State Public Health System Assessment - Maine
State Public Health System AssessmentA Brief Review of the FindingsFinal ReportSeptember, 2010Prepared for:Maine Center for Disease Control and Prevention286 Water StreetState House Station 11Augusta, ME 04333-0011Prepared by:Brenda Joly, PhD, MPHGeorge Shaler, MPHMaureen Booth, MRPMuskie School, University of Southern MaineP.O. Box 9300Portland, ME 04101For More Information Contact: bjoly@usm.maine.edu
State Public Health System AssessmentBackgroundThe Maine Center for Disease Control and Prevention contracted with the University of Southern Maine’sMuskie School to conduct an assessment of the statewide public health system based on the National PublicHealth Performance Standards Program state assessment tool. The purpose of this assessment was toidentify system strengths and gaps to inform the development of an improvement plan.Format of the ReportThis summary report provides a brief overview of the assessment process and a synopsis of the majorfindings for each of the 10 Essential Public Health Services (EPHS). The EPHS include:1. Monitor health status to identify community health problems.2. Diagnose and investigate health problems and health hazards in the community.3. Inform, educate, and empower people about health issues.4. Mobilize community partnerships to identify and solve health problems.5. Develop policies and plans that support individual and community health efforts.6. Enforce laws and regulations that protect health and ensure safety.7. Link people to needed personal health services and assure the provision of health care whenotherwise unavailable.8. Assure a competent public and personal health care workforce.9. Evaluate effectiveness, accessibility and quality of personal and population-based health services.10. Research for new insights and innovative solutions to health problems.Assessment ProcessThe assessment was conducted in May 2009. A broad range of participants from various disciplines wereinvited to participate and approximately 110 were in attendance at the assessment meeting. Participantswere assigned to one of five groups, each focusing on a different set of essential services and questions.Rating cards were used to signify a participant’s perception of the system’s performance on an element.When perceptions varied widely during the initial vote, further discussion took place and the commentswere recorded. Prior to the breakout sessions, an overview of the assessment process, tool andexpectations was provided. A follow-up meeting was held in June to identify the specific contributions of thestate public health agency and to share preliminary results.Benefits and Limitation of AssessmentWhile there is an element of subjectivity to this assessment and the findings are based on the knowledge ofthose who participate in the process, there are several benefits. We anticipate this assessment will result in:1) increased collaboration among system partners, 2) a more informed public health system, particularlyregarding system strengths and opportunities, 3) increased identification of opportunities for qualityimprovement efforts, and 4) benchmarks for public health practice improvement.2
Summary of Overall ResultsScores for Essential Public Health ServicesAs depicted below in Figure 1, Maine’s overall score was 41 with a range of 14 (EPHS #10) to 68 (EPHS #2).The top three performing EPHS include: 1) diagnose and investigate health problems and health hazards, 2)develop policies and plans that support health efforts, and 3) enforce laws and regulations that protecthealth and ensure safety.FIGURE 1. SCORES FOR ALL ESSENTIAL PUBLIC HEALTH SERVICESOptimal Performance 10010090Essential Public Health rkforceEvaluateResearch1. Monitor health status2. Diagnose and investigate3. Inform and educate4. Mobilize partnerships5. Develop policies and plans6. Enforce laws and regulations7. Link people to needed services8. Assure competent workforce9. Evaluate health services10. Research for new insightsMaine versus National ScoresFigures two and three highlight Maine scores compared to national aggregate results (provided by CDC) inrank order. In general Maine’s scores were lower in all but two essential services (EPHS #2, #3). Essentialservices eight and ten were dramatically lower than the national score, suggesting areas of opportunity.FIGURE 2. COMPARISON OF MAINE WITH NATIONAL AGGREGATE SCORES100Maine90National80706068 6340445549 EvaluateResearch3
