New insights about community benefit evaluation: Using the Community Health Implementation Evaluation Framework to assess what hospitals are measuring.

BACKGROUND: Nonprofit hospitals are required to conduct community health needs assessments (CHNA) every 3 years and develop corresponding implementation plans. Implemented strategies must address the identified community needs and be evaluated for impact. PURPOSE: Using the Community Health Implementation Evaluation Framework (CHIEF), we assessed whether and how nonprofit hospitals are evaluating the impact of their CHNA-informed community benefit initiatives. METHODOLOGY: We conducted a content analysis of 83 hospital CHNAs that reported evaluation outcomes drawn from a previously identified 20% random sample ( n = 613) of nonprofit hospitals in the United States. Through qualitative review guided by the CHIEF, we identified and categorized the most common evaluation outcomes reported. RESULTS: A total of 485 strategies were identified from the 83 hospitals' CHNAs. Evaluated strategies most frequently targeted behavioral health ( n = 124, 26%), access ( n = 83, 17%), and obesity/nutrition/inactivity ( n = 68, 14%). The most common type of evaluation outcomes reported by CHIEF category included system utilization ( n = 342, 71%), system implementation ( n = 170, 35%), project management ( n = 164, 34%), and social outcomes ( n = 163, 34%). PRACTICE IMPLICATIONS: CHNA evaluation strategies focus on utilization (the number of individuals served), with few focusing on social or health outcomes. This represents a missed opportunity to (a) assess the social and health impacts across individual strategies and (b) provide insight that can be used to inform the allocation of limited resources to maximize the impact of community benefit strategies.

Laws Governing State Health Official Appointments: A Legal and Historical Review.

OBJECTIVE: The current study presents the legal epidemiological review of State Health Official (SHO) appointment laws, including the evolution of educational and experience requirements of SHOs over time. Findings can inform the discussion about state laws and the substantive, multidisciplinary qualifications essential to successfully leading state public health agencies in the 21st century. METHODS: Standard policy surveillance methods were used to collect and assess the statutes governing SHO appointment and eligibility from all 50 states and the District of Columbia between 1995 and 2020. RESULTS: SHOs are most frequently appointed by their jurisdiction's Health Secretary (n = 17), followed by Governor nominations with legislative approval (n = 15), and 13 states where the Governor is the sole SHO appointing authority. While a large majority of jurisdictions require certain professional and/or educational minimum qualifications to serve as an SHO, 11 states have no professional or experiential minimum qualifications. The most common minimum requirement found was possessing a medical degree, which is required in 22 jurisdictions (including Washington, District of Columbia). Twelve of these states require the physician to have additional education or experience, such as the possession of experience in public health (n = 5), experience in both public health and management (n = 3), or holding an additional health-related degree (n = 2). Four states added a medical degree as a requirement for SHOs over the last 25 years, while 5 states removed their medical degree requirement. CONCLUSIONS: States should reassess their eligibility requirements for SHO service in light of the advancement and demands of public health leadership in the 21st century, as many states continue to look to those with medical training as the primary source for such leadership.

State Laws Governing the Hiring of Public Health Government Employees, 2023.

OBJECTIVE: Governmental public health agencies have experienced longstanding challenges in recruiting individuals at the state and local level. Understanding civil service laws as they relate to the hiring processes is an important component of recruitment and increasing public health workforce capacity. This study presents state hiring laws and regulations governing the public health government workforce. METHODS: Legal mapping techniques were employed to collect and code data on current hiring laws governing governmental public health employees across all 50 states. The review of laws included constitutions, statutes and regulations, and searches of administrative code. RESULTS: In 12 states, the laws do not specify civil service exam criteria or they have no mention of civil service exams in the law. Almost a third of states have laws that establish civil service exam requirements without specifying conditions for when exams must be required, or which positions allow which types of exam/criteria. Similarly, almost all of the states that have civil service exams denoted in their laws have unspecified language about whether there are exam fees. Requirements for the maintenance/use of state hiring lists are in place in 36 states and 26 states have a non-public health agency managing this process. Nearly all states (n = 48, 96%) require hiring preferences for certain types of individuals, most commonly veterans (n = 48, 96%) and family members of veterans (n = 30, 60%). No state laws provide hiring preferences for individuals from public health fellowships or special training programs. CONCLUSION: Key findings suggest that the laws governing the merit system and civil service vary and often lack clarity, which may be difficult for public health agencies and for potential employees to understand, navigate, and successfully recruit key employees. The recruitment and hiring of new governmental public health staff are complicated by the management of hiring by other state agencies and the vague civil service exam requirements and process. Developing preferences for hiring individuals who have additional practical training in public health (eg, public health fellowships and AmeriCorps) should be considered.

