1 Across the nation, constant improvement in public health is - - PDF document

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Across the nation, constant improvement in public health is carried out via continuous cycles of assessment, planning, action, and evaluation. Nationally, assessment efforts such as the County Health Rankings help determine health issue areas for celebration and improvement. Likewise, the National Public Health Performance Standards Program structures assessment of our ability to provide essential health services. Initiatives like the Center for Disease Control’s Winnable Battles identify focus areas for planning

• efforts. Healthy People 2020 and similar efforts orient action and evaluation efforts by providing

baseline measures, standards and goals to which to aspire, and indicators to measure progress. At the state level, the Colorado Public Health Act was signed into law in 2008 to assure that core public health services are available to every person in Colorado with a consistent standard of

• quality. The state of Colorado has developed a comprehensive public health improvement plan

that outlines how quality public health services will be provided. At the county level, the Colorado Public Health Act also mandates that each local health department conduct a community health needs and system capacity assessment and develop its

• wn corresponding local public health improvement plan.

At the agency level, BCPH develops operational plans for each program that respond to the local, state, and national needs and capacity. Further, over the next few years, BCPH will develop an agency strategic plan and will apply for accreditation as a local public health department. The operational name for these nested processes is the Public Health Improvement Process, or

• PHIP. The various PHIP cycles span periods of one, five, and ten years. PHIP requires closely-

coordinated work at the state and county levels to develop health improvement plans.

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At the same time that the nation and the state move forward with public health improvement, Boulder County moves forward with our PHIP. Here’s our “road map.”

• Essentially, we assessed health needs, then assessed the capacity of our health system to

address those needs.

• We then chose a few focus areas on which to concentrate system-wide health improvement

efforts over the next few years.

• Now, we’re ready to engage the community in unified, integrated strategic planning around

those focus areas.

• After that, we’ll take action.
• We’ll close out the cycle by evaluating how we are doing.
• Every 5 years, we start the cycle over again.

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To identify our top health needs, the idea was to draw on existing literature and experience, secondary data (no primary data collection this time), and staff and community partner expertise to first define the broad realm of health issues and subsequently to whittle those down to a manageable number of issues, for each of which we could explore the local data behind it and use a transparent process to prioritize them to yield a small number of health improvement focus areas. How did we do this? First, given the plethora of health issues, the size of our health system, and the intricacies of prioritization, we hired consultants: Primetime Research & Evaluation. This was a key decisions, as it allowed us to come to the table and sit next to our community partners and listen and contribute to the discussion rather than directing it. Primetime did an archival and literature review on the public health improvement process at the national, state, and local levels, of tools available for this task, of means of prioritization, etc. They conducted one-on-one and group interviews with staff and community partners. In this process, Primetime engaged more than 200 people representing over 50 entities in our local public health system, many of which are represented here today. At the same time that Primetime reached into our community, an internal BCPH team reached into the data. We studied the range of health issues and focus areas at the national, state, and local levels. We looked at everything from the CDC’s 6 winnable battles to the state health department’s focus areas, to local strategic planning efforts. We were able to assemble a list of 40 broadly-recognized health outcomes that Primetime then took back to staff and community for your thoughts. Primetime collected input on these 40 issues as well as other health issues that arose, and analyzed it in both quantitative and qualitative terms. This analysis yielded recommendations for 7 potential health improvement focus areas.

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Mental health, substance abuse, unplanned pregnancy, and obesity were recommended based on the community

• input. Cancer, heart disease, and unintentional injury were recommended as these are the top 3 causes of death in

Boulder County. Further, Primetime urged us to adopt mental health and substance abuse due to the very broad and deep staff/public sentiment about the need in these areas. Because it can take significant time, resources, and support to impact health trends, we voted to take on just three focus areas. An internal BCPH team studied the quantitative and qualitative data collected from literature, staff, and partners, and were tasked with prioritizing the 7 recommended areas on the basis of:

• the number of people they impact
• the degree to which they cause poor quality of life and death
• the degree they are perceived as serious health issues among our staff and community stakeholders
• the degree to which they are actionable (there are existing, demonstrated practices that could improve outcomes)

[Additional notes on each focus area if necessary.] Mental Health: Almost everyone interviewed identified Mental Health as a top health issue area and indicated that they felt current resources were inadequate to meet the need in Boulder County. Discussion of the impact of mental health on physical health, as well as the wide spread impact depression and other mental health problems have on those around the sufferer were also mentioned. Substance Abuse: People also agreed that substance abuse was an issue in Boulder County. Many people felt that this fell under mental health; many others identified it as a separate issue. Again, the primary feeling was that there were drastically limited resources compared to the need they see within the county. Unplanned and Teen Pregnancy: This was mentioned by many as a fundamental problem that needs to be addressed due to major consequences for the parents and children involved and for the county and its monetary output in services for these families. In addition, this was frequently cited as an underlying issue for many of the health problems on the outcomes list and was directly connected to both mental health issues and substance abuse. Obesity: This was identified as a major health concern despite its absence from the original list of outcomes. Most people felt that this was an underlying cause of most of the health outcomes on the list presented to them. They also felt that this was an area that was specifically a problem in East Boulder County and among the Latino population, and that it is an important one to address in order to improve communitywide health.

