Public Health Modernization Implementation - Oregon
Public Health ModernizationImplementationInterim Evaluation ReportSeptember 2018Public Health Division
About this reportWelcome to the Oregon HealthAuthority’s (OHA) Public HealthModernization InterimEvaluation Report.In 2017, the OHA received aninitial 5 million legislativeinvestment to begin publichealth modernization in thethree areas of communicabledisease control, health equityand cultural responsiveness, andassessment and epidemiology.Local public health authoritiesare using 3.9 million toimplement regionalcommunicable disease controlinterventions, and OHA is usingthe remaining 1.1 million toimprove the collection andreporting of population healthdata.This report highlights changesresulting from the legislativeinvestment in the first six monthsof the funding period.Table of contentsLetters of Support3Executive Summary5Introduction7Project Descriptions8Evaluation Areas10State Public Health Role 21For questions or comments aboutthis report, or to request thispublication in another format orlanguage, please contact theOregon Health Authority, Office ofthe State Public Health Director at:Regional Partnerships23(971) 673-1222 orPublicHealth.Policy@state.or.usTechnical Appendix32Public Health Modernization Implementation Interim Evaluation Report2
Lillian Shirley, Public Health Division DirectorDear Colleagues,We know that the majority of what influences health happens outside of thedoctor’s office. In recent years, the landscape for public health has changeddramatically as the ways that we live, work, play and learn have created aseries of new, complex public health issues. Examples include escalatingopportunities for the spread of international disease outbreaks and new demands on communities to be prepared for and respond to events like wildfires and water toxins. At the same time, Oregon’s health system transformation creates an opportunity for the public health system to refocus onpopulation-wide interventions to protect and improve health, working in tandem with the health system to address population health priorities.In 2017, Oregon’s Legislature made an initial investment of 5 million tobegin implementing modern approaches to public health. The majority ofthese funds were allocated to regional partnerships of local public healthauthorities and their partners to develop new systems for communicable disease control, with an emphasis on eliminating communicable diseaserelated health disparities.The Public Health Modernization Interim Evaluation Report for 2017-19highlights the successful models and changes we’re seeing within the firstsix months of the funding period that can be expanded in other areas of thepublic health system and shows the challenges of developing and using newmodels. It celebrates the work that has been accomplished to date, andgives clear direction on how to move forward.Public health is our health.Respectfully,Lillian Shirley, BSN, MPH, MPAPublic Health DirectorOregon Health Authority, Public Health DivisionPublic Health Modernization Implementation Interim Evaluation Report3
Rebecca Tiel, Public Health Advisory Board ChairDear Colleagues,As Chair of Oregon’s Public Health Advisory Board, I am pleased to presentthis interim evaluation on public health modernization for the 2017-19 biennium. Oregon’s public health system is at a pivotal moment, and the initialwork of state and local public health authorities to demonstrate new approaches for solving population health problems is instrumental for definingthe future course for public health in Oregon.To understand the future of public health, it’s important to know wherewe’ve been. The history of public health can be divided into three phases.Public Health 1.0 – during the 19th century and into the 20th century – wasa period of great improvements to population health through preventionmeasures including sanitation, clean food and water, vaccinations, and antibiotics.During Public Health 2.0, which spanned from the mid- to late- 20th century,the public health system organized around public health programs to address emerging threats like the rising burden of chronic disease and emerging infectious disease like HIV/AIDS.We now find ourselves in a third phase for public health – Public Health 3.0 that calls on us to think beyond traditional public health departments anddisease-specific programs. Oregon’s public health system will accomplishthis through public health modernization. A modern public health system willmove upstream to address and mitigate the impacts of new challenges andemerging threats – whether they be acute diseases resulting from a changing environment or social issues like substance use or suicide – through robust partnerships, using data to inform policy, and an unyielding focus oneliminating the disproportionate burden of death and disease that falls oncertain populations.The Public Health Advisory Board looks forward to ongoing work in the coming years to bring Oregon into the future of public health.Sincerely,Rebecca Tiel, MPHChairOregon Public Health Advisory BoardPublic Health Modernization Implementation Interim Evaluation Report4