Leadership: Bright Spots of Governmental Public Health Employee Reflections on the COVID-19 Response.

The protracted nature of the COVID-19 pandemic demanded extraordinary efforts and innovation from public health agencies and their leaders. This is the first of 3 research briefs that highlight valuable experiences and opportunities that can be thought of as "bright spots" of the public health workforce's pandemic response. Using Public Health Workforce Interests and Needs Survey 2021 data, we qualitatively examined responses to an open-ended question about pandemic workforce experiences. Leadership was emphasized as a critical component of employees' experiences during the response, and 7 "leadership" subthemes were identified among 157 responses. Findings illustrate the importance of leaders prioritizing safe and supportive environments for employees. Respondents also highlighted the importance of leaders fostering teamwork alongside employees and advocating for and demonstrating appreciation for employees. In addition, effective leadership communication was reported to be motivational and alleviate uncertainty during crisis situations. Focusing on these leadership skills and competencies may aid the workforce during future emergency response events.

Teamwork and Collaboration: Bright Spots of Governmental Public Health Employee Reflections on the COVID-19 Response.

The public health emergency response following the outbreak of COVID-19 necessitated greater internal public health agency teamwork and external collaboration. Building on previous research, this article is the third of 3 research briefs that highlight "bright spots" or valuable experiences and opportunities from the COVID-19 response. Using PH WINS 2021 data, we qualitatively examined responses to a question about pandemic workforce experiences. Teamwork and collaboration were emphasized as a critical component of employees' experiences. Across 260 responses, 7 subthemes emerged, generally commemorating the ways that the response effort and employees were supported by teamwork and collaboration. Findings highlight the value of ongoing cross-division teamwork within agencies, the role of leaders in teamwork, and that lessons from teamwork/collaboration experiences can inform organizational system improvements. Maintaining and expanding on improved external collaboration and partnerships should be prioritized for preparing for future emergency events and serving public health communities on a daily basis.

On-the-Job Learning: Bright Spots of Governmental Public Health Employee Reflections on the COVID-19 Response.

This article is one of 3 research briefs that highlight valuable experiences and opportunities that can be thought of as "bright spots" of the governmental public health workforce's pandemic response. Using PH WINS 2021 data, we qualitatively examined responses to an open-ended survey question about workforce experiences during the pandemic response. On-the-job learning was emphasized as a critical component of employees' experiences. Seven "on-the-job learning" subthemes were identified among 91 responses. Findings indicate that the pandemic facilitated opportunities for on-the-job learning for various skills and workplace activities. Public health employees were appreciative of the opportunity to gain new technical and practical skills including communicating with the public and to experience new roles and responsibilities. Respondents reported other related benefits including career growth and leadership opportunities. Highlighting these unexpected benefits of the COVID-19 pandemic is important for employee morale and continued workforce development planning.

Accredited Public Health Department Characteristics Associated With Workforce Gaps Identified in Workforce Development Plans.