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From the 7 issue areas brought forth by Primetime, BCPH identified 3 focus areas for system-wide public health improvement in Boulder County: mental health (including depression and suicide), substance abuse, and obesity (healthy eating and active living, aka HEAL). These 3 focus areas do not necessarily aligned with any one single program or organization; rather there is overlap between programs, divisions, and the work of our community partners. Rather than replacing programs, these focus areas complement ongoing health and wellbeing work by providing a system-wide, unified focus for the next 5 years. Focus areas will help us to integrate services, activities, and communication between programs and partners. Our goal is to see county-level improvements in these focus areas within the next five years. As you’ve heard, these focus areas are both the recommendation of the local public health system and the shared responsibility of the system, including BCPH and all who work to improve health in Boulder County. So, if moving the needle on these focus areas is a shared responsibility of our public health system, the next thing we needed to know is what our system capacity is to address public health

• needs. Simultaneous with the health needs assessment then, was a health system capacity
• assessment. Again, Primetime helped us out.

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Primetime used a larger local public health quality improvement process known as the National Public Health Performance Standards Program (NPHPSP). This program supports local health systems in answering questions such as, “What are the components, activities, and competencies of our public health system?” and, “How well are the Ten Essential Public Health Services being provided in the local public health system?” The Ten Essential Public Health Services, shown in this color wheel, are the means of addressing our needs. They include monitoring health status, diagnosing and investigating health problems and hazards, informing and educating, mobilizing partnerships, developing policy, enforcing laws and regulations that protect health, linking people to care, assuring a competent workforce, evaluating our work, and conducting needed research. The system capacity assessment is based on:

• this ten essential public health services framework,
• a focus on the public health system (which includes and extends far beyond the health department),
• a set of optimal standards to which to compare our system, and
• continuous quality improvement.

The health system capacity assessment tool contained over 300 questions designed to generate discussion and a rating of the major activities, components, and practice areas for each essential service. Primetime facilitated 10 small group meetings, consisting of staff and community partners (many of you), in which participants discussed our system capacity to perform one of the essential services. Group discussion and consensus-building yielded a collective rating, a quantitative score, as well as qualitative data.

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I’m happy to report that our public health system has the capacity and infrastructure to provide the ten essential public health services to those who live, work, study, and play in Boulder County. In fact, our public health system did better

• n this capacity assessment than did others across the nation!

As the bars indicate here, most of the essential services assessed already have moderate to significant levels of activity (38%-74%). One area exceeds the optimal (>75%) level of capacity: diagnosing and investigating health problems and protecting people from health problems and hazards. Our system also received strong ratings in enforcing public laws, developing policy and plans that support community efforts, and evaluating accessibility and quality of services. The lowest ratings were given in monitoring and diagnosing health problems and informing, educating, and empowering people about health issues. That said, there were no areas that received a rating less than 25%, indicating little or no activity. If you take a look at the black lines, these indicate the range of ratings among participants, evidence that the final group consensus on one rating incorporated a wide variety of perspectives and considerable discussion. I’m proud to say that we took process that is typically conducted by a handful of health department administrators, and expanded it to include the direct input of hundreds of people and many institutions in a system-wide approach to identifying both our county’s health needs and our system’s capacity to address public health needs. It is now evident what health issue areas most need improvement in our county, as well as where our system capacity shines and where it needs improvement. This sets the stage for the next steps in Boulder County’s public health improvement process: strategic planning.

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As we think about where we want to go its always helpful to revisit where we’ve been. Certainly these advertisements from the 40’s, 50’s, and 60’s demonstrate how far we’ve come. The Robert Wood Johnson Foundation conducts a County health Rankings assessment each year, which places Boulder at 4th healthiest in CO. I would challenge all of us to think about how we move from #4 to #1 in the next five years.

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As we spoke earlier about requirements of the Public Health Act, we felt it is important to show what those requirements look like for BCPH. Our next step is to develop our local public health improvement plan, a 5-year, systematic road map for community and/or regional partners to improve the public health system and the population’s health. With these three focus areas in mind, we hope to unite common providers around shared issues, goals, measurements and results, and then actively support and strengthens strategies that work. Motivating existing health partners to tackle these issues in a collective manner. Develop a single

• ver-arching goal or vision for each task force. Share outcomes data and measure progress

toward agreed upon measureable objectives. What are the concrete changes we aspire to make? If we are successful, what will change in five years? This plan must… To accomplish this, we will implement both internal and community structures. First, lets take a look at what we are proposing for the community structure (Next Slide)

