Rurality, Quality Improvement Maturity, and Accreditation Readiness: A Comparison Study of Colorado, Kansas, and Nebraska Local Health Departments.

OBJECTIVE: To compare local health department (LHD) accreditation readiness (AR) and quality improvement (QI) maturity in 3 states, between LHDs with varying levels of rurality, and across an LHD staffing-level continuum. DESIGN: This was a cross-sectional comparative study that included an online survey administered to LHD directors in Colorado, Kansas, and Nebraska. The survey included 10 questions assessed on a 5-point Likert scale covering 3 QI domains and 13 questions covering 5 AR domains. The median score for both QI maturity and AR was calculated by each state, by the number of full-time equivalent staff employed at the LHD, and by a measure of rurality and population density. SETTING AND PARTICIPANTS: A total of 156 LHDs from the states of Colorado, Kansas, and Nebraska. MAIN OUTCOME MEASURE(S): QI maturity and AR scores. RESULTS: A majority (59%) of the surveyed LHDs plan to apply or have already applied for Public Health Accreditation Board (PHAB) accreditation. The overall QI maturity and AR scores were highest in Nebraska, as was the intent to seek PHAB accreditation and current use of PHAB standards. Across levels of rurality and staffing, LHD QI maturity scores were similar; however, AR scores improved as LHD staffing levels increased and rurality decreased. CONCLUSIONS: Small LHDs and rural LHDs have QI maturity levels that are comparable to larger, less rural LHDs, but their AR is much lower. As accreditation has been found to have positive benefits, it is important that all LHDs have the capacity and resources to meet the performance standards required of accredited LHDs. Small, rural LHDs may need additional resources and support in order to improve their ability to be accredited and/or certain accreditation requirements may need modification to make accreditation more accessible to small LHDs.

Strategic Methodologies in Public Health Cost Analyses.

CONTEXT: The National Research Agenda for Public Health Services and Systems Research states the need for research to determine the cost of delivering public health services in order to assist the public health system in communicating financial needs to decision makers, partners, and health reform leaders. OBJECTIVE: The objective of this analysis is to compare 2 cost estimation methodologies, public health manager estimates of employee time spent and activity logs completed by public health workers, to understand to what degree manager surveys could be used in lieu of more time-consuming and burdensome activity logs. DESIGN: Employees recorded their time spent on communicable disease surveillance for a 2-week period using an activity log. Managers then estimated time spent by each employee on a manager survey. Robust and ordinary least squares regression was used to measure the agreement between the time estimated by the manager and the time recorded by the employee. MAIN OUTCOME MEASURES: The 2 outcomes for this study included time recorded by the employee on the activity log and time estimated by the manager on the manager survey. SETTING: This study was conducted in local health departments in Colorado. PARTICIPANTS: Forty-one Colorado local health departments (82%) agreed to participate. RESULTS: Seven of the 8 models showed that managers underestimate their employees' time, especially for activities on which an employee spent little time. Manager surveys can best estimate time for time-intensive activities, such as total time spent on a core service or broad public health activity, and yet are less precise when estimating discrete activities. CONCLUSIONS: When Public Health Services and Systems Research researchers and health departments are conducting studies to determine the cost of public health services, there are many situations in which managers can closely approximate the time required and produce a relatively precise approximation of cost without as much time investment by practitioners.

Minimum package of public health services: the adoption of core services in local public health agencies in Colorado.

OBJECTIVES: We examined the effect of a state law in Colorado that required local public health agencies to deliver a minimum package of public health services. METHODS: We used a longitudinal, pre-post study design, with baseline data collected in 2011 and follow-up data collected in 2013. We conducted means testing to analyze the change in service delivery and activities. We conducted linear regression to test for system structure effects on the implementation of core services. RESULTS: We observed statistically significant increases in several service areas within communicable disease, prevention and population health promotion, and environmental health. In addition to service and program areas, specific activities had significant increases. The significant activity increases were all in population- and systems-based services. CONCLUSIONS: This project provided insight into the likely effect of national adoption of a minimum package as recommended by the Institute of Medicine. The implementation of a minimum package showed significant changes in service delivery, with specific service delivery measurement over a short period of time. Our research sets up a research framework to further explore core service delivery measure development.

