Seven Years, 3 Surveys, a Changed World: The State Public Health Workforce 2014-2021.

CONTEXT: The COVID-19 pandemic and other public health challenges have increased the need for longitudinal data quantifying the changes in the state public health workforce. OBJECTIVE: To characterize the state of governmental public health workforce among state health agency (SHA) staff across the United States and provide longitudinal comparisons to 2 prior fieldings of the survey. DESIGN: State health agency leaders were invited to have their workforce to participate in PH WINS 2021. As in prior fieldings, participating agencies provided staff lists used to send e-mail invitations to employees to participate in this electronic survey. SETTING AND PARTICIPANTS: State health agency staff. MAIN OUTCOME MEASURES: PH WINS 2021 maintains the 4 primary domains from 2014 and 2017 (ie, workplace engagement, training needs assessment, emerging public health concepts, and demographics) and includes new questions related to the mental and emotional well-being; the impact of the COVID-19 pandemic on staff retention; and the workforce's awareness of and confidence in emerging public health concepts. RESULTS: The percentage of SHA staff who self-identify as Black, Indigenous, and people of color increased from 30% (95% confidence interval [CI]: 29%-32%) to 35% (95% CI: 35%-37%) between 2014 and 2021. Staff younger than 31 years accounted for 11% (95% CI: 10%-12%) of the SHA workforce in 2021 compared with 8% in 2014 (95% CI: 8%-9%). From 2014 to 2021, staff who self-identify as a woman increased from 72% (95% CI: 71%-74%) to 76% (95% CI: 75%-77%). Overall, 22% (95% CI: 21%-23%) of the SHA workforce rated their mental health as poor/fair. CONCLUSION: The 2021 PH WINS results represent unique and current perspectives on the SHA workforce and can inform future public health infrastructure investments, research, and field practice to ensure a strong public health system.

Health Departments' Role in Addressing Social Determinants of Health in Collaboration With Multisector Community Partnerships.

Multisector community partnerships (MCPs) are key component of the public health strategy for addressing social determinants of health (SDOH) and promoting health equity. Governmental public health agencies are often members or leaders of MCPs, but few studies have examined the role of health departments in supporting MCPs' SDOH initiatives. We engaged 42 established MCPs in a rapid retrospective evaluation to better understand how MCPs' SDOH initiatives contribute to community changes that promote healthy living and improved health outcomes. As part of this work, we gained insights into how health departments support MCPs' SDOH initiatives, as well as opportunities for enhanced collaboration. Results indicate that health departments can support MCPs' SDOH initiatives through the provision of funding and technical assistance, data sharing, and connecting community organizations with shared missions, for example. Findings can be used to inform the development of funding opportunities and technical assistance for MCPs and health department partners.

COVID-19 Case Investigation and Contact Tracing Programs and Practice: Snapshots From the Field.

Between Fall 2020 and Spring 2021, the Association of State and Territorial Health Officials conducted 2 rapid queries to collect information from the field regarding the status of COVID-19 case investigation and contact tracing (CI/CT) programs and practice. These short surveys were distributed to senior deputies in state and territorial health agencies, yielding a response rate of 45.8% (November 2020) and 40.7% (April 2021). Findings indicated that CI/CT staff roles and assigned functions varied across jurisdictions, as did staffing levels/capacity, approaches for linking individuals to social supports, and program changes that were planned or underway. Agency-reported staffing levels/capacity and programmatic challenges changed over time, highlighting the dynamic nature of CI/CT program practice and implementation. While findings from the surveys cannot be generalized to the national level, they provide critical insights from the field on CI/CT program implementation, challenges, and changes in response to the evolving COVID-19 epidemic in the United States.

Comparative cost-effectiveness of mailed fecal immunochemical testing (FIT)-based interventions for increasing colorectal cancer screening in the Medicaid population.