OBJECTIVE: When pursuing accreditation by the Public Health Accreditation Board, local health departments (LHDs) must submit a workforce development plan (WDP). The purpose of this study was to examine LHD characteristics associated with workforce gaps identified and strategies implemented by LHDs. DESIGN: We conducted a qualitative content analysis of all WDPs submitted to the Public Health Accreditation Board between March 2016 and November 2021. SETTING: We examined WDPs from all accredited LHDs (n = 183) at the time of data collection in January 2022. A majority of LHDs had more than 50 staff members (n = 106, 57.9%), had a decentralized governance structure (n = 164, 89.6%), had county-level jurisdictions (n = 99, 54.1%), and served rural populations (n = 146, 79.8%). MAIN OUTCOME MEASURES: For each overarching theme, we constructed 2 binary variables indicating whether the LHD identified a workforce gap or strategy among any subthemes within each overarching theme. Logistic regressions were used to examine relationships between LHD characteristics and identification of a workforce gap or strategy for each theme. RESULTS: Few LHD characteristics were significantly associated with gaps identified or strategies implemented by LHDs. LHDs applying for reaccreditation had higher odds (adjusted odds ratio [AOR], 2.44; confidence interval [CI], 1.04-5.83) of identifying a leadership gap and of identifying a recruitment gap (AOR, 2.94; CI, 1.11-7.52) compared to LHDs applying for accreditation for the first time. LHDs serving urban populations had higher odds (AOR, 2.83; CI, 1.32-6.25) of identifying a recruitment strategy compared to LHDs that only served suburban/rural populations. CONCLUSIONS: Overall, many workforce gaps reported by LHDs were universally observed irrespective of LHD characteristics. While most LHDs identified strategies to address gaps, our findings also reveal workforce areas where LHDs reported gaps without an accompanying strategy, indicating areas where LHDs could use more technical assistance and support.

Conducting a Comprehensive Assessment of the Public Health Workforce: Lessons Learned and Opportunities for the Future.

Indiana was one of the earliest states to conduct a comprehensive public health workforce assessment in preparation for the use of federal funds for infrastructure strengthening. Experiences from this assessment provide insights that may be useful to other public health agencies and partners. This brief summarizes key lessons and highlights opportunities for improved workforce assessments. For example, the lack of standardized job titles within local health departments (LHDs) can be mitigated by collecting the top 3 job tasks employees engage in daily and reassigning standardized titles based on nationally collected workforce data. This facilitates comparisons across LHD employees nationally. In addition, many employees felt their job tasks did not align well with the Foundational Public Health Services (FPHS) areas and capabilities, which contributed to the likely overestimation of effort. Further consideration of how to better align and/or integrate FPHS assessment within current practice is needed in addition to improved ways of assessing efforts toward FPHS.

State Policies Associated with Availability of Mobile Crisis Teams.

Mobile crisis teams are comprised of multidisciplinary mental health professionals that respond to mental health crisis calls in community settings. This study identified counties with mobile crisis teams and examined state policies associated with mobile crisis teams. Descriptive statistics and geographic information system software were used to quantify and map counties with mobile crisis teams in the United States. Relationships between state policies and mobile crisis teams were examined using an adjusted logistic regression model, controlling for county characteristics and accounting for clustering by state. Approximately 40% (n = 1,245) of all counties in the US have at least one mobile crisis team. Counties in states with legislation in place to fund the 988 Suicide and Crisis Lifeline were more likely to have a mobile crisis team (Adjusted Odds Ratio (AOR): 2.0; Confidence Interval (CI): 1.23-3.26), whereas counties in states with 1115 waivers restricting Medicaid benefits were less likely to have a mobile crisis team (AOR: 0.43; CI: 0.21-0.86). Additionally, counties with the largest population were more likely to have a mobile crisis team (AOR: 2.20; CI:1.43-3.38) than counties with the smallest population. Having a mobile crisis teams was positively associated with legislation to fund 988. Legislation that encourages expansion of existing crisis care services, specifically funding aimed at mobile crisis teams, may help increase availability of services for people who are experiencing a mental health crisis in the community.

The State of the US Public Health Workforce: Ongoing Challenges and Future Directions.

Between the 2009 Great Recession and the onset of the COVID-19 pandemic, the US state and local governmental public health workforce lost 40,000 jobs. Tens of thousands of workers also left during the pandemic and continue to leave. As governmental health departments are now receiving multimillion-dollar, temporary federal investments to replenish their workforce, this review synthesizes the evidence regarding major challenges that preceded the pandemic and remain now. These include the lack of the field's ability to readily enumerate and define the governmental public health workforce as well as challenges with the recruitment and retention of public health workers. This review finds that many workforce-related challenges identified more than 20 years ago persist in the field today. Thus, it is critical that we look back to be able to then move forward to successfully rebuild the workforce and assure adequate capacity to protect the public's health and respond to public health emergencies.

