Creating a Sustainable Model of Public Healthfor All of Montana: Strategies for Best Practices in Innovative Policy Development: The Journey of HB 173

Michele Sare, MSN, RN

Nurses for Nurses International

March 2011: AHECSpokane, WA

Prevents epidemics and the spread of diseaseProtects against environmental hazardsPrevents injuriesPromotes and encourages healthy behaviorsResponds to disasters and assists communities in recovery Assures the quality and accessibility of health services

(*CDC slide)

Public Health has some issues

10 million children…18 each minute

1 million girls and women

32 million with HIV/AIDS

13 million with TB

27 million with malaria…most children

½ of the world‟s children will go to bed hungry …again

Disparity - Inequity

20% of our population

“If you’ve seen one PH Department, you’ve seen one PHD”

7 days/week

HH care 2 – 3 x/d

No governance support for PH

Governance miss-management of funds

No cavalry

My Life as a LPHO

PH is a little broken…and has been neglected

Should not be ‘person-bound’….

A profession has guidelines, standards & ethics

Concern for regionalization, loss of services

Sustainable Local Public Health?

Poor Health/Healthcare Hurts

25% > 65 by 2015 in MC

18% poverty rate in MC….increasing

44% of all Montana children uninsured (therefore do not seek healthcare appropriately)

High rates of obesity (40%) in MC

Alcohol & drug abuse in MC

Leading causes of premature death in MC are heart disease, cancer & stroke – all early prevention

MVA, resistant microbial infections, STDs & other preventable factors disable or kill our citizens

Changing Paradigms

Evidence

Knowledge

Cultural Shifts

Collaboration

„De-siloing‟

Accountability

WE ASKED:

“WHAT’S UP WITH THIS?”

We Went Fishing…

Michele & Peggy & her crew – Mineral Co.

Dan & Gordon

MPHA, AMPHO & other Local HDs

DPHHS

___________

= HB 173

National & International ‘Mandates’ for PH

We ended Healthy People 2010

We’re headed toward a new set of national health goals in Healthy People 2020 (HP 2020)

MDG -The United Nations – with the World Health Organization (WHO) http://www.un.org/millenniumgoals/

1. End Poverty and Hunger

2. Universal Education

3. Gender Equality

4. Child Health

5. Maternal Health

6. Combat HIV/AIDS

7. Environmental Sustainability

8. Global Partnership

Millennium Development Goals

Mission:

Promote Physical and

Mental Health

and

Prevent Disease,

Injury, and Disability(*CDC slide)

Vision:

Healthy

People in

Healthy

Communities

National Trends…Others have been asking “What’s up w/ this?”

HC reform nationally – cost, quality and access

3,000 LHD nationwide…independent models …‟made-up/person-bound‟

Not standardized – Old mantra = “If you‟ve seen one LHD, you‟ve seen one LHD”

Dilution of services – vying for HC dollars

„Regionalization‟ and loss of services

National Guidelines

US DHHS CDC

PHAB

APHA

NACCHO, ASTHO & NALBOH

RWJF & W. K. Kellogg Foundation

Institute of Medicine (IOM)Reports

Tipped the HC world on its ear…

“Quality Chasms”

1988 PH Improvement came

assessment, policy development

& assurance

An update in 2003, The Future of the Public’s Health in the 21st Century

Still not doing too well…

State Laws & GuidelinesMontana Code Annotated (MCA) – Title 50-2 (http://data.opi.state.mt.us/bills/mca_toc/50.htm)Administrative Rules of Montana (ARM) – 37 – (http://www.mtrules.org)MPHAAMPHOLocal ordinancesMT Environmental Health AgenciesBON

PH Drivers

• IOM - The Institute of Medicine serves as adviser to the nation to improve health.

• CDC – Overall lead for coordination

• ASTHO – Develop and support state instrument

• NACCHO – Develop and support local instrument; MAPP

• NALBOH – Develop and support governance instrument

• APHA –Marketing and communications

• PHF- Performance improvement; data collection and reporting system

• NNPHI – Support through institutes, training workshop and user calls

• PHAB - In order to improve the health of the public, the Public Health Accreditation Board (PHAB) is developing a national voluntary accreditation program for state, local, territorial and tribal public health departments

(*from a CDC slide)

Strengthening systems, improving the public’s health

History of the NPHPSP

Key Dates

– Began in 1998

– Version 1 instruments released in 2002

– 2002-2007 – Version 1 instruments used in more than 30 states

– Development of Version 2 instruments – 2005-2007

Comprehensive Development of Instruments

– Practice-driven development by CDC and ASTHO, NACCHO and NALBOH Work Groups

– Field testing

– Creation of PHAB – 2007(*CDC slide)

Schools

Community

Centers

Employers

Transit

Elected

Officials

Doctors

EMS

Law

Enforcement

Nursing

Homes

Fire

Corrections

Mental

Health

Faith Institutions

Civic Groups

Non-Profit

Organizations

Neighborhood

Organizations

Laboratories

Home

Health

CHCs

Hospitals

Tribal Health

Drug

Treatment

Public Health

Agency

Public Health System

(*CDC slide)

Existing Tools

Tools to Implement 173

‘10 Essentials’

The ‘PH Wheel’ (10 Essentials)

NACCHO’s Operational Definition of a Functional Local Health Department & Metric

NALBOH’s Local PH Governance Instrument, Version 2

PHAB Domains, Standards & Measures and corresponding tools – in beta

ANA Scope & Standards of PHN….(& MCA & BON)

Evidenced Based Practice (EBP): research, literature reviews, journals & current texts

Operational Definition of a Functional Local Health Department:

NACCHO

+ Metrics

PHAB’s Purpose

“In order to improve the health of the public, the Public Health Accreditation Board (PHAB) is developing a national voluntary accreditation program for state, local, territorial and tribal public health departments. The goal of the accreditation program is to improve and protect the health of every community by advancing the quality and performance of public health departments.” www.phaboard.org/

PHAB Draft Tools (Based on the ’10 Essentials’)

Local Standards & Measures Self-Assessment Tool

Health Department Readiness Checklist

Guide to National Voluntary Accreditation

Domains, Standards & Measures (final)

PHAB Beta Test: Paralleling 173

30 PH Departmentso 3 Tribal

o 8 State HD

o 19 Local HD

o Beta testing Domains, Standards & Measures

o Accreditation tools in draft form as beta test continues

o Existing tools in-use

o Beta Test - October 2009 – December 2010

We are on the crest of a great wave of change in public health….

