Public Health Departments Partner Across Regions to Provide Expanded Services
The impact of the economic crisis on budget coffers has prompted a growing number of state and local health department officials to consider cross-jurisdictional sharing as a strategy to cut costs and deliver services more effectively and efficiently. At the 2011 APHA meeting, a packed room of researchers and practitioners from across the country heard from a panel on this emerging topic, which included presentations on the experience of two states with vastly different sociopolitical landscapes: sprawling Colorado with its large rural expanses, and dense Massachusetts with its 351 local boards of health, just over half of which serve 10,000 people or less.
Despite the differences, two major themes dominated the discussion, which was moderated by Pat Libbey, former executive director of the National Association of County and City Health Officials and now a consultant and leading expert on cross-jurisdictional sharing: more information is needed to illuminate which approaches may be most appropriate for specific locales, and proactive stakeholder engagement is critical to gain buy-in for changes that may be seen as potential threats to local control.
"The minute you say regionalization, it’s a top-down approach," said Lisa VanRaemdonck, MPH, MSW, executive director of the Colorado Association of Local Public Health Officials and co-director for the Colorado Public Health Practice-Based Research Network, who shared findings from a recent examination to identify what types of service-sharing among local health agencies are most prevalent in the Centennial state, what the law allows, and why agencies have entered into these agreements and relationships. "Language and finding a careful balance is really important."
VanRaemdonck said the Colorado Public Health Act of 2008 allows the creation of district health departments to do regional work, and many agencies have begun regional approaches to provide services that were not previously available.
Justeen Hyde, PhD, senior scientist at the Institute for Community Health in Cambridge, Mass., and an instructor at Harvard Medical School, presented findings from interviews with local public health officials to inform the formation of local public health districts in Massachusetts created through a Centers for Disease Control and Prevention infrastructure grant in 2010.
Hyde said most local public health services in Massachusetts focus on regulation and enforcement, and municipalities are grappling at once with vast disparities in the qualifications of the public health workforce and with the competition of public health priorities against local issues (such as schools, emergency services and potholes). She said an increasing number of cities and towns in the state are open to the concept of working together to increase capacity to meet national public health performance standards and provide state-mandated services, or to expand services that are currently offered. "There is a lot more service-sharing going on than I think anyone recognizes in our state," she said. What there is not, she said, is clear guidance or an evidence base on the ideal composition of a local public health department based on population size or other demographic variables, or on the array of services that should be offered. “Research focused on the structure and organization of local health departments would be incredibly valuable to jurisdictions that want (or are required) to partner in service delivery,” she said.
Hyde also noted the importance of leadership, and advised that public health officials and other leaders who would like to pursue the possibility of service sharing agreements involve elected officials early, and “sit down and think first about what they want to get out of it, and then find like-minded partners.”
Julie Willems Van Dijk, RN, PhD, community engagement director of the County Health Rankings, noted that the Rankings model can provide a framework to help leaders across jurisdictions appreciate the crucial factors outside health care that drive health in communities – such as high school graduation rates and prevalence of obesity and poverty – and identify policy and systems changes that communities can come together around. As an example of this type of action, she cited Wyandotte County, Kansas, where Mayor Joe Reardon has spearheaded an effort involving elected officials, public health leaders and residents in advancing solutions to the county’s health problems. Similarly, in Michigan, Clare County’s low ranking in the 2010 County Health Rankings served as a call-to-action for Central Michigan District Health Officer Mary Kushion, who convened a health summit and has since led a process involving a range of leaders, officials and citizens to develop a plan to improve the health of the more than 187,000 people living in the six-county region. “Action to focus on the social determinants of health needs to involve not just public health agencies but elected officials, business leaders, community leaders and funding partners all coming together,” Van Dijk said.
The Robert Wood Johnson Foundation recently commissioned two studies to begin building a body of knowledge and best practices to help guide local health agencies through the process of developing and executing shared service agreements. Libbey’s study draws from interviews with leadership and key staff at national public health and policy-maker organizations, and with state and local public health leaders and local policy-makers in seven states where some communities have experience with cross-jurisdictional relationships between local health departments. A companion report by Nancy J. Kaufman of The Strategic Vision Group examines the potential benefits of consolidating public health services in order to reduce costs and increase quality. Read both reports here. The Foundation has also supported projects in Kansas and Massachusetts to explore regionalization and shared approaches to public health.