Grad. Admin & Policy Exam

10 essential services of public health + 3 core fxns

My Dear, I Must Deliver Each Letter At Every Residence Assessment- 80% do this Monitor health Diagnose and investigate Policy Development- 49% do this Inform, educate, empower Mobilize community partnerships Develop policies Assurance- 42% do this Enforce laws Link to/provide care Assure a competent workforce Evaluate + Research

Strategic prevention framework

colorful screenshot -sustainability and cultural competence are at its core

What is Community Engagement?

-...the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people -It is a powerful vehicle for bringing about environmental and behavioral changes that will improve the health of the community and its members -It often involves partnerships and coalitions that help mobilize resources and influence systems, change relationships among partners, and serve as catalysts for changing policies, programs, and practices

Protections re: Pre-Existing Conditions in Jeopardy

-20 state attorneys general filed a lawsuit arguing that the ACA should be thrown out -The case argues that the ACA's Individual Mandate -which was previously upheld by the Supreme Court based on the federal government's power to tax- is unconstitutional now that Congress has set the tax penalty associated with the Individual Mandate to 0 -According to the suit, the rest of the ACA is not severable from the Individual Mandate and should therefore be overturned -Trump administration filed a brief in the case agreeing that the Individual Mandate is unconstitutional, and that the ACA's protections for pre-existing conditions should be invalidated along with it -Polling by the Kaiser Family Foundation (KFF) found that 64% of the public does not want the Supreme Court to overturn the ACA's protections for people with pre-existing conditions -H.B. 692 Pre-existing Protections Act of 2019 - introduced in 1/2019 by Rep Walden (R-OR) (would de-couple it from the ACA and attach it to the Social Security Act, so it'll be less likely to be thrown out) -If you change jobs w/ a pre-existing condition and switch insurers, if there are no protections for these conditions, your premiums are going to go way, way up -Federal money to states for expanding Medicaid = policy carrot -Individual mandate = policy stick

Why Complete a Community Assessment & Improvement Plan?

-A Community Health Assessment gives organizations comprehensive information about the community's current health status, needs, and issues -This information can help develop a community health improvement plan by justifying how and where resources should be allocated to best meet community needs, leading to- -Improved organizational and community coordination and collaboration. -Increased knowledge about public health and the interconnectedness of activities. -Strengthened partnerships within state and local public health systems. -Identified strengths and weaknesses to address in quality improvement efforts. -Baselines on performance to use in preparing for accreditation. -Benchmarks for public health practice improvements.

Medicaid Expansion

-Adopted in 37 states, including DC -Not adopted in 14 states -Trends- Further expansion among states Waivers, esp. work requirements SA/Opioids "Public Charges" changes Payment and delivery system reforms

State and Local Public Health Agencies

-Agency Actions- Rule-making Enforcement Quasi-Judicial Powers -Legislation- MA Legislature decriminalized Narcan to prevent Opiate overdoses, approved funding for programs that train health workers, and Narcan provision •Organizations- Can promote and train health workers on using Narcan to prevent overdoses •Boards of Health - BPHC mandated that EMS personnel and other health workers be trained in administering Narcan •Consolidation- Cross-sector partnerships and efforts

MA Determination of Need (DoN)

-An important source of funding for Community Health is the MA DoN process -When a health care institution intends to build a new facility or make a major capital purchase, it is required to file a DoN application with the MA Department of Public Health -If the application is approved, the applicant facility then provides the equivalent of 5% of the capital outlay to support community health initiatives (CHI) which are non-clinical initiatives that, for the most part, take place outside of the hospitals and address a range of social determinants of health: built environment, social environment, housing, violence, education and employment -In addition to addressing DPH's health priorities, a CHI can also address other needs identified by hospitals' Community Health Assessments (CHA) as well as other community needs assessments and community health improvement plans (CHIP) -Having established funding priorities, a hospital then needs to develop and implement a process for determining exactly how funds will be used and distributed -This is often in the form of a Request for Proposals process, and evaluation of the merits of the specific proposals -Funding can be distributed over a number ofyears, usually 3-7 years

National Violent Death Reporting System (NVDRS)

-Beginning in 2002, NVDRS collects state level data from 4 major sources about the same incident, and pools information into a usable, anonymous database -An incident can include one victim or multiple victims --The four major data sources are: Death certificates Coroner/medical examiner reports Law enforcement reports Toxicology reports -The facts that are collected about violent deaths include: -Circumstances related to suicide such as depression and major life stresses like relationship or financial problems The relationship between the perpetrator and the victim -for example, if they know each other -Other crimes, such as robbery, committed along with homicide; multiple homicides, or homicide followed by suicide

Federal Public Health Agencies

-CDC- Policies for monitoring, controlling and preventing disease -NIH- supports research, trains investigators and disseminates information -FDA- food, drugs, medical devices, cosmetics, etc. -Dept. of Labor & Occupational Safety and Health Admin (OSHA)- Safety standards in the workplace -Environmental Protection Agency (EPA)- Laws, regulations and water safety -Department of Homeland Security (DHS)- Legal policies, laws and enforcement

