A Regional Public Health System in NH

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A Regional Public Health System in NH

• What Do We Have Now?
• Why Regionalize?
• How Do We Make a Case for Regional
• Public Health in a State Like NH?
• What Would Change?

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What Does Public Health Look Like in NH Today?

• Each of New Hampshires 234 cities and towns
  are required by law to have a health officer
• Only five New Hampshire communities maintain
  public health departments of various size
  no county health departments

• At the State level, DHHS is the lead public
  health agency. The Department of Environmental
  Services, Department of Education, and
  Department of Safety also play key roles
• In almost all New Hampshire communities,
  non-governmental organizations provide a
  significant sub-set of public health services

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2004 New Hampshire Public Health Network
Assuring the health and safety of all NH
residents

• 14 Coalitions
• 118 Towns
• 50 of NH towns
• 70 of the NH population
  
  
  
  covered
• 5-11 communities per coalition

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All Health Hazard Regions

• Organized to plan for and respond to public
  health emergencies
• 19 Regions

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And more maps for other services

• Community health centers
• Tobacco coalitions
• WIC services
• HIV prevention
• Etc, etc, etc.

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Why Regionalization?
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Potential Benefits of Regionalization

• Study in the AJPH, March 2006 examined
  performance of public health agencies, size and
  resources
• It noted that small public health agencies may
  benefit by combining resources and operations
• But gains may diminish with size too big is not
  good (but NH is small in both geography and
  population)

Mays, G, McHugh, M et al. AJPH, March 2006 Vol.
96, No. 3
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Regionalization Goal

• Overall Goal A performance-based public health
  delivery system, which provides all 10 essential
  public health services throughout New Hampshire
• Provide high quality public health based on
  national standards

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Why do we need regional public health in one of
the healthiest states?

• What is killing us and making us sick today are
  chronic illnesses (heart disease, cancer,
  respiratory disease, injuries)
• Many of the contributing factors to these are
  preventable tobacco, diet, physical activity,
  alcohol consumption
• Well-run community based public health programs
  can prevent these problems
• Money can be saved

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What is Public Health ?

• The study and practice of managing threats to the
  health of a community or population
• The public health approach is applied to
  populations ranging from a handful of people to
  the whole human population
• Priorities are to prevent (rather than treat) a
  disease or injury through the study of cases
  promoting healthy behaviors preventing the
  spread of disease and addressing policy issues.

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.
How does public health differ from health care?

• Individual vs. Populations

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Example- Smoking

• Health care response
• Treat an individual for smoking related health
  problems asthma, pneumonia, heart disease,
  cancer, etc.
• Counsel to quit smoking
• Provide nicotine replacement therapy

• Public Health Response
• Study the effects of tobacco Surgeon Generals
  report
• Labeling of cigarettes
• Public information campaigns
• Promote policies such as non-smoking workplaces
• Enforcement of laws such as limiting tobacco
  sales to minors

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Public Health Goes to You

• Unlike personal health care services, in many
  cases the public does not have to travel to
  receive public health services
• Public health staff go out to do investigations
• Public health staff analyze diseases by
  populations
• Public health education campaigns are delivered
  where people go or access information (radio,TV,
  billboards, schools, workplaces, etc.)
• So public health regions do not need to align
  exactly with hospitals or doctors offices service
  areas

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Public Health Saves Money

• 10 per person per year in proven community-based
  disease prevention (improvements in physical
  activity, nutrition and preventing smoking) could
  yield saving of 2.8 billion in health care costs
  in 2 years
• Thats 2 in return for every 1 invested in the
  first 1-2 years
• Prevention for a Healthier AmericaInvestments in
  Disease Prevention Yield Significant Savings,
  Stronger Communities. Trust for Americas Health
  July 2008 www.healthyamericans.org

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Obesity for example

• 23.6 population is obese, 61.8 are overweight
  or obese significant increase from 2005-2007
• NH ranks 35th in the nation, despite having the
  lowest poverty rate
• Worst in New England ¹
• For the first time in 2 centuries our childrens
  life expectancy is potentially less than ours
  (2-5 years) due to obesity and related factors
  (diabetes, heart disease, kidney failure, cancer)
  

F as in Fat How Obesity Policies are Failing in
America 2008, Trust for Americas Health, August
2008 www.healthyamericans.org NEJM March 2005
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Example - Obesity

• Health Care Response
• Treatment for conditions such as heart disease,
  high blood pressure, diabetes, cholesterol
• Nutritional counseling
• Bariatric surgery

• Public Health Response
• Working with schools to provide healthy lunch
  menus
• Working with community coalitions to develop
  walkable communities
• Assist in developing policies for physical
  activities in schools

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The 10 Essential Public Health Services
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The Proposed Approach

•  The DPHS and Regionalization Initiative
  workgroup envision one lead public health agency
  per region. It must be linked a governmental
  entity that is responsible to coordinate or
  directly provide the 10 essential services. The
  lead agency may subcontract or create memoranda
  of understanding for some essential services
• Regions based on existing ones (many are quite
  similar) and take into account geographic
  features, existing public health services and
  population size
• Two levels of public health (primary and
  comprehensive) that acknowledge existing
  resources and capacity to carry out public health
  services. Comprehensive Manchester and
  Nashua
• Primary everywhere else

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Approach

• Will be based on national standards for what a
  public health agency should look like and how it
  should perform
•  Will be an evolutionary process some may not
  meet all components of a primary agency from the
  beginning but will move there in time.
•  Will require changes to state law.

