Savings, Service and Sensitivities: The Rural New York Cross Jurisdictional Sharing Experience  Donald W. Rowe, PhD  Director Office of Public Health Practice, University at Buffalo, State University of New York  Paul Pettit, MSL Public Health Director  Genesee and Orleans County

Background  Programmatic and fiscal environment  National  State  Local

National View  Politics  Continued downward trend in money and resources  Annual uncertainty with funding streams  Large difference in delivery system from state to state  Accreditation - focus

New York State View  Politics  NYS structure  State DOH, regional/district offices, county LHDs  State adopts/sets direction – carried out LHDs  New focus by NYS Health Commissioner  Provide reimbursements/funding to Counties  Grants, article 6 – state aid

Local Health Department View  Shrinking county budgets – NYS tax cap  Focus on mandates  Limited capacity for “add-on's”  Reducing direct service delivery  Certified Home Health Agencies  County run nursing homes  Mental health clinical services  2014 – NYS budget – tax rebates tied to staying with cap and shared services  County Collaboration efforts - Healthy Orleans Network

LHD Workforce

Need for Collaboration – background to Cross Jurisdictional Sharing  Current Federal, State & local environment  Limited resources on the ground  Philosophical shift  facilitators vs. doers  New reality for government including Public Health

RWJF – Shared Services Learning Community Grant  Two year study ( ) through the Kansas Institute focused on cross jurisdictional activities in public health  75 public health departments and 26 local and state governments - explore ways to share resources with the goal of providing more efficient and effective public health services  $125,000 over to two years to study cross jurisdictional services (CJS) across geographical barriers  3 - on site project meetings & site visits at each participating project  Applied through Lake Plains Community Care Network

RWJF –Cross Jurisdictional Sharing Grant  16 sites were identified and accepted into the project  Notified of award in early December 2012  National Announcement released January 31 st.

Definitions  Cross-jurisdictional sharing is the deliberate exercise of public authority to enable collaboration across jurisdictional boundaries to deliver essential 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

12 “Handshake” MOU Information sharing Equipment sharing Coordination Service provision agreements Mutual aid agreements Purchase of staff time Joint projects addressing all jurisdictions involved Shared capacity Inter-local agreements 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

A Tool For Sharing  A roadmap to develop cross-jurisdictional sharing (CJS) initiatives  Developed by the CSPHS  Based on what we have learned from your projects (and other published material)  Also available at:

Next Step 14

Genesee & Orleans PILOT  Agreements put in place in September for October 1, 2012 start date  Sharing PHD, Deputy PHD/Environmental Health Director  Notification of RWJF grant came in November 2012  First quarter – learning systems, cultures, getting our feet wet  Move to RWJ grant – overlap of the projects

Year 1  Focus on programmatic and fiscal savings  Brought on board nursing director (now 3 shared staff)  Reduced travel to meetings (1 covering both)  Sharing educational messaging  Aligning policies, fee schedules, local sanitary codes  Sharing consulting services (medical, engineering, transportation)  2 joint Boards of Health meetings

Return on Investment – year 1  Quantitative  Over $400,000 saved between the two counties  Includes splitting costs of 3 administrative positions  Shared travel expenses  Consulting services  CDC PHAP associate

Return on Investment – Year 1  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

CJS Fiscal impact/Savings to date CriteriaDescription Genesee County Enhanced Benefits/ Savings Orleans County Enhanced Benefits/ Savings Annual Enhanced Benefits/ Savings Total Enhanced Benefits/ Savings to Date (from 10/1/12) Shared Staffing* Public Health Director$66,000 $132, $396,000 Emergency Preparedness Coordinator $34,506 $69,011$86,264 Director of Children with Special Needs $41,790 $83,581$20,895 Environmental Health Director $21,941$0$21,941.00$65,823 Director of Community Health Services $51,000 $102,000.00$178,500 PHD Travel Expenses Savings Attending conferences, education and training $513.89$651.89$1,165.78$2,332 Sharing Medical and Environmental Engineering Consultation Savings Existing Genesee County consultation being shared with Orleans County $0Medical: $7,500 Environ: $13,000 $20,500.00$56,375 CDC PHAP Associate Benefit Assist both counties with research/analysis. Provided and paid for by CDC $21,843.1 $43,686.23$87,372 Shared Transportation Savings Joint RFP for Early Intervention and 3-5 Preschool Transportation $0$107, $107,291.61$295,052 Total $ 428,584.62$1,188,613 *Shared staffing estimates consists of both salary and benefits

Service  Shared medical director  Shared environmental engineering consultant  Shared training  Shared Early Intervention transportation  Shared public health education  Shared emergency response functions  Joint Community Health Assessments  Shared governance  Increased service efficiency

Sensitivities  Political change  Cultural differences  State continued support  Maintaining autonomy  Funding  Regulatory  Separate collective bargaining units

Necessities for Successful Sharing  Clarity of objectives  Present and acceptance of mutual benefit  Decision maker buy in & commitment  difficult with changing leadership  Strong leadership skills – change management  Transparency  TRUST

Factors / Barriers to Sharing  CHANGE!  Cultural differences in each organization  Buy in of staff – leadership and workers  Logistics - Reduced physical presence by shared staff  Keeping decision makers happy & informed  burnout

Summary  Savings exceeding $1,000,000  No loss of Service  No person has lost their job  Significant increase in efficiency  Sustainable for the foreseeable future  Model has broad rural health application

Contact  For additional information please contact  Paul Pettit, Public Health Director, Genesee and Orleans Counties 

Acknowledgement  The Robert Wood Johnson Foundation  The New York State Department of Health  The Lake Plains Community Care Network  The University at Buffalo School of Public Health and Health Professions

Thank You Questions?