Regionalization in Local Public Health: Variation in Rationale, Implementation, and Impact on Public Health Preparedness Michael A. Stoto PHSR CyberSeminar, May 2007

Stoto PHSRCyberSeminar 2 5/07 Washington Metropolitan Area Definitions National Capital Region (NCR) Metropolitan Washington Council of Governments (COG) Media market Healthcare markets Federal government

Stoto PHSRCyberSeminar 3 5/07 NCR organization and governance Who’s in charge? –“Let me speak to the health officer for the National Capital Region” MWCOG Health Officers Committee (HOC) –Forum to communicate on a regular basis, but no legal authority Senior Policy Group (SPG) and COG Chief Administrative Officers (CAO) committee –Receive and distribute federal funds

Stoto PHSRCyberSeminar 4 5/07 Regional capacity in the NCR ESSENCE II regional surveillance system MWCOG –Conference call facility –Regional Incident Communication and Coordination System (RICCS) DC Hospital Association emergency radio network (H-MARS) VDH Northern Virginia Regional Team

Stoto PHSRCyberSeminar 5 5/07 NCR conclusions Regional capacity created Numerous regional entities and relationships among public health and partners Relationships tend to be informal –More formality may not be possible –May be optimal: personal relationships more important than formal arrangements in an emergency “Who’s in charge” will remain an issue Biggest challenge is role of the federal government

Stoto PHSRCyberSeminar 6 5/07 Cross-cutting issues: Impetus for regionalization Efficient use of preparedness funds –MA, others to lesser degree Crisis or perceived need for a coordinated response –MA 4b, NCR, others to lesser degree Building local public health capacity –Strengthening existing local public health structures (No. IL) –Building local public health itself (NE)

Stoto PHSRCyberSeminar 7 5/07 Formal organizational relationships vs. informal professional networks NACCHO Public Health Ready typology –CoordinationStandardization –CentralizationNetworking Describes collaboration of existing LHDs –Not as effective for building local public health capacity (e.g. MA, NE) Does organization build social capital? Or, are the professional networks built through regionalization the most important effect?

Stoto PHSRCyberSeminar 8 5/07 Relationship between public health regions and geopolitical jurisdictions Variety of combinations –Combinations of local LHDs (No. IL, MA) –Combinations of counties (NE) –NCR: multiple definitions, cross-state, sub-regions Congruence with –Regional structures for partner agencies (e.g. EMA) –Hospital markets, HRSA funding regions, etc. –Need to preserve existing relationships if possible Impact on political support and social capital? –Authority and resources for public health follow jurisdictional lines, but outbreaks don’t

Stoto PHSRCyberSeminar 9 5/07 Leadership, trust and sustainability MA 4b started with a small group formed in a crisis and grew from 15 to 27 communities with state funding –Cambridge (fiscal agent) had to ensure it was not perceived as “driving” Competition for UASI funds in NCR Can the perceived need for regional response overcome home rule barriers? –Need perception that at the end of the day it will be worth it Do regions build social capital? –Does this help with sustainability?

Stoto PHSRCyberSeminar 10 5/07 Does regionalization improve preparedness? May depend on setting, existing resources, and variety of regionalization Logically, yes –More efficient use of resources –Outbreaks don’t respect geopolitical boundaries, so need coordination Demonstrated progress in –Planning and coordination –Memoranda of Understanding, etc. –Development of local and regional capacity, training, exercises –Professional network development Response to –Flu vaccine shortage (MA) –Anthrax and tularemia alarms (NCR)

Stoto PHSRCyberSeminar 11 5/07 Does regionalization improve public health generally? Same efficiency, communication needs Regional capacities address other needs –Regional epidemiology in NCR Preparedness concerns are forcing us to think about public health structures in a way not done in decades –Communities think about preparedness in terms of day-to-day activities Network development may be creating social capital that helps with other concerns But, do preparedness demands draw resources and attention from other areas?

Acknowledgements RWJ HCFO Public Health Systems Initiative MA: Howard Koh, Christine Judge MA 4b: John Grieb, Mary Clark No. IL: Patrick Lenihan NE: Dave Palm, Colleen Svoboda NCR: Lindsey Morse Contact Information (202)