Category Archives: Keeneland Conference
During opening remarks at this year’s Keeneland Conference, hosted by the National Coordinating Center for Public Health Systems and Services Research (PHSSR) based at the University of Kentucky in Lexington, Professor Douglas Scutchfield, director of the Center, proudly announced that three of the first health departments to be accredited by the Public Health Accreditation Board (PHAB) earlier this year were in Kentucky. Accreditation had its own track during the conference scientific sessions, including a presentation from Jessica Kronstadt, MPP, PHAB’s director of research and evaluation.
NewPublicHealth caught up with Kronstadt to talk about her presentation on some very early findings from an internal evaluation of the accreditation process.
>>Read more on national public health department accreditation.
NewPublicHealth: What information is PHAB seeking to gain from an evaluation of the accreditation process?
Jessica Kronstadt: Just as we’re asking health departments to engage in quality improvement, PHAB is very much committed to engaging in quality improvement of the accreditation program. So these evaluation efforts will really help us understand what is working well in our accreditation program, and what the experience was like from the perspective of the health departments and the site visitors. This evaluation will allow us to continue to improve the accreditation process.
The last session of the Keeneland Conference focused on translation and dissemination of public health systems and services research, with the critical goal of more efficient and effective delivery of public health services and improving population health. NewPublicHealth spoke with Ross Brownson, PhD, of the Prevention Research Center at Washington University in St. Louis. Dr. Brownson has received funding from the Robert Wood Johnson Foundation to explore evidence-based decision making at local health departments.
NewPublicHealth: How far back does evidence-based public health go?
Ross Brownson: The formal underpinnings of evidence-based public health were developed in the late 1990s, so at least the formal literature has been around for probably about 15 years. Of course, research on effective interventions has been around for many more decades. The newer field of public health services and systems research is much newer, just within the last five years or so, and these different bodies of research are now converging.
The early research focused a lot on identifying evidence-based interventions. The newer research is more on the process of evidence-based public health—regardless of the intervention, how do you develop and implement an evidence-based health department?
We identified five domains that are really important:
- leadership of the agency;
- ability to develop, formalize and maintain good partnerships within the community;
- workforce training and development;
- focus on organizational climate and culture; and
- effective financial and budgeting processes.
The ultimate goal is to make the population healthier and we know that the way to improve the overall health of the public is largely through state and local governmental public health. To reach that ultimate goal you want to have the most effective health department possible and also make the most efficient use of resources. We’re always in a time of tight resources, but probably now more than ever. That calls on us to be as effective and efficient as we can be in the delivery of public health services.
NPH: How will you disseminate these best practices and this evidence base to state and local public health officials?
Primary care and public health share a common goal but historically have functioned independently of each other. However, health experts say that better integration of the two disciplines could result in critical improvements in the health of individuals and communities. The Centers for Disease Control and Prevention and the Health Resources and Services Administration asked the Institute of Medicine (IOM) to look at issues related to the integration of primary care and public health, and the resulting report was released earlier this year.
The recent report on integrating was so groundbreaking, that it has launched a number of discussions and publications on the issue, including a keynote panel at the recent 2012 Keeneland Conference, a first ever joint issue of the American Journal of Preventive Medicine and the American Journal of Public Health and a session on the report at next week’s AcademyHealth Annual Research Meeting by the IOM report’s committee chair, Paul Wallace, MD. NewPublicHealth spoke with Dr. Wallace, Director of the Center for Comparative Effectiveness Research at the Lewin Group, about the committee’s critical finding and recommendations.
The IOM identifies a set of core principles common to successful integration efforts, such as involving the community in defining and addressing its needs. The principles provided in this report can serve as a roadmap to move the nation toward a more efficient health system.
NewPublicHealth: What were the key findings were in the report?
Dr. Wallace: There are many instances in which communities have figured out aspects of integration but, as we learn over and over again in health care, solutions often need to be locally adaptive, and that holds true in thinking about how integration takes place as well.
I think what was very helpful for us was recognizing that integration is really a continuum, sort of extending from either being disintegrated or, if you will, parallel play on one end up through quite formal partnerships or mergers on the other end. There are opportunities for creating better care and efficiencies along that continuum. For public health to be aware of what primary care is doing and for primary care to be deeply aware of what public health is doing would be a substantial element of progress.
NPH: Why is integration coming about now?
Dr. Wallace: It isn’t quite yet. Until about a hundred years ago health care was the province, almost exclusively, of the clinician-patient relationship. Previously, though, if you go back 150 years, in medical schools, there was really a sort of blending of what we now would think of as public health and what we think of as health care. But the Flexner Report back in the early 20th century re-configured how medical education took place, which changed the structure of medical schools, and public health wasn’t really part of that.
