142nd Annual Meeting and Exposition New Orleans, LA Sharing Public Health Functions and Capabilities Wednesday, November 19, 2014: 12:30 PM – 2:00 PM  Moderator―Ann Forsberg, MA, MPH  Presenter―Patrick Libbey Sharing Public Health Functions and Capabilities: Leadership Strategies  Presenters―Donald W. Rowe, PhD ; Paul Pettit, MSL ; Kenneth Oakley, PhD, MS, MBA, FACHE ; and Suman Sarker Public Health Cross Jurisdictional Sharing: The Rural New York Experience  Presenter―Gianfranco Pezzino, MD, MPH Sharing Public Health Functions and Capabilities: Critical Issues  Presenters―Kenneth Oakley, PhD, MS, MBA, FACHE & Sandy Tubbs, RN, PHN Sharing Public Health Functions and Capabilities: Models of Full and Partial Integration

Sharing Public Health Functions and Capabilities: Leadership Opportunities Patrick Libbey, Co-Director Center for Sharing Public Health Services phsharing.org

Definitions  Cross-jurisdictional sharing is the deliberate exercise of public authority to enable collaboration across jurisdictional boundaries to deliver essential public health services.  Collaboration means working across boundaries and in multi-organizational arrangements to solve problems that cannot be solved – or easily solved – by single organizations or jurisdictions.* *Source: Rosemary O’Leary, School of Public Affairs and Administration, University of Kansas

Two Critical Questions  Who makes the decision to enter a CJS arrangement?  What are the drivers behind deciding to engage in CJS?

Public Health Officials: - Health department administrators - Program managers Policymakers: - Boards of Health - Elected officials - City-county managers The Key Players

Drivers National Public Health Standards Increasing burden of chronic disease Emergency Preparedness Lean fiscal environments Health care reform CJS Agreements

“Handshake” Information sharing Equipment sharing Coordination Assistance for surge capacity Service provision agreements (e.g., contract to provide immunization services) Purchase of staff time (e.g., environmental health specialist) Joint projects addressing all jurisdictions involved (e.g., shared HIV program) Shared capacity (e.g., joint epidemiology services) New entity formed by merging existing LHDs Consolidation of 1 or more LHD into existing LHD Informal and Customary Arrangements Service Related Arrangement Shared Functions with Joint Oversight Regionalization Cross-Jurisdictional Sharing Spectrum Looser integrationTighter integration

Center for Sharing Public Health Services  DOB: May 2012  National initiative  Managed by the Kansas Health Institute  Funded by the Robert Wood Johnson Foundation  Goal:  Explore, inform, track and disseminate learning about shared approaches to delivering public health services

The Learning Community  Policymakers  ICMA  NACo  USCM  NGA  NCSL  Learning community  16 local projects  Both groups will  Learn  Share  Explore  Public Health Officials  ASTHO  NACCHO  NALBOH  CDC

Shared Services Learning Community 16 sites  75 health departments  125 political jurisdictions 14 states 2-year grants

Range of Site Activities  Select sharing model  Develop strategic plan  Prepare for implementation  Begin implementation 11

Example – Massachusetts  City of Worcester created health alliance  Six towns receive additional PH services  One health officer serves all seven towns  Alliance pursuing accreditation

Example – Colorado  In San Luis Valley six HD have formalized PH partnership  Joint environmental health assessment.  Five of the counties are receiving environmental health services through the partnership that they otherwise could not have procured on their own.