FIGURE 3. DIFFERENCES IN MAINE SCORES BASED ON NATIONAL AGGREGATEHigher than NationalAggregate Scores151055National AggregateScores02-2-1-3-6-5-5-10Lower than NationalAggregate Scores-5-13-13-15MonitorDiagnoseEducateMobilize Plan/PolicyEnforceLinkWorkforceEvaluate ResearchScores for Model StandardsThe assessment instrument was organized into four areas known as model standards including: planning andimplementation, state-local relationships, performance management and quality improvement (QI) andpublic health capacity and resources. Overall, the assessment revealed system strengths in planning andimplementation for many of the essential public health services. Appendix A provides additional data on theresults for each essential service by model standard for both Maine and the national aggregate.FIGURE 4. OVERALL SCORES FOR MODELS 2433420100Planning andImplementationState and LocalRelationshipsPerformance Managementand QIPublic Health Capacityand Resources4
Essential Public Health Service #1: Results At-A-GlanceMonitor Health Status to Identify and Solve Community Health ProblemsThis essential service includes FIGURE 5. SCORES FOR MODEL STANDARDSAssessment of statewide health status and itsdeterminants, including the identification of healththreats and the determination of health service needs.Analysis of the health of specific groups that are athigher risk for health threats than the generalpopulation.Identification of community assets and resources,which support the state public health system (SPHS) inpromoting health and improving quality of life.Interpretation and communication of healthinformation to diverse audiences.Level ofCollaboration in integrating and managing publicActivityhealth related information systems.Optimal Level of E 1. SCORES FOR ESSENTIAL SERVICE #1Item1.1 Planning and Implementation1.1.1 Surveillance and monitoringprograms1.1.2 Health data products accessibleto data usersScore6547Key Findings 481.1.3 State health profile751.1.4 Disease reporting system781.1.5 Protection of personal healthinformation75 1.2 State-Local Relationships1.2.1 Assistance in interpretation anduse of health data1.2.2 Uniform set of timely communitylevel health data1.2.3 Assistance with local informationand monitoring systems1.3 Performance Management and QualityImprovement1.3.1 Review effectiveness inmonitoring efforts1.3.2 Active performance management2625 2925 4744501.4 Public Health Capacity and Resources381.4.1 Commit financial resources251.4.2 Coordinate system-wideorganizational efforts461.4.3 Workforce expertise44Our small state allows for direct access to people and afair amount of information exchangeThere are several quality improvement efforts in the staterelated to this essential service including the work ofepidemiologists in assuring data qualityProactive infectious disease identification capacity hasbeen built and established in the past few years withskilled people in place. (e.g.,H1N1 efforts)More financial and personnel resources are needed tocarry out this essential serviceExisting datasets are often not adequate in size and aremissing important information (e.g., race/ethnicity,occupational health)There is limited training on the use of existing data,including how to interpret the information.Possible Next Steps Seek opportunities to strengthen, integrate and automatepublic health data systemsContinue promoting the application of qualityimprovement to assure adequate monitoring ofcommunity health statusContinue coordinating with system partners to integrateand expand public health data collection effortsProvide training at the district and local level on data use5
Essential Public Health Service #2: Results At-A-GlanceDiagnose and Investigate Health Problems and Health Hazards in the CommunityThis essential service includes FIGURE 6. SCORES FOR MODEL STANDARDSEpidemiologic investigation of disease outbreaks andpatterns of infectious and chronic diseases, injuries, andother adverse health conditionsPopulation-based screening, case finding, investigation,and the scientific analysis of health problemsRapid screening, high volume testing, and activeinfectious disease epidemiologic investigationsOptimal Level of Performance70TABLE 2. SCORES FOR ESSENTIAL SERVICE #2Item2.1 Planning and Implementation2.1.1 Broad scope of surveillanceprograms2.1.2 Enhanced surveillance capability2.1.3 Statewide public healthlaboratory system2.1.4 Laboratory analysis capabilities2.1.5 Investigations of health problems2.2 State-Local Relationships2.2.1 Assistance with epidemiologicanalysis2.2.2 Assistance in using laboratoryservices2.2.3 Guidance in handling publichealth problems and threats2.2.4 Capability to deploy responseteams to local areas, when needed2.3 Performance Management and QualityImprovement2.3.1 Review surveillance andinvestigation procedures2.3.2 Active performance management2.4 Public Health Capacity and Resources2.4.1 Commit financial resourcesScoreLevelLevel ignificant547378Key Findings 75736956 75717575 757558502.4.2 Coordinate system-wideorganizational efforts542.4.3 Workforce expertise69Maine’s monitoring and investigation capacity forinfectious diseases is fairly robust and includes state andregional capacityMaine’s statewide public health laboratory system is awell-functioning systemSeveral state-level programs routinely receive surveillancedata and review their individual surveillance programThere are ongoing reviews for many surveillance andinvestigative proceduresThere are few local epidemiologists and limited data isavailable at the local levelExisting epidemiology efforts lack integrationThere are several gaps in surveillance data including:mental health, substance abuse, occupational health andinjuryPossible Next Steps Continue to expand, integrate and automate surveillanceefforts Provide training at the district and local level on epidemiologyand the use of surveillance dataCreate incentives to retain highly qualified surveillance andlaboratory workforceContinue ongoing assessment efforts to assure high qualitydata and laboratory results 6
