1. Public Health Systems Research: What, Why, and How?

2. Public Health Systems Research: What, Why, and How? Lunch and Learn 23 September 2005

3. Public Health Systems Research: What, Why, and How? 23 September 2005 Hugh H. Tilson

4. Public Health Systems Research: What, Why, and How? Hugh Tilson (Glen Mays)

5. What is Public Health Systems Research? A field of inquiry examining the organization, financing, and delivery of public health services at local, state and national levels, and the impact of these activities on population health Mays, Halverson, and Scutchfield. JPHMP 2003

6. What Constitutes a Public Health System? The collection of governmental and private entities that contribute to the delivery of public health services for a defined population.  How to define the population?  Local vs. state systems  Variation in system structure and composition

7. But first... a word from our sponsors!

8. Committee on Assuring the Health of the Public in the 21st Century INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES T HE F UTURE OF THE P UBLIC’S H EALTH in the 21st Century

9. Background in the Report u Health = Public Good u Government has fundamental, statutory duty to assure the health of the public, BUT … u Government cannot do it alone u Need for inter-sectoral engagement in partnership with government u Health = social goal of many sectors and communities

10. The Committee’s Conclusion u An inter-sectoral public health system is needed u In 1988 report, public health refers to the “organized efforts of society, both government AND OTHERS, to assure conditions in which people can be healthy” u THIS report elaborates on the efforts of the other potential public health system actors.

11. The Public Health System ME!! Employers and Business Academia Governmental Public Health Infrastructure The Media Health care delivery system Community

12. The Public Health System Assuring the Conditions for Population Health Employers and Business Academia Governmental Public Health Infrastructure The Media Health care delivery system Community

13. more inter-organizationally complex, slower rate of improvement organizationally complex, faster rate of improvement What Kinds of Work Must the Public Health System Perform? Public Work (organizing, governance, citizenship, mutual accountability) Professional Work (customers, products, services) Safer, Healthier Population Becoming Vulnerable Becoming no longer vulnerable Vulnerable Population Becoming Affected Population with Disease Developing Complications Population with Complications Targeted protection Primary prevention Secondary prevention Dying from Complications Tertiary prevention Society's Health Response General protection Adverse Living Conditions Milstein and Homer 2003 Demand for response

14. Why Study Public Health Systems? “Unlike the medical care system, there is little research and relatively few measures for studying how well the public health system operates.” — Center for Studying Health System Change, 1996

15. Why Study Public Health Systems? “The Committee had hoped to provide specific guidance elaborating on the types and levels of workforce, infrastructure, related resources, and financial investments necessary to ensure the availability of essential public health services to all of the nation’s communities. However, such evidence is limited, and there is no agenda or support for this type of research, despite the critical need for such data to promote and protect the nation’s health.” —Institute of Medicine, 2003

16. Why Study Public Health Systems? u Concerns about preparedness for emerging threats u Wide variation in public health resources u Persistent disparities in outcomes u Difficulties demonstrating accountability/value for investments in public health u Desire for evidence-based decision-making

17. Why Study Public Health Systems? Intervention Research u What works – proof of efficacy u Controlled trials u Guide to Community Preventive Services Systems & Services Research u How to implement in real-world settings –Expand reach –Improve quality, efficiency –Reduce disparities u Observational studies, CBPR

18. Where Are We Now? Descriptive Inferential Interventional Translational How are public health systems organized and financed? What do they do? What factors influence their work? How does their work influence the public’s health? How can we improve performance and population health? Research topics:Type:

19. The National PH Performance Standards Program(NPHPSP) u THREE “instruments” u OMB approved with ‘control numbers’ u STATE u LOCAL u GOVERNANCE

20. The local public health system assessment instrument u OMB Control Number 0920-0555 u 24 hours per response u “…ALL entities that contribute to the delivery …”

21. The local public health system assessment instrument u “How much of this Model Standard is achieved by the local PHS collectively?” u What percent of the answer reported in Q 1 is the direct contribution of the local PH agency?

22. Public health system assessment instruments and A CCREDITATION u Can achievement of a “passing grade” on a performance assessment be used for accreditation? u How should WHO accredit WHOM and HOW? (not to mention WHY?)