Strategic use of tobacco treatment specialists as an innovation for tobacco cessation health systems change within health care organizations.

BACKGROUND: Tobacco screening interventions have demonstrated effectiveness at improving population health, yet many people who want to quit using tobacco lack access to professional assistance. One way to address this gap is to train members of the clinical team as tobacco treatment specialists (TTSs). PURPOSE: The purpose of this study was to understand how TTSs have been used across a variety of health care organizations implementing health systems change for tobacco treatment and examine the sustainability of TTSs as a health systems change innovation for tobacco cessation. METHODOLOGY: This study used qualitative interviews ( n = 25) to identify themes related to implementing TTSs as a health systems change innovation and examined these themes within the constructs of the theory of innovation implementation. RESULTS: Insights about implementing TTSs as an innovation primarily aligned with four theoretical constructs: implementation policies and practices, implementation climate, innovation-values fit, and implementation effectiveness. Specific themes were perceived to facilitate the sustainability of TTSs including team-based TTS efforts, widespread awareness of TTS roles, leadership buy-in, and recognized value of TTS services. Barriers to sustainability included inadequate resources (e.g., time and staff), lack of tracking outcomes, inappropriate referrals, and lack of reimbursement. PRACTICE IMPLICATIONS: Health care organizations planning to implement health systems change for tobacco cessation can encourage committed use of TTSs as an innovation by considering the insights provided in this study. These primarily related to five overarching implementation considerations: staff selection and training, tracking and dissemination of impacts, adequate resources, referrals and workflow, and billing and reimbursement.

Qualitative Insights From Governmental Public Health Employees About Experiences Serving During the COVID-19 Pandemic, PH WINS 2021.

OBJECTIVE: The purpose of the current study was to examine governmental public health employee experiences during the COVID-19 pandemic. DESIGN AND SETTING: A total of 5169 responses to a PH WINS 2021 open-ended question were qualitatively coded. The question asked employees to share their experiences during the COVID-19 response. The 15 most common themes are discussed. PARTICIPANTS: Responses from governmental public health employees in state health agencies (SHAs), big cities (Big City Health Coalition or BCHC agencies), and local health departments (LHDs) across all 50 states were included. RESULTS: The most frequently identified theme was pride in public health work and/or the mission of public health (20.8%), followed by leadership (17.2%), burnout or feeling overwhelmed (14%), communication (11.7%), and overtime/extra work (9.7%). Among the top 15 themes identified, comments about pride in public health work and/or the mission of public health (95.9%), teamwork (81.5%), and telework (61%) were predominantly positive. Co-occurring themes for responses that expressed pride in public health work and/or the mission of public health were often countered with explanations of why respondents remain frustrated, including feeling burned out or overwhelmed , disappointment with the community's sense of responsibility or trust in science , and feeling unappreciated either by the community or their agency. All of these co-occurring themes were predominantly negative. CONCLUSIONS: Employees are proud to work in public health and value teamwork but often felt overworked and unappreciated during the COVID-19 pandemic. Reviewing existing emergency preparedness protocols in the context of lessons learned during the COVID-19 pandemic and listening to employees' experiences with teleworking and task sharing may better prepare agencies for future challenges. Creating channels for clear communication during a period of changing information and guidelines may help employees feel more prepared and valued during an emergency response.

Evaluation of Community Benefit Activities Among Nonprofit Hospitals, 2018-2021.