BACKGROUND: Mailed reminders to promote colorectal cancer (CRC) screening by fecal immunochemical testing (FIT) have been shown to be effective in the Medicaid population, in which screening is underused. However, little is known regarding the cost-effectiveness of these interventions, with or without an included FIT kit. METHODS: The authors conducted a cost-effectiveness analysis of a randomized controlled trial that compared the effectiveness of a reminder + FIT intervention versus a reminder-only intervention in increasing FIT screening. The analysis compared the costs per person screened for CRC screening associated with the reminder + FIT versus the reminder-only alternative using a 1-year time horizon. Input data for a cohort of 35,000 unscreened North Carolina Medicaid enrollees ages 52 to 64 years were derived from the trial and microcosting. Inputs and outputs were estimated from 2 perspectives-the Medicaid/state perspective and the health clinic/facility perspective-using probabilistic sensitivity analysis to evaluate uncertainty. RESULTS: The anticipated number of CRC screenings, including both FIT and screening colonoscopies, was higher for the reminder + FIT alternative (n = 8131; 23.2%) than for the reminder-only alternative (n = 5533; 15.8%). From the Medicaid/state perspective, the reminder + FIT alternative dominated the reminder-only alternative, with lower costs and higher screening rates. From the health clinic/facility perspective, the reminder + FIT versus the reminder-only alternative resulted in an incremental cost-effectiveness ratio of $116 per person screened. CONCLUSIONS: The reminder + FIT alternative was cost saving per additional Medicaid enrollee screened compared with the reminder-only alternative from the Medicaid/state perspective and likely cost-effective from the health clinic/facility perspective. The results also demonstrate that health departments and state Medicaid programs can efficiently mail FIT kits to large numbers of Medicaid enrollees to increase CRC screening completion.

Facilitators and Barriers of a Health Department-based Mailed Fecal Testing Program.

BACKGROUND Mailed at-home stool testing offers a promising strategy for overcoming barriers to colorectal cancer (CRC) screening in vulnerable populations. This paper evaluates the facilitators and barriers of successful implementation of a mailed fecal testing program among Medicaid populations within a health department setting.METHOD Interviews were conducted with key informants involved in intervention start-up and implementation tasks. The Consolidated Framework for Implementation Research (CFIR) was used to design the interview guide and structure the analysis. Axial coding was used to connect the themes to each other under the major categories of facilitators and barriers.RESULTS Overall, the process evaluation suggests that with strong partnerships, effective champions, and existing infrastructure, a large county health department can successfully implement a mailed fecal testing program targeted at Medicaid beneficiaries. The identified facilitators and challenges to implementation provide important information for similar emerging programs.LIMITATIONS The sample size of this evaluation is small. Additionally, we are unable to discern whether participating stakeholders' responses represent the feelings of non-interviewed staff, program implementers, or participants. We were not able to collect data on patient perspectives of the intervention. The nursing staff and interns were not able to be included in the process evaluation. Lastly, the information taken from this process evaluation may not be applicable to organizations and systems with different attributes.CONCLUSION The process evaluation suggests strong partnerships, effective champions, and elegant program designs were key contributors to successful implementation of a CRC screening program targeted at Medicaid beneficiaries in a large county health department.

A Public Health Framework to Improve Population Health Through Health Care and Community Clinical Linkages: The ASTHO/CDC Heart Disease and Stroke Prevention Learning Collaborative.

Thirty-one state and territorial public health agencies participated in a learning collaborative to improve diagnosis and management of hypertension in clinical and community settings. These health agencies implemented public health and clinical interventions in medical settings and health organizations using a logic model and rapid quality improvement process focused on a framework of 4 systems-change levers: 1) data-driven action, 2) clinical practice standardization, 3) clinical-community linkages, and 4) financing and policy. We provide examples of how public health agencies applied the systems-change framework in all 4 areas to assess and modify population-based interventions to improve control of hypertension. This learning collaborative approach illustrates the importance of public health in the prevention and control of chronic disease by supporting interventions that address community and clinical linkages to address medical risk factors associated with cardiovascular disease.

Comparative effectiveness of mailed reminders with and without fecal immunochemical tests for Medicaid beneficiaries at a large county health department: A randomized controlled trial.