Importance of Intersectoral Efforts in Public Health

-Due to the complexity of public health issues, prevention, surveillance and response relies on coordinated efforts among these entities: • Levels of Government • Community • Academia/Institutes • Providers- Healthcare delivery • Employers and businesses • Media Ex. Opioid Epidemic- -Federal- Set the agenda for harm reduction and treatment referrals, supply and demand (e.g. law enforcement and public health agencies) -State- Use of data and surveillance, promoting policy and awareness (e.g. prevention of overdoses and addictions) -City- Hire staffing for referrals and disseminating information about harm reduction -Healthcare providers- Healthcare delivery, transport, and recovery programs -Community coalitions- Community approaches to awareness and enactment of prevention strategies -Universities- Provide research on prevention and reducing stigmas -Employers/businesses- Offer paid time off and behavioral health coverages -Media- Raise awareness, support prevention, sharing strategies and resources

Ethical Approaches

-Organizational Ethics: Mission, Values, Systems -Ethical Boards •Institutional Review Board (IRB) •Public Health Accreditation Board -Ethical Violation Examples: -Tuskegee Experiment - Syphilis (predated the Belmont Report) -Henrietta Lacks -1990s John Hopkins Lead Paint study -Public Policy: Moral Justification Cost-Benefit Analysis Interests Values Scientific Justification Legal Justification

common types of Public Health Data

-Federal and State government survey data (e.g. CPS) Scope- representative, broad in scope Access- very easily accessible Timeliness- regularly updated Limited value of health indicators -NHIS and NHANES (exams,diagnosticsandinterviews) Scope- broad in terms of health Access- not publicly available, primarily researchers Timeliness- fairly timely Only represents individuals involved in survey -CMS claims data and ICD-10 codes Scope- wide for individuals in government programs Access- restricted Timeliness- long time lag for when it is available Limited usefulness in PH research and surveillance

Planning and Evaluation Cycle

-Formative ▫Assessment ▫Feasibility ▫Environmental scan "Evaluate the Need" (Ex. TFC in U.S. States, CHA/CHIP in Boston) -Process ▫Measurable ▫Objectives ▫Implementation "Evaluate the Doing" (Issues of fidelity, dosage) -Analysis ▫Outcome = short-term ▫Impact= Long-term ▫Summative "Evaluate the Outcome/s" (Ex. HCIA 2, FluQM, SAMHSA)

Boston Children's Hospital - CHA Response

-Health Issues and Needs -Approach -Key Programs and Services -Implementation Strategies -Community Partners

Public Health Law Reform

-In instances where reform is deemed necessary due to overreach, antiquity, etc. the following guidelines are suggested- •Define mission and essential functions and ensure conditions of health •Provide a full range of public health powers •Impose substantive limits on powers- qualifying circumstances •Impose procedural limits on powers- procedural due process •Strong protection against discrimination •Strong protection for privacy and security of PHI -Example of Public Health Law Reform: Vermont Vaccination Exemption

2015 PHS S4A

-Investigate the implementation and impact of strategies designed to; -achieve alignment, collaboration, and synergy across delivery and financing systems -reduce and eliminate health inequities through cross-system alignment, collaboration, and synergy -Investigate the effectiveness and efficiency of information and decision support strategies in achieving alignment, collaboration, and synergy across delivery and financing systems -Investigate the role of incentives in achieving alignment, collaboration, and synergy across delivery and financing systems

Information Systems, Management, and Policy

-Issues of data access and privacy (PHI) -HIPAA 1996 -HITECH ACT 2009 (part of ARRA) - extends HIPAA "Health Info Tech for Economic and Clinical Health Act" -Ultimate Goal= Bi-directional Data Exchange (cities, states, hospitals, etc) -Health Information Systems (USDA, PopMedNet) -Data Portals, Warehouses and Cloud/s -Issues of Integrating - Networking - Utilizing -MDPHNet- Also called ESP; an initiative by the MA Department of Public Health to organize and map electronic health record data and analyze the data for conditions of public health interest. -CHORDs- The Colorado Health Observation Regional Data Service (CHORDS) is a collaborative regional pilot project that uses electronic health record (EHR) data to monitor public health trends, as well as to measure the efficacy of public health interventions

Research & Evaluation

-Issues of methodology, sample, reliability, validity, generalizability, causation, analysis -Qualitative Data (key informant Interviews, focus Groups, participant-observation; stories) -Quantitative Data (All-payer claims data, administrative data; numbers) -Mixed Methods (triangulation of data; qualitative and quantitative data) -Community Health Assessments -Health Impact Assessments -Monitoring & Evaluation (Reporting) -IRB compliance

Public Health Law

-Law is a critically important tool in PH -A government and policy approach that is often neglected Purpose? -Influence health behavior -Respond to threats -Set and enforce health and safety standards -Federal, state, local, and tribal PH law = effects of federalism Model Public Health Statutes- -State Emergency Health Powers Act - preparedness, surveillance, management, protection, info., and communication -Turning Point Model, State Public Health Act- tool to revise statutes and regulations

NB medicaid work requirements

-Nebraska's 2-tiered approach to Medicaid expansion could stand up to legal scrutiny -Rather than pursue a conventional Medicaid expansion, Nebraska opted to request a Medicaid 1115 or "state innovation" waiver from the CMS -waiver would allow NB to create 2 tiers of Medicaid benefits for the newly eligible population -The "Prime" tier will allow expansion enrollees to receive the same Medicaid benefits as Nebraska's traditional Medicaid population if they fulfill community engagement, personal responsibility and wellness activities -The "Basic" package would cover basic health services and prescription drugs, but drop coverage for dental, vision, and over-the-counter drugs

Developing Effective Objectives

-Need to clearly state expected effects/benefits -Issues of consistency and dosage -Differences need to be specific and measurable -Need benchmarks to establish and evaluate objectives

Socio-Economic Determinants of health

-Nonmedical factors that affect average and distribution of health -Distal - Political will, legal and regulatory factors, institutional complexity/coordination, cultural needs & barriers -Proximal - SES, environment, working conditions, social network, family, behavior/lifestyle, demographics •To effect change and equity in health status and outcomes, inequality in distal and proximal factors needs to be assessed and addressed.