OBJECTIVE: This study examined approaches that nonprofit hospitals use to evaluate community benefit activities in the Community Health Needs Assessment/Implementation Plan (CHNA/IP) process. DESIGN: Content analysis of CHNAs/IPs completed between 2018 and 2021 from a 20% stratified random sample (n = 503) of US nonprofit hospitals. MAIN OUTCOME MEASURES: A coding sheet was used to record details about the evaluation content reported by hospitals in their CHNAs/IPs. Evaluation was coded into 4 categories: (1) no mention of evaluation; (2) description of evaluation without reporting any measures; (3) reporting reach (number of people served) only; and (4) reporting social/health outcomes. For logistic regression analyses, categories 1 and 2 were grouped together into "no evaluation measures" and categories 3 and 4 were grouped into "evaluation measures" for binary comparison. Multinomial logistic regression was also used to individually examine categories 3 and 4 compared with no evaluation measures. RESULTS: While a majority of nonprofit hospitals (71.4%, n = 359) mentioned evaluation in their CHNAs, almost half (49.7%, n = 250) did not report any evaluation measures. Among the 50.3% (n = 253) of hospitals that reported evaluation measures, 67.2% (n = 170) only reported reach. Fewer than 1 in 5 hospitals (16.5%, n = 83) reported social/health outcomes. Hospitals that hired a consultant (adjusted odds ratio [AOR] = 1.61; 95% confidence interval [CI], 1.08-2.43) and system members (AOR = 1.76; 95% CI, 1.12-2.75) had higher odds of reporting evaluation measures. Using hospitals that reported no measures as the base category, system members (AOR = 7.71; 95% CI, 2.97-20.00) also had significantly higher odds of reporting social/health outcomes, while rural locations had lower odds (AOR = 0.43; 95% CI, 0.20-0.94). CONCLUSIONS: Although hospitals are required to evaluate the impact of actions taken to address the health needs identified in their CHNAs, few hospitals are reporting social/health outcomes of such activities. This represents a missed opportunity, as health/social outcomes could be used to inform the allocation of resources to maximize community benefits and the expansion of successful community initiatives.

Community Engagement in Nonprofit Hospital Community Health Needs Assessments and Implementation Plans.

CONTEXT: Nonprofit hospitals are required to provide community benefits in exchange for their tax-exempt status. This includes a community health needs assessment (CHNA) to identify community needs and an implementation plan (IP) with strategies to address top needs every 3 years. In addition, hospitals are required to engage community members in these assessments. OBJECTIVE: The objective of this study was to explore community engagement and representation in CHNAs and IPs. DESIGN: The researchers conducted a content analysis of CHNAs and IPs from a nationally representative sample of 503 nonprofit hospitals between 2018 and 2021. MAIN OUTCOME MEASURES: For CHNAs, a coding sheet was used to record the types of community members engaged by hospitals. For IPs, the team coded whether community engagement was reported at all and then performed an in-depth analysis to identify categories of community members, engagement methods used, and roles of community input. Finally, frequencies of categories across IPs were quantified. RESULTS: Eighty-nine percent of hospitals (n = 449) engaged community members in their CHNA, but only 14% (n = 71) engaged community members in their IP. An in-depth look at these IPs found that hospitals engaged underserved/minority populations, low-income populations, high school students, public health experts, and stakeholder organizations. Community members were involved in multiple steps, including brainstorming ideas, narrowing down needs, developing strategies, and reacting to proposed strategies. CONCLUSIONS: Although IPs are intended to benefit the community, there is a lack of community involvement reported in IPs. Hospitals may need incentives, resources, and personnel support to ensure representation of community members throughout the entire CHNA and IP process.

Turnover, COVID-19, and Reasons for Leaving and Staying Within Governmental Public Health.