Executive Summary“Eight regions of local public health authorities (LPHAs) are using 3.9 million for regional communicable disease control interventions, and OHA is using the remaining 1.1 million to improve the collectionand reporting of population health data.- Tri-County Public HealthModernization CollaborativeThis report examines outcomes of the legislative investment during the first sixmonths of the funding period.Increasing coordination, capacity,and sustainability Local public health authorities (LPHAs) have usedmodernization dollars to establish intergovernmentalpartnerships; LPHAs have created formal policiesfor coordination and resource sharing,including memoranda of understanding and crossjurisdictional agreements. LPHAs’ funded projects aim to lower rates ofcommunicable diseases, including hepatitis C,gonorrhea, and vaccine-preventable diseases. Increased capacity for assessment and epidemiology,through hiring of specialized staff, has providedregional surge capacity for outbreakresponse and coverage for ongoing communicabledisease case investigation in counties with fewerresources. LPHAs are better prepared for public healthemergencies because of policies for formalcoordination and sharing and improved capacity forepidemiology and assessment.Modernization is a heavy liftto get where we truly need togo and one shot funding isnot going to be enough whenwe’re talking about corefundamental issues related tohealth disparities.“In 2017, the Oregon Health Authority(OHA) received an initial 5 million legislative investment to begin implementingpublic health modernization in 2017-19.Supporting meaningful partnerengagement LPHAs have established or expanded uponpartnerships with Coordinated CareOrganizations, Tribes, and Regional Health EquityCoalitions for participation in communicable diseaseplanning and outreach. LPHAs have also provided partners with trainingsfor communicable disease prevention,including trainings on immunization qualityimprovement for CCOs and health care providers,infection prevention to long-term care facilities, andcommunicable disease reporting for LPHA and tribalhealth department staff.Identifying and addressing healthdisparities LPHAs are working with partners on healthequity assessments to identify communitiesexperiencing communicable disease disparities andinform action plans to address identified disparities.Public Health Modernization Implementation Interim Evaluation Report5
Executive SummarySupporting innovative practiceand a new focus on prevention LPHAs are using funds to implement innovativepractices; one LPHA is advancing a localapproach to identifying health disparitiesand allocating needed resources, and two regions areforging Academic Health Department partnerships withOregon State University to strengthen the linkbetween public health practice and academia andprovide the next generation of the publichealth workforce with hands-on experience.In addition, LPHAs are working with partners oncommunicable disease prevention interventionsthat were not possible without funding;these include pneumococcal vaccinations in hospitalsand infection prevention training and assessment inlong-term care and childcare facilities.State public health’s role OHA has used funds to collect and report oncollect and report on population-healthdata to inform clinical and communitydecision-making.Specifically, enhancements to the state immunizationinformation system (ALERT IIS) support clinicaldecision-making for providers, and stopgapfunding for crucial youth and adult risk behaviorsurveys ensure communities have data forprogram and policy decision-making.OHA staff have provided more than 200documented in-kind hours of technical supportand subject matter expertise, including consulting ondevelopment of health equity assessments andtraining on best practices for improving childhoodimmunization rates and communicable diseasereporting.Early successes:Overall shared coordination:30 local public health authorities,4 Regional Health Equity Coalitions, 3 CCOs, 1 tribe, and 1school of public health are represented in regional policies for coordination and resource sharing.In communities across thestate:60hours of communicable disease investigation logged by a newdisease investigator covering a 13county area.19 long-term care facilities received infection prevention trainings (63% of facilities in region).18 CCO-participating clinics implemented a quality improvementprogram to increase childhoodvaccination.16 staff from 9 clinics participated in training on “root causes” oflow immunization rates and developed plans for improvement.2 local doctors recruited as“medical champions” to advocatefor strategies to reduce STI, Hepatitis C, and HPV health disparities.Public Health Modernization Implementation Interim Evaluation Report6
