May 2009

Grant Results

National Program

Changes in Health Care Financing and Organization

SUMMARY

In this 2006 to 2007 project, Michael A. Stoto, Ph.D., and a team of researchers and public health officials at RAND Corporation and elsewhere conducted case studies of five regional public health structures and then compared them. (Regional public health structures are local public health departments that work together to maximize resources and improve responses to emergencies and the provision of essential public health services.)

The five regions were Massachusetts; one region in the Boston area; Northern Illinois; Nebraska; and the Washington, D.C., metropolitan area. Each case study documents the rationale for creating the regional public health structure and describes how it was organized, implemented and governed.

The project was part of the Robert Wood Johnson Foundation (RWJF) Changes in Health Care Financing and Organization (HCFO) national program (see Grant Results for more information). HCFO supports policy analysis, research, evaluation and demonstration projects that provide public and private decision leaders with usable and timely information on health care policy and financing issues.

Key Findings
The project director reported the following findings in an article in Public Health Reports (July–August 2008):

  • The five regions developed their regional public health structures using different combinations of coordination, standardization, centralization and networking. Each region used multiple approaches for different public health functions.
  • Regionalization improves public health preparedness by allowing for more efficient use and better coordination of resources.
  • Regionalization may improve public health in general.

Funding
RWJF provided a $145,594 grant for the project from 2006 to 2007.

 See Grant Detail & Contact Information
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THE PROJECT

Heightened concerns about bioterrorism and general public health preparedness after September 11th led many states to set up or enhance regional public health structures. Regional public health structures are local public health departments that work together to:

  • Leverage or pool available resources
  • Improve their ability to respond to an emergency
  • Improve their ability to provide essential public health services.

Regions can be composed of part of a state or parts of neighboring states in a metropolitan area.

To enable local public health departments developing regional public health structures to learn from their colleagues' collective experience, Michael A. Stoto, Ph.D., and a team of researchers from the RAND Corporation, universities and health departments as well as public health officials conducted case studies of five regions and then compared them. Stoto, formerly with RAND, is a professor of health systems administration and population health at Georgetown University.

The team prepared case studies covering:

  • Massachusetts
  • One region in the Boston area
  • Northern Illinois
  • Nebraska
  • Washington, D.C., metropolitan area.

Each case study documents the rationale for creating the regional public health structure and describes how the structure was organized, implemented and governed. Some of the case studies were based on interviews by Stoto and the RAND researchers with public health officials and other people in the regions who were familiar with the issues and on document review and observations. Other case studies were prepared by public health officials on the team who were directly involved in creating the regional public health structures.

To make the case studies comparable, the team used a similar outline and framework based on four approaches to regionalization identified by the National Association of County and City Health Officials:

  • Networking
  • Coordinating
  • Standardizing
  • Centralizing.

For more information about these approaches, see the Appendix.

To review the case studies and identify commonalities and differences, the team held a workshop (October 12–13, 2006, in Washington, D.C.) with public health officials and other people from the regions covered by the case studies, as well as national public health experts.

The team published an overview article and the five case studies in Public Health Reports. Stoto also wrote an issue brief under a subcontract with the California Health Policy Forum. See the Bibliography for details.

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FINDINGS

Stoto reported the following findings in the overview article, "Regionalization in Local Public Health Systems: Variation, Rationale, Implementation and Impact on Public Health Preparedness" (Public Health Reports, July–August 2008).

  • The five regions developed their regional structures using different combinations of coordination, standardization, centralization and networking. Each region used multiple approaches for different public health functions.
    • Coordination was common in regions with relatively well-established, independent health departments, such as Northern Illinois and the Washington metropolitan area.
    • Standardization was used less frequently. Typically, the regions that used coordination also used standardization.
    • Centralization was seen in various forms in most regions. For example:
      • Nebraska created local public health departments to serve multiple areas that previously had no local public health agency.
      • Three regions—Massachusetts, the Boston area and the Washington metropolitan area—have staff members dedicated to preparedness activities. These staff members relieve the burden of local public health department staff and can assist in emergencies.
      • The Washington metropolitan area also established central capacities for surveillance and communication.
    • In areas where regionalization was new, networking was the most common approach used. Networking was most prominent in the Washington metropolitan area, where the number of jurisdictions and federal agencies involved made it unlikely that a clear chain of command would ever exist:
      • Networking was seen as effective in planning and other preparedness efforts and in building social capital by forging connections among people in different agencies who would have to work together during a public health emergency.
  • Regionalization improves public health preparedness by allowing for more efficient use and better coordination of resources.

