increase in demand is expected to exacerbate the existing shortage of physicians, particularly primary care providers. Primary care specialties include family practice, general practice, internal medicine, obstetrics/gynecology, and pediatrics. Despite the high-‐demand for these professionals, only 35% of U.S. physicians practice

b A Qualified Health Plan is an insurance plan that is certified by the Marketplace, provides essential health benefits and follows established limits on cost sharing, among other requirements.

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primary care, compared to 50% in many other industrialized countries.6 Experts estimate that by 2025, there will be a 27% shortage of primary care physicians.6 In 2011, North Carolina had 7,520 primary care physicians and needed an additional 339 practitioners to achieve the recommended physicians per capita ratio.6 Several incentive programs have been implemented to reduce the shortage. For example, in 2010, the North Carolina Association of Family Physicians (NCAFP) received $1.18 million from Blue Cross and Blue Shield of North Carolina to encourage medical students to enter primary care. There are also scholarship opportunities for students who enter family practice residencies.7

It is important not only to train more primary care providers but also to ensure that they will work in high-‐needs areas of North Carolina where access is lowest. Medically Underserved Areas (MUAs) are areas in which residents have inadequate access to personal health services. These areas continue to face enormous challenges in recruiting healthcare professionals.8 Figure 4 displays the MUA’s in North Carolina. Clearly, access issues are widespread.9

Figure 4: Medically Underserved Areas in North Carolina, 2006 (Shaded)

The ACA has made a 5-‐year, $1.5 billion investment in the National Health Services Corps to support scholarships and loan assistance for approximately 16,000 additional professionals practicing primary care, dental care, or mental health in these underserved areas.10

The ACA also attempts to mitigate access problems by requiring Qualified Health Plans to have a sufficient number and adequate geographic distribution of essential community providers to ensure reasonable access for low-‐income medically underserved individuals in the plan’s service area. Various entities fit the definition of essential community provider. Among these are providers designated in the Public Health Service Act and in Section 1927 of the Social Security Act, which include safety net providers like health centers and local health departments.11,12

Access to mental health services is of particular concern because mental disorders are among both the most prevalent and the most costly conditions in the United States. An estimated 26% of Americans

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ages 18 and above suffer from a diagnosable mental disorder in a given year. The estimated lifetime prevalence of any mental disorder among the U.S. adult population is 46%.13 Between 2000 and 2010, the number of patient visits for medical care in the U.S. rose by approximately 90%, but the number of visits for mental healthcare increased 400%.8 Yet over 60% of adults and over 70% of children in need of mental health services still do not receive these needed services. The trend toward increased visits is likely to continue as a result of recent legislation. The Mental Health Parity and Addiction Equity Act of 2008 requires insurance companies to cover medical, surgical, and behavioral health services with parity. The ACA also requires the inclusion of mental health services in the essential benefits package.14

Funding for Public Health

The economic downturn has resulted in damaging budget cuts for LHDs and has reduced the capacity of local agencies to provide public health services. Trust for America’s Health reports that 29 states decreased their public health budgets from FY 2010-‐2011 to FY 2011-‐2012. In 23 states, this was the second consecutive year of cuts.15 Table 3 provides detailed information on the percentage of local health departments in North Carolina and the U.S. that have made cuts in their budgets, staffing, and programs. These data are based on a series of nationally representative surveys by NACCHO documenting the impact of the recession on local health departments.16

Table 3. LHD Cuts in Funding, Programming, and Staffing

*Not all health departments responded to every question. Between 627 and 647 U.S. health departments and between 21 and 23 NC health departments responded to each item.

Notably, 71% of local health agencies surveyed in North Carolina had lost some staff due to funding cuts, compared to 44% nationwide, and these staff reductions were associated with program cuts.16 A statement from an employee at the Wayne County Health Department points to the impact of the cuts:

US LHDs (N=627-‐647*)

NC LHDs (N=21-‐23*)

Lost some staff through layoffs and/or attrition

44% 71%

Reduced staff time by cutting hours and/or mandated furlough

21% 26%

Made cuts to at least one program 57% 75%

Made cuts to three or more programs 28% 22%

Current budget lower than last year 41% 62%

Expect budget to be lower next year 41% 55%

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“The only position in our county that addressed childhood obesity and education to prevent chronic disease was eliminated as a result of cuts to the preventive block grant funding.”17

Two important ACA infusions of funding are Federally Qualified Health Centers (FQHC) funding ($9.5 billion nationally from 2011 -‐ 2016) intended to expand FQHC capacity to accommodate the anticipated influx of Medicaid recipients, and the Prevention and Public Health Fund (PPHF).18 The Fund is offering several grants and programs that may be of interest to LHDs, including grants for school-‐based health centers, incentives for prevention of chronic disease, Community Transformation Grants, Healthy Aging Living Well Grants, and funds for maternal, infant, and early childhood home visiting programs.18

Unfortunately, funding for FQHCs has already been cut by $600 million, and by 2016, funding will return to base funding lower than that of 2010. This return to lower base funding is particularly problematic in a state like North Carolina, which is not participating in the ACA Medicaid Expansion program. These states will have a continued, substantial need for safety net providers.19 In addition, pressure to reduce the federal deficit is likely to result in Congressional proposals to cut the Prevention and Public Health Fund.18,20 The ACA initially allocated $18.75 billion for the PPHF between FY 2010 and 2022. However, the fund was cut by $6.25 billion in February 2012 and reallocated to avoid a cut to Medicare physician payments.50 The structure of most prevention-‐related funding will continue to be “grants-‐based.” In other words, funding priorities are typically predetermined and the grant is subject to an end date. Limited flexibility may preclude a LHD from targeting their community’s health priorities, and staffing and prevention-‐related resources come and go periodically based on the grant performance periods.21,22

Health Information Technology (HIT)

Another major structural change in the health systems of North Carolina is the widespread adoption of HIT, which has led to a dramatic increase in the availability, sharing, and reporting of digital patient information. Nationally, physician practices have shown a steady increase in the adoption of electronic health records (EHRs), from an adoption rate of 18.2% in 2001 to a rate of 51% in 2010. The rate of adoption has accelerated vastly just in the past few years. In 2012, 71.8% of providers nationwide and 80.7% of providers in North Carolina had some form of EHR.23 Physicians have adopted electronic prescribing as well, with nearly 70% of North Carolina doctors relying on e-‐prescriptions in 2011.24

The capacity to share and aggregate this information continues to grow dramatically with infrastructure advances such as:

1. The North Carolina Health Information Exchange (NC HIE), which will provide access to North Carolina’s State Lab and to various medical registries. It will also enable patient information sharing by safety net providers.25

2. The adoption of the EPIC electronic health record by many of North Carolina’s major health systems, which enables the exchange of patient information within and across these health systems.26

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3. NC Direct, which will enable secure sharing of patient information with community providers.27

4. The development of a number of population-‐based analytical repositories and tools like the CCNC Informatics Center’s Provider Portal and NC Community Health Information Portal (NC-‐HIP), to analyze the health status of different patient populations.28

5. The NC Telehealth Network (NCTN), a dedicated, redundant, high-‐quality broadband network for nonprofit healthcare providers in North Carolina, including public health agencies.29

6. Maturing interoperability standards that enable common data definitions, formats, and transport.30

Finally, telehealth services (i.e., the use of information and telecommunication technologies to deliver health-‐related services remotely) are rapidly evolving and are becoming increasingly economical and increasingly commonplace. Important applications that have seen significant growth in North Carolina are home monitoring to foster disease management compliance, and telepsychiatry programs to increase the availability of mental health services in rural communities. Medicaid is currently reimbursing telepsychiatry and select pediatric telehealth services.19

Delivery of Clinical & Preventive Care

Quality Improvement

While the U.S. spends more money on healthcare than any other country, the country has fallen behind many other nations in terms of life expectancy, infant mortality, and the incidence of preventable diseases. This is primarily a result of lack of access to care in many communities, but improvements are also needed in the quality of care that people are receiving.31 With this in mind, the ACA has required the Department of Health and Human Services (DHHS) to establish a National Strategy for Quality Improvement in Health Care, also known as the National Quality Strategy or NQS. The NQS serves as a blue print for healthcare stakeholders across the country – patients, providers, employers, health insurance companies, academic researchers, and local, state, and federal governments – that helps prioritize quality improvement efforts, share lessons, and measure collective successes. The Strategy’s three goals are Better Care, Healthy People and Healthy Communities, and Affordable Care. NQS also identifies 10 principles that can be used when designing specific initiatives to achieve the three goals. In addition, the NQS defines the following six priorities:31

1. Make care safer by reducing harm caused in the delivery of care.

2. Ensure that all persons and families are engaged in their care.

3. Promote effective communication and coordination of care.

4. Promote the most effective prevention and treatment practices for top mortality causes.

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5. Work with communities to promote best practices for healthy living.

6. Develop and spread new healthcare delivery models to reduce quality care’s costs.

The Triple Aim Framework is another initiative intended to enhance the quality of healthcare. It was developed by the Institute for Healthcare Improvement and is an approach to optimizing health system performance. The three goals of the Triple Aim are similar to the three aims of the NQS. They are:32

1. Improve patient experience of care (including quality and satisfaction).

2. Improve the health of populations.

3. Reduce the per capita cost of healthcare.

Enacting the Triple Aim will require recognition of a population as the unit of concern, externally supplied policy constraints (such as a total budget limit or requirement that all subgroups be treated equally) and the existence of an ‘integrator’ that can focus and coordinate services.32

Outcomes -‐ Based Reimbursement

The dilemma in pursuing the Triple Aim and the National Quality Strategy is that doing so is not in the immediate self-‐interest of individual actors. For instance, hospitals will try to fill their beds and expand clinical services to bring in income even though the net cost is higher in the long run. For this reason, payment reform is an essential piece of pursuing the Triple Aim, NQS, and overall healthcare reform.32

The ACA encourages innovative restructuring of healthcare practices to improve healthcare quality, efficiency, and health outcomes. It is investing in integrated approaches that reward practices for improving health outcomes, rather than merely adhering to guidelines. Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs) are two prominent approaches. On the most basic level, ACOs can be understood as containing providers that are jointly held accountable for achieving measured quality improvements and reducing the rate of spending growth.33 ACOs may involve a variety of provider configurations, ranging from integrated delivery systems and primary care medical groups, to hospital-‐based systems and virtual networks of physicians, such as independent practice associations. Although ACOs have considerable flexibility in many aspects of design, all are based on the following core principles:33

1. Provider-‐led organizations with a strong base of primary care are collectively accountable for quality and per capita costs across the full continuum of care for a population of patients.

2. Payments are linked to quality improvements that also reduce overall costs.

3. Reliable and progressively more sophisticated performance measurements are used to support improvement and provide confidence that savings are achieved through improvements in care.

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CMS has recently signed ACO contracts with 106 provider organizations around the country, including the Physicians HealthCare Collaborative in Wilmington, North Carolina. Twenty-‐seven of these are participating in the Medicare Shared Savings Program. Fifteen ACOs will participate in the Advance Payment model. These are rural or physician-‐based models that also receive monthly and upfront investments for capital expenditures. CMS Innovation launched 32 “Pioneer” ACOs in 2012.34

PCMHs facilitate the coordination of the full range of primary and acute physical health services, behavioral healthcare, and long-‐term community-‐based services and supports. PCMHs are characterized by seven functions and attributes:35

1. Personal physician: Each patient has a personal physician.

2. Physician-‐led team: Physician directed medical practice involves a team of care providers including physicians, nurses, pharmacists, nutritionists, social workers, health educators, and care coordinators.

3. Whole person orientation: The team meets the majority of the patient’s healthcare needs, including prevention, acute care, chronic care, and mental health.

4. Coordinated care: PCMHs coordinate care across hospitals, home healthcare, and community services through the use of registries, information technology, health information exchange, and culturally and linguistically appropriate services.

5. Accessible services: Access is enhanced by offering shorter waiting periods for immediate needs, longer in-‐person hours, and 24-‐hour access to a team member via telephone or Internet.

6. Quality and safety: Care is patient-‐centered and holistic and emphasizes building relationships with patients to understand their unique needs, culture, values, and preferences. Evidence-‐based medicine, quality improvement, patient participation in care, and practice participation in a voluntary recognition process are other elements of this core feature. PCMHs also measure performance, patient satisfaction, and population health to guide improvement activities.

7. Payment reform: Financial incentives are aligned to support coordination of care, alternative scheduling arrangements, use of new technologies, and improved quality of care.

Community Care of North Carolina networks are leaders in the PCMH movement nationally. Roughly 350 CCNC practices are now PCMHs.36

Two key differences between these models and the traditional pay-‐for-‐procedure approach to healthcare are: 1) the baseline health of a population is important as the overall health of a provider’s population is key to successful patient outcomes, 2) these models require coordinated care by a team of

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providers. While these models are expected to provide significant improvement over fee-‐for-‐service models, challenges remain. For instance, many public health professionals are concerned that healthcare providers will still consider their patient base to be the population of concern, rather than the entire community.