IntroductionBackgroundEvaluation approachPublic health modernization means that every personin Oregon has access to the same basic public healthprotections, and that the public health system isaccountable for being efficient and driven towardhealth outcomes.Local public health administrators and OHA PublicHealth Division staff were convened as an evaluationadvisory group to determine a shared evaluationpurpose, evaluation questions, and evaluation datacollection methods. The purpose of the evaluation is tocharacterize the outcomes of the legislative investmentto address communicable disease control and relatedhealth disparities.In 2017, the Oregon Health Authority (OHA) receivedan initial 5 million legislative investment to beginimplementing public health modernization in the threeareas of communicable disease control, health equityand cultural responsiveness, and assessment andepidemiology.The advisory group selected the following aspects ofthe grant for evaluation: Local use of funds;Of this investment, eight regions of local public healthauthorities (LPHAs) are using 3.9 million (reaching 33of Oregon’s 36 counties) to implement communicabledisease control interventions focused on mitigatingdisease risks in their jurisdictions with an emphasis onreducing health disparities. Regional governance structures; Addressing communicable disease risks; Partnerships development and maintenance; Identifying and addressing health disparities; Sustainability of funded work; andOHA is using the remaining 1.1 million to improvecollection and reporting of population health data andmetrics to evaluate the outcomes of the 2017–19legislative investment, and to provide support toLPHAs implementing public health modernization. The role of state public health.Data for the evaluation were collected throughquarterly online reporting and key informant interviewswith LPHA representatives.Public health modernization implementation and evaluation timelineJuly 2017Legislature allocates 5million for Public HealthModernization in 2017-19July-August 2018LPHAs complete firstevaluation reportingNovember 2017OHA awards funds to eight regional partnerships of LPHAs for communicable disease control strategies0 months7 monthsJanuary 2019LPHAs toComplete secondevaluation reportingJuly 2019Funding for 201719 ends; finalevaluation reportingSeptember 2018Interim evaluation reportpublished for first six monthsof funding period9 months13 months18 monthsPublic Health Modernization Implementation Interim Evaluation Report7
Public Health Modernization 2017-19 ProjectsThe table below provides a brief description of 3.9 million in awards to local publichealth authorities that span from December 1, 2017 through June 30, 2019.Regional partners Project descriptionNorth CoastModernizationCollaborativeClatsop, Columbia andTillamook counties Convene partners to assess regional data on sexually transmittedCentral Oregon PublicHealth PartnershipDeschutes, Crook andJefferson counties Form the Central Oregon Outbreak Prevention, Surveillance andAward amount 100,000infections and develop priorities. Identify vulnerable populations and develop regional strategies toaddress population-specific needs. 500,000Response Team that will improve: Communicable disease outbreak coordination, preventionand response in the region; Communicable disease surveillance practices; and Communicable disease risk communication to health careproviders, partners and the public. Funds will be directed to communicable disease prevention andcontrol among vulnerable older adults living in institutionalsettings and young children receiving care in child care centerswith high immunization exemption rates.South West RegionalHealth Collaborative Improve and standardize mandatory communicable diseaseDouglas, Coos and CurryCounties: Coquille IndianTribe; Cow Creek Band ofthe Umpqua Tribe ofIndians, Advanced HealthCCO, and Umpqua HealthAlliance CCO Implement strategies for improving 2-year-old immunization 468,323reporting.rates. Focus on those living in high poverty communities and withhealth inequities.Jackson and Klamath Work with regional health equity coalitions and communitycounties; Southern Oregonpartners to respond to and prevent sexually transmittedRegional Health Equityinfections and hepatitis C, focused on reducing health disparitiesCoalition; Klamath Regionaland building community relationships and resources.Health Equity Coalition Promote HPV vaccination as an asset in cancer prevention. 499,923Lane, Benton, Lincoln and Establish a learning laboratory to facilitate cross-countyLinn counties; Oregon Stateinformation exchange and continuous learning.University Implement an evidence-based quality improvement program,AFIX, to increase immunization rates. Pilot three localvaccination projects, including: 689,517Public Health Modernization Implementation Interim Evaluation Report8