An examination of state laws and policies regarding public health agency accreditation prerequisites.

CONTEXT: The Public Health Accreditation Board (PHAB) began accepting applications for national voluntary accreditation in the fall of 2011. There are 3 prerequisites for accreditation: health assessments; health improvement plans; and strategic plans. These prerequisites must be in place for a state or local public health agency to apply for PHAB accreditation. Completion of the prerequisites can become a barrier for agencies that are considering applying for accreditation. OBJECTIVE: This project looked at all 50 states through a legal lens to identify legal tools in the form of laws, rules, executive orders, contracts, legislative resolutions, and other tools that are used to authorize or require that a state or local health agency complete 1 or more of the prerequisites. DESIGN: Using legal research platforms and a Boolean search stream, an inquiry of legal tools in all 50 states was completed to determine where legal tools are used to authorize or require the 3 PHAB prerequisites. Once legal tools were found, interviews were conducted with key informants from each state to understand the implementation and use of the legal tools found and collect any additional legal tools that were not found from the legal search. RESULTS: The results include key findings and, importantly, an inventory of laws and legal tools that are being used around the country to require and support completion of the prerequisites. Within all 50 states, 26 states have some type of a mandate regarding 1 or more of the PHAB prerequisites. This includes 1 state that includes a mandate for PHAB accreditation. CONCLUSIONS: States use a wide variety of legal tools to implement the prerequisites for voluntary accreditation. It is important to understand the interpretation, enforcement, and support of the laws and legal tools to determine whether the tools have impact in individual states.

Development and Scoring of a Survey on Public Health Accreditation Capacity.

OBJECTIVES: Public health accreditation is a 7-step process that starts with a period of preapplication during which a health department assesses its readiness for accreditation. However, no tools with established reliability and validity that quantitatively measure a local health department's (LHD's) capacity for accreditation are available to complete this initial step. We developed and validated a survey to measure accreditation capacity for LHDs. METHODS: From January through April 2015, we administered a cross-sectional electronic survey instrument with 15 questions that tapped into domains of capacity for public health accreditation. We analyzed and grouped responses by using a confirmatory maximum likelihood factor analysis with oblique rotations. We assessed reliability by using Cronbach α, and we assessed validity by comparing responses with previously established instruments. We administered the survey to 174 LHD directors in Colorado, Kansas, and Nebraska, 153 (88%) of whom responded. RESULTS: The factor analysis produced a 3-factor model of accreditation capacity, suggesting that accreditation capacity depends on 3 distinct latent constructs: support for accreditation, preparation, and planning and approach. The model had good scale reliability (average Cronbach α = 0.7) and validity (average factor correlation = 0.43). CONCLUSIONS: The survey developed and scored in this analysis can be used by LHDs to inform the feasibility of initiating the time-intensive and costly process of accreditation.

Identifying Barriers to Collaboration Between Primary Care and Public Health: Experiences at the Local Level.

OBJECTIVES: Interest is increasing in collaborations between public health and primary care to address the health of a community. Although the understanding of how these collaborations work is growing, little is known about the barriers facing these partners at the local level. The objective of this study was to identify barriers to collaboration between primary care and public health at the local level in 4 states. METHODS: The study team, which comprised 12 representatives of Practice-Based Research Networks (networks of practitioners interested in conducting research in practice-based settings), identified 40 key informants from the public health and primary care fields in Colorado, Minnesota, Washington State, and Wisconsin. The key informants participated in standardized, semistructured telephone interviews with 8 study team members in 2014 and 2015. Interviews were audio recorded and transcribed verbatim. We analyzed key themes and subthemes by drawing on grounded theory. RESULTS: Primary care and public health participants identified similar barriers to collaboration. Barriers at the institutional level included the challenges of the primary care environment, in which providers feel overwhelmed and resources are tight; the need for systems change; a lack of partnership; and geographic challenges. Barriers to collaboration included mutual awareness, communication, data sharing, capacity, lack of resources, and prioritization of resources. CONCLUSIONS: Some barriers to collaboration (eg, changes to health care billing, demands on provider time) require systems change to overcome, whereas others (eg, a lack of shared priorities and mutual awareness) could be addressed through educational approaches, without adding resources or making a systemic change. Overcoming these common barriers may lead to more effective collaboration.