Community Health

Prevalence of and Costs Associated with Chronic Diseases

Chronic diseases have become a critical public health concern in the United States. In 2005, 133 million Americans had at least one chronic condition, and this number is expected to continue to rise.6 Chronic conditions place an immense financial burden on the nation’s economy, accounting for over 75% of the $2.6 trillion spent on medical care annually.37 Furthermore, indirect annual costs in terms of diminished labor supply and worker productivity have been estimated at over $1 trillion.30 National health expenditures are increasing at an unsustainable rate. By 2019, an estimated 19.3% of GDP will be directed toward medical care programs such as Medicaid and Medicare, and chronic conditions are largely responsible for the increases. Obesity alone accounts for 20% of the rise in healthcare expenditures over the past decade.30

Many of these conditions are largely preventable. Of the ten most costly medical conditions in the U.S, six are chronic conditions associated with modifiable risk factors such as smoking, poor diet, or physical inactivity.30 While the clinical care system is designed to treat illness, public health agencies promote wellness through prevention. Reinvestment in public health can thus “reduce the rising prevalence of chronic diseases…and simultaneously attenuate the downstream medical care costs associated with them.”30p20

Social Determinants of Health and Health in All Policies

The Institute of Medicine has called for the adoption of a social determinants perspective to complement the health system’s predominantly biomedical orientation. Social determinants are the “conditions in which people are born, grow, live, work and age.”39 These circumstances are influenced by the distribution of power, money and resources at local, national and global levels.11 A social determinants perspective recognizes that social connectedness, social capital, economic inequality, social norms, and public policies have strong influences on an individual’s health behavior, resulting in persistent health disparities.21 We are seeing increasing attention and resources devoted to improving community health by addressing these social determinants. Institutions such as the Robert Wood Johnson Foundation (RWJF) and the CDC are encouraging the use of policy interventions to impact them. For example, the CDC-‐funded Community Transformation Grants target policy interventions for tobacco-‐free living, active living and healthy eating, and quality clinical and other preventive services.39

This line of thinking is also reflected in the concept of “Health in All Policies”(HiAP), which promotes the protection of health through policy decisions taken outside the health sector and its traditional partners. This approach has received national support from federal, state, and local agencies across the country largely due to the recognition of the importance of addressing social determinants of health. The HiAP

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approach requires an increased capacity of health systems to effectively engage other sectors in adopting policies that maximize health gains while allowing the target sectors to achieve their own goals as well.48 As an example, California’s Health in All Policies Task Force (created by executive order in 2010) mandates 19 agencies, departments and offices, including the Natural Resources Agency, Department of Finance, Air Resources Board, Department of Education and others to incorporate public health considerations into their polices.40 In another example, the Baltimore City Health Department has institutionalized the HiAP approach in the “Healthy Baltimore 2015” initiative, which includes redesigning communities to become tobacco free and prevent obesity.41 HiAP is a particularly strategic approach to health improvement because policy-‐based interventions have been shown to have the greatest bang for the public health buck. That is, the reach of individual-‐level interventions is limited to the number of people to whom an agency can directly provide services. In contrast, policy interventions improve the health of the entire population. For example, the entire population’s health benefits from bans on smoking in public places, whereas only the individual smoker benefits from tobacco cessation counseling.

Creating and providing user-‐friendly tools that facilitate the inclusion of health considerations by those outside the field can assist in engaging these partners. Conducting a Health Impact Assessment (HIA) is often the best way to begin. HIAs use a “flexible, data-‐driven approach that identifies the health consequences of new policies and develops practical strategies to enhance their health benefits and minimize adverse effects.”49 National initiatives such as the Health Impact Project are focused on promoting the use of HIAs while simultaneously building a training and technical assistance network to support HIA practitioners.49

Community Health Improvement: Partnering with Traditional and Nontraditional Partners

Recognizing the central role that chronic disease, injury, and high-‐risk behaviors play in a community’s health, lawmakers have introduced reform legislation, to be implemented by the IRS, that requires nonprofit hospitals to conduct Community Health Needs Assessments (CHNAs) every three years. These assessments are to be followed by a Community Health Improvement Plan (CHIP), the implementation of interventions included in the plan, and an evaluation of these interventions. Hospitals must report on their facility-‐specific interventions, noting how they are meeting identified priority health needs and benefitting the community.3,38 Historically, local health departments in North Carolina have been the leaders in conducting health assessments and action planning efforts. As a result, collaborations between nonprofit hospitals and their LHDs are an obvious strategy. These collaborations are under way in a number of North Carolina counties, including a nationally recognized collaborative effort in Western North Carolina, WNC Healthy Impact.

LHDs might also look into partnerships with private businesses, nonprofits, schools of public health and community colleges, and other non-‐traditional organizations. These entities are becoming increasingly interested in prevention efforts. Public-‐private partnerships (PPPs) are one way to engage these non-‐traditional partners. Partnering makes it possible for the right skills and resources to be deployed, and for risks to be shared. Specialized skills may include manufacturing, distribution, marketing, business

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planning, development, data collection, and data analysis. Partnerships can have a wide range of objectives, such as:44

1. Developing products (primarily drugs and vaccines) 2. Strengthening health services 3. Educating the public 4. Improving product quality or regulation 5. Distributing a donated or subsidized product to control a specific disease

Worksite wellness programs are a commonly cited example of PPPs. These programs bring comprehensive wellness services into workplaces to help create an environment supportive of healthy choices and to improve access to services.45 Healthy People 2020 aims to increase the percentage of worksites that offer comprehensive wellness programming, and the American Heart Association provides recommendations for the components that should be included.46

Evidence-‐Based Strategies

Evidence-‐based strategies (EBSs), whether they are policy or program-‐based, are considered most likely to yield positive health outcomes. For some time, the CDC, and more recently, the National Quality Strategy have advocated for the use of EBSs. They have developed a core set of public health objectives and related strategies from which agencies can select and customize public health interventions. Most notable among these are the Guide to Community Preventive Services (CG), which includes population-‐based policies and programmatic prevention strategies compiled by the Task Force on Community Preventive Services; the work of the U.S. Preventive Services Task Force (USPSTF), which is an independent panel of experts in prevention and evidence-‐based medicine; Healthy People 2020 objectives, science-‐based 10-‐year objectives intended to promote healthier communities; and selected studies done by the Institute of Medicine.42

Some NC LHDs are undertaking EBSs, but considerable work remains. In a survey conducted by the NC Institute of Medicine (NCIOM), 68% of responding health directors said that less than half of the staff members in their health department were aware of EBSs. When asked to rate their current use of EBSs on a scale of 1 to 10, with 1 meaning no programs and polices based on EBSs and 10 meaning all based on EBSs, the mean rating was 5.88. There are several barriers to the effective use of EBSs in local health departments. Survey respondents indicated that “limited financial resources” was the greatest barrier, followed by “lack of knowledge and skills about how to test and adapt EBSs or approaches so they work in the LHD’s community.” Other barriers included a lack of ongoing staff training and the time required to learn how to correctly implement a specific strategy.43

PHAB and NCLHDA place a strong emphasis on evidence-‐based practices. PHAB standards repeatedly state that strategies used across all domains should be evidence-‐based. Knowledge of EBSs is critical not only to improve health department services, but also to provide policy guidance, a core function of public health. LHDs are one of the only entities that have the capacity to inform and educate policymakers on how their decisions impact health. By becoming more conversant in EBSs, LHDs are in a

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stronger position to advocate for the needs of their communities, achieve accreditation status, and improve relationships with external stakeholders.

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References

1. University of North Carolina School of Government. Comparing North Carolina’s Local Public Health Agencies: The Legal Landscape, the Perspectives, and the Numbers. May 2013. Available at: http://www.sog.unc.edu/sites/www.sog.unc.edu/files/Comparing%20Public%20Health%20Agencies%20FINAL%20May%202013.pdf.

2. Baldwin G. The Price of I.T. Progress. Health Data Management. May 2012. Available at: http://www.healthdatamanagement.com/issues/20_5/hospital-‐physician-‐i.t.-‐information-‐technology-‐ehr-‐44378-‐1.html Accessed September 30, 2012.

3. Silberman P, Liao CE, Ricketts TC,3rd. Understanding health reform: A work in progress. N C Med J. 2010;71(3):215-‐231. 4. U.S. Department of Health & Human Services. HealthCare.gov. 2012. Available at: http://www.healthcare.gov/. Accessed September 26, 2012. 5. Maryland Health Benefit Exchange Request for Information. August 3, 2012. Available at: http://dhmh.maryland.gov/exchange/pdf/MD%20HBE%20Navigator%20Program%20RFI.pdf. Accessed November 8, 2012.


7. North Carolina Academy of Family Physicians. Innovative program tackles shortage in primary care. North Carolina Academy of Family Physicians Web site. 2010. Available at: http://www.ncafp.com/residents_and_students/innovative-‐program-‐tackles-‐shortage-‐primary-‐care. Accessed October 13, 2012.

8. Community Health Centers and the Affordable Care Act: Increasing Access to Affordable, Cost Effective, High Quality Care. Available at: http://www.healthcare.gov/news/factsheets/2010/08/increasing-‐access.html Accessed October 28, 2012.

9. Rural Policy Research Institute. Demographic and economic profile: North Carolina. June 2006. Available at: http://www.rupri.org/Forms/NorthCarolina.pdf.

10. Kaiser Commission on Medicaid and the Uninsured. Community health centers: The challenge of growing to meet the need for primary care in medically underserved communities. March 2012. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/03/8098-‐03_es.pdf.

11. Rosenbaum, S. Essential community providers. March 2011. Available at: http://www.healthreformgps.org/wp-‐content/uploads/3.11.11-‐Rosenbaum-‐Essential-‐Community-‐Providers.pdf.

12. ACA. Sec 1311, 45 CFR § 156.235(a)(1) of regs.

13. Centers for Disease Control and Prevention. Public Health Action Plan to Integrate Mental Health Promotion and Mental Illness Prevention with Chronic Disease Prevention 2011-‐2015. Atlanta: U.S. Department of Health and Human Services; 2011.

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14. Garfield RL. Mental Health Financing in the United States. A Primer. Kaiser Commission on Medicaid and the Uninsured. April 2011. Executive Summary pp. i-‐v. Available at: http://www.kff.org/medicaid/upload/8182.pdf Accessed October 29, 2012.



17. American Public Health Association. The State of Public Health in North Carolina. Available at: http://www.apha.org/NR/rdonlyres/13AF9BF2-‐4DE4-‐46D9-‐8E5E-‐C34B03813EA3/0/NorthCarolina2012PHACTCampaignSheet.pdf. Accessed March 24, 2013.


19. North Carolina Institute of Medicine. Examining the impact of the Patient Protection and Affordable Care Act in North Carolina. May 2012. Available at: http://www.nciom.org/wp-‐content/uploads/2012/05/Full-‐Report-‐Online-‐Pending.pdf. Accessed October 23, 2012.

20. Novick LF. Local health departments: Time of challenge and change. Journal of Public Health Management and Practice. 2012; 18(2): 103-‐105.



23. Hsiao CJ, Hing E. Use and characteristics of electronic health record systems among office-‐based physician practices: United States, 2001-‐2012. NCHS data brief, no 111. Hyattsville, MD: National Center for Health Statistics. 2012.

24. Surescripts. The National Progress Report on E-‐Prescribing and Interoperable Health Care Year 2011. Available at: http://www.surescripts.com/about-‐e-‐prescribing/progress-‐reports/national-‐progress-‐reports.aspx. Accessed November 11 2012.

25. North Carolina Healthcare Information & Communications Alliance, Inc. Available at: http://www.nchica.org/GetInvolved/NCHIE/intro.htm. Accessed September 29, 2012.

26. Ranii D. Duke kicks off digital health records plan. News and Observer. July 17, 2012. Available at: http://www.newsobserver.com/2012/07/17/2204389/duke-‐kicks-‐off-‐digital-‐health.html.

27. North Carolina Health Information Exchange. North Carolina Health Information Exchange (NC HIE) partners with Orion Health to offer NC Direct. 2012. Available at: http://nchie.org/wp-‐content/uploads/2012/06/NCDIRECT_factsheet_2012-‐06-‐14.pdf. Accessed May 29, 2013.

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28. Community Care of North Carolina. North Carolina Community Health Information Portal. 2013. Available at: http://www.communitycarenc.com/informatics-‐center/north-‐carolina-‐community-‐health-‐information-‐portal/. Accessed May 29, 2013.

29. Bloch C. North Carolina's HIT Initiatives Federal Telemedicine News Saturday, January 21, 2012. Available at: http://telemedicinenews.blogspot.com/2012/01/north-‐carolinas-‐hit-‐initiatives.html Accessed September 30, 2012. 30. Institute of Medicine (US). For the public’s health: Investing in a healthier future. Washington, DC: The National Academies Press. 2012. 31. U.S. Department of Health & Human Services. 2012 Annual Progress Report to Congress. National Strategy for Quality Improvement in Health Care. April 2012.

32. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs. 2008; 27(3): 759-‐769.

33. McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Affairs. 2010; 29(5): 982-‐990.

34. Centers for Medicare and Medicaid Services. Pioneer Accountable Care Organization Model: General Fact Sheet. September 12, 2012. Available at: http://innovation.cms.gov/Files/fact-‐sheet/Pioneer-‐ACO-‐General-‐Fact-‐Sheet.pdf. Accessed May 27, 2013.

35. Agency for Healthcare Research and Quality. Patient Centered Medical Home. 2012. Available at: http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/PCMH_Defining%20the%20PCMH_v2. Accessed October 24, 2012.

36. Community Care of North Carolina. CCNC PCMH Resource Center. 2013. Available at: http://www.communitycarenc.com/emerging-‐initiatives/pcmh-‐central1/. Accessed May 27, 2013.

37. Henry J. Kaiser Family Foundation. U.S. Health Care Costs. 2012. Available at: http://www.kaiseredu.org/issue-‐modules/us-‐health-‐care-‐costs/background-‐brief.aspx. Accessed September 30, 2012.

38. Hellinger FJ. Tax-‐exempt hospitals and community benefits: A review of state reporting requirements. Journal of Health Politics, Policy and Law. 2009; 34(1): 37-‐61.


40. Strategic Growth Council. Health in All Policies Task Force. 2012. Available at: http://www.sgc.ca.gov/hiap/. 2012. Accessed September 25, 2012.

41. Spencer M, Petteway R, Bacetti L, Barbot O. Healthy Baltimore 2015: A city where all residents realize their full health potential. Baltimore City Health Department. May 2011.

42. Community Preventive Services Task Force. The Community Guide. 2013. Available at: http://www.thecommunityguide.org/index.html. Accessed May 27, 2013.

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44. McDonnell S, Bryant C, Harris J, Campbell MK, Lobb A, Hannon PA, Cross JH, Gray B. The private partners of public health” Public-‐private alliances for public good. Preventing Chronic Disease : Public Health Research, Practice, and Policy. 2009; 6(2): 1-‐8.

45. Goetzel RZ, Roemer EC, Short ME, et al. Health improvement from a worksite health promotion private-‐public partnership. Journal of Occupational and Environmental Medicine. 2009;51(3):296-‐304.

46. U.S. Department of Health & Human Services. 2010. Healthy People 2020. Available at: http://www.healthpeople.gov/2020/default.aspx. Accessed January 10, 2013.

47. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010; 363(14): 1296-‐1299.

48. Kahlmeier S, Racioppi F, Cavill N, Rutter H, Oja P. " Health in all policies" in practice: Guidance and tools to quantifying the health effects of cycling and walking. Journal of physical activity & health. 2010;7(1):120.