Example – Nevada  Carson City HD signed agreement with neighboring Douglas County to provide environmental health services  Douglas county approves ordinances, code  Carson City implements and enforces them on behalf of Douglas county (through contract)

Outcomes SOURCES  Shared Services Learning Community Experience  Recent ICMA Survey and Case Study Development  Other

Increased Efficiency  Reduced costs – both overall costs and unit costs  Greater productivity and economy of scale  Ability to employ more robust and current service management systems  Increased eligibility in some instances for state and federal grants

Increased Effectiveness  Greater range of public health services and/or functional capacities available  Improved quality of services Timeliness Accessibility Professional level  Ability to meet state or other performance standards

(855) The Center for Sharing Public Health Services is a national initiative managed by the Kansas Health Institute with support from the Robert Wood Johnson Foundation. 18

Western New York A history of collaboration Don Rowe, PhD Director Office of Public Health Practice, School of Public Health and Health Professions Paul Pettit, MSL Director of Public Health Genesee & Orleans County Health Departments Kenneth Oakley, Ph.D. FACHE Chief Executive Officer, LPCCN & R-AHEC Suman Sarker, MPH Public Health Cross Jurisdictional Sharing: The Rural New York Experience

Fertile ground It is much easier to collaborate when collaboration is already part of the culture. Past successes lay the foundation for the future

History of Collaboration WNY Public Health Coalition WNY Public Health Alliance – – Regional Adult Behavioral Health Risk Assessment – Physician’s Guide to Public Health – Regional Office of Public Health Emergency preparedness – Multiple regional spin-offs

Organizational collaborations P2 Collaborative – AHEC’s – NYSARH – Rural Health Networks – Lake Plains Community Care Network – S2AY RHN – Allegany Western Steuben RHN – Chautauqua County Health Network – Healthy Community Alliance

Planting the seed With decades long history of multidisciplinary collaboration and partnership, coupled with economic imperatives, the notion of cross jurisdictional sharing in public health was an idea whose time had come. Thus begins the story of a collaboration between a university, 2 health departments and a not for profit agency exploring the potential for cross jurisdictional sharing

The Genesee & Orleans Project Two rural counties in Western New York

Local Landscape Background – First Discussions in 2007 – Lack of NYSDOH & Local support / feasibility – Changes in Public Health Law – 2012 allowed for favorable environment – Opportunity arose with retirement of Genesee County PHD – Process began in October 2012

Establishing Buy In Identify a Project Driver Preliminary meeting with Genesee BOH – Fall 2012 “coffee time” – Establishing buy in from key players – 5 decision making body’s to agree on plan Summer 2012 – general agreement to proceed with PILOT project – Memorable week – “stars aligned” Began development of Inter-municipal agreements Shared services start in October 2012 PILOT thru 2014 Participation in RWJ shared service learning community First Counties in NYS

Return On Investment Quantitative – Over $400,000 saved between the two counties – Includes splitting costs of 4 administrative positions – Shared travel / meeting expenses – Common/Shared Consulting and professional services – CDC PHAP associate

Return On Investment Qualitative – Coordination of public health education and community messaging – including joint Community Health Assessment / Community Health Improvement Plan – Joint Purchasing / Vendors – cost reports – Program changes – septic program alignment (in Orleans – theoretical savings of $185,000) – Sharing interns between the counties – Shared service staffing agreement

Moving Forward Finishing up second year of RWJ project Beginning joint strategic planning Exploring joint accreditation Meeting with decision makers – Making recommendations on future direction – Renewing inter-municipal agreements – Merging Boards of Health – Institutionalizing shared services relationship

For further information on this project, please contact us at: Don Rowe: Paul Pettit: Kenneth Oakley:

Thank You

Sharing Public Health Functions and Capabilities: Critical Issues Gianfranco Pezzino, Co-Director Center for Sharing Public Health Services phsharing.org

Overview of this Session Identify known factors for success for CJS projects Propose a new framework for thinking about CJS initiatives Provide contextual reference – why does it matter?

Overview of this Session Identify known factors for success for CJS projects Propose a new framework for thinking about CJS initiatives Provide contextual reference – why does it matter?

Factors for Success  Prerequisites:  Take care of these before you even start planning  Facilitating factors:  Leverage them if they apply to your team and project  Project characteristics:  Build them in your project

Factors for Success Prerequisites Clarity of objectives A balanced approach (mutual advantages) TRUST!