The Economic Cost of Communicable Disease Surveillance in Local Public Health Agencies.

OBJECTIVE: We identify economic costs associated with communicable disease (CD) monitoring/surveillance in Colorado local public health agencies and identify possible economies of scale. DATA SOURCES/STUDY SETTING: Data were collected via a survey of local public health employees engaged in CD work. Survey respondents logged time spent on CD surveillance for 2-week periods in the spring of 2014 and fall of 2014. Forty-three of the 54 local public health agencies in Colorado participated. STUDY DESIGN: We used a microcosting approach. We estimated a statistical cost function using cost as a function of the number of reported investigable diseases during the matched 2-week period. We also controlled for other independent variables, including case mix, characteristics of the agency, the community, and services provided. DATA COLLECTION/EXTRACTION METHODS: Data were collected from a microcosting survey using time logs. PRINCIPAL FINDINGS: Costs increased at a decreasing rate as cases increased, with both cases (ß = 431.5, p < .001) and cases squared (ß = -3.62, p = .05) statistically significant. CONCLUSIONS AND IMPLICATIONS: The results of the model suggest economies of scale. Cost per unit is estimated to be one-third lower for high-volume agencies as compared to low-volume agencies. Cost savings could potentially be achieved if smaller agencies shared services.

Primary Care and Public Health Perspectives on Integration at the Local Level: A Multi-State Study.

OBJECTIVE: The Institute of Medicine argues that the integration of primary care (PC) and public health (PH) is of paramount importance. We undertook this qualitative study to better understand how these collaborations function. DATA SOURCES: Investigators from PC and PH practice-based research networks in Colorado, Minnesota, Washington, and Wisconsin identified 40 key informants from the PH and PC fields within their respective states. STUDY DESIGN: The key informants participated in standardized, semistructured interviews. DATA COLLECTION: Coinvestigators from each state conducted telephone interviews. The interviews were recorded, transcribed, and analyzed using NVivo 10. PRINCIPAL FINDINGS: Participants described 2 main types of themes. One, which we have termed "foundational" aspects of partnership, includes leadership, communication, mutual awareness, formal processes, history and values. The other, which we have characterized as "energizing" aspects of partnerships, includes having a shared strategic vision, opportunity, and the shifting culture in PC and PH. While the vast majority of participants described the value of foundational aspects of partnership, those who reported having more active collaborations were more likely to also describe the energizing aspects of partnerships. CONCLUSIONS: Our findings indicate that interactions between foundational aspects and energizing aspects of partnerships are dynamic. Further exploration of these aspects may help us to understand how best to support the integration of PC and PH.

Applying Community-Based Participatory Research Partnership Principles to Public Health Practice-Based Research Networks.

With real-world relevance and translatability as important goals, applied methodological approaches have arisen along the participatory continuum that value context and empower stakeholders to partner actively with academics throughout the research process. Community-based participatory research (CBPR) provides the gold standard for equitable, partnered research in traditional communities. Practice-based research networks (PBRNs) also have developed, coalescing communities of practice and of academics to identify, study, and answer practice-relevant questions. To optimize PBRN potential for expanding scientific knowledge, while bridging divides across knowledge production, dissemination, and implementation, we elucidate how PBRN partnerships can be strengthened by applying CBPR principles to build and maintain research collaboratives that empower practice partners. Examining the applicability of CBPR partnership principles to public health (PH) PBRNs, we conclude that PH-PBRNs can serve as authentic, sustainable CBPR partnerships, ensuring the co-production of new knowledge, while also improving and expanding the implementation and impact of research findings in real-world settings.