BACKGROUND: Colorectal cancer (CRC) screening is effective but underused. Screening rates are lower among Medicaid beneficiaries versus other insured populations. No studies have examined mailed fecal immunochemical testing (FIT)-based outreach programs for Medicaid beneficiaries. METHODS: In a patient-level randomized controlled trial, a mailed CRC screening reminder plus FIT, sent from an urban health department to Medicaid beneficiaries, was compared with the same reminder without FIT. The reminder group could request FIT. Completed FIT kits were processed by the health department laboratory. Respondents were notified of normal results by mail. Abnormal results were given via phone by a patient navigator who provided counselling and assistance with follow-up care. The primary outcome was FIT return. RESULTS: In all, 2144 beneficiaries at average CRC risk were identified, and there was no evidence of screening with Medicaid claims data. To the reminder+FIT group, 1071 were randomized, and 1073 were randomized to the reminder group; 307 (28.7%) in the reminder+FIT group and 347 (32.3%) in the reminder group were unreachable or ineligible (previous screening). The FIT return rate was significantly higher in the reminder+FIT group than the reminder group (21.1% vs 12.3%; difference, 8.8%; 95% confidence interval, 3.7%-13.9%; P < .01). Eighteen individuals (7.2%) who completed FIT tests had abnormal results, and 15 were eligible for follow-up colonoscopy; 66.7% (n = 10) completed follow-up colonoscopy. CONCLUSIONS: A health department-based, mailed FIT program targeting Medicaid beneficiaries was feasible. Including a FIT kit resulted in greater screening completion than a reminder letter alone. Further research is needed to understand the comparative cost-effectiveness of these interventions.

The Mecklenburg County Interlocal Agreement: An 18-Year Collaboration Between Medicine and Public Health.

CONTEXT: Better integration of public health and medical services has been a long-standing goal in the United States and has been widely discussed in the scientific literature. OBJECTIVE: To identify key lessons and outcomes of the Mecklenburg County Interlocal Agreement, one of the longest running efforts integrating health care delivery and public health services in a major metropolitan area. DESIGN: In-depth key informant interviews and brief questionnaires of leaders involved in the Mecklenburg County Interlocal Agreement. SETTING: Charlotte-Mecklenburg County, North Carolina. PARTICIPANTS: Convenience sample of 15 past and present employees and administrative leaders of the Mecklenburg County Privatization Initiative from the Mecklenburg County Health Department (N = 7) and Carolinas Healthcare System (N = 8). MAIN OUTCOME MEASURES: Attitudes reflecting the effects of the Mecklenburg County Privatization Initiative, based on 6 "synergies" for evaluating the effectiveness of health care and public health system collaboration. RESULTS: Mean scores were calculated for 21 questionnaire items, using 5-point Likert scales (1 = no impact; 5 = great impact). Mean scores were calculated by averaging the multiple-item question sets reflecting each of the 6 synergies. Synergy scores ranged from a low of 3.1 (3 items reflecting whether the collaboration "Used clinical practice to identify and address community health problems") to a high of 3.7 (3 items reflecting whether the collaboration "Improved health care by coordinating services for individuals"). The in-depth interviews indicated a clear impact for the 2 synergies linked to individual care. Increased access to care emerged as a strong theme, along with the belief that medical care services were improved and that these improvements persist. CONCLUSION: The findings of this study provide perspective from an 18-year contractual agreement for a large health care system to operate county public health functions. Implications include the need to incorporate well-defined public health principles in any collaborative agreement and to focus these efforts at the primary care level.

Accountable Care Communities.

Accountable care communities are a new health model that involves multiple stakeholders working together to improve the health and well-being of their communities by addressing social determinants of health. Stakeholders include health care delivery systems, public health organizations, and community organizations. In an accountable care community, the stakeholders commit to share responsibility, resources, and data to improve community health indicators. Accountable care communities are a promising model to both decrease medical costs and improve health outcomes by placing greater emphasis on addressing social and economic issues that ultimately define health. This issue of the NCMJ highlights accountable care communities in other states and provides an overview of how accountable care community initiatives are working in North Carolina to improve the overall health of our communities.

CDC Grand Rounds: the future of cancer screening.

Cancer is the second leading cause of death in the United States, with 52% of deaths caused by cancers of the lung and bronchus, female breast, uterine cervix, colon and rectum, oral cavity and pharynx, prostate, and skin (melanoma). In the 1930s, uterine cancer, including cancer of the uterine cervix, was the leading cause of cancer deaths among women in the United States. With the advent of the Papanicolaou (Pap) test in the 1950s to detect cellular level changes in the cervix, cervical cancer death rates declined significantly. Since this first cancer screening test, others have been developed that detect the presence of cancer through imaging procedures (e.g., mammography, endoscopy, and computed tomography) and laboratory tests (e.g., fecal occult blood tests).