Dickey Amendment - 1996

-On December 20, 2019 Trump signed legislation authorizing $25 million for gun violence research, reversing 23 years of policy. Why? What was the Policy Window? -Congress included language in the 1996 Omnibus Consolidated Appropriations Bill (PDF, 2.4MB) for Fiscal Year 1997 that "none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control" -Referred to after its author, former U.S. House Representative Jay Dickey (R-AR), this language did not explicitly ban research on gun violence -However, Congress also took $2.6 million from the CDC's budget — the amount the CDC had invested in firearm injury research the previous year — and earmarked the funds for prevention of traumatic brain injury -"Precisely what was or was not permitted under the clause was unclear -But no federal employee was willing to risk his or her career or the agency's funding to find out -Extramural support for firearm injury prevention research quickly dried up"

The Importance of Planning

-Operational (day to day planning) versus Strategic (larger vision, usually has some reason/change behind it)? -A Process and as an Outcome -Increasingly required (e.g. accreditation, preparedness, required by NACCHO)

Painless and painful Cost Control

-Painless = making more efficient use of existing level of resources -Controlling (lowering) fees and provider incomes (2-sided risk) -Controlling administrator incomes* -Reducing administrative waste (marketing, billing, utilization reviews) *NOT compromising Quality Initiatives or Measurement -Cutting cost of prescriptions and supplies -Substituting less costly technologies that are equally effective -Eliminating medical interventions of no benefit, not necessary -Focusing on/bolstering prevention (Ounce of Prevention) -Painful- -Sacrificing quantities of medically beneficial services -Ethical considerations come into play

Types of Public Health Surveillance

-Passive •Diseases are reported by health care providers •Simple and inexpensive •Limited by incompleteness of reporting and variability of quality -Active •Health agencies contact health providers seeking reports •Ensures more complete reporting of conditions •Used in conjunction with specific epidemiologic investigation

2 kinds of data

-Primary -Secondary- Descriptive statistics Quantitative- cross-tabs, comparison of means Qualitative- coding themes (interviews, focus groups)

Code of Ethics

-Public Health Leadership Society (PHLS) has developed a Code of Ethics •Prevent adverse health outcomes •Respect individual rights •Allow input from community members •Empowerment of disenfranchised community members and provision of resources •Use info to develop effective policies and programs that promote and protect health •Act within a timely manner, given resources and public mandate •Incorporate a variety of diverse approaches to policies and programs •Enhance the physical and social environment •Protect confidentiality of information unless there is a risk of harm •Ensure professional competence of employees •Engage in collaborations to increase trust and effectiveness

Public Health Systems Research

-Public Health Systems Research differs from Clinical, Biomedical, Health Services Research and Epidemiology: Focus on both population - and systems Focus on both process - and outcomes IT and workforce resources are key components Governance structure affects public health performance -Spearheaded by CDC in 1994 -Since 2004, largely funded by RWJF and coordinated by U of KY CPHSSR -RWJF also supports Academy Health PHSR interest group -Recent funding provided to CDC in 2006 for emergency preparedness, disseminated to SPR for PHSR

Surveillance Link to Action

-Public health surveillance should always have a link to action Data collection --> data analysis --> data interpretation --> data dissemination --> link to action

ICPSR

-Publicly available datasets -Resources for students -An international consortium of more than 750 academic institutions and research organizations, Inter-university Consortium for Political and Social Research (ICPSR) provides leadership and training in data access, curation, and methods of analysis for the social science research community -ICPSR maintains a data archive of more than 250,000 files of research in the social and behavioral sciences -It hosts 21 specialized collections of data in education, aging, criminal justice, substance abuse, terrorism & other fields -ICPSR collaborates with a number offunders, including U.S. statistical agencies and foundations, to create thematic data collections and data stewardship and research projects -ICPSR's educational activities include the Summer Program in Quantitative Methods of Social Research, a comprehensive curriculum of intensive courses in research design, statistics, data analysis, and social methodology -ICPSR also leads several initiatives that encourage use of data in teaching, particularly in undergraduate instruction -ICPSR-sponsored research focuses on the emerging challenges of digital curation and data science. ICPSR leads or takes part in many policy initiatives and grant-funded activities that result in publications that address issues related to data stewardship -ICPSR researchers also examine substantive issues related to our collections, with an emphasis on historical demography and the environment -ICPSR is a unit within the Institute for Social Research at the University of Michigan and maintains its office in Ann Arbor

Public Health Surveillance-Epidemiology

-Purpose: To collect information for action -Focus is on "person, place and time" 1) Case definition 2) Unit of Interest - population 3) Transmission patterns 4) Reporting procedures (technology) https://www.cdc.gov/publichealth101/surveillance.html

keys to successful organizing

-Recruiting highly energized people -Learning what skills they bring to the table -Designing a comprehensive action plan -Raising a lot of money (typically)

research vs. evaluation

-Research - A careful study that is done to find and report new knowledge about something. Increasingly mandated QA & QI Tools (outlined on pg. 424-425) -Evaluate - To determine the significance, worth, utility or condition of, usually by careful appraisal and study Increasingly costly Performance Measurement