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As we spoke earlier about requirements of the Public Health Act, we felt it is important to show what those requirements look like for BCPH. This plan must…

• Illustrate health needs
• Describe health system capacity
• Identify focus areas for improvement
• List the contributing partners
• Outline steps or strategies for improvement
• Describe method for evaluating progress

To accomplish this, we are proposing an internal structure (ie. a Steering Committee) and a community structure (ie. a Task Force for each focus area). First, lets take a look at what we are proposing for the community structure (Next Slide)

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Drawing on community and staff expertise, BCPH will facilitate a process to incorporate the three areas into a local public health improvement plan. A task force will be established for each focus

• area. Each task force will, for one focus area:
• review and supplement data
• determine what is currently being done
• identify contributing factors
• identify specific strategies that can be implemented by BCPH and/or partnering organizations

to address these factors

• define specific populations needing attention
• set measurable targets for improvement over the next five years
• develop an action plan

In order to make a significant impact, the key will be to address each issue together with partners, through integrated services and approaches. When identifying strategies, the task forces will consider:

• the resources needed to implement the strategy
• the individual factors at play (i.e. current behaviors, mental health status, access to care etc.)
• the social circumstances (determinants) at play (i.e. physical environment, social factors,

economic opportunity) The task forces will work together to share tools and resources and identify overlap among focus areas and strategies (i.e. mental health and substance abuse). Timeline is approximately four months with the first meeting to hopefully occur in early October.

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This should keep us on track to seek approval from our Board of Health within the first quarter of next year.

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Here’s an example of a local public health improvement plan that better demonstrates what we are looking for when thinking about measureable objectives and tracking progress over time. This example comes from NYC. You can see that they clearly identify, in simple language, what they want to do, what indicators they will use to measure progress, what their baseline was, and what their measureable objective is. Each year NYC does an annual report on their health improvement plan to better track and report

• n their progress.

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Today, we’d like help identifying a pool of potential task force members from which the BCPH Steering Committee will select 8-12 participants for each task force. Individual attributes:

• specific focus area expertise
• solid working knowledge about what the community is currently doing to tackle the issue
• Credible from the perspective of those partners not at the table

Task Force attributes:

• Mix of ground-level and system-level representation
• Mix of BCPH staff and system partners
• Representation of communities more adversely affected by disparities in one of the focus

areas Time Commitment:

• August through December
• Meet up to 3 times per month
• Will likely require additional time outside of these meetings on an order of 4-8 hours per month

Selection of Participants:

• Made by BCPH Management Team
• Mix of invitations and applications
• Meets above attributes

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• Staff must have supervisor approval

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BCPH will convene a Steering Committee that will help ensure our local public health improvement plan meets the requirements of the Public Health Act. Additionally, these committee will help ensure the necessary support exists for the task forces. For example,

• Facilitation will help keep the task forces moving align given the sort turn around. The

facilitator will also serve as a liaison between the task forces to ensure they are working together where and when appropriate.

• As an agency we will help ensure the needed administrative support exists, for example,

scheduling meetings, confirming locations, providing meeting minutes, etc. Again, this will hopefully help enable the task forces to progress smoothly. Additionally, we will obtain the desired technical assistance if and when necessary from the state health department or other counties who are also conducting their assessment and planning processes.

• We recognize that participation is one of the limiting factors in this structure, so we want to

work on improving the information flow and opportunities for input to those that aren’t participating on the task force. Jeff will talk more about this a bit later.

• And finally, the steering committee within BCPH will ensure all the requirements are met as

described in the public health act of 2008. Ongoing Support

• Resource development to implement, strengthen, and improve strategies over time
• Help connect or leverage current work throughout the county on these issues

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How will we develop and carry out a local PHIP Plan? Sep - Jan Task forces will work to develop long-term measureable objectives and the strategies that can be implemented throughout the community to successfully reach that objective Jan - Feb BCPH will incorporate the targets and strategies identified by each task force for each focus area into the public health improvement plan for Boulder County. Feb - Mar As required by the Public Health Act of 2008, the Boulder County public health improvement plan will be submitted to the Colorado Board of Health. 2012-2015 The public health system will carry out Plan strategies. We aim to begin the assessment and process again in 2015, in alignment with the Public Health Act of 2008 and the state PHIP process. Ongoing tasks include oversight by a BCPH PHIP Steering Committee, linkages to other community efforts, evaluation, and communication.

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We recognize how important ongoing communication is to this process. As task force members develop measureable objectives and the strategies that will help us reach those objectives, there will be a need to share information, as well as create

• pportunities for additional input to further strengthen the work of each task force.

To help ensure this communication is open and timely we are proposing a few strategies

• External website and/or Internal website
• List serve – more information - feedback directly to representatives
• Direct reach outs (forums)

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To support our message, we will combine data management and display with outreach. This includes:

• easy reference to indicators and trends
• target graphs
• trend analysis

… all of which drive strategic direction.

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