BACKGROUND AND OBJECTIVES: Public health workforce recruitment and retention continue to challenge public health agencies. This study aims to describe the trends in intention to leave and retire and analyze factors associated with intentions to leave and intentions to stay. DESIGN: Using national-level data from the 2017 and 2021 Public Health Workforce Interests and Needs Surveys, bivariate analyses of intent to leave were conducted using a Rao-Scott adjusted chi-square and multivariate analysis using logistic regression models. RESULTS: In 2021, 20% of employees planned to retire and 30% were considering leaving. In contrast, 23% of employees planned to retire and 28% considered leaving in 2017. The factors associated with intentions to leave included job dissatisfaction, with adjusted odds ratio (AOR) of 3.8 (95% CI, 3.52-4.22) for individuals who were very dissatisfied or dissatisfied. Odds of intending to leave were significantly high for employees with pay dissatisfaction (AOR = 1.83; 95% CI, 1.59-2.11), those younger than 36 years (AOR = 1.58; 95% CI, 1.44-1.73) or 65+ years of age (AOR = 2.80; 95% CI, 2.36-3.33), those with a graduate degree (AOR = 1.14; 95% CI, 1.03-1.26), those hired for COVID-19 response (AOR = 1.74; 95% CI, 1.49-2.03), and for the BIPOC (Black, Indigenous, and people of color) (vs White) staff (AOR = 1.07; 95% CI, 1.01-1.15). The leading reasons for employees' intention to stay included benefits such as retirement, job stability, flexibility (eg, flex hours/telework), and satisfaction with one's supervisor. CONCLUSIONS: Given the cost of employee recruitment, training, and retention of competent employees, government public health agencies need to address factors such as job satisfaction, job skill development, and other predictors of employee retention and turnover. IMPLICATIONS: Public health agencies may consider activities for improving retention by prioritizing improvements in the work environment, job and pay satisfaction, and understanding the needs of subgroups of employees such as those in younger and older age groups, those with cultural differences, and those with skills that are highly sought-after by other industries.

What Are Public Health Agencies Planning for Workforce Development? A Content Analysis of Workforce Development Plans of Accredited Public Health Departments.

OBJECTIVE: Recruiting and retaining public health employees and ensuring they have the skills necessary to respond are vital for meeting public health needs. As the first study examining health department (HD) workforce development plans (WDPs), this study presents gaps and strategies identified in WDPs across 201 accredited HDs (168 initial/33 reaccreditation plans). DESIGN: This cross-sectional study employed qualitative review and content analysis of WDPs submitted to the Public Health Accreditation Board (PHAB) between March 2016 and November 2021. MAIN OUTCOME MEASURES: Eight overarching workforce themes were examined: planning/coordination, leadership, organizational culture, workplace supports/retention, recruitment, planning for departmental training, delivery of departmental training, and partnership/engagement. Within each theme, related subthemes were identified. Coders indicated whether the WDP (1) identified the subtheme as a gap; (2) stated an intent to address the subtheme; and/or (3) identified a strategy for addressing the subtheme. RESULTS: The most common gaps identified included prepare workforce for community engagement/partnership (34.3%, n = 69), followed by resource/fund training (24.9%, n = 50). The subtheme that had the most instances of an identified strategy to address it was assess training needs (84.1%, n = 169), followed by foster quality improvement (QI) culture/provide QI training (63.2%, n = 127). While both of these strategies were common among the majority of HDs, those subthemes were rarely identified as a gap. Secondary findings indicate that increase recruitment diversity/recruit from a more diverse applicant pool was rarely identified as a gap (6.0%, n = 12) and rarely had an identified strategy for addressing the subtheme (9.0%, n = 18). CONCLUSION: While HDs recognized many workforce gaps, HDs did not always propose a strategy for addressing them within the WDP. Conversely, some WDPs proposed strategies for subthemes that did not reflect recognized gaps. Such discrepancies between identified gaps and strategies in WDPs may suggest areas where HDs could use additional support and guidance.

Institutional factors associated with hospital partnerships for population health: A pooled cross-sectional analysis.