Overview of the Affordable Care Act (ACA)

-Signed in 2010 by President Obama -Reforming Health Care, primarily through expanded access to Health Insurance (everyone in the pool!) = Making pools more heterogenous and reducing the number of people in the uninsured pool -Triple Aim- cost, experience of care, population health -Strengthen and update public health infrastructure (workforce, HIT) -Expand and coordinate prevention -Coordinate research and evaluation -Incentivize innovative financing structures and care delivery: ACO's, Bundled Payments, Primary Care Models and HCIA I and II (CMMI at CMS) -Increase access and utilization = -Expansion of coverage through both Employer and Individual Mandates -Medicaid expansion (however, uneven and disparate - becoming even more so) -Health Insurance Marketplace (state and federal marketplaces) -Precluded insurers from refusing coverage, or charging higher premiums for Pre-Existing Conditions. -Established 10 Essential Health Benefits that insurers had to cover -Expanded health coverage for all youth, up until age 26, including those in foster care -Prevention and Public Health Fund *Much opposition and many legal challenges* -1 success in repealing ACA = repealing individual mandate; Jan. 2019 -Pre-existing conditions protections are being attacked as well

Earlier PHS Research Priorities

-Social Determinants -Public Health Policy and Population Health Determinants -Public Policy and Public Health -Public Health Performance and Governance Structure *Including Health Equity, under each priority area Regarding social determinants... -Examining magnitude among social determinants - what is an optimal balance of investments? -Understanding how determinants effect, and affect, health disparities - how best to reduce and/or eliminate? -Examining effects of inequality of income and SES on health (Gini coefficient) -Need a strong, broad policy mandate to address, income, education, employment and housing as determinants of health

Hypothesis

-States a relationship between 2 or more variables, with one influencing the other -A change in one variable predicts a change in another (or original/baseline condition when comparing groups "unit of analysis") -An independent variable causes the variation -A dependent variable changes under the influence of the independent variable -The direction of association, or causation, is important (+/-) Causation --> directly causes Association --> X is observed when y is present X leading to Y X = ind. Y = dep.

what does Public Health Surveillance entail

-Surveillance entails collecting, processing, analyzing, and interpreting health data: Notifiable (e.g. food-borne)- if you have a case of it, it's reportable to the dept. of PH Sentinel (polio)- don't expect to see polio, but reported at federal and international levels Syndromic (public health, health care and EHR technology, zika?)- unclear on how it's being transmitted (early HIV, corona virus currently) Disease Registries (cancer)- state depts. Of PH do this Vital Statistics (births and deaths) Health Surveys (NHANES (nutrition) and BRFSS (adults)) Combined Approaches (avian flu)

500 Cities project

-The 500 Cities project is a collaboration between CDC, the Robert Wood Johnson Foundation, and the CDC Foundation -The purpose of the project is to provide city and census tract-level small area estimates for chronic disease risk factors, health outcomes, and clinical preventive service use for the largest 500 cities in the United States -These small area estimates allow cities and local health departments to better understand the burden and geographic distribution of health-related variables in their jurisdictions and help them plan public health interventions

Community Health Assessment

-The ACA (2010) requires tax-exempt (non-profit) hospitals to create a hospital Community Health Assessment every 3 years -Tied in with PHAB Accreditation too -Ideally, a hospital CHA should be developed alongside community stakeholders. Requirements as of 2014 include: -Demographic Assessment identifying the community the hospital serves (data and maps) -A Community Health Assessment survey of perceived healthcare issues (internal and external stakeholder interviews, surveys, small group discussions -Quantitative analysis of actual health care issues (internal & external community advisory committees, facilitators) -Appraisal of current efforts to address the healthcare issues -Formulate a 3-year plan - the community comes together to address those remaining issues collectively, ultimately working towards growing a healthier community

budget justification

-The Budget is the financial expression of the project and should accurately reflect the costs of the proposed research/education/service program -The Budget Justification provides descriptive information re: why costs are programmatically necessary and how they are calculated -Reviewers analyze the financial data to determine if the proposed costs are allocable and reasonable

CMS Innovation Center

-The Innovation Center allows the Medicare and Medicaid programs to test models that improve care, lower costs, and better align payment systems to support patient-centered practices -The Innovation Center carefully evaluates innovative reform efforts widely used in the private sector, and is unique in its ability to develop provider-proposed approaches and quickly adjust models in response to feedback from clinicians and patients -Innovation Center is currently focused on the following priorities: 0Testing new payment and service delivery models, including Quality Payment Program Advanced Alternative Payment Models -Evaluating results and advancing best practices -Engaging a broad range of stakeholders to develop additional models for testing

Roles & Responsibilities at the Local Level - County and Municipal

-The National Association of County and City Health Officials (NACCHO) is trying to standardize the functions of LHDs due to wide variation (e.g. states, urban vs. rural, etc.) -Local boards of health- Revisiting their role and authority -Size and scope- Scaling up for efficiency and coordination -Staffing- Contracting with consultants -Financing- Shared across towns, counties, etc. -Regionalization trends- Public health departments, fire, police, and emergency medical technicians