Factors for Success PrerequisitesFacilitating factors Clarity of objectives Success in prior collaborations A balanced approach (mutual advantages) A sense of “regional” identity TRUST!Positive personal relationships

Factors for Success PrerequisitesFacilitating factorsProject characteristics Clarity of objectivesSuccess in prior collaborations Senior-level support A balanced approach (mutual advantages) A sense of “regional” identity Strong project management skills TRUST!Positive personal relationships Strong change management plans Effective communication

Overview of this Session Identify known factors for success for CJS projects Propose a new framework for thinking about CJS initiatives Provide contextual reference – why does it matter?

Is There a Good Path?  A roadmap to develop cross-jurisdictional sharing (CJS) initiatives  Developed by the CSPHS  Based on what we have learned from demonstration sites (and other published material)  See handout  Also available at:

Phase 1: Explore Is CJS a feasible approach to address the issue you are facing? Who should be involved in this effort? Phase 1: Explore Is CJS a feasible approach to address the issue you are facing? Who should be involved in this effort? Phase 2: Prepare and Plan How exactly would it work? Phase 2: Prepare and Plan How exactly would it work? Phase 3: Implement and Improve Let’s do it! Phase 3: Implement and Improve Let’s do it!

AreasExamples of Issues to Consider Goals and expectations: WHY would you consider CJS? 1)What is the issue that needs to be addressed? 2)Is CJS likely to help solve the issue being addressed? 3)What are the goals of the CJS initiative being considered? Scope of the agreement: WHAT services and capacities would be shared? 1)What are the PH services currently offered by each jurisdiction? 2)What are the CJS agreements currently in place? 3)What are the service gaps to fill? 4)What could be considered for sharing? a) Functions (e.g., billing, HR, IT) b) Programs (e.g., WIC, environmental health) c) Capacity (e.g., epidemiology, lab) 5)What issues should NOT be considered because of lack of support? What are the boundaries of this initiative that should not be trespassed? Partners and stakeholders: WHO are the partners that should be involved? What is the history of their relationships? 1)What is the history of their relationships? 2)What are the motivations of each key partner? 3)What are the guiding principles that the CJS effort would have? Do all the partners share these principles? 4)What individuals and groups does the issue affect, and how? Phase 1: Explore Is CJS a feasible approach to address the issue you are facing? Who should be involved in this effort? Phase 1: Explore Is CJS a feasible approach to address the issue you are facing? Who should be involved in this effort?

AreasExamples of Issues to Consider Context and history1)Strengths-weaknesses-threats-opportunities 2)What can be learned from past CJS initiatives? Governance1)What are the governance options being considered for the new CJS agreement? Is there at least one governance option that could be acceptable to everybody? 2) What is an organizational structure adequate to assure proper management? Fiscal and service implications 1)Does the plan achieve a balance between increasing efficiency and effectiveness? 2)Will public health essential services be provided in a manner that meets or exceeds current levels of performance? Legal sharing agreement1)What kind of agreement will be at the base for the CJS initiative? 2)Who will have the authority to make decisions? 3)Who will have the authority to allocate resources? Legal issues1)Are there issues related to personnel and vendor contracts (e.g., benefits, collective bargaining agreements, procurement processes, etc.)? 2)Are there any liability and insurance issues to be addressed? Phase 2: Prepare and Plan How exactly would it work? (1 of 2) Phase 2: Prepare and Plan How exactly would it work? (1 of 2)

AreasExamples of Issues to Consider Logistical issues1)What are the implications of the new agreement for buildings, office space, transportation, other properties, etc.? 2)Are there adequate facilities to house all personnel, equipment, and programs within reasonable geographical proximity to the customers for the shared services? Communications1)How will the parties communicate? 2)Are there external audiences with whom the partners also should communicate? If so, is there a communications strategic plan in place? Change management1)How are the changes produced by the CJS initiative going to be managed?  Who will be affected by the changes?  Who is going to want this initiative?  Who is going to oppose it?  Who has the most to gain?  Who has the most to lose? 2)What is the change management plan for this initiative? Timeline1)Is there a timeline including specific steps that have to be taken for the success of the sharing initiative? Monitoring1)How would you know if the CJS initiative is successful? 2)Who will monitor the implementation and results of the CJS initiative? 3)What will be the measures to monitor to assess the results of the initiative? Phase 2: Prepare and Plan How exactly would it work? (2 of 2) Phase 2: Prepare and Plan How exactly would it work? (2 of 2)

