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Advancing the Public Health System by Defining the Foundational Capabilities of Public Health

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Public health departments have the unique role and responsibility for improving health in schools, workplaces and neighborhoods. They are charged with identifying top health problems and developing strategies to solve these issues.

Indeed, they are the chief health strategist in communities.

Unfortunately, public health departments at all levels of government have been chronically underfunded for decades. In fact, according to a 2008 analysis by the New York Academy of Medicine (NYAM), there was a shortfall of $20 billion per year in spending on federal, state and local public health and, in most cases, there is no officially defined mode of coordination for targeting or strategically focusing funding.

To be the chief health strategists for communities, public health departments need the tools and skills required to provide basic public protections while adapting to and effectively addressing changing health threats. The Institute of Medicine (IOM) and the Transforming Public Health project, funded by the Robert Wood Johnson Foundation (RWJF), identified some of these foundational capabilities as developing policy, using integrated data assets, communicating with the public and other audiences to disseminate information, mobilizing the community and forging partnerships, cultivating leadership skills, and demonstrating accountability and protecting the public in the event of an emergency or disaster.

Ensuring these foundational capabilities should become a primary focus of federal, state and local funding, even if it means restructuring some categorical funding streams. Funding must be maintained at a level that ensures these capabilities can be effectively maintained and delivered.

With adequate, stable funding that ensures these basic foundational capabilities, the nation's chief health strategists can take advantage of several evolving opportunities to turn the nation's sick care system into a true health care system.

Opportunity: Changes in the Health System

More than ever before, the health system emphasizes cost containment and improved health. In addition, more people have or will have insurance coverage for direct preventive services under the Affordable Care Act (ACA). The ACA also created the Prevention and Public Health Fund, which includes the Community Transformation Grants (CTG) that help communities invest in proven strategies to improve health.

Public health departments must assume greater accountability for the design and development of the overall strategic plan for improving health in their communities. To do this, health departments must clearly establish their value and role in a reformed health system -- especially in the identification, implementation, coordination and evaluation of cost-beneficial prevention programs and activities.

In addition, public health departments must partner with other sectors (education, transportation, housing and others) and members of the community to make healthier choices easier in every neighborhood and classroom. Public health officials must capitalize on the many opportunities, including CTGs, to promote health and wellness where Americans live, learn, work and play.

The West Virginia Department of Health used CTG support to help local health departments (LHDs) in every county in the state implement targeted initiatives, including: safe places in communities to work and play, farm-to-school initiatives to improve nutrition in school settings, child and daycare center nutrition programs to educate and empower children to choose healthy lifestyles through physical activity and healthy food choices, and community-coordinated care systems that link and build referral networks between the clinical system and community-based lifestyle programs so people can manage their health.

Through the process, West Virginia began transforming the health of the state and has positioned LHDs as the chief health strategist, which will ensure capacity is maintained and programs continue if grant funding disappears.

Opportunity: Budget and Workforce Cuts

As the economy has dipped, massive budget and workforce cuts at all levels of government have forced public health to be nimble and strategic in investments.

The public health workforce should be more versatile and better equipped to handle various public health challenges or threats. The workforce should have policy development skills, management/administrative skills, technological skills and communications skills. To accomplish this, the public health workforce measures in the ACA must be fully funded and implemented; public health curricula and job re-training must include developing skills in Health Information Technology (HIT), policy and legal areas, and cross-sector management; and training programs must emphasize the need for multiple sectors to work.

Currently, some public health departments provide direct services in their communities along with other preventive programs. Since the ACA will expand the number of individuals with coverage and many preventive services are mandated to be covered by many insurance providers, public health departments should reassess their role in the direct provision of medical services (including the option of becoming a federally qualified health center), to ensure they do not use their public health budgets to pay for services that could be billed to insurers or paid for through health center dollars.

Public health departments must also adapt to work with new entities and financing mechanisms in the reformed health system, such as by working with accountable care organizations (ACOs) or within new capitalized care structures and global health budgets.

In FY 2006, Vermont began a five-year "Global Commitment to Health" demonstration agreement (which has been extended until the end of 2013) with the federal government to test the impact of a federal funding cap on Medicaid spending to give the state increased flexibility to manage Medicaid health services. The state pursued this approach to help improve cost containment and expand coverage to the uninsured. Vermont has been receiving monthly payments to cover the needs of all Medicaid beneficiaries. Independent actuaries determined the global budget pool for the state, and if the state was able to control spending under the agreed-upon cap, it could keep the difference, but if it exceeded the agreed-upon cap, the state would absorb the difference. The state was able to keep spending significantly below the agreed-upon amount, and invested some of these excess funds to help improve the health of the population, which in turn helps limit future health care needs, further reducing costs.

Opportunity: New Technologies

For the first time, new technologies -- including electronic health records (EHRs) -- make it possible to revolutionize health tracking by collecting and analyzing health data in real-time and allowing interactive communication among providers, health departments and other sectors

Instead of continuing to have a series of siloed systems to track different diseases and other health problems, connecting different sources of data so they are interoperable and available in real-time could lead to breakthroughs in identifying health trends and patterns. In addition, public health must monitor a range of factors -- from educational attainment to employment -- that impact health outcomes even if they are not under the direct purview of public health.

To take advantage of all these opportunities, the foundational capabilities of public health departments must be defined and supported. As chief health strategists, public health is the essential component of an integrated health system that looks out for the population as a whole, rather than focusing on the health outcomes of individuals alone.

Quite simply, public health is responsible for identifying the biggest, highest cost health problems and developing the most effective strategies for improving health. With adequate resources and appropriate capabilities, public health can lead communities toward comprehensive health care systems that help people get and stay as healthy as they want.

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