Public Health Surveillance

-The ongoing, systematic collection, analysis, and interpretation of health-related data essential to planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control -Passive (flu) vs. Active surveillance (Corona Virus)

KY medicaid work requirements

-Work requirement Waiver granted to KY •KY was unique among Southern states in establishing their own Health Insurance Exchange early on in 2014 (expanded coverage to 400,000 individuals and created 12,000 jobs) -Currently, 1/3 of the state population is enrolled in Medicaid •ED visits dropped and RX compliance increased in KY •Role of Seema Vermaand Tea Party Governor Bevin (elected in 2015)- •Vermaand drafted the waiver proposal as a consultant, and then approved once she was appointed CMS director •Bevin shut down the KY exchange and moved individuals to Federal Exchange Healthcare.gov •Upwards of 90,000 individuals could stand to lose coverage •Kentucky has won permission to make Medicaid only available to non-disabled adult residents who work at least 20 hours per week, volunteer, study, or take care of a family member -Former foster care youth, pregnant women, and full-time students are exempt from the work requirement -The state also now has the ability to charge low-income Medicaid recipients health care premiums, eliminate full coverage of dental care, vision services, and over the counter medications for many adults, end retroactive Medicaid coverage (if I'm uninsured and had a heart attack in March and then applied for Medicaid in April, all of my hospital bills would still be covered), and implement a 6-month lockout period for people who fail to re-enroll in time or report a change in income -LeonardoCuello, director of health policy at the National Health Law Program, believes many of these provisions are subject to court challenges because they violate Congress' original intent for Medicaid and they do not meet the waiver law's requirement that they consist of a novel policy experiment

Public Health Ethics

-about understanding right and wrong -a useful lens to assess the moral aspects of Public Health issues and provide justification for Public Health policies and interventions -Virtue Ethics- Honesty, Loyalty, Sincerity, Courage, Reliability, Trustworthiness, Benevolence = skills that cannot be acquired/skills that are natural -Professional Ethics Expertise, Integrity, Judgment = skills that can be acquired

Framework for Ethical Analysis and Justification

-analyze- -Analyze Ethical Issues Associated with Public Health Issue Risks and harms? (pg. 127 of the text) Goals? Stakeholders and Moral Claims? Scope of Authority? Historical Context? -identify -Identify Options and Evaluate Ethical Dimensions Utility Justice Respect for Individuals Respect for Public Institutions -justify -Provide Justification Effectiveness Proportionality Necessity Least Infringement Public Justification

health insurance risk pools

-high-risk individuals- those with higher healthcare needs and costs -broad risk pools- when plans have a balance of low and high risk individuals -segmented risk pools- when plans do not have a balance or low and high risk individuals -death spiral- could occur if the concentration of high-risk individuals is so high that the premiums are too expensive to lower-risk individuals (Plan 1's overall risk increases, so Plan 1's premiums increase, so lower-risk individuals choose other options, and the expensive plan gets higher and higher in risk)

data and tech challenged with GIS

-issues of data quality and completeness -confidentiality issues- PHI -cost of hardware, software, training staff -defining communities and establishing parameters accurately and appropriately -risk of community members misinterpreting data and findings -delineating government and community responsibility

GIS tools and analyses

-overlays- display more than one attribute at a time -buffers- create polygons based on the distance from the target object -chloropleth maps- use colors to visually depict different rates

GIS mapping and public health

-spatial data are related to descriptive data -GIS maps are a useful epi. tool -useful for conducting community health assessments (CHAs) -blood lead levels in Flint, MI -Geocoding- GIS software matches each record in the attribute database to the geographic data files -spatial/geographic data components- street address, zip codes, counties, census tracts and blocks -attribute data components- public health issues of interest, demographic, economic, social, health, environmental, vital stats, law enforcement

Strategic Planning

1.Assessment of internal and external environment (environmental scan; internal and external) 2.Identifying and involving key people- internal and external 3.Facilitation and decision-making (outside facilitators are neutral and unbiased = fresh eyes) 4.Clarifying Vision and Mission 5.Developing (and/or refining) Goals and Objectives 6.Identifying and allocating resources (sometimes comes at the beginning; planning is often driven by the availability of resources) 7.Developing and implementing Strategies and Action Steps 8.Communicating the plan (through internal memos and meetings (written and oral), launch event, Q&A event, promotional events 9.Evaluating/measuring and feedback Overview video- https://youtu.be/HQzxjsj69f8

Course of Action re: Research Priorities

1.Theory and Analysis re: how Public Health Efforts can reduce Health Disparities/Inequities 2.Develop Indicators to measure Public Health Performance 3.Use Case-Studies to develop lessons from other countries 4.Advocate for, fund, evaluate and disseminate State-level Innovations 5.Integrate Research and Practice in Community-Based Project 6.Innovative Ways of funding PHSR 7.Develop new Methodologies and Analytic Tools 8.Disseminate and Educate 9.Engage the Policy community (Health Impact Assessments) 10.National Center/Effort

U.S. Federal Government

3 Branches: •Executive (president, cabinet, White House staff/advisors, federal agencies (heads of agencies are appointed by president and can enact Rules and Regulations without passing things through Congress) •Legislative (Congress = House (Dems) and Senate (Rep)) •Judicial (Supreme Court, District Courts, Courts of Appeals (many lower court positions are being filled by the Executive branch)) Intended to serve as 'checks and balances' -Federalized structure of states = large degree of self-determination, policy variation and, thus, disparities in determinants and health between states -Due to mistrust of big, centralized government = shared power between Federal and State governments