49. Health Impact Project: Advancing Smarter Policies for Healthier Communities. The HIA process. 2011. Available at: http://www.healthimpactproject.org/hia/process. Accessed September 25, 2012. 50. American Public Health Association. Get the facts: Prevention and Public Health Fund. May 2013. www.apha.org/NR/rdonlyres/3060CA48-‐35ES-‐4F57-‐B1A5-‐CA1C110209C/0/APHA_PPHF_factsheet_May2013.pdf.

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IV. Opportunities

The review of contextual changes suggests that North Carolina’s LHDs must navigate a very dynamic and complex environment. In North Carolina, the ACA will provide access to care for more people, but the need to assure and, in some cases, to provide clinical services will continue. Coordination of care is at the heart of efforts to improve the quality of care and to constrain costs. In many cases, coordination of care includes disease management and prevention-‐related services.1 In addition, communicable disease surveillance continues to be an important need that LHDs are uniquely qualified to provide.1 The “sweet spot” for LHDs in the larger health system continues to be community-‐based prevention. These all represent important opportunities for LHDs.

Provision and Assurance of Clinical Care

Given the NC legislature’s decision to opt out of Medicaid expansion, roughly 500,000 people who would have been covered by Medicaid will not be, and many will need a safety net provider.2 The continued and expanding need for care by low-‐income and immigrant populations, along with an anticipated shortage of providers, points to a continuing and in some cases growing need for the provision of general pediatric and adult primary care services in many counties.3 If North Carolina were to expand Medicaid in the future, there would be a drastic increase in demand for reimbursable services. Thus, regardless of the state of Medicaid expansion, there will likely be a growing need for LHDs to provide direct services. Agencies could also make care more accessible by contracting with local healthcare providers to supply low-‐cost or free services through clinics at LHDs. In addition, the shortage of dentists and behavioral health providers and the increasing demand for services by low to moderate income and immigrant populations suggest a continuing and probably growing need for direct provision of dental and behavioral health services by some local health departments.3

The expanded ACA coverage for USPSTF recommended preventive services, vaccinations endorsed by the Advisory Committee on Immunization Practices, and prevailing preventive care practices for children, in addition to HRSA’s guidelines on preventive women’s health services, suggest a potential “partnering” role for LHDs with community healthcare providers. The ACA provided $11 billion in mandatory funding to FQHCs. LHDs could perhaps capitalize on this influx of funds by contracting with FQHCs and serving as sources of referrals, case managers, or “prevention services navigators.”4 LHDs could also contract with local healthcare providers to supply services through clinics at LHDs.

Coordination of Care

Healthcare providers, third party payers, and governments at all levels are under unprecedented pressure to control healthcare costs and to improve the quality of care. In response they are exploring alternative models of care. Many of the models rely on performance-‐based reimbursement, which compensates outcomes rather than the number of procedures performed.5,6 In other words, keeping a population healthier becomes a more financially rewarding priority than simply attempting to restore health. Chronic diseases are now epidemic and require a long-‐term and multifaceted approach to care that is fundamentally different from the traditional acute care model.7 Both of these changes point to

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the value of prevention to reduce the incidence of disease and the value of disease management to reduce disease complications. They also point to the need for teamwork through which a range of different healthcare and community-‐based providers work together, providing different but coordinated services to individual patients and to populations of patients.1 The traditional role of LHDs in the provision and coordination of population health interventions could be leveraged, with the LHD playing a key role in formally linking prevention, acute care, disease management, and other wrap-‐around services for patients at risk of chronic disease or of chronic disease complications.

The National Strategy for Quality Improvement (NQS) and the Triple Aim model both point to potential roles for local public health agencies as participants/coordinators in improving their community’s health system. These roles include promoting effective patient and family engagement, promoting effective communication and coordination of clinic-‐based and community-‐based care, promoting prevention practices in the clinic and in the community, and creating/improving new healthcare delivery models.

Sustaining Communicable Disease Surveillance and Environmental Health Services

Without local public health agencies, a continuing and critical health “gap” in a community’s health system is communicable disease control, including biohazard and foodborne illness surveillance.1 At present, no other governmental or private organizations or healthcare providers have the capacity or incentive to provide these services. Yet in the context of accountable care, when a community’s baseline health is central to the health system’s performance, communicable disease outbreaks can have a material and relatively immediate impact on a community’s health status. As a result, surveillance is one of the most important roles for LHDs to focus on as they define, communicate and negotiate their larger role as a partner in the community health system. In addition, as noted above, assuring access to and providing immunizations remain core public health services and are another important role for LHDs in the evolving health system.

Environmental health has likewise traditionally fallen under the purview of local health departments. As discussed in the Current Status section, nearly all health departments in North Carolina are providing some type of environmental health service. The most commonly provided services are restaurant/lodging/institutions sanitation and inspections, on-‐site sewage and wastewater disposal, and water sanitation and safety.22 These services, like LHD’s communicable disease services, are essential in protecting a community’s health. Furthermore, new areas of environmental health are developing. Climate change, for instance, is likely to result in more variable and extreme weather patterns over the coming decades, including stronger tropical storms, droughts, and flooding, potentially increasing contamination of wells and stressing septic systems, sewage treatment, and storm sewer systems. The need for environmental health services will clearly be sustained and will likely increase. LHDs can serve as a convener of environmental protection agencies, healthcare providers, and other community agencies to address these issues.

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Promotion, implementation, and evaluation of community-‐based health promotion and disease prevention

Given the epidemic of chronic disease and the population-‐related aspects of healthcare reform, like the Community Health Needs Assessments required of nonprofit hospitals, opportunities for community-‐based health promotion and disease prevention are key for LHDs. Most hospitals and other healthcare providers have limited, if any, capacity to undertake community-‐based assessments and prevention interventions. In contrast, prevention has always been the purview of LHDs, and as the incidence of chronic diseases grows, becoming a major threat to a community’s health, LHDs can be important partners in their community’s health system.8 Indeed, health promotion and disease prevention will be central to an effective health system that provides high-‐quality integrated care at a reasonable cost.

Of course, this role and related opportunities that have emerged from the changing context are multifaceted. As noted earlier, evidence-‐based strategies are available and if LHDs are to be effective and to demonstrate their effectiveness in health promotion, they will need to adopt, adapt and evaluate these EBSs more regularly and systematically than in the past.9 With the rapid adoption of electronic health records, patient information is now becoming available digitally. Infrastructures, standards, and tools are rapidly developing that enable the sharing and aggregation of the data.10 Successful health promotion must leverage these changes in health information technology to precisely target areas of greatest need with the potential for greatest impact. It will also be important for LHDs to assess the efficacy of interventions, refine interventions, add to the body of knowledge on EBSs, and systematically link direct care and prevention efforts.

As mentioned previously, social determinants of health, or the conditions in which people are born, grow, live, work and age, have received increased attention in recent years. It is becoming widely recognized that the most effective strategies address these factors, rather than merely attempting to alter individual behavior. LHDs should consider how social determinants are influencing health in their communities and attempt to address these issues through their health promotion and disease prevention efforts.

Taking a Health in All Policies approach is another means of tackling social determinants of health and health disparities. In order to effectively engage other sectors, health systems will need to be able to reframe matters that have not traditionally fallen under the purview of public health. Health departments will need to demonstrate how policies can maximize health gains while also allowing the target sector to achieve its own goals as well.13 Many health agencies have begun taking this approach, particularly in regards to businesses and worksite wellness. For instance, The Business Case for Breastfeeding, developed by DHHS, educates employers about the benefits of breastfeeding. It emphasizes how providing lactation support and private spaces for breastfeeding employees to express milk results in more satisfied, loyal employees, a reduction in sick time taken to care for sick children, and lower healthcare and insurance costs.23 Child maltreatment and foster care are other potential areas for such work. One key informant discussed the need to work across siloes in these areas given that foster children are at high-‐risk for poor health outcomes. Because they are transient, it is difficult to provide coordinated healthcare services, which puts the child at additional risk. Reframing these issues

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can help health departments build new partnerships, become relevant in new fields, and increase awareness of the value of public health.

LHDS can also pursue HiAP by continuing to take on the traditional LHD role as a “convener” of community prevention partners. In some cases, LHDs will need to strengthen their capacity as conveners, shifting from temporary project-‐based partnerships to enduring partnerships based on sustained prevention interventions and practices. An important example of sustaining partnerships is collaboration between LHDs and their community hospital(s) to address the Community Health Needs Assessment (CHNA) and follow-‐up activities.14 LHDs can provide a range of assessment, planning, and evaluation services based on the needs of their partners and community. The CHNA can be a centerpiece and starting point for a range of partnerships with the hospital and other community health system agencies in the design and implementation of coordinated care services “beyond the clinic.” Thus LHD promotion and prevention roles should dovetail closely with the coordination of care services noted earlier. In taking on a more prominent role as convener, LHDs can ensure that all entities pursuing improved health outcomes complement each other’s efforts. Resources can be more effectively aggregated and duplication of efforts can be avoided.

Rarely have there been greater opportunities for LHDs to effectively partner with others interested in their community’s health. As noted above, hospitals and other healthcare providers are increasingly aware of the importance of population health solutions in their efforts to enhance the quality of care and constrain healthcare costs.15 Also, third party payers recognize the major role that the epidemic of chronic disease is playing in driving up healthcare costs. Increasingly, businesses understand the impact that widespread obesity and chronic disease have on a community’s attractiveness for investment, and both businesses and schools recognize the impact of chronic diseases on day-‐to-‐day performance and absenteeism.16 In other words, effective collaborative prevention strategies which demonstrate value are recognized as a win-‐win for all partners today.

As an aside, web conferencing and social networking technologies are now available that will enhance the LHD’s role as a convener. These technologies will enhance the productivity and effectiveness of practitioners by promoting regular and inexpensive communications with prevention partners, with individuals in the community, and with the community overall.

Enhancing capacity through resource sharing, leveraging technology, and the provision, evaluation, and communication of value to health system partners and other key stakeholders

As noted in the Contextual Changes section, many NC local health departments are continuing to experience funding cuts (local, state, and federal budget cuts that ironically stem from increasing healthcare costs).17 They are also subject to the same grants-‐oriented funding model for prevention interventions, potentially limiting their capacity to dovetail their interventions with their community’s public health priorities, and placing constraints on their ability to hire, retain, and develop health promotion professionals. The prevention-‐oriented funds that are currently available also face the prospect of being diverted or cut altogether.12 Finally, as many of North Carolina’s LHDs struggle to sustain traditional public health services, they must also adapt to the requirements of their changing

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health system. Given that the need to expand services and related capacity is occurring when funding is being cut at all levels of government, LHDs must pursue alternative, sustained funding sources and resource sharing strategies.

This is particularly imperative for LHDs that serve smaller populations and have correspondingly fewer resources upon which to draw. Local health departments, especially those serving small or rural populations, face low revenues and inefficiencies.18 A systematic review of studies examining the structures of health departments found that those serving larger populations had greater capacity to provide the Ten Essential Public Health Services.19 However, smaller LHDs can partner with other local health agencies through cross-‐jurisdictional sharing. These partnerships can result in economies of scale and enhance the capacity of participating LHDs.

Webinar and social networking tools are now economically available. These tools are expressly designed to facilitate discussion, share and store information of common interest, and form virtual communities. LHDs can leverage these in any collaboration, but they especially make geographically dispersed regional collaborations much more feasible, fostering regular, economical communications.

Rarely has there been a greater need for LHDs to collaborate with other agencies and community partners. The recognition that “pushing prevention upstream” (e.g., through policy change) provides the biggest bang for the prevention buck only increases the need for effective, ongoing cross-‐agency collaboration.20 At a time when health departments are facing budget and programmatic cuts, agencies need to carefully consider where to invest limited resources. Given these circumstances, it is important to keep in mind that policy is an area where public health has the potential to make big gains and reach entire populations.

In addition, the pressure to constrain costs and to improve quality by healthcare providers, payers, and the government has led to a laser-‐like focus on outcomes and the impact of those outcomes on the bottom line. All players expect a worthwhile return on investment.20 For LHDs, this means that if they are to participate as valued and compensated partners in their health system, they must 1) track the outcomes of their population-‐based interventions and clinical services, 2) effectively target and prioritize their public health interventions, and 3) regularly pursue data-‐driven quality improvement activities.

Finally, telehealth tools now make possible a large number of diagnostic and treatment services from a distance, and most of these tools have become much more economical. As clinical providers, LHDs can leverage these tools to enhance their provider capacity and productivity. Particularly in smaller, rural health departments where recruitment and retention of providers are a challenge, leveraging these tools can enable access to providers and provision of a range of primary care and specialty services to their community (e.g., disease management for chronic diseases, telepsychiatry, trauma and disease related consultations). In addition, providers can regularly “visit” home health, disabled, and physically inaccessible patients. In some cases, not only will this access enhance provider productivity and related clinical capacity for the local health department, but it may also bring a competitive advantage for those LHDs that require clinical receipts to sustain clinical and population-‐based services. As public health

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practitioners, LHDs can promote the adoption of telehealth tools by community healthcare providers to enhance their population’s access and in so doing, reduce rural/urban, racial, and income disparities.21

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References

1. Institute of Medicine (US). Primary care and public health: Exploring integration to improve population health. Washington, DC: The National Academies Press. 2012. 2. Fitzsimon, C. Medicaid, unrealistic budget cuts, and denying healthcare to 500,000. February 19, 2013. Available at: http://www.ncpolicywatch.com/2013/02/19/medicaid-‐unrealistic-‐budget-‐cuts-‐and-‐denying-‐health-‐care-‐to-‐500000/. 3. Kaiser Commission on Medicaid and the Uninsured. Community health centers: The challenge of growing to meet the need for primary care in medically underserved communities. March 2012. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/03/8098-‐03_es.pdf.

4. National Association of City and County Health Officials. Implementation of the Patient Protection and Affordable Care Act. June 2011. Available at: http://www.naccho.org/advocacy/healthreform/upload/ACA-‐white-‐paper-‐final.pdf. Accessed October 9, 2012. 5. U.S. Department of Health & Human Services. 2012 Annual Progress Report to Congress. National Strategy for Quality Improvement in Health Care. April 2012. 6. McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Affairs. 2010; 29(5): 982-‐990.


8. National Association of County and City Health Officials. Statement of policy: Role of local health departments in community health needs assessments. March 2012. Available at: http://www.naccho.org/advocacy/positions/upload/12-‐05-‐Role-‐of-‐LHDs-‐in-‐CHNA.pdf. Accessed October 21, 2012.