BACKGROUND: Hospitals are increasingly engaging in partnerships to address population health in response to national policies, such as value-based payment models. However, little is known about how institutional factors influence hospital partnerships for population health. PURPOSE: Guided by institutional theory, we examine the association between institutional pressures (coercive, normative, and mimetic isomorphism) and hospital partnerships for population health. METHODOLOGY: A pooled cross-sectional analysis used an unbalanced panel of 10,777 hospital-year observations representing respondents to a supplemental question of the American Hospital Association's annual survey (2015-2017). The analysis included descriptive and bivariate statistics, and regression models that adjusted for repeated observations to examine the relationship between key independent variables and partnerships over time. FINDINGS: In regression analyses, we found the most support for measures of coercive (e.g., regulatory factors) isomorphism, with nonprofit status, participation in accountable care organizations, and acceptance of bundled payments, all being consistently and significantly associated with partnerships across all organization types. Modest increases were observed from 2015 to 2017 for hospital partnerships with public health organizations (+2.8% points, p < .001), governmental organizations (+2.0% points, p = .009), schools (+4.1% points, p < .001), and businesses (+2.2% points, p = .007). PRACTICE IMPLICATIONS: Our results suggest that institutional factors, particularly those related to regulatory policies and programs, may influence hospital partnerships to support population health. Findings from this study can assist hospital leaders in assessing the factors that can support or impede the creation of partnerships to support their population health efforts.

Dance of Dollars: State Funding Effects on Local Health Department Expenditures.

OBJECTIVE: We examined changes in total local health department (LHD) expenditures in the state of Washington following introduction of a new state funding program to support core public health services and infrastructure. METHODS: We used a pre/posttest design regression model to evaluate changes in LHD expenditures 1, 2, and 6 years into the new state program. To address potential endogeneity in the model, we repeated all 3 analyses using 2-stage least squares regression. RESULTS: In the base case, overall spending among LHDs significantly increased with receipt of the new state funds in the first years of the program (2008 and 2009). However, those increases were not sustained over the longer term (2013). In subpopulation analyses, total LHD spending increased more among larger LHDs. CONCLUSIONS: Between 2006 and 2013, new state investments in core public health functions increased Washington State LHD expenditures in the short term, but those increases did not persist over time. For public health financial modernization efforts to translate into public health infrastructure modernization successes, the way new investments are structured may be as important as the amount of funding added.

The Role of Local Health Departments in Strengthening the Alignment Between Nonprofit Hospitals' Community Health Needs Assessments and Their Implementation Strategies.

Nonprofit hospitals frequently partner with their local health department on developing community health needs assessments (CHNAs); yet, little is known about the role that such partnerships play in strengthening the alignment between needs identified in hospitals' assessments and the strategies adopted by hospitals to address identified needs. Using data for 486 hospitals from the third round of CHNAs (spanning the years 2018-2021), this study showed strong alignment between the health needs identified in the CHNAs and those addressed in hospitals' implementation strategies, independent of collaboration with the local health department. One noteworthy exception to this finding was that hospital-public health collaboration remained important for improved alignment of needs related to substance use. Involvement of the local health department may strengthen hospitals' capacity to address needs outside their traditional areas of expertise, such as substance use.

Local Health Department Revenue Diversification and Revenue Volatility: Can One Be Used to Manage the Other?

OBJECTIVE: Revenue volatility-particularly in the form of sudden and significant reductions in funding-has been shown to negatively affect local health departments (LHDs) by impacting the amount and type of services delivered. This study examined the potential effectiveness of revenue diversification as a means of managing LHD financial risk. More specifically, we examine the relationship between revenue diversification and revenue volatility among LHDs in Washington State. DESIGN AND SETTING: We applied fixed-effects linear regression models with robust standard errors to revenue data reported during 1998-2014 by all LHDs operating in Washington State. We also assessed the robusticity of our results to alternative specifications for revenue diversification and volatility. MAIN OUTCOME MEASURES: LHD revenue and revenue volatility. RESULTS: Between 1998 and 2014, LHDs in Washington State were exposed to considerable upside and downside fiscal risks. While average revenue volatility was close to 0 (0.2%), observed values ranged from -35% to 63%. LHD revenues were already highly diversified: as measured using a reversed Herfindahl-Hirschman Index, diversification values ranged between 0.56 and 1.00. There is little evidence to suggest the existence of a statistically significant relationship between revenue diversification and volatility. CONCLUSIONS: Revenue volatility presents LHDs with important short- and long-term operational challenges. Our models suggest that revenue diversification did not reduce revenue volatility among Washington State LHDs in 1998-2014. Further research will need to examine whether revenue diversification reduces LHD financial risk in other settings.