The other thing that happened was that public health was figuring out what it needed as an academic base, and that was about the time that the Rockefeller Foundation stepped up and started funding separate schools of public health. So really what happened is that the education and the academic foundation sort of diverged and they followed separate paths for most of the last century.
NPH: With stronger collaboration between public health and health care, what could be achieved?
Dr. Wallace: I think if you look at it from a patient-centered perspective, there would be rational and consistent availability and access to a whole range of services like healthy food and the ability to exercise, and it would be reinforced by our public policy. There would be a shared awareness of who are the people at greatest risk, perhaps related to data and information systems. There would be an alignment between messaging from public health agencies and what you would hear in your clinician’s office. And in the clinician’s office there would be recognition that it isn’t just about doing physical exams and prescribing pills, it’s also thinking about aspects of healthy living such as active living and healthy eating.
But I think that there really would just be a blending of the whole continuum, and I think that the other really important thing is that a lot of the emphasis would shift from fixing things through health care to more of a proactive context of prevention, and really primary prevention. It’s about not waiting until people have high cholesterol and heart attacks and then trying to treat them with lipid-lowering drugs, but thinking how you get ahead of this in public schools, in the workplace and in our communities.
NPH: Would money be saved with the appropriate integration?
Dr. Wallace: Another way to think about it would be—can we get more health for the dollars we’re spending? We certainly could make the system more efficient. There are a lot of issues of maldistribution, for instance, where we tend to over-treat certain people in certain ways, and as a consequence there are other folks who are poorly treated. The disparities discussion I think is a very rich one that’s right in the middle of this.
Over time, we might start to see spending migrate from very high-risk dollars on things that are very unlikely to work with expensive interventions, to more fundamental upstream interventions that will have dividends over many years.
NPH: Is it sufficient to just have primary care and public health at the table together to solve the massive problems that have been created?
Dr. Wallace: If you really want to create health on a community basis, you need public health and you need the health care delivery system, primary care, but almost all of the successful programs also have some third party. And that third party may be government, it may be schools, it may be a faith-based organizations. It gives you sort of a place to convene. Rather than having public health and primary in a tug of war over who is bigger and brighter and smarter, you realign that effort to think about how we can collectively engage to support this third party. That sort of triangulation I think is a really critical thing about trying to bring these mindsets and forces back together.
NPH: What are the next steps to the report’s findings?
Dr. Wallace: What was different about this report we feel is that it involved people who have a direct interest in this, who are motivated to actually do some things to try and support this. CDC and HRSA, who together commissioned the report, between them have a footprint that really extends into every community. They’re actively thinking together about a lot of things that we’ve suggested, but a lot of our suggestions reflected openness from them to where they want to go. CDC and HRSA are increasingly aware of what each other are doing, they actively cooperated in funding the study and they’re collaborating now in thinking about some funding models.
There are also workforce issues. There probably is a set of workers who are critical to this and they aren’t necessarily traditional health care roles, but they’re more like the community health worker who can help people with education. They’re in the community, they understand the culture, they understand the nuance and may be more effective at translating some of these messages.
NPH: What made it feasible to have a receptive audience for this report now?
Dr. Wallace: There is a growing understanding of what population health is, and in a sense that population health is bigger than either primary care or public health and it’s only going to get addressed if they do it collaboratively. The other really critical factor that makes things different now is the availability of data. That is just fundamentally changing people’s thinking. An example of that would be creating community-wide registries that can be used to recognize where there’s opportunity such as pockets of a city that have a very high incidence of asthma, and then being able to think about what are the community or public health-based interventions.
Data democratization is also creating new levels of transparency and accountability. There’s this growing recognition that you can now know what is going on, where before people always wondered or hypothesized.
Last week’s Keeneland Conference included a session that looked at research in the area of law and legal process. The session was moderated by Scott Burris, JD, director of Public Health Law Research, a program of the Robert Wood Johnson Foundation, based at Temple University.
Burris noted several key presentations during the conference including one by Julia Costich, JD, PhD, who is an associate professor in the Department of Health Services Management at the University Of Kentucky College Of Public Health. Costich presented on the importance of how health agencies enforce the power they have. Burris says there is a huge body of literature from regulatory and governance sources on how effective regulators regulate—and that public health is only beginning to draw on. “That’s really opening a big important door, and we’ll see a lot more about that in future years.”
Jennifer Ibrahim, PhD, MPH, an associate professor of public health at Temple University, looked at how law is being figured out at the local level. Burris said that researchers both at the Public Health Law Research Program and collaborators have conducted research on the relationship between state and local health officers and their lawyers.