Essential Public Health Service #3: Results At-A-GlanceInform, Educate, and Empower People about Health IssuesThis essential service includes FIGURE 7. SCORES FOR MODEL STANDARDSHealth information, health education, and healthpromotion activities designed to reduce health risk andpromote better health.Health communication plans and activities such asmedia advocacy and social marketing.Accessible health information and educationalresources.Health education and promotion program partnershipswith schools, faith communities, work sites, personalcare providers, and others to implement andLevelLevel ofofreinforce health promotion programs andActivityActivitymessages.Optimal Level of tModerateModerateSignificantSignificantTABLE 3. SCORES FOR ESSENTIAL SERVICE #3Item3.1 Planning and ImplementationScore613.1.1 Health education and promotionprograms633.1.2 Health communication programs523.1.3 Emergency communicationscapacity683.2 State-Local Relationships3.2.1 Assistance with healthcommunication and healtheducation/promotion programs3.2.2 Assistance in developing localemergency communication capabilities3.3 Performance Management and QualityImprovement3.3.1 Review effectiveness of healthcommunication and healtheducation/promotion efforts3.3.2 Active performance managementKey Findings 5143 6026 28253.4 Public Health Capacity and Resources593.4.1 Commit financial resources753.4.2 Coordinate system-wideorganizational efforts463.4.3 Workforce expertise56There are many agencies and organizations throughoutthe system working to achieve this essential serviceMaine has been able to communicate efforts aboutemergencies in a coordinated manner – as evidenced bythe consistent messaging seen with H1N1Training opportunities exist at the local level regardingrisk/emergency communicationOur health education and promotion efforts may notalways be based on sound theory or evidence, nor arethey often appropriate for diverse audiencesThere are few comprehensive evaluations of our healtheducation, promotion and communication effortsthroughout MainePossible Next Steps Expand efforts to evaluate and continually improve thequality of health education, promotion andcommunication effortsCoordinate efforts to reduce duplicationExpand efforts to reach diverse audiences with healtheducation and promotion programsProvide assistance at the district and local level regardingthe identification, selection or development of theorybased and evidence-based interventions7
Essential Public Health Service #4: Results At-A-GlanceMobilize Community Partnerships to Identify and Solve Health ProblemsThis essential service includes FIGURE 8. SCORES FOR MODEL STANDARDSThe organization and leadership to convene, facilitate,and collaborate with statewide partners (including thosenot typically considered to be health-related) to identifypublic health priorities and create effective solutions tosolve state and local health problemsThe building of a statewide partnership to collaborate inthe performance of public health functions and essentialservices in an effort to utilize the full range of availablehuman and material resources to improve the state’shealth statusLevelLevel ofofAssistance to partners and communities to organize ActivityActivityand undertake actions to improve the health of thestate’s communitiesOptimal Level of inimalMinimalSignificantSignificantTABLE 4. SCORES FOR ESSENTIAL SERVICE #4Item4.1 Planning and Implementation4.1.1 Building statewide support forpublic health4.1.2 Partnership organization anddevelopment4.2 State-Local RelationshipsScore6465 38254.2.2 Incentives for local partnerships504.3.2 Active performance management 634.2.1 Assistance in buildingcollaborative skills4.3 Performance Management and QualityImprovement4.3.1 Review effectiveness ofpartnershipsKey Findings 2525 254.4 Public Health Capacity and Resources504.4.1 Commit financial resources504.4.2 Coordinate system-wideorganizational efforts444.4.3 Workforce expertise56Maine has a strong track record of convening andcollaborating with partners to solve health problemsMaine has a network of community coalitions and DistrictCoordinating Councils in each region that represent themajor public health system partners through the stateWhile there may be a fair amount of cooperation amongsystem partners, there is limited coordination of effortsEfforts to evaluate the effectiveness of our partnerships,coalitions and collaborative efforts are under-resourced,sporadic and limited to specific programsLimited training opportunities exist regardingcollaborative skill buildingPossible Next Steps Integrate partnership efforts, including the number ofstatewide disease specific consortia, councils andcommittees to decrease duplicationEvaluate the effectiveness of partnerships and identifyareas for strengthening planning and improvementefforts8