23. Variation in System Performance Mays et al. AJPH 2004 Local Jurisdictions with at Least 100,000 Population, 1998

24. Who Contributes? Proportion of Effort Contributed by Local Health Departments and Other Organizations Mays, Halverson, Stevens. Public Health Reports 2001

25. Who Contributes? State Agencies Local Agencies Federal Hospitals Physicians CHCs Health Plans Universities Others Mays, Halverson, Stevens. Public Health Reports 2001

26. How Does System Composition Affect Performance? Increases in System Performance Associated with Participation by Other Organizations Mays, Halverson, Stevens. Public Health Reports 2001 % Change in Performance

27. Performance Associated with System Size Monitor Investigate Inform Partnerships Policy/plan Spline Regression Estimates After Controlling for other Variables in the Model Mays et al. AJPH in press

28. Performance Associated with Local Agency Spending Per Capita % Change in Performance Mays et al. JPHMP 2004

29. Priorities for Future Research u Measuring “performance” and “quality” u Measuring public health spending/cost u Estimating impact on population health u Evidence-based decision making regarding society’s investments in public health

30. More Questions than Answers? Priorities for Future Research u What strategies and interventions are effective in improving PH system performance & outcomes? –Performance measurement ─ NPHPSP –Local and state QI collaboratives –Agency accreditation –Workforce training & competencies –Financing

31. WORKFORCE RESEARCH ADAPTABILITY Local (ACHD) Federal (HRSA) Academics (POPHTC)Evaluation Public Health Specialists Adult Educators LEARNING INTERVENTION Content Expertise Capacity building: Employees’ time and organizational improvement Effective teaching methods, attitudes, beliefs, the use of skills, and the quality of training Managerial Expertise: Valid, reliable tools, systematic individual tracking Accountability to taxpayers: Standardized data collection Quality of effectiveness of learning experience

32. Developing a Public Health Systems Research Agenda: CDC Experience Dennis Lenaway, Paul Halverson, Hugh Tilson (2), Sergey Sotnikov, Liza Corso, & Wayne Millington (1) Div of Public Health Systems Development and Research, Public Health Practice Program Office, CDC (2) School of Public Health, University of North Carolina

33. The 14 Major Themes (and votes) u Agency structure & performance (40) u Dimensions of public health systems (33) u Performance & health outcomes (30) u Characteristics of high-performing agencies (29) u Social determinants & system performance (28)

34. The 14 Major Themes (and votes) u Cost of optimal system performance (27) u Infrastructure & categorical programs (27) u Framework for high-performing systems (26) u Health outcomes & system performance (26) u Accreditation & performance improvement (21)

35. The 14 Major Themes (and votes) u Policy, finance & system performance (19) u Community involvement, NPHPS & system improvement activities (19) u High performing systems & preparedness (19) u Effectiveness of governance structures (16)

36. But first... a word from our sponsors!

37. Council on Linkages Between Academia and Public Health Practice 16 NATIONAL MEMBER ORGANIZATIONS American College of Preventive Medicine American Public Health Association Association of Schools of Public Health Association of State and Territorial Health Officials Association of Teachers of Preventive Medicine Association of University Programs in Health Administration Centers for Disease Control and Prevention Community-Campus Partnerships for Health Council on Accredited Master of Public Health Programs Health Resources and Services Administration National Association of County and City Health Officials National Association of Local Boards of Health National Environmental Health Association National Network of Public Health Institutes QUAD Council of Public Health Nursing Organizations Society for Public Health Education u The overall objective of the Council is to improve the relevance of public health education to practice u Grew out of the Public Health Faculty / Agency Forum  Grew out of the 1988 IOM Report Funded by HRSA and Staffed by PHF

38. What’s been achieved... u Public health systems research agendas - general, workforce, rural, preparedness u “Centers of Excellence” - several universities u Customers and demand for research - NACCHO resolution u PHSR “support group” - AcademyHealth u Research fellowship program - Pfizer u APHA Forum annually u THIS wonderful effort … THANKS RWJ!!

39. The road from here: FULL of opportunities!

40. Whaddya’ mean “Opportunities”? In THIS mess?

41. What’s left to be done... Turning pennies into dollars

42. Examples of Organizational Commitments u APHA –Host leadership forum –Publish article –Executive Board action u CDC –Convene federal agencies –Support PH Affiliate –Develop specific agendas u NACCHO –Executive Board input –Annual meeting presentations –Process to develop agenda u Pfizer, Inc. –Develop fellowship u Research!America –Develop case for PHSR –Seek ideas for opinion polls u AHRQ –Meet with leadership –Promote PHSR in solicitations u ACPM –Annual meeting presentations –Communicate with members

43. The Road from Here … FULL of opportunities u AcademyHealth Public Health Systems Research Interest Group u Council on Linkages/PHF u CDC Futures Initiative u Foundation initiatives, e.g. HCFO, u RWJ’s strong commitment u State-supported efforts

44. The road from here: YOU drive!