Assessment, Policy Development, and Assurance activities

3 screenshots

MA DoNHealth Priorities

6 DoN Health Priorities, common social determinants of health: 1) Social Environment 2) Built Environment 3) Housing 4) Violence and Trauma 5) Employment 6) Education Current DPH Focus Issues, statewide trends and overall burden of morbidity and mortality point to: 1) Substance use disorders (SUDs) 2) Housing Stability/Homelessness 3) Mental illness and mental health 4) Chronic disease with a focus on Cancer, Heart Disease and Diabetes

general budget areas

A. Salaries and Wages Provide the following information for each position identified on the budget: Name Degree(s) Title Time commitment Duties and responsibilities in relation to the program goals and objectives B. Fringe Benefits Indicate how fringe benefit costs are calculated, based on the types of positions for which funding is requested. Typically, this is set by an institution. NOTE: Fringe benefit rates are updated periodically. C. Consultant Costs Professional services may be obtained from individuals who are not employees of the grantee institution. The following information should be provided: Name of consultant (if known) Organizational affiliation (if applicable) Nature of services to be rendered Number of days of consultation Expected rate of compensation -Hourly or day rate -Other (Travel, per diem, other related expenses) D. Equipment Requests for equipment should include the following information: Description Quantity Unit Cost Justification for the use of each item related to specific program objectives: -How the equipment will enable the project personnel to fulfill the scientific objectives of the project. -How the use of such equipment will be solely allocable to the project E. Supplies To the extent possible, list: Item description Quantity Unit Cost Total amount F. Travel Provide a breakdown of travel costs, including: Purpose of trip Name/position of traveler Number of Trips Total Cost To the extent possible, itemize per person travel costs: Airfare Lodging Meals Car Rental (parking, mileage, registration fees) G. Overhead, Facilities & Administration (F&A) or Indirect Costs F&A or indirect costs must be calculated in compliance with the budget guidance provided by the sponsor agency, and the institution submitting the proposal. Can vary considerably, from mid-range (15%) to very high (50%).

Health Surveys

BRFSS- Behavioral Risk Factor Surveillance System NHANES- National Health and Nutrition Examination Survey YRBSS- Youth Risk Behavioral Surveillance System

BPHC Community Health Improvement Plan

Boston Alliance for Community Health (BACH) and Boston Public Health Commission (BPHC) 4 Priorities Identified in the 2017 CHIP for Boston Communities: 1. Achieving Racial and Ethnic Equity 2. Improve Coordination and Integration of Healthcare and Community-Based Prevention Services 3. Build and Increase Resilience in Communities Impacted by Trauma 4. Improve Health Outcomes by Focusing on Education, Employment and Transportation Policies and Practices

Health impact pyramid

Bottom to top = increasing individual effort needed Top to bottom = increasing population impact Corn Class Loves Changing Seats BOTTOM- Socioeconomic factors Changing the context to make individuals's default decisions healthy Long-lasting protection interventions Clinical interventions Counseling and education -TOP

Grants

Categorical grants- Discretionary programs Entitlement programs- such as Medicaid and State Children's Health Insurance Program (SCHIP) block grants- Matching requirements

Public Health Surveillance-Based Action

Describe the burden of or potential for disease Monitor trends and patterns in disease, risk factors, and agents Detect sudden changes in disease occurrence and distribution Provide data for programs, policies, and priorities Evaluate prevention and control efforts Underlying legal bases at LHD, state, national and international levels

categories of cost control

FUCS PP -Financing - Flow of $ from Individuals and Employers (Taxes and Premiums) to Insurers (Government and Private) -Payment - Flow of $ from Insurers to Providers (Price and Utilization) oPrice oUtilization- Changing the Unit of Payment (Aggregation) Patient Cost-sharing (OOP costs for patients re: HI and/or HC services, influence Pt behavior) Utilization Management (Seeks to influence Provider behavior) Supply limits (Limiting Dx Tests and Types: Generalists vs. Specialists) Ultimately, Price Controls are most significant and have greatest impact -Ex.- Medicare and Medicaid dictating fees Private HI engaging in negotiation Providers bidding $ -Unsuccessful when applied in piecemeal fashion -Control of Price often leads to increase in Quantity (Utilization)

Health Care Financing options for individuals

Funding Sources/Mechanisms for individual health care: Uninsured Government Health Insurance: Medicare Medicaid CHIP VA Indian Health Service Privately insured through employer Privately insured through self HIM - Federal and State exchanges

APHA and AMA Working Partnership

In an effort tofoster better collaboration between public health and medical professionals and organizations, the following shared elements were agreed upon: •Engage the community •Change the educational process •Create joint research efforts •Devise a shared view of health and illness •Work together in healthcare provision •Develop health care assessment measures •Create local and national networks

TREW objectives

In what Timeframe What portion of Recipients What Extent of change Which type of change

Health insurance marketplace

Kinds- Federally-facilitated state-based state-based marketplace on federal platform state-partnership marketplace

CITI Training and Revisions to the Common Rule

New slide? Restrictions are relaxed -An unintended consequence of having a single entity IRB- Requirements could be too strict or too broad Can be biased (only one pair of eyes) IRB can have a vested interest in the study and overlook things -Now, you have to go through multiple IRBs