Regional Partnership Funded ProjectsThe table below provides a brief description of 3.9 million in awards to local publichealth authorities that span from December 1, 2017 through June 30, 2019.Regional partners Project descriptionCoast-to-Valley RegionalPartnershipLane, Benton, Lincoln andLinn counties; Oregon StateUniversity (continued)Award amount Hepatitis A vaccination among unhoused people in Linnand Benton counties; HPV vaccination among adolescents attending school-based health centers in Lincoln County; and Pneumococcal vaccination among hospital dischargepatients in Lane County. Establish an Academic Health Department model with OregonState University to support evaluation.Marion and Polk counties;Willamette ValleyCommunity Health CCO Focus on system coordination and specific interventions toEastern OregonModernizationCollaborative Establish a regional epidemiology team.North Central Public HealthDistrict; Baker, Grant,Harney, Hood River, Lake,Malheur, Morrow, Umatilla,Union and Wheeler counties;Eastern Oregon CCO; MidColumbia Health Advocates 463,238control the spread of gonorrhea and chlamydia. Increase HPV immunization rates among adolescents. 495,000 Create regional policy for gonorrhea interventions. Engage community-based organizations to decrease gonorrhearates through shared education and targeted interventions.Tri-County Public Health Develop an interdisciplinary and cross-jurisdictionalModernizationcommunicable disease team to focus on developing andCollaborativestrengthening surveillance and communications systems. 679,999Washington, Clackamas and With leadership and guidance from the Oregon Health EquityMultnomah counties;Alliance, this cross-jurisdictional team will develop culturallyOregon Health Equityresponsive strategies that:Alliance Identify and engage at-risk communities; and Reduce barriers (e.g., language, stigma, access to care) toinfectious disease control, prevention and response. Both qualitative and quantitative evaluation methods areincluded in the overall design. Evaluation results will guideimplementation of best practices across the region focused onreducing and eliminating the spread of communicable diseases.Public Health Modernization Implementation Interim Evaluation Report9
Evaluation AreasThis section describes findings from all eight regionalpartnerships of LPHAs across evaluation areas, including use offunding, addressing communicable disease risks, the role ofpartners, and identifying and addressing health disparities.Public Health Modernization Implementation Interim Evaluation Report10
Local Use of FundsLocal public health authorities are strengthening local systems for communicable disease control andcreating structures for ongoing coordination.Highlights The majority of funds have been used to hire newshared and local staff to implement strategies toreduce communicable disease rates. Thesepositions have been instrumental in implementingstrategies including engaging health care providers inimmunization quality improvement and infectionprevention trainings and assessments in long-termcare and childcare facilities.LPHAs are using funding to create formal policiesfor inter-governmental coordination andresource sharing, including memoranda ofunderstanding and cross-jurisdictional agreements.Several LPHA partnerships used funds tocompensate community partners for theirparticipation in planning and implementingstrategies.Several LPHA partnerships used funds for internalstaff trainings on health equity, as well as trainingsto partners on immunizations quality improvementand infection control assessment and response.“Any time you are taking on aprevention project of thisscale it takes people morethan anything else.- Jackson & Klamath CountiesWhat positions areneeded for the modernpublic health systems?The diversity of expertise requiredfor public health modernizationimplementation demonstrates thecomplexity of cross jurisdictionalinterventions. Some positionshired, include: Epidemiologist Data Analyst Public Health InformaticsCoordinator Communicable DiseaseInvestigator Infection Prevention Nurse Community OutreachEducator Communications and OutreachLiaisonLessons Learned In-kind time required by existing staff to beginmodernization projects was more than expected.Several LPHA partnerships experienced hiringchallenges due to truncated project timelinesrequiring less desirable limited-duration positionsand the inability to provide competitive salaries forspecialized positions.“A modern public health system requires fundingto provide communities with the information toidentify, respond to and prevent leading causes ofdeath and disability and to eliminate healthdisparities.Public Health Modernization Implementation Interim Evaluation Report11