National Public Health Accreditation launched last fall, and since then 64 local health departments, three tribal health departments and one state department have submitted applications to the National Public Health Accreditation Board (PHAB). Carol Moehrle, chair of PHAB and director of public health for the Idaho North Central District, spoke about the accreditation process and benefits during a keynote speech at the Keeneland Conference. NewPublicHealth caught up with Carol Moehrle during the meeting.
NewPublicHealth: Are you pleased with the number of applicants you’ve seen so far?
Carol Moehrle: We are pleased. We knew we’d have some early adopters. And to have 68 complete their applications with the last seven months, that’s a great start. We’ve got a long way ahead, but we also know we have many applicants in the queue waiting to apply. We’re hearing lots of good energy, and departments beginning the process now can look to the earlier applicants for best practices, so applying will be easier as time goes on.
NPH: What is the process and timetable for accreditation application review?
Richard J. Umbdenstock, American Hospital Association: Opportunities for Collaboration Between Health and Health Care
The intersection of health and health care was an important theme at this year’s Keeneland Conference—during sessions on recent IOM reports, in hallway conversations, in discussions of Public Health Services and Systems Research that explores the most efficient ways to deliver public health services, and, notably, during the keynote address by Richard Umbdenstock, president and CEO of the American Hospital Association.
In his presentation, Umbdenstock talked about hospitals and public health, "collaborating for communities," and said that as health care providers, hospitals had tended to focus on treating the individual, rather than on prevention for the population. Now, he said, the money is gone and the public cares more about health, meaning it makes less and less sense for either hospitals or public health to be concerned with protecting their turf. “We need to incent health and deglamourize consumption.” Quoting a colleague, Umbdenstock said “what we need to do is create an epidemic of health.”
Umbdenstock spoke frankly when he told the attendees, “hospitals want to improve the lives of their patients, and not just their health care. Rather than wait for an [hospital] admission that won’t be paid, they’d rather get upstream on primary care.”
“Public health departments must be funded and supported so that wellness and prevention touches all and there are enough resources to do that,” said Umbdenstock. “And this is where research can play a big part—collaborative health research. We need to know the most effective collaborative models and the most effective ways to advocate for greater personal and community responsibility.”
NewPublicHealth caught up with Richard Umbdenstock following his talk.
NewPublicHealth: What are you hearing from hospitals about the new IRS community benefit requirement?
Richard Umbdenstock: Some hospitals have had similar responsibilities at the state level and many have had to put out accountability reports to their communities, so for many it’s not a new concept. In addition, hospitals have long been under a microscope and they also understand that community benefit is a wonderful community education tool. If they can tell it in a clear and consistent fashion, there’s a real opportunity for the public to better understand what hospitals and public health departments do.
NPH: Do hospitals and public health understand the critical community roles each one plays?
Richard Umbdenstock: I don’t think there’s any question what public health departments do after you’ve see them spring into action after a disaster, just as a lot of people don’t value what hospitals do until after they’ve been a patient. On a day-to-day basis we can all get so deep in our work that we just don’t see what the other person is doing. What we’re learning is that we all serve the same person.
Frontiers in Public Health Services & Systems Research: Making Critical Research Accessible, Quickly
Idea Gallery is a recurring editorial series on NewPublicHealth in which guest authors provide their perspective on issues affecting public health. Today, Glen Mays, MPH, PhD, F. Douglas Scutchfield Endowed Professor of Health Services and Systems Research at the University of Kentucky College of Public Health, talks about the launch of a brand new online journal covering public health systems and services research, and why it is so critical right now, to inform smart investments in public health and prevention. The new journal, Frontiers in PHSSR, is designed to disseminate the most critical early findings from PHSSR research much faster—making these findings accessible far in advance of the fully-developed scientific manuscript. To be eligible for inclusion in Frontiers, findings must have the potential to guide future public health practice, health policy, and research. Mays is the editor in chief of the new journal.
Portions of the post below are adapted from the opening commentary in Frontiers, authored by Mays, F. Douglas Scutchfield, Paul K. Halverson, William Riley and Peggy Honore.
The need for a strong and effective public health system in the United States is perhaps more urgent today than at any other time in our nation’s history. Preventable diseases and injuries account for more than three-fourths of the $2.6 trillion in health care expenditures incurred annually in the U.S. The growing prevalence of obesity, diabetes and other preventable conditions constrains the nation’s economic productivity and global competitiveness. The American public health system—the diffuse constellation of governmental public health agencies and their peers and partners in community-based settings and the private sector—is tasked with developing and delivering strategies that promote health and prevent disease and injury on a population-wide basis. They share the mission of creating conditions in which people can be healthy.
The public health system is uniquely positioned—but not optimally equipped or resourced—to take on these challenges. Only about 3 percent of the nation’s $2.6 trillion in annual health expenditures is devoted to public health activities. Some of our greatest uncertainties now lie in how best to organize, finance, and deliver effective public health prevention strategies to communities across the U.S. The field of public health services and systems research (PHSSR) has emerged to fill this void.