10. North Carolina Healthcare Information & Communications Alliance, Inc. Available at: http://www.nchica.org/GetInvolved/NCHIE/intro.htm. Accessed September 29, 2012. 11. World Health Organization. Social determinants of health. 2012. Available at: http://www.who.int/social_determinants/en/. Accessed September 25, 2012


13. Kahlmeier S, Racioppi F, Cavill N, Rutter H, Oja P. " Health in all policies" in practice: Guidance and tools to quantifying the health effects of cycling and walking. Journal of physical activity & health. 2010;7(1):120.

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14. American Public Health Association. Maximizing the community health impact of community health needs assessments conducted by tax-‐exempt hospitals. Marcy 13, 2012. Available at: http://www.naccho.org/advocacy/upload/CHNA-‐Consensus-‐0313-‐12-‐FINAL.pdf.

15. McDonnell S, Bryant C, Harris J, Campbell MK, Lobb A, Hannon PA, Cross JH, Gray B. The private partners of public health” Public-‐private alliances for public good. Preventing Chronic Disease : Public Health Research, Practice, and Policy. 2009; 6(2): 1-‐8. 16. Partnership to Fight Chronic Disease. The burden of chronic disease on business and U.S. competitiveness. 2009. Available at: http://www.prevent.org/data/files/News/pfcdalmanac_excerpt.pdf. 17. National Association of County and City Health Officials. Local Health Department Job Losses and Program Cuts: State-‐Level Tables from January/February 2012 Survey. April 2012. Available at: http://www.naccho.org/topics/infrastructure/lhdbudget/upload/State-‐level-‐tables-‐Final.pdf.

18. Libbey P. Cross Jurisdictional Sharing of Services and Resources [PowerPoint slides]. May 23, 2012. Available at: http://nnphi.org/CMSuploads/Libby%20-‐NNPHI%20May%202012.pdf.

19. Hyde JK, Shortell SM. The structure and organization of local and state public health agencies in the U.S. Am J of Prev Med. 2012; 42(5-‐1):S29-‐S41.

20. National Business Coalition on Health. Community health partnerships: Tools and information for development and support. Available from http://www.nbch.org/NBCH/files/ccLibraryFiles/Filename/000000000353/Community_Health_Partnerships_tools.pdf.

21. North Carolina Institute of Medicine. Examining the impact of the Patient Protection and Affordable Care Act in North Carolina. May 2012. Available at: http://www.nciom.org/wp-‐content/uploads/2012/05/Full-‐Report-‐Online-‐Pending.pdf. Accessed October 23, 2012.

22. North Carolina Department of Health and Human Services Division of Public Health. State Center for Health Statistics. Local Health Department Staffing and Services Summary: Fiscal Year 2011. January 2012. Available at: http://www.schs.state.nc.us/schs/data/lhd/2011/FacStaff.pdf.

23. US DHHS. The business case for breastfeeding. 2008. Available at: http://www.womenshealth.gov/breastfeeding/government-‐in-‐action/business-‐case-‐for-‐breastfeeding/business-‐case-‐for-‐breastfeeding-‐for-‐business-‐managers.pdf.

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V. Recommendations

Changes in the context of local public health, ranging from the adoption of pay-‐for-‐performance reimbursement models to extensive and growing investments in health information technology, all point to a different world in which North Carolina’s LHDs must operate. If LHDs are to continue in and expand on their traditional roles, they must proactively recognize and respond to these differences. Further, Task Force members and key informants interviewed in this project repeatedly emphasized that local health departments must build on their traditional strengths as they craft their roles in this changing world in general and in their evolving community health system in particular.

The recommendations below are presented as inter-‐related options in no particular order. In other words, depending on the particular circumstances of a LHD, its leadership may choose to prioritize and pursue a subset of the options below. No one particular option is recommended above the others. While presented as separate options, both the overarching initiatives and the more specific recommendations are frequently inter-‐related such that the success of one may be dependent on the effective execution of another. In addition, the LHD leadership should play a central role in spearheading many of these initiatives if they are to succeed. LHDs may find that there is a need for workforce development in order to adequately approach these options. Local health directors should provide guidance and oversight, while identifying and providing access to resources and technical assistance when necessary. Some resources can be found in the Next Steps section, along with suggested areas for professional development and a list of agencies that may be able to provide training in those areas.

Finally, we also present a number of ongoing examples intended to demonstrate how these initiatives might in fact be undertaken. These are only a sampling of a significant innovative activities going on in LHDs throughout North Carolina and elsewhere.

Option 1: Take a leadership role in the promotion, implementation, and evaluation of community-‐based health promotion and disease prevention.

Opportunities related to community-‐based health promotion and disease prevention are key for LHDs. Most hospitals and other healthcare providers have limited, if any, capacity to undertake community-‐based assessments and prevention interventions. In contrast, prevention has always been the purview of LHDs. As the incidence of chronic disease has grown, becoming a major threat to a community’s health, LHDs can be crucial partners in their community’s health system. Health promotion and disease prevention are central to an effective health system that provides high-‐quality integrated care at a reasonable cost. This role is the “sweet spot” for LHDs.

Ø Collaborate with area nonprofit hospitals to develop CHNAs and CHIPs, implement evidence-‐based strategies, and evaluate interventions. One informant commented that “LHDs have been doing [assessments] for so long…[in contrast] it is a large shift for healthcare systems to have to do a CHNA and CHIP.” The ACA provides an important opportunity for LHDs to partner with

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nonprofit hospitals and in so doing, to demonstrate the value of their agency. Given the importance of this opportunity, LHD leadership should be heavily involved in all aspects of the assessment. Leadership engagement will also highlight the importance of this project to LHD staff and indicate LHD commitment to other partners. Finally, this engagement will give LHD leadership a useful window into the actual capacity of the LHD to undertake an assessment and to partner with other community health system stakeholders. The capacity to engage in health planning is essential if LHDs are to establish themselves as leaders in health promotion and disease prevention. Much of this collaborative work will be new to hospitals and LHDs, particularly the follow-‐on steps of Community Health Improvement Planning, the implementation and management of action plans, the use of quality improvement methods, and the evaluation of interventions. Although many skilled public health professionals have a clear understanding of the deliverables and tasks associated with these follow-‐up phases, the collaboration will in a sense be an exploration as the partners sort out their roles and responsibilities. To assure that the overall process is successful and leads to effective and appreciative partners, LHDs need to anticipate their potential roles and the capacity required to effectively undertake these roles. Again, this points to the need for leadership engagement and the assignment of talented staff to the collaboration. This role represents a key opportunity to become the ongoing “convener” for community health-‐related issues and initiatives in the LHD’s community health system. Ongoing relationships built on trust and mutual respect with community partners and hospitals are essential if LHDs are to take a leadership role in community-‐based health promotion and disease prevention efforts.

Ø Become the community health system’s resource of evidence-‐based best practices. In the Opportunities section, we observed that evidence-‐based strategies are available and have been proven effective. If LHDs are to be effective as leaders in community health promotion and prevention activities, they will need to adopt, adapt, and evaluate these EBSs. There are many steps associated with the effective application of EBSs, including the identification of priority public health issues, selection of a preferred EBS, adaptation and resourcing of the EBS, maintenance of fidelity while accommodating contextual idiosyncrasies, and assessment and revision of the EBS based on evaluation. Thus, the competencies associated with effective adoption of EBSs are varied and sophisticated. Fortunately, in collaboration with the Division of Public Health, the Center for Healthy North Carolina has been tasked with providing training and technical assistance to help LHDs develop the capacity to effectively adopt EBSs in their communities.29 The NC Institute for Public Health and the CDC’s Prevention Research Centers may offer additional training resources.

Ø Become the community health system’s resource for population health interventions outcomes evaluation. In the Contextual Changes section, we noted that digital patient information is now being collected by the majority of healthcare providers, and this information is increasingly being shared, aggregated, and analyzed.22 Successful health promotion will leverage this information to precisely target the areas of greatest need with the potential for greatest impact. The information will also enable LHDs to assess the efficacy of interventions, refine

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interventions, add to the EBS body of knowledge, and systematically link healthcare and prevention outcomes, demonstrating the bottom line value of prevention.

Of course, building an informatics capacity is at the heart of this role for LHDs. Being the health system evaluation resource is an informatics application that requires particular expertise, and it is one upon which LHDs should focus when considering their workforce development priorities.

Option 2: Play an integral role in the reform of your community’s health system.

Identifying the role that local health departments will play in Accountable Care Organizations and Patient Centered Medical Homes will be particularly critical in the coming years. One informant said, “If you are not in the vein of PCMH, you are going to get left out of the loop.” While interviewees noted that the shift to outcomes-‐based compensation should theoretically drive healthcare providers to work with LHDs, they also expressed concern that health systems would not consider what LHDs bring to the table. One said, “I don’t think ACOs are going to think about including LHDs in their organizations. LHDs need to have data to help them make their case for inclusion.” Given these circumstances, LHDs need to be proactive about claiming a role and reaching out to providers. LHDs have expertise in community engagement, controlling communicable diseases, and population health promotion and disease prevention. Therefore, local health departments should embrace opportunities related to coordination of care and integration of health services and prevention activities in the clinic and the community.1,2

Ø Collaboratively identify clinical services that your LHD will provide directly. As suggested in the Opportunities section, in many counties there is a continuing need for the direct provision of clinical services by the LHD. Some clinical services will vary by county. Others, like behavioral health, appear to be an important need in most counties. When contemplating the actual

Box 5-‐1. WNC HealthyImpact

An example of the prevention and promotion role for LHDs is WNC HealthyImpact, a “partnership between hospitals and health departments in Western North Carolina to improve community health.“ A regional partnership that includes 16 Western North Carolina health departments and 16 hospitals, WNC HealthyImpact makes the most of the region’s resources, enhancing the capacity of many individual participant organizations and standardizing collection and measurement tools to prioritize and target interventions, plan and implement interventions, and evaluate intervention outcomes. The partnership is organized around a project steering committee that includes representatives from the member organizations, workgroups composed of hospital and health department staff, and selected consultants and data collection experts. WNC HealthyImpact has developed standard community health assessment protocols and measures and they have completed their first data collection and assessment activities. They are currently prioritizing local and regional health needs, and will begin planning related interventions shortly.

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provision of services, the question is, “Is there a gap?” LHDs and other community healthcare professionals should consider not only gaps where certain services may not exist at all, but where the demand for services (possibly by particular sub-‐populations) is greater than the supply. Further, both actual and perceived gaps are important. As a potential partner in the evolving health system, understanding that a gap(s) exists and being able to effectively communicate the degree and nature of the gap, the agency’s potential role, and the rationale for having the agency provide these clinical services will be key to selecting the services to provide and negotiating roles with potential partners. Identifying, undertaking and sustaining new clinical services and expanding existing services will require ongoing collaborations with other community providers.

Several key informants in this project noted that provision of clinical services is not in the purview of local public health. Some LHDs may therefore choose not to provide these services or to provide them only under the most challenging circumstances. Others, however, may choose to provide the services because this is the only way to assure access to care. In addition, clinical services may generate surplus funds from service fees to support other more traditional public health services (see Box 5-‐2.)

Oral health was frequently mentioned as a severe deficit throughout the state and some informants suggested that provision of dental services might be a means of earning surplus revenue. Similarly, the gap in available pediatric care has potential to create a surplus given the fact that most children have North Carolina Health Choice or Medicaid coverage. Shortages in behavioral health, gerontology, and senior psychiatric services were also noted.

Ø More systematically integrate the goals/priorities, tasks, and staff of LHDs and those of community primary care providers and hospitals. In 2010, the IOM formed a Committee on Integrating Primary Care and Public Health to explore how these two sectors could complement each other and align their resources to improve population health. The 17-‐member committee

Box 5-‐2. Primary Care in Craven County

The Craven County Health Department initiated an Adult Primary Care program at the urging of Carolina East Medical Center, Craven County’s community hospital, and Community Care of Eastern North Carolina. The hospital was seeing many non-‐emergent cases in its ER and needed a provider for referrals. In addition, the Craven County DSS had a large number of adult Medicaid patients who required a referral provider. Thus, the Craven County Health Department now works with local physicians, the hospital, and East Carolina University’s Brody School of Medicine to provide a comprehensive system of care for these patients, with care paths for diabetes, hypertension, etc. The hospital says that they have already seen a marked improvement in the use of their ER services and now are planning to expand the program with an additional provider.

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prepared a report titled Primary Care and Public Health: Exploring Integration to Improve Population Health.2 Based on a review of past integration efforts, the Committee developed a set of principles they believed to be essential for successful integration of primary care and public health. These include:2

• A shared goal in population health improvement. • Community engagement in defining and addressing population health needs. • Aligned leadership that:

o Bridges disciplines, programs, and jurisdictions to reduce fragmentation and foster continuity,

o Clarifies roles and ensures accountability, o Develops and supports appropriate incentives, o Has the capacity to manage change.

• Sustainability achieved though establishment of shared infrastructure and building for enduring value and impact.

• Sharing and collaborative use of data and analyses.

Presently, primary care and public health operate largely independently, with complementary functions. By working together more closely, they can achieve their own goals while also having a greater impact on the health of populations compared to working independently. In a sense, direct provision of clinical services is an integrative activity in the larger community health system as LHDs cover “gaps” not being addressed by other primary care providers. However, true integration occurs only when LHDs and/or their partners identify “gaps” in existing services and then partner to address these gaps. Such partnering may include the alignment of organizational goals/priorities and associated strategies (e.g. effectively preventing and managing chronic diseases), assignment of complementary tasks or procedures for the participating LHD and its partners (e.g. LHD staff enroll patients at risk of diabetes in community-‐based health promotion programs, promote and track the patient’s participation, and formally communicate patient participation and progress to the patient’s primary care physician), and perhaps sharing of staff (e.g., contract providers from the local hospital provide services in the local health department.) Primary care providers who expand their provision of preventive healthcare services under the Affordable Care Act might rely on their LHD to act as a source of referrals, case managers, or “prevention services navigators.” Public health agencies could also contract with local healthcare providers to supply services through clinics at LHDs (See Box 5-‐3). To encourage a more strategic approach to enhanced integration, LHDs should continue their leadership role in community health assessments and community health improvement planning.

