1

A Regional Public Health System in NH

What Do We Have Now?

Why Regionalize?

How Do We Make a Case for Regional

Public Health in a State Like NH?

What Would Change?

2

What Does Public Health Look Like in NH Today?

•At the State level, DHHS is the lead public health agency. The Department of Environmental Services, Department of

Education, and Department of Safety also play key roles

• In almost all New Hampshire communities, non-governmental organizations provide a significant sub-set of public health services

• Each of New Hampshire’s 234 cities and towns are required by law to have a health officer

• Only five New Hampshire communities maintain public health departments of various size ; no county health departments

3

2004 New Hampshire Public Health Network

“Assuring the health and safety of all NH residents”

o 14 Coalitions

o 118 Towns

o 50% of NH towns

o 70% of the NH population covered

o 5-11 communities per coalition

4

All Health Hazard Regions

Organized to plan for and respond to public health emergencies

19 Regions

5

And more maps for other services

Community health centers Tobacco coalitions WIC services HIV prevention Etc, etc, etc.

6

7

Why Regionalization?

8

Potential Benefits of Regionalization

Study in the AJPH, March 2006 examined performance of public health agencies, size and resources

It noted that small public health agencies may benefit by combining resources and operations

But gains may diminish with size – too big is not good (but NH is small in both geography and population)

Mays, G, McHugh, M et al. AJPH, March 2006 Vol. 96, No. 3

9

Regionalization Goal

Overall Goal – A performance-based public health delivery system, which provides all 10 essential public health services throughout New Hampshire

Provide high quality public health based on national standards

10

Why do we need regional public health in one of the healthiest states?

What is killing us and making us sick today are chronic illnesses (heart disease, cancer, respiratory disease, injuries)

Many of the contributing factors to these are preventable –

tobacco, diet, physical activity, alcohol consumption

Well-run community based public health programs can prevent these problems

Money can be saved

11

What is Public Health ?

The study and practice of managing threats to the health of a community or population

The public health approach is applied to populations ranging from a handful of people to the whole human population

Priorities are to prevent (rather than treat) a disease or injury through the study of cases; promoting healthy behaviors; preventing the spread of disease; and addressing policy issues.

12

.

Individual vs. Populations

How does public health differ

from health care?

13

Example- Smoking

Health care response

Treat an individual for smoking related health problems – asthma, pneumonia, heart disease, cancer, etc.

Counsel to quit smoking Provide nicotine

replacement therapy

Public Health Response Study the effects of tobacco

– Surgeon General’s report Labeling of cigarettes Public information

campaigns Promote policies such as

non-smoking workplaces Enforcement of laws such as

limiting tobacco sales to minors

14

Public Health Goes to You

Unlike personal health care services, in many cases the public does not have to travel to receive public health services Public health staff go out to do investigations Public health staff analyze diseases by populations Public health education campaigns are delivered where

people go or access information (radio,TV, billboards, schools, workplaces, etc.)

So public health regions do not need to align exactly with hospitals or doctors offices service areas

15

Public Health Saves Money

$10 per person per year in proven community-based disease prevention (improvements in physical activity, nutrition and preventing smoking) could yield saving of $2.8 billion in health care costs in 2 years

That’s $2 in return for every $1 invested in the first 1-2 years

Prevention for a Healthier America:Investments in Disease Prevention Yield Significant Savings, Stronger Communities. Trust for America’s Health July 2008 www.healthyamericans.org

16

Obesity for example

23.6 % population is obese, 61.8% are overweight or obese – significant increase from 2005-2007

NH ranks 35th in the nation, despite having the lowest poverty rate

Worst in New England ¹ For the first time in 2 centuries our children’s life

expectancy is potentially less than ours (2-5 years) due to obesity and related factors (diabetes, heart disease, kidney failure, cancer)

F as in Fat: How Obesity Policies are Failing in America 2008, Trust for America’s Health, August 2008 www.healthyamericans.org

NEJM March 2005

17

Example - Obesity

Health Care Response

Treatment for conditions such as heart disease, high blood pressure, diabetes, cholesterol

Nutritional counseling Bariatric surgery

Public Health Response

Working with schools to provide healthy lunch menus

Working with community coalitions to develop walkable communities

Assist in developing policies for physical activities in schools

18

The 10 Essential Public Health Services

19

The Proposed Approach  The DPHS and Regionalization Initiative workgroup envision one lead public

health agency per region. It must be linked a governmental entity that is responsible to coordinate or directly provide the 10 essential services. The lead agency may subcontract or create memoranda of understanding for some essential services

Regions based on existing ones (many are quite similar) and take into account geographic features, existing public health services and population size

Two levels of public health (primary and comprehensive) that acknowledge existing resources and capacity to carry out public health services. Comprehensive = Manchester and Nashua

Primary = everywhere else

20

Approach

Will be based on national standards for what a public health agency should look like and how it should perform

 Will be an evolutionary process – some may not meet all components of a primary agency from the beginning but will move there in time.