Essential Public Health Service #5: Results At-A-GlanceDevelop Policies and Plans that Support Individual and Community Health EffortsThis essential service includes FIGURE 9. SCORES FOR MODEL STANDARDSSystematic health planning that relies on appropriatedata, develops and tracks health objectives, andestablishes strategies and actions to guide communityhealth improvement at the state and local levels.Development of legislation, codes, rules, regulations,ordinances, and other policies to enable performance ofthe Essential Public Health Services.The process of dialogue, advocacy and debate amonggroups affected by the proposed health plans andpolicies prior to adoption of such plans or policies.LevelLevel ofofActivityActivityTABLE 5. SCORES FOR ESSENTIAL SERVICE #5Item5.1 Planning and ImplementationScore635.1.1 Convene collaborative planningprocesses705.1.2 State health improvement plan675.1.3 State all-hazards preparednessplan and emergency response capacity505.1.4 Policy development activities675.2 State-Local Relationships5.2.1 Assistance and training for localplanning5.2.2 Assistance in integratingstatewide strategies in health plans5.2.3 Assistance in development oflocal preparedness plans5.2.4 Assistance in local policydevelopment5.3 Performance Management andQuality Improvement5.3.1 Monitor progress in healthimprovement595.3.3 Exercises and drills to testpreparedness plans635.3.4 Active performance management505.4 Public Health Capacity and Resources555.4.3 Workforce expertise in planning5.4.4 Workforce expertise in policydevelopment SignificantSignificantSignificantSignificantMaine has a strong history of collaborative planningeffortsA significant amount of policy development is driven bythe private sectorThere appears to be adequate training and assistance inlocal planning efforts for emergency preparednessMultiple public health-related plans with differenttimelines makes coordination challengingInput is routinely sought through public forums as part ofmost planning efforts– yet, there is little representationoutside of the public health communityThere are few training opportunities related to localpolicy development and health planningPossible Next Steps 75505.4.2 Coordinate system-wideorganizational effortsModerateModerate345.3.2 Review policies for impact5.4.1 Commit financial resources 3871SignificantSignificantKey Findings4433Optimal Level of Performance 50505663 Develop templates for existing planning efforts to provideconsistency, apply public health planning frameworks anddecrease duplication and inefficiencyEducate districts and local system partners on policydevelopment and health planning theory and practiceDevelop and integrate statewide strategies to supportcommunity and district level health plansEvaluate the impact of policy planning and developmenteffortsContinue to seek opportunities for engaging the public inpolicy development and planning effortsAssure that priorities identified in health plans guide thework of Maine’s public health system9
Essential Public Health Service #6: Results At-A-GlanceEnforce Laws and Regulations that Protect Health and Ensure SafetyThis essential service includes FIGURE 10. SCORES FOR MODEL STANDARDSThe review, evaluation, and revision of laws (laws refersOptimal Level of Performanceto all laws, regulations, statutes, ordinances, and codes)designed to protect health and ensure safety to assurethat they reflect current scientific knowledge and bestpractices for achieving compliance.Education of persons and entities in the regulatedenvironment and persons and entities that enforce lawsdesigned to protect health and ensure safety.Enforcement activities of public health concern,including, but not limited to, enforcement of cleanLevelLevel ofofair and potable water standards; regulation cantModerateActivityActivityhealth care facilities; safety inspections ofworkplaces; review of new drug, biological, and medical device applications; enforcement activitiesoccurring during emergency situations; and enforcement of laws governing the sale of alcohol andtobacco to minors, seat belt and child safety seat usage, and childhood immunizations.ModerateModerateTABLE 6. SCORES FOR ESSENTIAL SERVICE #6Item6.1 Planning and ImplementationScore656.1.1 Review of public health laws696.1.2 Emergency powers756.1.3 Cooperative