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Community health improvement planning involves a long-‐term systematic effort to address public health problems on the basis of community health assessment activities and the community health improvement process. The plan should define the vision for the health of the community through a collaborative process, should address strengths, weaknesses, challenges and opportunities that exist to improve the health status of the community, and should incorporate evidence-‐based strategies.3

Ø Explore and become expert in outcomes-‐based reimbursement models and play a leadership role

in planning discussions. Examples of these outcomes-‐based models include CMS’s Pioneer ACO, a Medicare Shared Savings Program, Patient Centered Medical Homes, a risk-‐bearing provider or a health plan collaborating with providers in risk-‐bearing contracts.4,5 As noted in the Opportunities section, chronic disease is now epidemic and requires a long-‐term and multifaceted approach to care that is fundamentally different from the traditional acute care model.6 The widespread presence of chronic diseases points to the value of health promotion and disease prevention to reduce the incidence of disease and to the value of disease management to reduce disease complications. This approach requires teamwork in which a range of different healthcare and community-‐based providers work together, providing different but coordinated services to individual patients and to populations of patients.7 The traditional role of LHDs in the provision and coordination of population health interventions could be leveraged, with the LHD playing a key role in formally linking prevention, acute care, disease management, and other wrap-‐around services for patients at risk of a chronic disease or of chronic disease complications. Health planning skills are central when exploring outcomes-‐based reimbursement models. Health systems partners need to understand the community priorities in order to determine which models will meet the community’s needs, convene the appropriate partners, and implement a well-‐targeted course of action. LHDs should not expect other community health system partners to solicit LHD participation in proposed pay-‐for-‐performance partnerships. There are a number of reasons for this, one of which is that potential partners frequently are not aware of the roles that local health departments play or the capacities they bring to the table. If an LHD expects to participate, the

Box 5-‐3. Partnership for Community Care (P4CC) in Guilford County

To decrease hospitalizations for diabetes, hypertension, and asthma, the Guilford County Health Department Family Planning staff refers its patients to a primary care provider for assessment and instructions to manage their chronic illness—before these patients require emergency care or hospitalization. The Family Planning staff also refer their patients to P4CC when patients need nutritional or behavioral health referrals.

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leadership must become conversant in various models, the ways in which partners might be reimbursed, and ways to combine aspects of different models to create a new variation that better fits the needs of the agency’s community. The leadership must also clarify partner roles, including their agency’s role (e.g., to contract with the hospital to provide communicable disease immunization and surveillance services). There was no consensus among informants regarding what the role of LHDs in outcomes-‐based models should look like. The majority, however, recognized the need to identify strengths and be able to communicate how LHDs will contribute. Some potential roles include health planning, community outreach, evaluation, and communicable disease management. In its traditional role as a “convener”, the LHD could initiate and facilitate planning discussions with community health system partners of a “one-‐stop” shop approach to coordinated care. The overall continuum of care would include more traditional clinical acute care services, but in addition, the continuum would include preventive healthcare, disease management, and importantly, community-‐based prevention. With the “one-‐stop” approach, the provision of these services would be seamless and would be independent of the “service door” the patient enters first. LHDs have a strong understanding of their community’s culture and needs, which will be valuable throughout the planning process. One key informant stated: “The area where LHDs have a lot more expertise is surveillance and community connections. They know the community better. They are better at partnering.” Another said: “Public health departments probably know the culture of the communities with the frequent flyer patients better than anyone else.” Cultural competence is key to improving the quality and effectiveness of both clinical care and public health services. In 2003, the IOM recognized cultural competency as one of eight new critical areas that should be addressed in public health professional education.31 By understanding how cultural beliefs and values influence health behavior, professionals are better able to respectfully respond to the needs of diverse communities. Cultural competence results in services that are more patient-‐centered, safer, and more effective at addressing health disparities.32 LHDs should leverage this strength and communicate its importance to health systems partners. Beyond the planning of outcomes-‐based collaborations, LHDs should play a key role in the implementation and ongoing performance evaluation of the model used. The success of an ACO or other outcomes model depends on whether it is able to support providers in achieving meaningful clinical improvements, and requires ongoing learning not only about the effectiveness of different approaches to reorganization, payment and clinical improvement in different markets, but also about how local contextual factors influence the success of different models.8 Most healthcare partners are not currently prepared to undertake any of the collection and analysis required to enable this learning. Thus, LHDs have an opportunity to establish a

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central niche in these organizations, particularly in regard to understanding the importance of contextual community factors on performance. As noted in the Background section, virtually all of NC’s Local Health Departments provide almost all of the Communicable Disease Control Services and “protective” environmental health services (e.g., inspections and permitting.)9 In this communicable and foodborne disease “protection” role, LHDs are effectively the “risk manager” for their pay for performance healthcare organization. In other words, should a communicable or foodborne disease outbreak occur (e.g., a flu outbreak), the baseline health status of a community can experience a material (though hopefully temporary) hit which leads to a spike in the cost of care and a related reduction in savings and reimbursement. As the risk managers and disease surveillance experts, LHDs prevent outbreaks by assuring timely, targeted immunizations or inspections, identify outbreaks, and respond quickly to limit the impact of outbreaks with targeted vaccinations, health education, and the enforcement of rules such as quarantine or closing contaminated establishments. An important emerging issue is the spread of antibiotic resistant bacteria. LHDs could play an important role in the promotion of appropriate use of antibiotics, surveillance of the spread of resistant bacteria, and outbreak response. In the pay-‐for-‐performance environment, the “risk management” capacity of local health departments needs to be evaluated and, where necessary, enhanced. In addition, research that closely maps the ROI associated with these communicable disease control activities must be conducted and communicated. The development of outcomes-‐based models of care is still in process. Questions about the size of ACOs, who will act as the managing authority, what the population-‐base will look like, and so on, remain. Each of these factors will affect the role of public health and how health departments become involved. It is important that LHDs be aware of these developments.

Box 5-‐4. Disease Surveillance in Guilford County

The Guilford County Health Department observed an unusually high incidence of infectious diseases in several of its older long-‐term care facilities. In addition, it was noted that while an institutional ordinance requires hand wash facilities in or near each patient room, older facilities are exempt from this ordinance. In response the health department’s Environmental Health Program staff educated the administration and caregivers in these facilities on the importance of hand washing and general sanitation. All of these older facilities have now instituted a hand wash hygiene program and some have added additional hand wash stations. The Environmental Health Program staff have also developed and distributed an Infectious Control Measures fact sheet to help long term care facilities slow or stop the transmission of communicable diarrheal illnesses. These disease surveillance and response activities are examples of cost-‐effective interventions that can have a material impact on patient outcomes and ACO performance.

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Option 3: Develop foundational capacity to sustain core public health services and to embrace emerging opportunities

As noted in the Contextual Changes section, the economic downturn has resulted in local and state funding cuts that have raised concern in local public health agencies about their ability to provide the services their area needs. TFAH reports that 29 states decreased their public health budgets from FY 2010-‐2011 to FY 2011-‐2012. In 23 states, this was the second consecutive year of cuts.10 In a nationwide NACCHO survey of local health departments, 71% of LHDs surveyed in North Carolina reported losing staff through layoffs or attrition and 75% reported making cuts to at least one program.11 Task Force members in this project recognized that resources and sustainable funding are critical to further the mission of local public health.

With the future of public health funding uncertain, however, it is critical that local health departments enhance their capacity to secure funding.

Ø Explore the cross-‐jurisdictional sharing of foundational functions. Many LHDs, particularly smaller, rural LHDs, are struggling to sustain existing services, and find it impossible to expand services and capacity. For these health departments, cross-‐jurisdictional sharing may be a means of meeting the community’s needs. In the Contextual Changes section, we noted that a systematic review of studies of health department structures found that those serving larger populations had greater capacity to provide the Ten Essential Public Health Services. This finding

Box 5-‐5. Southeastern Diabetes Initiative (SEDI)

The Southeastern Diabetes initiative (SEDI) is an example of the “one-‐stop” shop approach and an example of integration of healthcare providers with a LHD as a community prevention leader. In SEDI, a county-‐based collaboration that tightly couples community-‐based prevention, acute care, and disease management, the Cabarrus Health Alliance and the Durham County Department of Public Health have teamed up with Duke University and the University of Michigan to undertake county-‐based programs. The programs address the Triple Aim priorities of improved population health and healthcare quality, and lower healthcare costs, by reducing the incidence of and complications associated with Type 2 Diabetes. It is a “one-‐stop-‐shop” program that leverages resources at clinical, community, and systems levels. SEDI is federally funded through the CMS Innovations Center. Led by a coalition of community partners like local health centers, hospitals, other healthcare and governmental agency providers, citizens, and local nonprofits, the SEDI projects in Cabarrus and Durham counties are 1) leveraging GIS systems to map neighborhoods and individuals with Type 2 Diabetes to identify concentrations of individuals at high risk for Type 2 Diabetes and related complications; 2) taking inventory of gaps in healthcare and other community resources associated with appropriate utilization of clinical care, screening for diabetes, and diabetes self-‐management, and; 3) designing and implementing a coordinated care model that relies on all the relevant community resources to address the diabetes related needs of high-‐risk neighborhoods.

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is particularly notable given that 64% of local health departments nationwide serve a population less than 50,000.12 Partnering with other local health agencies, or cross-‐jurisdictional sharing, can result in economies of scale and enhance the reach of health services with existing resources.

Merging or consolidation is not necessarily the only or best option for cross-‐jurisdictional sharing. Rather, cross-‐jurisdictional sharing can involve a variety of organizational structures. Collaborative relationships may vary based on the relative formality of the relationship, the nature of what is being shared (e.g., purchase of a service, shared capacity, etc.), the duration and timing of the relationship, the degree of financial commitment, and the mode of governance.13 In addition, the roles of the participants may vary. For example, one LHD with a particular strength (e.g., grant writing, informatics) could contract services to other partner agencies.

Agencies that are interested in pursuing some form of shared services should engage in an in depth planning process, beginning with a meeting of partners where the demographics of the community, operating budgets, staffing and governance structures, and current strengths and challenges are discussed openly. Throughout the planning process, partners should clearly define their goals and measures of success. More specifically, it is essential to:14,15

• Conduct assessment of the health department’s strengths and weaknesses in regards to the provision of essential services, perhaps leveraging the assessment work already done through the North Carolina Local Health Department Accreditation program.

• Convene potential partners and key stakeholders, including members of Boards of Health, Health Directors, town administrators, Mayors, City Councils, local health facilities, and hospitals and other partnering health departments.

• Analyze partners’ strengths and weaknesses in order to decide on an appropriate sharing model.

• Evaluate outcomes of shared service arrangements.

To explore options related to cross-‐jurisdictional sharing, LHDs will benefit from the capacity to engage in health planning, identify common priorities and develop shared solutions.

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Box 5-‐6. Public Health Incubators in North Carolina

The NC Public Health Incubator Collaboratives (PHICs) are teams of local health departments voluntarily working together to address pressing local public health issues using innovative approaches. Six NC PHICs (Western, Northwest, Central, South Central, Southern Piedmont, and Northeastern) have been formed across the state. The purpose of the Incubator Collaboratives program is to foster innovation and to broaden resource sharing across rural areas of the state. Incubators enable both local autonomy and the sharing of resources and ideas, such that health departments can focus on local community health needs while benefiting from regional public health initiatives. Over the nine years of its existence, the Incubator program has secured over $20m in funding and also used cost savings to enhance LHD capacity (e.g., Quality Improvement training and initiatives, environmental health automation, BOH trainings, Broadband Networking) and to introduce promotion and prevention programs (e.g., Teen Tobacco Cessation, Diabetes Umbrella Program, Heart Disease and Stroke) around the state.

Box 5-‐8. Shared Staffing by Scotland County Health Department

Scotland County Health Department has provided staff for nearby local health departments and a Local Community Health Center. They have contracted an Environmental Health Specialist to Richmond County to conduct food and lodging inspections. Scotland also provided two Enhanced-‐Role RN’s to help cover Hoke County Health Department’s STD clinics. Finally, the LHD has a standing contract with the Scotland Community Health Center to provide a Physician Assistant PRN. Cross-‐jurisdictional sharing is working well in Scotland and provides additional revenue streams for the health department in a county challenged with shrinking local dollars.

Box 5-‐7. Project Smile in Cabarrus and Guilford Counties

The Cabarrus Health Alliance and the Guilford County Health Department received funding from the Kansas Health Institute’s Center for Public Health Sharing to pursue a joint dental program. The project will involve an assessment of each program to identify options for collaboration. The potential of sharing staff and resources will be explored and an action plan for implementation of the selected sharing model will be developed. The joint program would serve a population of over 670,000.30

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Ø Secure grant scanning and grant making capacity. In the Contextual Changes section, we described the Prevention and Public Health Fund (PPHF), a landmark investment of $18.75 billion from 2010 to 2022. The Fund has already been cut by $6.5 billion and pressure to reduce the federal deficit is likely to result in additional Congressional proposals to cut or divert the Fund.16,17 Even so, some funding will in all likelihood be available, and most of the funds will be “grants-‐based”. Generally, smaller LHDs, districts, and authorities rely extensively on grant funding to support a number of programs, particularly their prevention work. If LHDs intend to build and leverage their prevention capacity as they work with other health system partners, they must secure necessary funding, and grant making is, of course, essential. LHDs must improve their ability to identify appropriate grant opportunities and write compelling grant proposals. To secure funding, particularly for smaller, rural agencies, grant making is one the promising potential services that might be secured through cross-‐jurisdictional sharing. Grant making prioritization and grant making for interventions that cross county lines are issues that would need to be resolved, but many of North Carolina’s health departments have extensive experience in resolving these issue as members of the Incubator Collaboratives. In addition, some LHDs pay for grant writers by splitting their duties, partly working as grant writers and partly as project managers or staff on projects funded through their grant writing.

Ø Provide fee-‐based services. As mentioned above, direct provision of reimbursed clinical/dental services (e.g., pediatric dental, behavioral health, primary care, pediatric care, home health) is an alternative that many of North Carolina’s local health departments have relied upon for many years. At the same time, other providers are offering competitive services so that there is no longer a “gap” in services, and payer reimbursements, particularly Medicaid, have been cut substantially. Nonetheless, with the right patient and service mix, fee-‐for-‐service can be an important funding source.