Roles & Responsibilities of NGOs: Communities

Non-Governmental Organizations - Communities • Voluntary Health Associations (ACS, AHA) • Social Service Organizations (United Way) • Community Coalitions • Faith-based

Roles & Responsibilities of NGOs: Institutes

Non-Governmental Organizations - Institutes • Foundations (RWJF and Kellogg) • Universities • Research and policy contract organizations (RTI, ABT, Mathematica, JSI)

Roles & Responsibilities of NGOs: Providers

Non-Governmental Organizations - Providers •Community Health Centers •Hospitals and Teaching Hospitals •Managed Care and Accountable Care Organizations (e.g. healthcare insurers)

7 interconnected processes and responsibilities commonly associated with the administrative role

Planning Organizing Staffing Directing Coordinating Reporting Budgeting Pg. 7- big textbook

Cost = Price X Quantity

Price Inflation in the U.S. Quantity = volume (patients, tests), intensity of services, length of stay Changes in P and/or Q have implications for patients and providers Cost-Benefit Analysis (aka Cost-Effectiveness) and Curve Focusing on Population Health Outcomes vs. Individual (difficult to disentangle and quantify) Unintended Consequences of undertaking Cost Control Merely shifting costs is insufficient to achieve systemwide savings

Public Health Definitions

Public Health- the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society Population Health- physical, mental, and social wellbeing of defined groups and the disparities in health between groups -Comprehensive and evidence-based approach to analyzing the determinants of health and disease to develop interventions to preserve and improve health -Public/Social Policy- intentional actions and inactions by gov't to address a problem affecting the public

Levels of Evidence

Randomized Control Trials (gold standard, expensive, ethical concerns) (people assigned randomly to experimental and control groups) Non-Randomized Control Trials (people assigned to experimental and control groups due to their attributes) Observational with Controls (cohort (similar attributes), cross-sectional (one point in time, looking across groups), case-controlled (cases with the disease and controls without the disease have their exposures are compared) (observational = not applying any intervention; passive) Observational without Controls +++ screenshot of pyramid

Evaluating Surveillance Data

Sensitivity- The degree of validity Predictive value positive- Reliability of data Representativeness- Data source bias Data quality- Understanding consistency and accuracy of how data was collected Timeliness- How quickly it is accessible Simplicity- How easily it is understood and applicable Flexibility- Usability in applicability for various purposes

Roles & Responsibilities at the state Level

There are two types of state department of public health models: -free standing agency -organizational unit within a larger structure •Most states distribute public health functions across departments and agencies •Vary in their relationship with regional, county, and local health departments •Related state agencies: housing, health insurance, labor, environmental, etc.

Top (14) Great Public Health Achievements

Voluminous Mothers Sometimes Can Do Some Hats, Fur, Furniture Rehab + 4 1)Vaccinations 2)Motor-vehicle Safety 3)Safer workplaces 4)Control Infectious Disease (Zika, Ebola, HIV) 5)Decline in Deaths attributable to heart disease and stroke 6)Safer and Healthier Foods 7)Healthier mothers and babies 8)Family Planning and Contraceptives 9)Fluoridation of drinking water 10)Recognition of Tobacco as Health Hazard 11)Tobacco Control 12)Cancer Prevention 13)Lead Poisoning Prevention 14)Preparedness and Emergency Response

CDC Framework for Program Evaluation

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Federal organization chart

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Key components of the new Healthy Adult Opportunity Guidance

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Public health approach from problem to response

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MAPP

screenshot circle -NACCHO and CDC -useful tool for planning evaluation

The Research Circle - Elements of Research Process

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Flint, MI

• A change in the source water (due to economic and political reasons) • Residents and children got sick due to contaminated water pipes • State and local officials provided no response or mitigation (no response from regional EPA) -Healthcare providers, researchers, and media (intersectoral efforts) brought this issue to the forefront on a national level to address lead in water

Limitations and Challenges facing the U.S. Public Health System Infrastructure

• Inadequate workforce (e.g. aging cohort and expanding need) • Old infrastructure and expanding roles (e.g. LHD established years ago) • Management by short-term crisis (e.g. reactive rather than proactive) • Weak, decentralized leadership (e.g. shared among government levels, public and private sector) • Inadequate system-wide planning and coordination • Fragmented IT technology and systems (e.g. lack of standardized EMR due to lack of federal policy, combined with free market principles)

Utilitarianism

•Ethical theory that supports: "The greatest good for the greatest number" •does not respect individual rights over the good of the community •The goal of maximizing the health of population is used to justify inconvenience or limited risk to individuals -Example: U.S. states mandating vaccinations among school children; NY state- no exemptions for vaccines except medical exemptions -In response to arguments that it may be unjust, utilitarianism is mitigated by Social Justice to minimize inequalities and ensure a sufficient level of health for all

Roles & Responsibilities at the Federal Level

•Health Policy - advocacy and agenda setting (e.g. Zika response in the U.S.) •Information Production and Dissemination- coordinating and disseminating info. to state and local levels (e.g. websites, brochures, fact sheets) • Regulation- development and enforcement (e.g. FDA, food inspection) •Tax Authority (e.g. establish and collect taxes which fund public health services and grants) • Resource Allocation (e.g. planning, services, and research)