Filling Capacity Gaps & Leveraging FundsLocal public health authorities with fewer resources have benefited from increased capacity within theregion. Some LPHAs have leveraged modernization funding to secure additional resources.Filling Gaps New cross-jurisdictional positions have provided less-resourced LPHAs with additional capacity forroutine communicable disease investigations. Inter-governmental governance has also providedless-resourced LPHAs with access to existing staffand resources, including epidemiologists who havesupported data analysis, and sharing of best practiceson clinical outreach and harm reduction. LPHAs with fewer resources have generallybenefitted from centralized project coordination,more robust communications infrastructures, andsystems for peer-to-peer sharing. One LPHA with fewer resources noted fundingprovided the opportunity to consider upstreamapproaches to communicable disease control ratherthan solely responding to disease reports.Leveraging Funds One LPHA leveraged modernization funding toacquire 18,000 in CCO Community BenefitFunds for a pneumococcal vaccination project. One LPHA partnership “braided” modernizationand CDC HIV intervention funding to pay for afull-time position for their regional health equitycoalition; several other regions have alignedmodernization and HIV intervention strategies tobroaden the impact and reach of services. One LPHA has aligned modernization fundingwith Kresge Foundation funding focused oncollaboration with clinical care partners.“We wouldn’t have had thecapacity to invest time infuture planning and upstreamand outreach approacheswithout modernization funds.“A modern public health system ensures all localpublic health authorities have the capacity to provide foundational public health to the community.- North Coast Modernization CollaborativeWhat is BraidingFunding?Braiding is a process forcoordinating two or more sourcesof funding to support the totalcost of a service. While recipientscoordinate funding fromindividual sources, each individualfunding source keeps its specificidentity. Braiding is a financingstrategy that federal, state, andlocal policymakers and programadministrators can use to integrateand align discrete categoricalfunding streams to broaden theimpact and reach of servicesprovided. Learn more at .pdf.Public Health Modernization Implementation Interim Evaluation Report12
Regional Governance StructuresLocal public health authorities are establishing and expanding on formal governance structures for decision-making and responsibilities for meeting shared goals.Highlights LPHA partnerships established governancestructures through formal policies, includingmemoranda of understanding, cross-jurisdictionalsharing agreements, and organizational charts. Several LPHAs indicated these formal structuressupported alignment of job descriptions, policiesand procedures between counties for coordinationof communicable disease response. One LPHA noted the intergovernmental agreement(IGA) for modernization led to work on a broadercross-jurisdictional sharing IGA that resolvedliability issues, staffing costs, and how LPHAsrequest staff from one another.Lessons Learned Significant time and resources are required tocoordinate across counties, including navigating the“red tape” of multiple governing boards. LPHA partnerships in regions comprised of largergeographical areas or larger population centers notethe difficulty of keeping large numbers ofstakeholders coordinated and engaged. One LPHA indicated that cross jurisdictional workhas focused on population centers, to have thelargest reach, at the expense of rural areas.“We have a commitment toour communities and weknow that people anddiseases don’t stay withinpolitical boundaries, so weknow we’re going to havehealthier communities if wework together.“A modern public health system looks for effectiveways to use resources within and betweencounties for common goals.- Marion & Polk CountiesWhat is CrossJurisdictional Sharing?Cross-jurisdictional sharing (CJS)is the deliberate exercise of publicauthority to enable collaborationacross jurisdictional boundaries todeliver essential public healthservices and solve problems thatcannot be easily solved by singleorganizations or jurisdictions. Thespectrum of CJS ranges from asneeded assistance toregionalization/consolidation.Learn more at https://phsharing.org/what-we-do/Public Health Modernization Implementation Interim Evaluation Report13
Communicable Disease PreventionLocal public health authorities are addressing specific communicable disease risks within theircommunities.Highlights LPHAs are using modernization funds to implementprevention strategies for the followingcommunicable diseases: hepatitis A, hepatitis C,gonorrhea, chlamydia, syphilis, HIV/AIDS,pneumococcal disease, HPV and other vaccinepreventable diseases, and latent tuberculosis.LPHAs are implementing strategies intended toimprove Public Health Accountability Metrics,including improvements to rates for two-year-oldimmunizations and gonorrhea.Communicable disease prevention interventionsfocus on both internal quality improvement andexternal partnerships; internally-focused workincludes communicable disease reporting trainings toimprove data quality and standardizing crossjurisdictional procedures for tracking treatment ofgonorrhea, while externally-focused work includespartnerships with hospitals on pneumococcal diseaseprevention and school-based health centers on HPVprevention.In addition to communicable disease prevention,new specialized staff have provided geographicsurge capacity for outbreak response andcoverage for routine communicable disease caseinvestigation in counties with fewer resources.Hiring new and sharing existing epidemiologists hasenhanced local data analysis to identifycommunicable disease disparities, which providesa focus for future prevention and outreach work.