Worksite wellness programs are another fee-‐based option. Increasingly, government agencies and businesses are appreciating how wellness initiatives improve employees’ performance, decrease absenteeism, and reduce health insurance costs. For example, Safeway provides an array of wellness programs to its employees, including discounts at fitness centers and a fitness center and onsite nurse at its corporate campus. In 2011, over 5,000 employees participated in the Safeway JumpStart Challenge and lost nearly 19,000 pounds.18 Many LHDs have experience in the provision of these programs, and they can leverage their experience to undertake more programs going forward. However, many of these programs have depended on grant funding. New fee-‐for-‐service arrangements will require the capacity to contract, collect fees, and conduct ongoing evaluations to demonstrate value. In some cases, LHDs will need to arrange for insurance reimbursement.

Ø Leverage telehealth tools. Economical telehealth tools are proliferating and LHDs can leverage these tools to enhance their healthcare capacity and productivity. Particularly for smaller, rural

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health departments where recruitment and retention of providers are a challenge, leveraging these tools can enable access to providers and provision of a range of primary care and specialty services to their community (e.g., disease management for chronic diseases, telepsychiatry, trauma and disease related consultations). In addition, through telehealth, providers can regularly “visit” homebound, disabled, and physically inaccessible patients. Not only does this access enhance provider productivity and clinical capacity for the local health department, but it may also represent a competitive advantage for those LHDs that require clinical receipts to sustain clinical and population-‐based services.19 Important telehealth applications that have seen significant growth in North Carolina include home monitoring to foster disease management compliance, and telepsychiatry programs to increase the availability of mental health services in rural communities.

Medicaid is reimbursing telepsychiatry and some pediatric care, but there are also other options. Telehealth applications are frequently sourced through grants. In addition, health plans, individuals, and employers may be interested in funding telehealth services (See Box 5-‐9). “Health plans might be willing to pay to help their members stay healthy and avoid unnecessary hospital visits, patients themselves might be willing to pay if it helps them avoid much more expensive healthcare encounters down the road, and employers – both large and small – might be willing to pay to ensure their workforce is healthy and productive and isn’t taking time off from work to visit the doctor or nurse for a cold…the development of accountable care organizations (there are some 150 proposals before the Centers for Medicare & Medicaid Services) will spur telemedicine because they require payers and providers to assume a portion of the risk in preventing avoidable health problems.”20

Ø Explore collaborations with other human service agencies. In the Contextual Changes section we

reported that institutions, such as the Robert Wood Johnson Foundation and the CDC are encouraging the use of policy interventions to impact social determinants of health (i.e., conditions in which people are born, grow, live, work and age.)21 In general, evidence suggests

Box 5-‐9. Telemedicine in the Hyde County Health Department

Like a number of northeast North Carolina counties, Hyde County has a limited number of healthcare providers and a significant number of dispersed, low-‐income citizens. The Health Department itself faces ongoing challenges in its efforts to recruit and retain providers. With support from the Office of Rural Health and the Kate B. Reynolds Foundation, the Hyde County Health Department has adopted video conferencing technology for its main site in Swan Quarter and for the Engelhard Medical Center in Engelhard. This technology provides two-‐way high-‐definition audio and video connections in real time to primary care providers in a comprehensive medical clinic in Jacksonville, North Carolina. It is expected that the technology will enhance access to care, improve the quality of care, reduce costs to the patient (e.g. travel costs), and enhance the capacity of the LHD.

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that policy change gives the biggest bang for the prevention buck. To undertake the HiAP approach requires close collaboration with other agencies, and collective efforts leverage the resources of all, hopefully with synergistic effect (See Box 5-‐10 and Box 5-‐11).2 A key informant stated: “We need to say goodbye to some of our old models. There’s not much room for working in a silo anymore. You have to work in an integrated fashion.”

Ø Identify new sources of revenue for health investment. Certain sectors make routine investments in community development. For instance, nonprofit hospitals are required to contribute to community benefit to be exempt from paying federal income tax. Non-‐health sectors also make contributions. Many community banks consider and attempt to address the needs of local families. LHDs should reach out to local organizations that regularly make investments in

Box 5-‐10. Health in All Policies in Wake County

The Wake County Division of Health and Clinics in Wake County Human Services engages with partner agencies to develop coordinated plans and interventions. For instance, the Division of Health and Clinics leads the agency’s obesity initiative but relies on other divisions to access certain populations and provide specific services (e.g., make EBT cards available, access foster kids). Another example is the “middle class express” program which helps low-‐income Wake County residents progress toward economic and social self-‐sufficiency. Participants engage in a Life Coaching and Planning program, and receive support from public health representatives who provide Healthy Lifestyles counseling.

Box 5-‐11. Active Living By Design

Founded in 2001 by the Robert Wood Johnson Foundation, Active Living By Design (ALBD) works with communities across the country to build environments where physical activity and healthy eating are accessible to all. ALBD engages diverse community stakeholders to pursue solutions at multiple levels. Projects address individual as well as interpersonal factors, environmental determinants, and public policy.33 In Lake Worth, Greenacres, and Palm Springs, Florida, the ALBD project is Healthy Kids, Healthy Communities (HKHC). HKHC began by planting community gardens at schools. Students learned how to cook with the produce at school and were allowed to bring produce home. HKHC is also working with schools, private businesses, and the faith community to develop joint use agreements that would increase accessibility to open, outdoor areas. Partnerships with law enforcement have been important in these strategies. One school was able to use funds from Florida’s Law Enforcement Trust Fund to build a fence around a joint use walking trail. HKHC has also developed relationships with neighborhood associations to increase trust and awareness among community members.34

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nonprofits or other charitable efforts. Educating these entities about the value of public health and how improving health will enhance their business may lead to new, sustainable sources of revenue.

Option 4: Become a community health system expert in clinical and population health data collection and analysis, including ROI analysis. Leverage these skills to demonstrate the value of public health.

In order to successfully collaborate with community partners, LHDs must become an integral partner in outcomes-‐based collaborations, advocate for continued and sustainable funding, and enhance their ability to demonstrate and communicate success with external stakeholders. Key informants and Task Force members emphasized the need to select outcome metrics, meet those metrics, and report results with an eye to the financial return on investment of public health services. Throughout key informant interviews, the experts indicated that LHDs do not package their ‘sales pitch’ well. Not only must LHDs be able to demonstrate success and return on investment, they must also learn how to communicate their value to others who may not understand public health roles and capacities. Similarly, LHDs may need to improve their understanding of the work of potential partners so as to be able to better articulate how the efforts of both entities are enhanced through collaboration. LHDs must demonstrate how public health benefits the entire population in order to gain the support of policymakers. Developing ongoing relationships before requesting financial or political support is particularly important. One Task Force member reported meeting regularly with hospital administrators to discuss public health concerns, while another served on a quality and community committee for the hospital along with the county commissioner, county manager, and human services representatives.

Ø Adopt and become conversant in available health information technology. As noted in the Contextual Changes section, a majority of healthcare providers are now relying on electronic health records and e-‐prescribing.22 The ability to share, aggregate, and analyze this information has evolved with the development of health information exchanges and the development of dashboards and other analytical tools. For LHDs these tools can be used in several ways. As providers of clinical services, LHDs can collect and analyze patient and workflow data to undertake data-‐driven QI initiatives and enhance operational efficiency in clinics. They can also share patient information with other community healthcare providers and pharmacists to avoid redundant tests and imaging, to coordinate medications, and to assure greater continuity of care, promoting better outcomes and lower costs. As noted in the section on telehealth above, HIT enables health departments to access and leverage the expertise of healthcare providers anywhere in the state and to provide access to patients who for various reasons may not be able to visit the LHD facility.19,20 As a purveyor of traditional public health services, LHDs are able to access the state lab and other disease registries. With HIT, infectious disease reporting will become more timely, and LHDs will have greater access to more timely community health assessment data. Finally new assessment tools and access to patient data will enable LHDs to better target and evaluate community-‐based prevention interventions.

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To leverage HIT to these ends, LHDs should:

• Adopt an electronic health record (EHR)/promote HIS enhancements to enable flexible clinic reporting and analysis. As required in the Meaningful Use Incentive program, EHRs must be meaningfully used if they are to have an impact on care quality and cost. In other words, EHRs should include functionality that allows them to track drug interactions, target panels of high-‐risk patients, track patient adherence to protocols and their progress, easily collect and report clinic quality measures, and readily provide patients with their medical information.23 In addition, practice management tools run the business side of clinics, scheduling patients, submitting claims, and checking patient eligibility. From a decision-‐support/QI perspective, practice management tools should provide a range of queries and reports.24 For example, “lag reports” track the time between a patient’s visit and the time when the clinic is paid. Other reports track patient volume and flow. In general, NC LHDs have common reporting needs. They also have their own reporting requirements (e.g., reporting for federally funded programs), which call for systems to support custom report writing. Most of North Carolina’s LHDs are in the process of securing an EHR solution. The key next step is accessing, analyzing, and distributing the EHR patient and practice management information in a “meaningful” way. In order to achieve Meaningful Use (MU), it will be necessary to be able to share data among providers. Informants emphasized the need for providers to have interoperable systems and metrics. One said: “Different metrics won’t allow LHDs and other providers to work together. There needs to be a common set of indicators.”

• Adopt and advocate for NC Direct with community providers. NC Direct is “a simple, secure, scalable, standards-‐based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet.”25 In other words, NC Direct enables the secure exchange of patient information and other clinical messaging between participating providers. Providers can share such things as lab results, continuity of care documents, and the patient’s healthcare providers.25

• Connect to the NC HIE through the CCNC Informatics Center or the DHHS Qualified

Organization. With its move to CCNC, the NC HIE is now focusing on connecting EHRs for North Carolina’s safety net providers, including local health departments. NC HIE will be a link through which most of North Carolina’s “batch” LHDs will link to other safety net providers, to the state lab, to disease registries, and to the community’s hospitals and primary care providers. Key informants emphasized the need to connect everyone directly into NC HIE.

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• Subscribe to a high-‐speed, reliable broadband network like the North Carolina Telehealth Network (NCTN). With increasing reliance on distributed electronic health records and administrative systems and increasing reliance on information sharing, LHDs must subscribe to a highly reliable, high-‐quality broadband network. Use of the commodity internet or sharing of services with other governmental agencies puts the LHD at risk (e.g., when the network goes down, clinic operations stop, appointments are cancelled, staff are idle). NCTN is a high-‐quality dedicated network on which LHDs qualify for substantial (85%) subscription discounts. NCTN is funded by the Federal Communications Commission (FCC) and will be followed up by a permanent FCC program called Healthcare Connect.26

• Adopt telehealth technologies to expand capacity and extend clinical reach. (See above.)

• Develop Informatics capacity. Informatics capacity refers to the ability to leverage information technologies (e.g., construct databases, develop queries and reports) and apply basic statistics/analyses (e.g., compare payment lag times across years) given a relatively informed understanding of the “business” of public health. This capacity pertains both to internal decision support (e.g. pulling and analyzing data as part of a PDSA quality improvement process) and to external community performance measurement (e.g., changing BMIs associated with selected community prevention interventions) and a community’s public health status.27

Some key informants were skeptical of LHD’s current ability to effectively use data in this manner. One said: “The LHDs are drowning in data, but being parsimonious in selecting that data that is helpful in driving QI and to improve the bottom line is a key issue.” Obviously, building this capacity will require hiring or developing staff with varied, complementary skills. There is currently a shortage of staff with these specific skills, but epidemiologists could redirect their skills relatively easily. In fact, given their traditional role in public health, epidemiologists may represent an important resource that public health agencies can put on the table as they explain the roles they can play in pay-‐for-‐performance organizations. Like grant making, an informatics capacity is a skill that would appear to be a candidate for cross-‐jurisdictional sharing. Given the preoccupation of healthcare leaders and public policymakers with healthcare costs and the “value” provided by partners in the community health system, LHDs must develop informatics capacity that shows ROI. If LHDs cannot develop credible performance measures that track to the bottom line, they will find it difficult to seek reimbursement for their services as a partner in their community health system. The NC Center for Public Health Quality offers training and technical assistance to healthcare

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professionals interested in improving informatics capacity and quality improvement efforts.

Below are three examples of ongoing work in North Carolina that demonstrates the value of HIT.

Box 5-‐13. CCNC Provider Portal

The Gaston County Health Department and other CCNC members have access to the CCNC Provider Portal. The Provider Portal was developed to aggregate and share patient history and pharmacy claims to improve patient care and care coordination for North Carolina Medicaid recipients. The Gaston County Health Department was introduced to the Portal through the Pregnancy Medical Home program. With a transient patient population and patients who moved from one practice to another and frequently visited emergency rooms, testing/labs/imaging results were largely unavailable. This resulted in repeat labs and imaging orders. With the Provider Portal, the Health Department can now review lab and imaging results across providers and has access to general patient history.

Box 5-‐12. NC-‐HIP

The North Carolina Community Health Information Portal (NC-‐HIP) is a population health dashboard intended to collect and report data on a number of health-‐related indicators. It collects data from a number of sources. Example sources include the Centers for Medicare and Medicaid Services (CMS) claims data, the DHHS Health Indicators Warehouse, and primary claims data from the CCNC network providers across North Carolina. With authorized access, this tool enables LHDs to track and locate such information as provider location, healthcare costs, and importantly, disease incidence. With the NC-‐HIP, local health departments can develop community assessments, target inventions, and track disease incidence outcomes for specific geographic locations.

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Ø Improve ability to communicate effectively with community health system partners and public

policymakers. The Public Health Task Force developed a “Communications Toolkit” that includes communications “tips and tools,” “talking points materials,” and “messaging” recommendations. This Toolkit is a compendium of a wide range of communications materials that have been developed by public relations specialists and by professional health organizations. The Toolkit tips and materials should be supplemented with communications strategies that incorporate regular public health reporting on outcomes and the value of the local public health agency to its community.28 More generally, building and sustaining positive relationships with other members of the community health system and other key community policymakers and stakeholders will be central to the successful evolution of LHD’s role in the health system.

Ø Calculate and leverage ROI analyses with external stakeholders. Effective communication will be enhanced by the inclusion of both personal, qualitative accounts of success as well as quantitative data and ROI analyses. Many external stakeholders will be interested in how public health impacts their bottom line. Thus, LHDs will need to improve the capacity to leverage data and calculate ROI. This strategy may be particularly important for developing relationships with county and local government because LHDs receive a large portion of funding from local tax dollars. Local officials will be more likely to continue sufficient levels of funding if they understand the ROI of public health. HB 438 presents a new opportunity for LHDs to demonstrate their value. As counties explore consolidated human services agencies and become involved in integrated systems, LHDs should consider how to measure their contributions.