CDC Healthy People 2020/2030

•Healthy People LHIs = Leading Health Indicators •Standardized health indicators used as local, state and federal measures to identify priorities and increase awareness and understanding of determinants of health and disease •Healthy People 2010 - first focus on eliminating health disparities

Uses of Public Health Surveillance

•Identify patients and their contacts for treatment and intervention •Detect epidemics, health problems, changes in health behaviors •Estimate magnitude and scope of health problems •Measure trends and characterize disease •Monitor changes in infectious and environmental agents •Assess effectiveness of programs and control measures •Develop hypotheses and stimulate research

Office of Civil Rights - DHHS

•Originally created by G.W. Bush; revived and expanded by Trump in January 2018 •To end discrimination against "people of faith;" protects healthcare providers from being required to perform tasks that conflict with their religious beliefs •Medical organizations and women's and LGBT rights groups expressed concern that the policy will hurt vulnerable populations and create an unequal system of health care -Obama administration had barred medical providers and insurers from discriminating in services or access to coverage based on gender, as well as gender identity •The National Women's Law Center, said "the wording on the rule creating the office appears to open the door for discrimination against patients because of their sexual orientation, gender identity or a whole host of other reasons." -Cases of denied or delayed care could multiply, describing controversies like one in Michigan in 2015, when a pediatrician refused to see an infant because the parents were lesbians •The American Medical Association ethics code says doctors should not refuse to care for patients based on "race, gender, sexual orientation, gender identity, or any other criteria that would constitute invidious discrimination." -These "rights" are superseding patients' rights to not be discriminated against = public justification of discrimination

public health systems perspective

•Public Health is a complex adaptive system composed of multiple, diverse, interconnected elements, capable of changing and learning from experience and its environment. It is highly interconnected and interdependent in relation to individuals, communities, and larger society. •Thus, Public Health efforts often involve multi-level, multi-disciplinary engagement and intervention from diverse stakeholders. •Important to understand how parts influence one another within a whole.

Challenges facing U.S. Public Health Infrastructure

•Public Health is an undervalued sector •Competition for resources among NGOs and all levels of government; Categorical and inadequate funding •Weak, decentralized leadership and system-wide planning and coordination; fragmentation, variation and disparities among U.S. states •U.S. is "a market dominated society that still considers health and health care to be primarily individual responsibilities." •Health has long been conceptualized as the "absence of disease" •Focus on Treatment, rather than Prevention •Inadequate workforce •Old infrastructure and expanding roles •Fragmented IT technology and systems • Complexity of issues (e.g. socioeconomic determinants)

Recent Public Health Developments in U.S.

•Repeal of the Individual Mandate of the ACA - effective January 2019 •Appeal Court judges ruled the Individual Mandate is Unconstitutional, but not the entire ACA (TX vs. U.S. 2018) •Work requirements proposed for Medicaid beneficiaries in certain U.S. states •States permitted to establish Short Term Health Plans & Health Associations (- EHB) •Expansion of insurance co. refusing to pay ER bills if deemed 'not emergency' •Expanded role for DHHS Office of Civil Rights (religious/spiritual protections) •New/revised abortion laws at state-levels and challenges from Senators + newly comprised SCOTUS •Ongoing Disparities in Infant and Maternal Health Outcomes •Gun Violence - Mass shootings, Suicide and DV •Opioids, legalization of Marijuana and e-cigarettes (vaping) •DACA status still unresolved and hostile environment re: Immigrants •Climate change - hurricanes, wildfires and coastal changes

Brief history of public health

•Sanitation and Hygiene •Recognizing, understanding, containing, treating and preventing Infectious Disease (through, for example, immunizations) •Reproductive Health •Reducing Accidents and Injury •Preventing and Containing Chronic Disease

Strong public health Infrastructure:

•Skilled workforce •Integrated electronic information systems •Public health organizations •Resources •Research •Responds to the Healthy People 2010 goal of "ensuring capacity to provide the essential public health services at federal, state, and local levels" •Example: ACA incorporated aspects of Healthy People

Prevention and Public Health Fund

▣Established in 2010 as part of ACA - initially $15 billion over 10 years ▣In 2012, cut back by Obama administration by $5 billion ▣Targeted in repeal efforts from 2016 on ▣In 2016 and 2018, cut by another couple of billion for remaining years ▣Between expenditures, cuts and reallocations = essentially gone

Public Health Finance

▣Primarily relies on public funding, through taxes and appropriations, for acquisition, utilization and management of resources ▣$3 trillion in U.S. Health Care spending in 2014, only 2.65% went to public health ▣Federalist system Federal - grants and contracts State - pass-through money Local - services and activities provided directly and contracted out -Federal and state money goes to Medicaid -Federal money goes to Medicare -State funding is vulnerable to change w/ federal gov't priorities and policies -25% of state funds in different states looks different = states' PH systems look different as a result

Financing and Taxes

▣Regressive- payments are a decreasing proportion of ability to pay (sales, property) ▣Proportional- payments are a constant proportion of ability to pay (state income tax in MA) ▣Progressive- payments are an increasing proportion of ability to pay (federal income tax, although capped at 37% at $500,000 threshold for an individual in 2018) **U.S. families, on average, spend 8% income on health care (premiums, deductibles, co-pays, OOP), but this varies widely and may be 17% or higher for those not receiving credits or subsidies -Income tax highest at 80% at its peak after Depression; paid for investments in highways, schools, infrastructure, etc.