relationships tosupport compliance6.1.4 Customer-centeredadministrative processes6.2 State-Local Relationships6.2.1 Assistance on enforcement oflaws6.2.2 Assistance to local governingbodies in developing local laws6.3 Performance Management and QualityImprovement6.3.1 Review effectiveness ofregulatory activities6.3.2 Active performance management7540Key Findings 5875 415050Possible Next Steps Provide stakeholder education on municipal, county anddistrict opportunities to develop science-based public laws andstatutes that promote and protect health Routinely monitor and document sub-state policydevelopment efforts to assure better coordination anduse of resourcesContinue to seek resources to track, support and evaluateenforcement efforts506.4 Public Health Capacity and Resources396.4.1 Commit financial resources256.4.2 Coordinate system-wideorganizational efforts296.4.3 Workforce expertise63Public health laws are based on science in some areas(e.g., traffic safety, environmental contaminants)There are several organizations in the public healthsystem that routinely monitor public health-related lawsThe State has sufficient power and authority to act in theevent of an emergencyThere are opportunities to assist local levels on theenforcement of laws designed to protect health andensure safetyThe public health enforcement efforts in Maine lackcoordination. 10
Essential Public Health Service #7: Results At-A-GlanceLink People to Needed Personal Health Services and Assure the Provision of Health CareThis essential service includes FIGURE 11. SCORES FOR MODEL STANDARDSAssessment of access to and availability of qualityOptimal Level of Performancepersonal health services for the state’s population.Assurances that access is available in a coordinatedsystem of quality care which includes outreachservices to link populations to preventive andcurative care, medical services, case management,enabling social and mental health services, culturallyand linguistically appropriate services, and healthcare quality review programs.Partnership with public, private, and voluntaryLevelLevel ofofsectors to provide populations with oderateModerateActivityActivitycoordinated system of health care.Development of a continuous improvement process to assure the equitable distribution of resources forthose in greatest need.TABLE 7. SCORES FOR ESSENTIAL SERVICE #7Item7.1 Planning and Implementation7.1.1 Assessment of access to care7.1.2 Delivery of services and programsto improve access7.1.3 SPHS entity responsible formonitoring and coordination7.1.4 Mobilizes to reduce healthdisparities, including during emergencyevents7.2 State-Local Relationships7.2.1 Assistance in assessment andservice delivery7.2.2 Assistance for providers servingunderserved populations7.3 Performance Management and QualityImprovement7.3.1 Review effectiveness of programsin improving access, appropriateness ofpersonal health care, and health carequality7.3.2 Active performance managementScore3647Key Findings 4825 25 40295027Possible Next Steps 29 257.4 Public Health Capacity and Resources417.4.1 Commit financial resources507.4.2 Coordinate system-wideorganizational efforts297.4.3 Workforce expertise44There are existing systems in place to improve the qualityof care (e.g., Maine Quality Forum, Quality Counts)There are many providers and organizations that assessaccess to care – yet, most efforts are not coordinatedWhile efforts are underway to assist underservedpopulations, many disparate subpopulations are notadequately served and gaps continue to existThere are relatively few evaluation efforts to determineappropriateness of care, and the quality of servicesprovided Provide training on best practices for increasing access tohigh quality care among vulnerable populations anddisparate groupsEvaluate improvement interventions and programs todetermine effectiveness and reachProvide opportunities for agencies to coordinate similarefforts focused on access to careEstablish an organizational leader to oversee theperformance standards in this essential service togenerate leadership and accountability11
Essential Public Health Service #8: Results At-A-GlanceAssure a Competent Public and Personal Health Care WorkforceThis essential service includes FIGURE 12. SCORES FOR MODEL STANDARDSEducation, training, development, and assessment ofhealth professionals--including partners, volunteers andother lay community health workers--to meet statewideneeds for public and personal health services.Efficient processes for credentialing technical andprofessional health personnel.Adoption of continuous quality improvement and lifelong learning programs.Partnerships with professional workforce developmentprograms to assure relevant learning experiencesLevelLevel ofoffor all participants.ActivityActivityContinuing education in management, culturalcompetence, and leadership development programs.Optimal Level of malMinimalMinimalTABLE 