Box 5-‐14. Operational Dashboard

A project team has been established to develop requirements for a LHD clinical decision-‐support dashboard. The team includes the health informatics specialist from the Orange County Health Department, representatives from several Patagonia EMR pilot counties, including those in the Appalachian Health District, and a developer from Patagonia, LLC (an EMR software company). Currently, dashboard requirements are being developed based on LHD operational and strategic needs and on MU requirements. More specifically, measures such as denials, patient experience, rate and speed of payments by the guarantor, and program and provider evaluations are required topics for the dashboard. The informatics specialist has drafted sample dashboard displays.

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References

1. National Association of City and County Health Officials. Implementation of the Patient Protection and Affordable Care Act. June 2011. Available at: http://www.naccho.org/advocacy/healthreform/upload/ACA-‐white-‐paper-‐final.pdf. Accessed October 9, 2012.

2. Institute of Medicine (US). Primary care and public health: Exploring integration to improve population health. Washington, DC: The National Academies Press. 2012. 3. American Public Health Association. Maximizing the community health impact of community health needs assessments conducted by tax-‐exempt hospitals. Marcy 13, 2012. Available at: http://www.naccho.org/advocacy/upload/CHNA-‐Consensus-‐0313-‐12-‐FINAL.pdf. 4. McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Affairs. 2010; 29(5): 982-‐990.

5. Centers for Medicare and Medicaid Services. Pioneer Accountable Care Organization Model: General Fact Sheet. September 12, 2012. Available at: http://innovation.cms.gov/Files/fact-‐sheet/Pioneer-‐ACO-‐General-‐Fact-‐Sheet.pdf. Accessed May 27, 2013.



8. AcademyHealth. Medical homes and Accountable Care Organizations: If we build it, will they come? Available at: http://www.academyhealth.org/files/publications/RschInsightMedHomes.pdf. Accessed November 6, 2012.

9. North Carolina Department of Health and Human Services Division of Public Health. State Center for Health Statistics. Local health department staffing and services summary: Fiscal year 2011. January 2012. Available at: http://www.schs.state.nc.us/schs/data/lhd/2011/FacStaff.pdf.



12. Hyde JK, Shortell SM. The structure and organization of local and state public health agencies in the U.S. Am J of Prev Med. 2012; 42(5-‐1):S29-‐S41.

13. Libbey P, Miyahara B. Cross-‐Jurisdictional Relationships in Local Public Health. Robert Wood Johnson Foundation. 2011.

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14. Massachusetts Public Health Regionalization Working Group. Massachusetts public health regionalization project status report. September 1, 2009.

15. Massachusetts Public Health Regionalization Working Group. Public health district planning toolkit: A roadmap for getting started. Available at: http://sph.bu.edu/images/stories/scfiles/practice/Roadmap_for_Getting_Started.pdf.


17. Novick LF. Local health departments: Time of challenge and change. Journal of Public Health Management and Practice. 2012; 18(2): 103-‐105.

18. Safeway. Health and wellness. Available at: http://csrsite.safeway.com/people/employees/health-‐wellness/. Accessed May 29, 2013.

19. Sing R, Mathiassen L, Stachura ME, Astapova EV. Sustainable rural telehealth innovation: A public health case study. Health Services Research. 2010; 45(4): 985-‐1004.

20. Wicklund E. Telemedicine financing takes center stage at ATA. Healthcare Finance News. May 2, 2012. Available at: http://www.healthcarefinancenews.com/news/telemedicine-‐financing-‐takes-‐center-‐stage-‐ata.


22. Surescripts. The National Progress Report on E-‐Prescribing and Interoperable Health Care Year 2011. Available at: http://www.surescripts.com/about-‐e-‐prescribing/progress-‐reports/national-‐progress-‐reports.aspx. Accessed November 11 2012.

23. Blumenthal D. Tavenner M. The “Meaningful Use” regulation for electronic health records. New England Journal of Medicine. 2010; 363(6): 501-‐504.

24. Gaylin D, Goldman S, Ketchel A, Moiduddin A. Community health center information systems assessment: Issues and opportunities. October 2005. Available at: http://aspe.hhs.gov/sp/chc/.

25. North Carolina Health Information Exchange. NC Direct. Available at: http://nchie.org/?program=nc-‐direct. Accessed May 25, 2013.

26. MCNC. Benefits and features. 2013. Available at: https://www.mcnc.org/our-‐community/healthcare/features-‐benefits. Accessed May 31, 2013.

27. Yasnoff WA, O’Carroll PW, Koo D, Linkins RW, Kilbourne EM. Public health informatics: Improving and transforming public health in the information age. Journal of Public Health Management and Practice. 2000; 6(6): 67-‐75.

28. North Carolina Public Health Incubator Collaboratives. Public Health Taskforce communications toolkit. 2012. Available at: http://nciph.sph.unc.edu/incubator/taskforce_comm_toolkit/index.html. Accessed May 31, 2013.

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30. Center for Public Health Sharing. #4: Project Smile North Carolina. 2012. Available at: http://www.phsharing.org/sites/project_smile_nc/. Accessed June 24, 2013.

31. Institute of Medicine (US). Who will keep the public healthy: Educating public health professionals for the 21st century. Washington, DC: National Academy Press. 2003.

32. Bettancourt JR. Improving quality and achieving equity: The role of cultural competence in reducing racial and ethnic disparities in healthcare. October 2006. Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2006/Oct/Improving%20Quality%20and%20Achieving%20Equity%20%20The%20Role%20of%20Cultural%20Competence%20in%20Reducing%20Racial%20and%20Ethni/Betancourt_improvingqualityachievingequity_961%20pdf.pdf.

33. Active Living By Design. Our approach. Available at: http://www.activelivingbydesign.org/our-‐approach. Accessed June 25, 2013.

34. Healthy Kids, Healthy Communities. Lake Worth, Greenacres, Palm Springs, FL: Creating open space through joint use. January 2013. Available at: http://www.healthykidshealthycommunities.org/sites/default/files/LakeWorth_Greenacres_PalmSprings.pdf.

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VI. Next Steps The previous strategic options were developed based on the comprehensive literature review, key informant interviews, and feedback from Task Force members. After discussion and based on the Strategic Options, the Task Force identified three priority next steps to recommend.

1. Identify priority roles for LHDs in community care coordination.

Coordination of care will become increasingly important as outcomes-‐based compensation takes hold. In addition, given the growing presence and impact of chronic disease, coordination of care will extend beyond the clinic to include the coordination of community-‐based services. Finally, “care” will address both individuals and populations of individuals. All these changes, point to changing potential roles for LHDs that must be identified, articulated, and negotiated by LHDs. If LHDs fail to identify these roles quickly and demonstrate their value through evaluations and ROI analyses, other entities may undertake these roles.

With this in mind, the Task Force has considered a number of potential priority roles. The Task Force proposes that LHDs leverage their traditional strengths in disease prevention and health promotion and that LHDs focus on specific conditions and perhaps on specific communities. Communicable disease, diabetes, and asthma in schools were identified as candidate conditions. Ultimately, the group recommends that LHDs focus on services that protect against the spread of communicable disease. As noted earlier, this is a service that most LHDs already provide in some fashion. It is one that only LHDs provide, and as we move to a pay-‐for-‐performance model, effective protection can have a material impact on the overall health (i.e. outcomes) of a community. Overall, this role includes prophylactic (e.g. immunization, promoting appropriate use of antibiotics, restaurant inspection), surveillance, and response roles. The Task Force recommends that LHDs focus in particular on immunization. This role will include undertaking the more traditional service of providing immunizations, but may also include immunization assurance (e.g. Immunization Registry reporting and follow up with local vaccination providers, assuring adequate vaccines are available to all providers for a selected set of diseases, working with schools to assure comprehensive student vaccinations.) In addition, LHDs will need to track and evaluate the impact of the Immunization program on community health and more specifically on the health of populations specifically served by community healthcare provider organizations. As a next step, the Task Force recommends that a workgroup be formed to fully articulate what this immunization role would be and to clarify how existing immunization-‐related capacities would need to change.

To gain a better understanding of models for care coordination as a starting point in identifying LHDs partnership roles, please see the following resources:

• AcademyHealth. Medical homes and Accountable Care Organizations: If we build it, will they come? o Discusses the challenges associated with implementing a medical home model and potential

solutions. • Centers for Medicare and Medicaid Services. CMS Innovation Center.

o Provides information on outcome-‐based compensation models, current demonstration projects, grant opportunities, and webinars.

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2. Explore, present, and encourage models for cross-‐jurisdictional sharing.

While the majority of key informants and Task Force members recognized the potential for cross-‐jurisdictional sharing to enhance the capacity of local health departments, barriers were also identified. Smaller health departments may have concerns over losing local control and larger health departments may feel that they have nothing to gain from collaborating. In the end, these concerns can be accommodated, and the required resources to enhance capacity, particularly with regards to informatics and disease surveillance, suggest that cross-‐jurisdictional sharing would make sense, even for larger LHDs. The North Carolina accreditation process presents an opportunity to analyze an agency’s strengths and weaknesses and identify potentially suitable areas for collaboration.

The Massachusetts Public Health Regionalization Working Group and the Kansas Health Institute’s Center for Sharing Public Health Services are currently conducting wide scale evaluations of cross-‐jurisdictional sharing models. Local health departments should track the progress of these projects to better understand various approaches and best practices. Meanwhile, local health departments should follow the steps outlined in the Strategic Options section to identify potential areas for collaboration and potential partners. Throughout these collaborative efforts, health departments should track successes and challenges for QI purposes and to contribute to this developing field.

The following resources may be of interest to LHDs interested in exploring opportunities related to cross-‐jurisdictional sharing:

• Hoornbeek J, Budnik A, Beechey T, Filla J. Consolidating health departments in Summit County, Ohio: A one year retrospective. June 29, 2012.

• Kansas Health Institute. Center for Sharing Public Health Services. 2012. • Massachusetts Public Health Regionalization Working Group. Public health district planning

toolkit: A roadmap for getting started. • Meit M, Kronstadt J, Brown A. Promising practices in the coordination of state and local public

health. NORC at the University of Chicago. May 2012.

3. Build capacity to effectively negotiate LHD roles and communicate the value of local public health.

The challenges that LHDs have in communicating the value of their services were nearly universally recognized among interviewees and Task Force members. Misperceptions regarding the type of services provided by LHDs appeared common place, and some stakeholders perceive health departments as inefficient and inflexible. Informants emphasized that LHDs need to be and appear to be more like lean and effective businesses that rely on data-‐driven decision-‐making. Among other things, all these messages point to the need for LHDs to more effectively communicate their value and going forward, to effectively negotiate their roles in their evolving community health systems.

Of course, more effective communication is multifaceted, and the initial Task Force project, to develop a communications toolkit and materials, addresses some communications-‐related needs. As a next step, selected LHD staff must become conversant in the language of their community health system partners.

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In particular, the Task Force recommends that they become conversant in the concepts, language (e.g nomenclature), and arguments made by key health system partners related to pay-‐for-‐performance models and organizations. In addition, selected LHD staff should become familiar with selected, established healthcare and business performance metrics and should develop and standardize on public health-‐specific metrics to track and improve clinical and general operational performance (e.g. clinic management, quality of care outcomes) and to track community health status (e.g. return on investment for health promotion interventions, standardized CHA indicators.) Public Health Incubator Collaboratives might establish working groups to do some of this work, and WNC Healthy Impact has already selected a standard set of community-‐based health status indicators. Finally, selected LHD staff should develop a foundational understanding of core health informatics subject areas and terminology.

Below are some resources that are available to LHDs interested in building communications capacity with health system partners.

• North Carolina Public Health Incubator Collaboratives. Public Health Taskforce Communications Toolkit. 2012.

• National Association of County and City Health Officials. Public health communications resources. 2013.

• National Association of County and City Health Officials. Statement of policy: Role of local health departments in Community Health Needs Assessments. 2012.

• Centers for Medicare and Medicaid Services. Clinical Quality Measures (CQMs), http://www.cms.gov/Regulations-‐and-‐Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures.html

Developing foundational capabilities

In 2012, the Institute of Medicine (IOM) published For the Public's Health: Investing in a Healthier Future with a set of basic programs (referenced in the Background section), and foundational capabilities. Foundational capabilities refer to the competencies and infrastructure required to successfully execute several basic public health department programs. For example, the ability to conduct surveillance is necessary for programs that focus on communicable diseases as well as those that focus on chronic diseases.1 Some services provided by most LHDs directly support these capabilities including registration of vital events, collection of morbidity data, vital records and statistics, laboratory services, and interpreter services.

Of course, LHD staff do have competencies required for these capabilities and when funding is available, these capabilities are also supported through professional development, particularly in the medium to larger health departments. Unfortunately, as we noted earlier, funding for many LHDs has been cut and most funding streams, such as block grants, target specific categories of services, rather than broad foundational capabilities support. As a result, it appears that most competencies associated with the foundational capabilities are frequently “learned by doing” on a project-‐by-‐project basis. While this approach can prove useful, it can lead to gaps, particularly with regards to best practices and a foundational understanding of the capabilities. In turn, these gaps can negatively impact performance. Given the expectations and the requirements associated with a pay-‐for-‐performance model,

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performance must be high and ever improving. All of which points to a renewed effort by LHDs to prioritize staff development, and to carefully target these development efforts.

To undertake some mix of the recommended options and next steps, the following training topics and investments in infrastructure should be prioritized. (Many of these foundational priorities are also included in the strategic options discussions, but all are also included here in one place.) There are many agencies in North Carolina that may be able to provide technical assistance in these areas. The NC Center for Public Health Quality, the Center for Healthy NC, the UNC Gillings School of Global Public Health, the Departments of Public Health at East Carolina University, UNC-‐Greensboro, and UNC-‐Charlotte, the NC Division of Public Health, the NC Institute of Medicine, the NC Institute for Public Health, the NC Office of Rural Health and Community Care, Community Care of North Carolina, and the NC Public Health Association, among others, are all sources of expertise that can help meet the professional development needs of local health departments.