AreasExamples of Issues to Consider Implementation and management 1)Are the activities being implemented as planned? 2)Is there a strong project management team in place? 3)Is senior-level support being secured? Communications and change management 1)Are the change management and the communications plans being implemented? 2)Is communications among all parties affected flowing well? 3)What are the specific concerns and communications needs of each group affected by the new initiative? Monitoring and improving1)Are the results of the activities satisfactory?  Is the level of satisfaction of the stakeholders and groups affected by the initiative high?  Are the goals of improved effectiveness and efficiency being achieved?  Is there a need to revise the initiative’s initial goals?  What are the adjustments that need to be made to the plan? 2)Is the knowledge acquired being shared within and outside the project team? Phase 3: Implement and Improve Let’s do it! Phase 3: Implement and Improve Let’s do it!

Overview of this Session Identify known factors for success for CJS projects Propose a new framework for thinking about CJS initiatives Provide contextual reference – why does it matter?

The Uncomfortable Questions  We have about 2,500 LHDs in the U.S.  Do we need 2,500?  Can we afford 2,500?  Can we imagine a day when all of them would meet accreditation standards?  Is it politically feasible to change the current LHD structure? Adapted from: Gene W. Matthews, JD

Key Points: CJS, QI, Accreditation 1.QI and PM tools can support successful CJS efforts 2.CJS can provide QI and PM documentation for accreditation 3.CJS may increase accreditation readiness  Use shared services to show conformity in shared areas  Some jurisdictions can achieve standards jointly, but not independently 4.Working jointly on accreditation may strengthen the coalition of sharing jurisdictions

What is Next?  Many questions remain:  Is this model applicable to CJS involving:  States?  Tribes?  System-wide changes?  Public-private and public-non profit collaborations?  What are the fiscal implications?  Cost of separate versus shared services  Apportionment: how do we split the tab?  Is there a taxonomy of CJS agreements that can be developed?  What are the long-term effects of CJS?  How do we measure success beyond a single project?

(855) The Center for Sharing Public Health Services is a national initiative managed by the Kansas Health Institute with support from the Robert Wood Johnson Foundation. 51

Sharing Public Health Functions and Capabilities: Models of Full and Partial Integration (Genesee & Orleans Counties NY) Kenneth Oakley, PhD, MS, MBA, FACHE CEO, Lake Plains Community Care Network, Inc.

SHARING PUBLIC HEALTH FUNCTIONS AND CAPABILITIES: MODELS OF FULL AND PARTIAL INTEGRATION in Minnesota SANDY TUBBS, RN, PHN PUBLIC HEALTH ADMINISTRATOR

Combined:  Population: 66,306  Land mass: 3043 square miles  Staff: 85 FTEs  Budget: $ 8 million  Governing Board: 13 5-COUNTY INTEGRATED PUBLIC HEALTH

WHY CONSIDER INTEGRATION? Would integration into a single public health department result in a more efficient and effective public health agency with greater capacity to meet the current and future challenges to the health and well-being of the people and the communities?

IT’S ALL ABOUT A STRONG TRUNK

BUT DON’T FORGET THE BRANCHES Your staff and your elected officials (decision makers) are among your most important stakeholders Seek to understand their fears and anxieties, however unwarranted they may be Find a champion (or two) and empower them to communicate your message Communicate with them, support them, engage them, motivate them Stay focused on the goal

THE MOST IMPORTANT THING TO REMEMBER IS…. Strong relationships and trust are essential Invest the time you need to get it right Strive for transparency A strong change management focus may provide a greater assurance of success than project management Never lose sight of your goal

QUESTIONS? Sandy Tubbs Public Health Administrator