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The Role of Government in Public Health

• Assessment Takes into account all relevant
  factors to the extent possible, based on
  objective factors, without self-interest
• Policy Development Takes place as a result of
  interactions among public and private
  organizations
• Assurance Assures that necessary services are
  provided to reach agreed upon goals by
  encouraging the private sector, requiring it, or
  providing services directly

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A Primary Regional Public Health Agency

• Staff, funding, and legal recognition to assure a
  fundamental public health presence
• Performs some level of the 10 essential services
• Collaborates extensively with system partners in
  the region to coordinate more comprehensive
  services
• The NH DPHS continues to provide some core
  services (i.e.. lab, disease investigations) to
  these regions
• Coordinates with local health officers or move
  towards shared health officer among municipalities

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Proposed Staffing

• Every region would have
• Administrator
• Health educator/marketing staff
• Nurse (?)
• Environmental health specialist
• Support staff

• Shared across regions
• Epidemiologist
• Emergency preparedness coordinator
• Medical consultant
• (Shared or in-kind)
• Financial manager
• IT support

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How is this Different than the Public Health
Networks?

• Proposal that there be a legally-recognized
  regional public health council which
• Designates a lead public health entity that
• Is responsible to the council and regional public
  health system partners for
• Implementing a coordinated approach to provide
  public health services to the public

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Next Steps-What Do We Have?

• Assessments to Help Us Determine, Resources,
  Costs, Needs and Approach
• June 2008- February 2010
• Financial analysis of all state/local/private
  public health funding with consideration of
  efficiencies from regionalization Patrick
  Bernet, FAU
•  Assessment of local/regional public health
  system capacity to deliver the 10 essential
  services- with a gaps analysis Lea Lafave, CHI
•  Assessment of what the link to government could
  look like - Jennifer Wierwille Norton

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Financial Assessment

• To gain an understanding of current public health
  expenditures in each region and for the state as
  a whole
• Will capture state, municipal and private-sector
  funding
• To try to understand the potential financial
  implications of regionalizing select public
  health services

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Capacity Assessment

• Purpose
• To identify assess and gaps in the region and
  these that may lend themselves to
  regionalization.
• Process
• Framework of the National Association of City and
  County Health Officials
• Essential Service
• Standard
• Indicator
• Revised Tool
• Lead organization Regional Partners State

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What is the Governance Assessment?

• Focuses on figuring out whos responsible or held
  accountable not doing the work but overseeing
  it
• Whos overseeing performance of the public health
  entities who are partners.
• Whos assessing the degree to which the partners
  in the region have the necessary authority,
  resources and policies to provide essential
  public health services.
• Assures that the infrastructure exists to protect
  and promote health in the community.

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Governance Assessmentin Two Parts

• Part I Examining Readiness to Serve in a
  Governance Function
• The first part of the assessment provides a tool
  to measure the regions readiness to serve as
  governing body or Public Health Council to
  oversee the delivery of services and programs.
• Part II Examining Types of Lead Public Health
  Entities
• Participants will use part II of the tool to hold
  a facilitated discussion about the different
  options available for the regions Public Health
  Council to choose as a lead public health entity
  (type of entity).

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What Will Change?

• Statewide, regional and more formalized
  recognized system, in law that provides a more
  even level of each essential service
• Coordinates the current fragmented system that
  delivers very different levels of service
• More efficient use/better coordination of
  existing resources
• Based on national standards -PHAB

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What Wont Change?

• Municipalities retain legal authority for
  enforcing state laws and local ordinances
• DPHS provides some core services such as lab and
  disease control
• Local agencies will still receive funds directly
  from DPHS but will need to be part of the
  regional system

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And the benefits will be

• Higher quality services at the best possible cost
• Ability to measure ourselves against national
  standards
• Better positioning for increasingly competitive
  federal funds

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Questions?

• Joan Ascheim
• NH Dept of HHS, Division of Public Health
  Services
• jascheim_at_dhhs.state.nh.us
• 1-800-852-3345 ext. 4110
• Lea Lafave
• Community Health Institute/JSI
• 603.573.3335
• lea_ayers-lafave_at_jsi.com