 Will require changes to state law.

21

The Role of Government in Public Health

Assessment – Takes into account all relevant factors to the extent possible, based on objective factors, without self-interest

Policy Development – Takes place as a result of interactions among public and private organizations

Assurance – Assures that necessary services are provided to reach agreed upon goals by encouraging the private sector, requiring it, or providing services directly

22

A Primary Regional Public Health Agency

Staff, funding, and legal recognition to assure a fundamental public health presence

Performs some level of the 10 essential services Collaborates extensively with system partners in the region

to coordinate more comprehensive services The NH DPHS continues to provide some core services (i.e..

lab, disease investigations) to these regions Coordinates with local health officers or move towards

shared health officer among municipalities

23

Proposed Staffing

Every region would have: Administrator Health educator/marketing

staff Nurse (?) Environmental health

specialist Support staff

Shared across regions:EpidemiologistEmergency preparedness coordinatorMedical consultant

(Shared or in-kind)Financial managerIT support

24

How is this Different than the Public Health Networks?

Proposal that there be a legally-recognized regional public health council which…

Designates a lead public health entity that… Is responsible to the council and regional public

health system partners for… Implementing a coordinated approach to provide

public health services to the public

25

Next Steps-What Do We Have?

Assessments to Help Us Determine, Resources, Costs, Needs and

ApproachJune 2008- February 2010

Financial analysis of all state/local/private public health funding with consideration of efficiencies from regionalization – Patrick Bernet, FAU

 Assessment of local/regional public health system capacity to deliver the 10 essential services- with a gaps analysis – Lea Lafave, CHI

 Assessment of what the link to government could look like - Jennifer Wierwille Norton

26

Financial Assessment

To gain an understanding of current public health expenditures in each region and for the state as a whole

Will capture state, municipal and private-sector funding

To try to understand the potential financial implications of regionalizing select public health services

27

Capacity Assessment Purpose

To identify assess and gaps in the region and these that may lend themselves to regionalization.

Process: Framework of the National Association of City

and County Health Officials Essential Service

Standard Indicator

Revised ToolLead organization : Regional Partners : State

28

What is the Governance Assessment?

Focuses on figuring out who’s responsible or held accountable; not doing the work but overseeing it;

Who’s overseeing performance of the public health entities who are partners.

Who’s assessing the degree to which the partners in the region have the necessary authority, resources and policies to provide essential public health services.

Assures that the infrastructure exists to protect and promote health in the community.

29

Governance Assessmentin Two Parts

Part I: Examining Readiness to Serve in a Governance Function:

The first part of the assessment provides a tool to measure the region’s readiness to serve as governing body or Public Health Council to oversee the delivery of services and programs.

Part II: Examining Types of Lead Public Health Entities Participants will use part II of the tool to hold a facilitated

discussion about the different options available for the region’s Public Health Council to choose as a lead public health entity (type of entity).

30

What Will Change?

Statewide, regional and more formalized recognized system, in law that provides a more even level of each essential service

Coordinates the current fragmented system that delivers very different levels of service

More efficient use/better coordination of existing resources

Based on national standards -PHAB

31

What Won’t Change?

Municipalities retain legal authority for enforcing state laws and local ordinances

DPHS provides some core services such as lab and disease control

Local agencies will still receive funds directly from DPHS but will need to be part of the regional system

32

And the benefits will be…

Higher quality services at the best possible cost

Ability to measure ourselves against national standards

Better positioning for increasingly competitive federal funds

33

Questions?Joan Ascheim

NH Dept of HHS, Division of Public Health Services jascheim@dhhs.state.nh.us

1-800-852-3345 ext. 4110

Lea Lafave

Community Health Institute/JSI603.573.3335lea_ayers-lafave@jsi.com