“Outbreaks don’t have countylines and I feel we are somuch stronger in just 6months that if we had aregional outbreak we wouldknow how to respond and wewould know how to work witheach other for it.“A modern public health system is prepared toaddress communicable disease threats by usingcomprehensive strategies for identifying,responding to, and preventing the spread ofcommunicable disease.- Central Oregon Public Health PartnershipWhat arecommunicable diseasecontrol accountabilitymetrics?The 2017 Legislature passedHouse Bill 2310, which requiredthe adoption of a set ofaccountability metrics todemonstrate LPHAs areimplementing strategies intendedto improve: Two-year-old immunizationrates; and Gonorrhea ratesLearn more at bilityMetrics.aspxPublic Health Modernization Implementation Interim Evaluation Report14
Partnerships Development & MaintenanceLocal public health authorities are establishing and enhancing local relationships for communicabledisease control and health equity.Highlights Some LPHAs are partnering with local CoordinatedCare Organizations (CCOs), Tribes, andRegional Health Equity Coalitions (RHECs) forcommunicable disease planning, outreach andimplementation. In addition, some LPHAs are working with healthcare providers and community health centers topromote communicable disease control strategies,including implementation of CDC’s immunizationsquality improvement program (called AFIX). LPHAs have provided partners with resourcesand trainings, including trainings on immunizationsquality improvement to CCO staff, infectionprevention to long-term care facilities, andcommunicable disease reporting to staff of a tribalhealth department. Two LPHA partnerships are partnering with OregonState University to implement an Academic HealthDepartment partnership to support evaluation,strengthen the link between public health practiceand academia, and provide the next generation of thepublic health workforce with hands-on experience. One LPHA noted that the ability for local publichealth to commit funds to joint work has enabledmore meaningful conversations with CCOs.“We don’t want to askcommunity partners to be atthe table unless we’recompensating them as partof our health equity policy.“A modern public health system recognizes thatvibrant partnerships are essential for achievingcommon goals.- Tri-County Public HealthModernization CollaborativeWhat is an AcademicHealth Department?An academic health department(AHD) partnership is formed bythe formal affiliation of a healthdepartment and an academic institution that trains future healthprofessionals. AHD partnershipscan enhance public health education and training, research, andservice. AHD partnerships help tostrengthen the links between public health practice and academiaand to lessen the separation between the education of publichealth professionals and the practice of public health. Learn moreat http://www.phf.org/programs/AHDLC/Pages/Public Health Modernization Implementation Interim Evaluation Report15
Identifying & Addressing Health DisparitiesLocal public health authorities are identifying and addressing community-level differences incommunicable disease outcomes.Highlights LPHA partnerships are working with partners toconduct health equity assessments, includingidentification of internal capacity building needs,assessment tools, additional partners, and sources oflocal data. Some LPHAs are providing financial support tocommunity partners to ensure communityengagement expertise is embedded in strategies toreduce communicable disease rates. Several LPHAs are conducting communitylistening sessions and interviews with affectedpopulations to understand barriers to accessingcommunicable disease services. One LPHA leveraged funding to support andevaluate existing work on Health Equity Zones, alocal approach to identifying health disparities andallocating resources accordingly. One LPHA used funds for translation services toensure communicable disease risk communicationsare in Spanish for equitable access to information.Lessons Learned Several LPHAs noted the limitation of working onhealth equity from a communicable diseaseperspective, and wanted to look more broadly at theroot or underlying causes of health inequities.
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The Public Health Modernization Manual is intended to guide administrators and staff of state and local public health authorities in implementing each foundational capability and program. This manual defines how these apply specifically to state and local public health authorities,
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