So….How did we ‘do It’?

Tools Synergy

Rule no. 1 to effecting a

positive policy change (and this is the biggy – the foundation for all

others) – do your dandiest to

create a ‘win-win’ situation for all

stakeholders

11 Rules to Effective Policy Change

Infrastructure

Federal „HD‟ HHS

SHD

State Laws

LHD

Local Governance

RULE NO. 2 TO

POSITIVE POLICY CHANGE: RECRUIT YOUR

LEGISLATIVE CALVARY

RULE NO. 3: EDUCATE, EDUCATE,

EDUCATE!

RULE NO. 4: NEVER CONSIDER ASKING FOR MORE MONEY FOR A PROGRAM IN A POOR STATE THAT IS ALREADY AWARDING TONS OF MONEY (IN THE LEGISLATOR’S VIEW) TO A PROGRAM THAT SOUNDS

AN AWFUL LOT LIKE WHAT YOU’RE TRYING

TO DO

RULE NO. 5: CLEARLY DEFINE THE ROLES AND

RESPONSIBILITIES OF STAKEHOLDERS

Partners & Stakeholders

Montana Legislature

Taxpayers – Mineral County citizens, governance & HC entities

Representative Gordon Hendrick & Education Policy Advisor Dan Villa

DPHHS – PH Improvement group

NWCPHP

PHAB & MLC III

PHSITF

HB 0173 Pilot Projects

BON, ANA, NLN +

National PH Agencies

RULE NO. 6 OF POLICY CHANGE: IT IS ‘S-L-O-W’, BE PATIENT

AND THOROUGH (THIS 18 MONTHS WAS ACTUALLY

PRETTY SPEEDY!

RULE NO. 7: CREATE A COMPELLING

PURPOSE THAT EVERYONE

CAN UNDERSTAND –

‘BRAND’ IT.

RULE NO. 8: CREATE BUY-IN BY MAKING SURE THAT IT ISN’T

ABOUT ‘YOU’ IT IS

ABOUT THE GREATER GOOD

RULE NO. 9: BE A MASTER

COMMUNICATOR AND LEAVE NO

ROCK UN-TURNED WHEN COMMUNICATING!

RULE NO. 10: BELIEVE IN YOUR

POLICY ‘PRODUCT’ AND LEARN THE BUSINESS OF

‘SALES’!

RULE NO. 11 IS AN ‘EXTRA’ – IT IS WHAT

YOU BECOME WHEN YOU WORK TO CREATE A WIN-

WIN – NO. 11 IS A BENEFIT – GAINING A SENSE OF

GROWTH AND

CONTRIBUTION

HB 0173 Sites

1. Butte-Silverbow

2. Yellowstone (Riverstone)

3. Richland

4. Mineral

5. Cascade

6. Hill

7. Prairie

Purpose

1. Determine what it takes to create a sustainable model of a local PHD in our frontier setting

2. Determine what it takes to create a sustainable model of an accredited local PHD in our frontier setting

4 Over-Riding Tasks

1. Conduct a Self-assessment based on the PHAB Self-Assessment Tool

2. Conduct a Community Health Assessment (CHA)

3. Develop a Community Health Improvement Plan (CHIP)

4. Develop a PH Strategic Plan (PHSP)

Who We Are Accountable To (who is watching us, wants reports & where the

money came from)

ARRA – The American Recovery & Reinvestment Act: Montana RRA $

“ARRA funds are targeted toward rebuilding infrastructure and positioning the country to grow the next

generation economy”.

Also Accountable To:

Legislators & Legislative Interim

Committee

Local Governance

DPHHS PH Improvement group

PHITF

Bruce & Jack (contractors to DPHHS –from NWCPHP)

PHAB

Little cross-over w/ RWJF & the MLC III

Project Schedule

Began 11/1/2009

Self-assessment 1/2010 – 4/30/2010

Began Community Health Assessment (CHA)

9/2010

Report to Legislative Interim Committee August

24, 2010

Year 1 – completed 6/30/2010

Year 2 – 7/1/2010 – 6/30/2011

Year 2 – CHA, CHIP & PHSP

MEASURING ACCOUNTABILITY:

Based on the language of

HB 0173http://data.opi.mt.gov/bills/2009/billhtml/HB0173.htm

Role of DPHHS & PHITF

Oversight of HB 0173 progress

Guidance materials and assistance

Resource

Technical assistance

Guidance

PHAB

CDC

NACCHO

Interpret & facilitate the guidance:

NWCPHP

PHSITF

DPHHS

The New Public Health

Together - We have work to do!

The End… …References

• CDC: http://www.cdc.gov/od/ocphp/nphpsp/

• PHAB: http://www.phaboard.org/

• NACCHO: http://www.naccho.org/

• IOM: http://www.iom.edu/

• MAPP: http://www.naccho.org/topics/infrastructure/MAPP/index.cfm

• PDSA: http://www.valuebasedmanagement.net/methods_demingcycle.html

• NFNI: http://www.nursesfornursesinternational.com