Frontiers in PHSSR
The American public health system and the populations it serves do not have the luxury of waiting the 15 years typically required to get research-tested solutions widely adopted into practice. The costs associated with missed opportunities for disease prevention and health promotion are straining government and household budgets now.
To help develop and grow this scientific learning community, we have launched a new, open-access, peer-reviewed journal, Frontiers in Public Health Services and Systems Research. This journal provides a platform for rapidly and widely communicating emerging findings and lessons learned from studies of public health services and delivery systems. Frontiers will feature brief descriptions of preliminary findings from ongoing or recently completed empirical studies and quality improvement projects that answer important questions regarding the organization, financing, and delivery of public health services.
In 2009, the Robert Wood Johnson Foundation, requested the Institute of Medicine (IOM) to convene a committee to consider three major topics in public health: measurement, law and policy, and funding. The last of these reports, which recommends new health targets and changes in how public health is funded and organized, was released last week and has been a key topic of discussion at this week’s Keeneland Conference.
Harvey Fineberg, MD, president of the IOM, delivered a keynote address on these three reports, as well as another recent report on the potential for collaboration between public health and primary care. NewPublicHealth spoke to Dr. Fineberg about the reports and next steps.
>>We're on the ground in Kentucky all week. Follow our coverage for the latest news.
NewPublicHealth: How will the findings from the three-report series on public health be helpful to public health service delivery going forward?
Dr. Harvey Fineberg: I think of these reports as the contemporary trilogy of public health. They each stand on its own and yet are also connected in a vital way.
The first report looks at how we can know where we stand in public health. It emphasizes the importance of a standard core set of indicators. The aim is to make them a guide for policy and practice of public health, and to monitor where we are and what needs to be done.
The second report was on the legal foundation that provides the authority for health agencies to protect the public’s health. It turns out that many of the statutes have been on the books for decades and don’t necessarily have the specifics for dealing with contemporary needs such as the challenge of dealing with obesity or emerging infectious diseases or bioterrorism. The report pointed to the ten essential services of public health which set a standard of practice, and spoke to what state laws would be needed to make the ten core functions operable.
The third report dealt with essentially the resources that would be needed to carry out public health services. And the committee found that we grossly under-invest in public health. They recommended a conservative estimate of doubling the national investment and proposed a fee on dollars that flow through the medical system to be captured and reinvested in prevention, which they said would ultimately protect and improve health.
NPH: How important was the evidence base to the committee in producing the reports?
Debra Joy Pérez, MA, MPA, PhD, assistant vice president for Research and Evaluation at the Robert Wood Johnson Foundation, was a keynote speaker at the Keeneland Conference yesterday and spoke about the evolution of public health services and systems research (PHSSR). NewPublicHealth asked Debra Pérez about that evolution.
>>Follow our continuing coverage of the Keeneland Conference.
NPH: Why is the field of PHSSR a priority for the Robert Wood Johnson Foundation?
Debra Pérez: Right now, I think more than ever we need evidence to provide decision-makers with the evidence for how best to apply limited resources. We know in the last year alone over 40,000 public health jobs were eliminated, so that means that health departments are struggling with staffing and infrastructure issues, and they need evidence to help them best apply the limited resources they have now.
NewPublicHealth: What’s the scope of the conference this year compared to previous years?
The annual Keeneland Conference kicked off today, where more than 300 public health services and systems researchers (PHSSR), public health officials and policy-makers have convened to discuss the latest issues in this growing field of research. PHSSR is aimed at establishing an evidence base to allow public health officials to make smarter, more-informed decisions with regard to resource allocation, staffing, operations and service provision.
NewPublicHealth is on the ground in Kentucky to capture the critical conversations and Q&As from leaders in the field. We spoke with F. Douglas Scutchfield, MD, director of the National Coordinating Center for PHSSR and the Peter Bosomworth endowed faculty in the University of Kentucky College of Public Health, to get his take on where the PHSSR field stands and the anticipated highlights of conference.
NewPublicHealth: What are the critical areas for public health as you head into the Keeneland Conference?
Dr. Scutchfield: I think there are several agendas that will be a backdrop against which Keeneland is taking place. One is a reformed healthcare system, with the Affordable Care Act and its implications for public health and public health’s relations with a variety of other service delivery systems, such as primary care and hospitals.
We will also see the rollout of a new research agenda, published as a supplement to the American Journal of Preventive Medicine,that will give us a new direction to pursue in terms of how we’re going to begin to try improving the infrastructure in the public health system.
NPH: What has been your sense in speaking with colleagues in the field about what kind of research is most in demand for public health leaders and decision-makers right now?