    The case studies demonstrated progress in terms of:
    • Planning and coordination
    • Regional capacity building, training and exercises
    • Development of professional networks.
    The case studies also suggest that information technology can build regional preparedness by coordinating planning and emergency response activities. Information technology also enables regional capacity in ways that were not previously available. For example, an epidemiologist with an Internet connection and a phone line can serve a large geographical area, going into the field only when necessary.
  • Regionalization may improve public health in general. Although this analysis focused on emergency preparedness, there is reason to believe that regional public health structures could improve public health services in other areas as well.

    Public health needs are not fundamentally different during an emergency and at other times. For example, regional epidemiology offices capable of detecting bioterrorism or pandemic flu can be used to monitor the spread of seasonal flu and chronic disease risk factors more efficiently than can each local public health department.

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CONCLUSIONS

The case studies illustrate a range of different approaches to regionalization, but a more systematic effort documenting the changes that have taken place at the local level would provide useful information for public health policy-makers. Case studies, by their nature, cannot provide strong evidence of efficacy, so the findings should be read as suggestions rather than definitive findings.

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GRANT DETAILS & CONTACT INFORMATION

Project

Regionalization in local public health systems: Variation in rationale, implementation and impact on public health preparedness

Grantee

RAND Corporation (Arlington,  VA)

  • Amount: $ 145,594
    Dates: February 2006 to April 2007
    ID#:  056470

Contact

Michael A. Stoto, Ph.D.
(202) 687-3292
stotom@georgetown.edu

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APPENDICES


Appendix 1

Approaches to Regionalization

  • Networking: This is the most informal and often the first aspect of regionalization to be implemented. It involves sharing preparedness information and approaches to planning. Although networking can lead to coordination of efforts across jurisdictions, it is done on an individual basis for mutual benefit and is not actively managed.
  • Coordinating: This occurs when local public health departments within the region work together to plan events such as meetings, training or exercises. Regional preparedness is achieved through actively managed coordination of individual local health departments.
  • Standardizing: This creates some uniformity across individual health departments in the region through mutual adoption of planning tools, press releases and response procedures, leading to interoperability among the health departments for one or more emergency preparedness functions. All response functions remain under the operational control of the individual health departments in which they reside.
  • Centralizing: This occurs when resources for planning or response are brought together or controlled by a centralized entity. Resources could be a single Web portal, an emergency notification system or a single regional training contractor or regional staff to provide epidemiologic support. Regional preparedness is achieved by pooling resources in a separate regional entity that would function as if it were a regional public health agency for certain functions during an emergency.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Grieb J and Clark ME. "Regional Public Health Emergency Preparedness: The Experience of Massachusetts Region 4b." Public Health Reports, 123(4): 450–460, July–August 2008.

Koh HK, Shei AC, Judge CM, et al. "Emergency Preparedness as a Catalyst for Regionalizing Local Public Health: The Massachusetts Case Study." Public Health Reports, Web Exclusive, 123(4): July–August 2008.

Lenihan P. "Regionalization in Local Public Health Departments: The Northern Illinois Public Health Consortium." Public Health Reports, Web Exclusive, 123(4): July–August 2008.

Palm D and Svodoba C. "A Regional Approach to Organizing Local Public Health Systems and the Impact on Emergency Preparedness: The Nebraska Experience." Public Health Reports, Web Exclusive, 123(4): July–August 2008.

Stoto MA. "Regionalization in Local Public Health Systems: Variation in Rationale, Implementation, and Impact on Public Health Preparedness." Public Health Reports, 123(4): 441–449, July–August 2008.

Stoto MA and Morse L. "Regionalization in Local Public Health Systems: Public Health Preparedness in the Washington Metropolitan Area." Public Health Reports, 123(4): 461–473, July–August 2008.

Reports

"Regionalization in Local Public Health Systems." (Issue brief) Sacramento, CA: California Health Policy Forum, September 2007.

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Report prepared by: Barbara Matacera Barr
Reviewed by: Lori De Milto
Reviewed by: Molly McKaughan
Program Officer: Nancy Barrand

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