1) Information systems and resources, including surveillance and epidemiology a. Infrastructure enhancements

i. Adopt an electronic health record (EHR)/promote HIS enhancements to enable flexible clinic reporting and analysis.

ii. Adopt and advocate for NC Direct with community providers. iii. Connect to the NC HIE through the CCNC Informatics Center or the DHHS

Qualified Organization. iv. Subscribe to a high-‐speed, reliable broadband network like NCTN. v. Adopt selected telehealth technologies to expand capacity and extend clinical

reach. vi. Identify and improve sources of local data.

b. Informatics development and training topics i. Develop public health practice management dashboard and undertake training

in analysis of practice management data. ii. Select clinical quality measures and undertake training in public health clinical

performance analysis. iii. Standardize health assessment indicators (with health system partners) and

enhance skills related to the manipulation/calculation/interpretation of health assessment indicators and the use of health assessment dashboards and tools (e.g., NC Community Health Information Portal, Community Commons Dashboard).

iv. Improve ROI design and analysis. Develop community-‐based outcome measures that tie to healthcare provider bottom lines.

v. Consult with the NC Center for Public Health Quality for training and technical assistance with quality improvement and informatics efforts.

c. Basic epidemiology analysis and reporting

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2) Health planning a. Enhance Community Health Improvement Planning and leadership skills such that LHD

staff have a leadership role in planning and as a trainer, can provide collaborative leadership training with health system partners and other community stakeholders.

b. Enhance public health business planning skills (develop “lines of business” for sustainability for fee-‐based services.)

3) Partnership development and community mobilization a. Improve negotiation/mediation/contracting skills. b. Enhance recruitment and enrollment skills.

4) Policy development, analysis, and decision support a. Develop policy-‐related evidence-‐based best practice skills including; 1) a thorough

knowledge of the evolving EBS literature, 2) thorough knowledge of actual EBS-‐based interventions, 3) the ability to customize EBS for a specific context, 4) EBS project management skills, and policy-‐based EBS evaluation skills.

b. Become a train-‐the-‐trainer expert for the LHD community health system in Health Impact Assessment.

5) Communication, including health literacy and cultural competence a. Improve value communications – effectively identify measures of value and develop

communications skills/strategies around these measures. b. Become experts in performance-‐based care (e.g., Accountable Care Organizations)

nomenclature and models. Propose alternative models and negotiate roles. 6) Public health research, evaluation and quality improvement

a. Improve grant writing capacity. b. Investigate CDC Framework for Program Evaluation in Public Health. c. Augment basic statistics and research design methods skills

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References:


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Appendix A: Definitions of Foundational Capabilities

Information systems and resources, including surveillance and epidemiology

The ability to conduct surveillance is a crucial component that enables planning, measurement and reporting. Surveillance allows for the assessment of the health status of populations and their related determinants of health and illness. Collected data can also be used for calculating return on investment in order to secure future political and financial support and to inform the creation of partnerships. It is ideal for systems used by partners, such as hospitals and local health departments, to be electronic and interoperable.2

Health planning

Community health improvement planning, involves a long-‐term systematic effort to address public health problems on the basis of community health assessment activities and the community health improvement process. The plan should define the vision for the health of the community through a collaborative process and should address strengths, weaknesses, challenges and opportunities that exist to improve the health status of the community.3

Partnership development, and community mobilization

The first step in partnership development, and community mobilization is to identify community assets and resources. Community linkages should be evaluated among multiple determinants of health. Community based participatory research (CBPR) efforts should be encouraged in public health organizations as a form of community engagement and mobilization. CBPR and other methods should be used to establish linkages with key stakeholders, including non-‐traditional partners. Collaboration can be ensured through the development of formal and informal agreements.2

Policy development, analysis, and decision support

LHDs should collect information that will inform policy decisions on institutional, local, state and national levels. In addition, collecting intervention data will help with assessing ROI. Data-‐driven decision support will aid in deciding where and when to concentrate resources. Public health should be capable of describing implications and critiquing the feasibility of various policy options.2

Communication

Ensuring the health literacy of populations served should be considered throughout all communication strategies. Likewise, public health should ensure that there are strategies for interacting with persons from diverse backgrounds. To maximize effectiveness of communication, public health information should be conveyed in a variety of approaches and community-‐based input should be solicited. Public health must remember to clearly communicate the role of public health with the overall system and to community partners.2

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Public health research, evaluation and quality improvement

Quality improvement refers to the continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community. Local health departments often address performance and quality improvement as they prepare for accreditation.2

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References:

1. Institute of Medicine (US). For the public’s health: Investing in a healthier future. Washington, DC: The National Academies Press. 2012. 2. The Council on Linkages Between Academia and Public Health Practice. Core competencies for public health professionals. 2010. Available at: http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Health_Professionals_2010May.pdf

3. Center for Disease Control and Prevention, National Public Health Performance Standards Program frequently asked questions. 2010. Available at: www.cdc.gov/nphpsp/documents/FAQ.pdf.

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Appendix B: Glossary of Terms

Relevant Terms:1-‐3 Accountable Care Organization (ACO): A group of healthcare providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get. The organization’s payment is tied to achieving healthcare quality goals and outcomes that result in cost savings. Affordable Care Act (ACA): The comprehensive healthcare reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law. Behavioral Risk Factors: Risk factors in this category include behaviors that are believed to cause, or to be contributing factors to, most accidents, injuries, disease, and death during youth and adolescence as well as significant morbidity and mortality in later life. This is a category of data recommended for collection in the Community Health Assessment. Behavioral Risk Factor Surveillance Survey (BRFSS): A national survey of behavioral risk factors conducted by states with CDC support. Care Coordination: The organization of treatment across several healthcare providers. Medical homes and Accountable Care Organizations are two common ways to coordinate care. Community Health Improvement Process: Community health improvement is not limited to issues classified within traditional public or health services categories, but may include environmental, business, economic, housing, land use, and other community issues indirectly affecting the public’s health. The community health improvement process involves an ongoing collaborative, community-‐wide effort to identify, analyze, and address health problems; assess applicable data; develop measurable health objectives and indicators; inventory community health assets and resources; identify community perceptions; develop and implement coordinate strategies; identify accountable entities; and cultivate community ‘ownership’ of the entire process. Electronic Health Records (EHR): Electronic Health Records are a repository of electronically maintained information about an individual's lifetime health status and healthcare, stored such that it can be accessible to authorized users (e.g., physicians, pharmacists, hospitals, home care) of the record. The U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology (ONC) is leading efforts to reach President Bush's call for most Americans to have electronic health records within 10 years. This initiative is part of the movement to advance electronic health information exchange by making health records digital and interoperable, and ensure

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that the privacy and security of those records are protected, in a smooth, market-‐led way. For more information, visit www.healthit.hhs.gov. Essential Health Benefits: A set of healthcare service categories that must be covered by certain plans, starting in 2014. The ACA defines essential health benefits to “include at least the following general categories and the items and services covered within the categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.” Insurance policies must cover these benefits in order to be certified and offered in Exchanges, and all Medicaid State plans must cover these services by 2014. Starting with plan years or policy years that began on or after September 23, 2010, health plans can no longer impose a lifetime dollar limit on spending for these services. All plans, except grandfathered individual health insurance policies, must phase out annual dollar spending limits for these services by 2014. The Department of Health and Human Services is working with a number of partners to develop the essential health benefits package. In the fall of 2011, HHS launched an effort o collect public comment and hear directly from all Americans who are interested in sharing their thoughts on this important issue. Essential Public Health Services: A list of ten activities that identify and describe the core processes used in public health to promote health and prevent disease. The framework was developed in 1994. All public health responsibilities (whether conducted by the local public health agency or another organization within the community) can be categorized into one of the services. Exchange: A new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Affordable Insurance Exchanges will offer a choice of health plans that meet certain benefits and cost standards. Federally Qualified Health Center (FQHC): Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally qualified health centers provide primary care services regardless of ability to pay. Services are provided on a sliding scale fee. Fee-‐For-‐Service (FFS): A method in which doctors and other healthcare providers are paid for each service performed. Examples of services include tests and office visits. Health Assessment: The process of collecting, analyzing, and disseminating information on health status, personal health problems, population groups at greatest risk, availability and quality of services, resource availability, and concerns of individuals. Assessment may lead to decision making about the relative importance of various public health problems.

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Health Information Exchanges (HIE) and Regional Health Information Organizations (RHIOs): Health Information Exchanges (HIEs) are organizations that support the exchange of personal health information. Also known as Regional Health Information Organizations (RHIOs), these organizations support the primary goal of the NHIN for interoperable health information systems. RHIOs will be the local collaborative of public/private sector health information exchange partners to facilitate data exchange between EHRs and public health. It is critical that LHDs have representation and are actively involved with RHIOs. Local public health involvement can increase the efficient use and standardization of information that is transmitted to public health, and increase the reliability of data exchange with our partners. Health Information System (HIS): The National Committee on Vital and Health Statistics describes HIS as "a comprehensive, knowledge-‐based system capable of providing information to all who need it to make sound decisions about health. Such a system can help realize the public interest related to disease prevention, health promotion, and population health." For more information, visit www.himss.org. Health Information Technology (HIT): HHS describes HIT as the tangible technical aspects of a health information system, including network backbones such as the Internet in its present and future versions; the World Wide Web, wireless connections, hardware, Internet appliances, and handheld devices, as well as applications for information management, decision-‐support tools, communication, and transactional programs. Also involved are technical capabilities in areas such as bandwidth and latency. For more information, visit www.healthit.hhs.gov. HITECH Act: An act passed by Congress in 2009 that authorizes expenditures of approximately $20 billion over five years to promote the adoption and use of electronic health record technologies that would be connected through a national health information network. » Health Insurance Portability and Accountability Act of 1996 (HIPAA): The U.S. Department of Health and Human Services (HHS) has issued new national health information privacy standards. The new regulations provide protection for the privacy of certain individually identifiable health data, referred to as protected health information (PHI). For more information, visitwww.hhs.gov/ocr/privacy/. Health Level 7 (HL7): HL7 is one of several American National Standards Institute (ANSI) accredited Standards Developing Organizations (SDOs) operating in the healthcare arena. Health Level Seven's domain is clinical and administrative data. For more information, visit www.hl7.org/. Hospital Readmissions: A situation in which an individual is discharged from the hospital and goes back in for the same or related care within 30, 60 or 90 days. The number of hospital readmissions is often used in part to measure the quality of hospital care, because it can mean that the follow-‐up care was not properly organized, or that the individual was not fully treated before discharge. International Classification of Disease 10th Revision Clinical Modification (ICD-‐10-‐CM):

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The ICD-‐10 CM is based on and is completely comparable with the International Classification of Diseases, Tenth Revision. The ICD-‐10 is used to code mortality data. Its purpose is to provide a common language, specifically number and letter codes, for identifying illnesses, injuries, and causes of death. This enables communities, healthcare organizations, insurance companies, regulatory agencies, etc. to compare rates of disease and injury, as well as cost and pricing practices. Interoperability: According to the Interoperability Clearing House, "interoperability is the ability of information systems to operate in conjunction with each other encompassing communication protocols, hardware software, application, and data compatibility layers. With interoperable electronic health records, always-‐current medical information could be available wherever and whenever the patient and attending health professional needed it. At the same time, EHRs would also provide access to treatment information to help clinicians as they care for patients." For more information, visit www.ichnet.org andwww.cdc.gov/phin. Local Control: The ability of a jurisdiction to adopt and enforce its own rules, policies, and procedures related to carrying out its functions. MAPP: Mobilizing for Action through Planning and Partnerships. A community-‐wide strategic planning process developed by NACCHO and CDC. Meaningful Use (MU): Still pending an official definition from CMS, but ARRA requires that the definition include e-‐prescribing, the ability to exchange information with other healthcare providers to improve care, and the reporting of clinical quality measures to CMS.» mHealth: A term used for the practice of medical and public health, supported by mobile devices. The term is most commonly used in reference to using mobile communication devices, such as mobile phones and PDAs, for health services and information. Nationwide Health Information Network (NHIN): HHS describes NHIN as an Internet-‐based architecture that links disparate healthcare information systems to allow patients, physicians, hospitals, community health centers, and public health agencies across the country to share clinical information securely. For more information, visitwww.healthit.hhs.gov. Payment Bundling: A payment structure in which different healthcare providers who are treating an individual for the same or related conditions are paid an overall sum for taking care of the condition, rather than being paid for each individual treatment, test, or procedure. In doing so, providers are rewarded for coordinating care, preventing complications and errors, and reducing unnecessary or duplicative tests and treatments. Personal Health Record (PHR): An electronic record of health information that is maintained, controlled, and shared by patient-‐consumer. http://www.myphr.com/index.php

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Primary Care: Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-‐term relationships with patients and advise and treat patients on a range of health related issues. They may also coordinate care with specialists. Qualified Health Plan: Under the ACA, starting in 2014, an insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost sharing (like deductibles, copayments, and out-‐of-‐pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Exchange in which it is sold. Risk Assessment: The scientific process of evaluating adverse effects caused by a substance, activity, lifestyle, or natural phenomenon. Risk assessment is the means by which currently available information about public health problems arising in the environment is organized and understood. Surveillance: The systematic collection, analysis, interpretation, and dissemination of health data to assist in the planning, implementation, and evaluation of public health interventions and programs. Sustainability: The long-‐term health and vitality—cultural, economic, environmental, and social—of a community, program, or policy. Sustainable thinking considers the connections between various elements of a healthy society, and implies a longer time span (i.e., in decades, instead of years). Value-‐Based Purchasing: Linking provider payments to improved performance by healthcare providers. This form of payment holds healthcare providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-‐performing providers. Wellness Programs: A program intended to improve and promote health and fitness that’s usually offered through the work pace, although insurance plans can offer them directly to their enrollees. The program allows an employer or plan to offer premium discounts, cash rewards, gym memberships, and other incentives to participate. Some examples of wellness programs include programs to help individuals stop smoking, diabetes management programs, weight loss programs, and preventative health screenings.

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References

1. National Association of City and County Health Officials. Mobilizing for Action through Planning and Partnerships (MAPP) glossary. Available at: http://www.naccho.org/topics/infrastructure/mapp/framework/clearinghouse/upload/MAPP-‐Glossary.pdf.

2. National Association of City and County Health Officials. Glossary of public health informatics organizations, activities, and terms. 2013. Available at: http://www.naccho.org/topics/infrastructure/informatics/glossary.cfm.

3. Healthcare.gov. Glossary. 2011. Available at: http://www.healthcare.gov/glossary/04262011a.pdf.