8. SCORES FOR ESSENTIAL SERVICE #8Item8.1 Planning and Implementation8.1.1 Assessment of population-basedand personal health care workforceneeds8.1.2 Statewide workforcedevelopment plan8.1.3 Programs to enhance workforceskills8.1.4 Assure excellence in professionalpractice of workforce members8.1.5 Incentives for life-long learning8.2 State-Local Relationships8.2.1 Assistance with workforceassessment8.2.2 Assistance with workforcedevelopment8.2.3 Education and training toenhance local workforce skills8.3 Performance Management and QualityImprovement8.3.1 Review workforce developmentefforts8.3.2 Review whether academicpractice partnerships are effective8.3.3 Active performance managementScore23Key Findings 3113 2722 231825Possible Next Steps 42580 2508.4 Public Health Capacity and Resources238.4.1 Commit financial resources258.4.2 Coordinate system-wideorganizational efforts25There are several educational opportunities in publichealth including academic-based programs andprofessional training seminarsThere is no workforce development plan, nor is there asingle database with basic information on our non-clinicalpublic health workforce in MaineThere are few financial resources and incentives thatsupport degree programs in public health and life-longlearning Expand the Department of Labor’s workforce database toinclude the major categories of public healthprofessionals in MaineConduct a workforce enumerationDetermine training interests and needs of the workforceand catalogue available educational opportunitiesExpand educational opportunities and provide incentivesfor employees to participateAlign educational opportunities with core public healthcompetenciesDevelop a workforce development plan for Maineincluding strategies for recruitment and retention12
Essential Public Health Service #9: Results At-A-GlanceEvaluate Effectiveness, Accessibility and Quality of Health ServicesThis essential service includes FIGURE 13. SCORES FOR MODEL STANDARDSEvaluation and critical review of health programs, basedon analyses of health status and service utilization data,are conducted to determine program effectiveness andto provide information necessary for allocating resourcesand reshaping programs for improved efficiency,effectiveness, and quality.Assessment of and quality improvement in the StatePublic Health System’s performance and capacity.LevelLevel ofofActivityActivityTABLE 9. SCORES FOR ESSENTIAL SERVICE #9Item9.1 Planning and Implementation9.1.1 Evaluate population-based healthprograms9.1.2 Evaluate personal health careservices9.1.3 Assess the performance of thepublic health system9.2 State-Local Relationships9.2.1 Assistance on evaluation9.2.2 Share state evaluation results toassist local planning9.3 Performance Management and QualityImprovement9.3.1 Review the effectiveness ofevaluation activities9.3.2 Active performance managementOptimal Level of nimalModerateModerateScore3319Key Findings 5428 2525 2523 Many system partners now recognize the need forevaluation and value its role in helping to inform publichealth practiceWhile specific evaluations of programmatic efforts exist inseveral areas, the work is often limited based on availableresourcesEvaluation is often not considered during the planning orgrant-writing phase of a projectMany evaluation efforts are hindered based on the lack ofavailable data21259.4 Public Health Capacity and Resources309.4.1 Commit financial resources259.4.2 Coordinate system-wideorganizational efforts219.4.3 Workforce expertise44Possible Next Steps Identify opportunities to integrate evaluation efforts withongoing data collection activitiesJointly establish goals and priorities for programevaluation throughout the systemContinue providing assistance on how to conductmeaningful evaluation activities despite limited resourcesAssess ongoing evaluation efforts to assure they are highquality, timely and useful13
Essential Public Health Service #10: Results At-A-GlanceResearch for New Insights and Innovative Solutions to Health ProblemsThis essential service includes FIGURE 14. SCORES FOR MODEL STANDARDSA full continuum of research ranging from field-basedefforts to foster improvements in public health practiceto formal scientific research.Linkage with research institutions and other institutionsof higher learning.Internal capacity to mount timely epidemiologic andeconomic analyses and conduct needed health servicesresearch.LevelLevel ofofActivityActivityTABLE 10. SCORES FOR ESSENTIAL SERVICE #10Item10.1 Planning and Implementation162310.1.2 Public health research
Essential Public Health Service #3: Results At-A-Glance Inform, Educate, and Empower People about Health Issues This essential service includes Health information, health education, and health promotion activities designed to reduce health risk and promote better health. Health communication plans and activities such as
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