1. Cross-jurisdictional sharing in public health: what we do (and do not) know Gianfranco Pezzino, Co-Director Center for Sharing Public Health Services phsharing.org

2. Overview of This Session Introduce the Center for Sharing PH Services Describe success factors for CJS projects Frame efficiency issue Review available information on impact of CJS projects

3. 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

4. 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

6. Does It Work?

7. Available Data About Impact  Qualitative information from demonstration projects  75 LHDs, 125 jurisdictions  5 in-depth case studies (ICMA)*  Quantitative information  Survey administered to local jurisdictions (ICMA)*  1,119 responses * ICMA data focused on back-office service sharing

8. Summary of 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

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

10. 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

11. 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

12. Does It Work???

13. “Does It Work?”  A common question from policymakers about sharing agreements:

14. “Does It Work?”  A common question from policymakers about sharing agreements: “HOW MUCH MONEY WOULD IT SAVE US?”

15. Framing the Cost Issue  “Return on Investment”:  How much money will be generated by our “investment”?  Investment: “the action or process of investing money for profit or material result”  Government is not a for-profit entity  Focus on material results

16. Framing the Cost Issue  “Return on objectives:”  What is the impact of our program/service/capability?  How does our “investment” position us closer to achieving our goals/objectives?  Shifting focus from $$ to impact.

17. Efficiency  Achieving maximum results for a given investment  Achieving a given result (“goal”) at the smallest possible cost Output Input

18. Efficiency  Achieving maximum results for a given investment  Achieving a given result (“goal”) at the smallest possible cost Output Bang Input Buck Or,

19. Does It Work??!!

20. Anecdotes Versus Evidence  Subject to bias  Distortion  Exaggeration  Often from a single source  Untestable  Lack of standardized conditions  Potentially harmful  Multiple anecdotes do not constitute evidence

21. Most preliminary evidence of impact of CJS activities is “semi-anecdotal”

22. Improved 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

23. Improved 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

24. ICMA Survey: Cost Savings  55% report cost savings  Cost saving reported more often among smaller jurisdictions  Greatest savings reported in:  Executive leadership  Billing  Office and facility maintenance  Communications and outreach  Little or no hard data available

25. ICMA Survey: Improved Efficiency  From ICMA survey:

26. Consolidation of Three Summit County, OH Health Departments: Pre/Post 2011 Merger Local PH Revenue Fiscal Year City of Akron City of Barberton Balance of Summit County Combined Public Health Spending 2008$16,445,449$1,992,618$12,769,359$31,207,426 2009$18,584,664$1,548,593$12,662,176$32,795,433 2010$15,993,025$1,009,468$13,655,691$30,658,184 2011$8,856,632$135,800$19,620,983$28,613,415 2012$4,020,810$135,163$ ??

27. Integration in Genesee & Orleans Counties, NY CriteriaDescription Genesee Co. Enhanced Benefit Orleans Co. Enhanced Benefit TOTAL Enhanced Benefit Shared Staffing Savings Public Health Director Environ Hlth Director Patient Svcs Director $66,000/yr $21,941/yr $51,000/yr $66,000/yr $ -0- /yr $51,000/yr $132,000/yr $ 21,941/yr $102,000/yr Travel Expense Savings PH Director attending conferences and trainings $514/yr$652/yr$1,166/yr Shared Consultation Savings Existing Genesee Co. consultation shared with Orleans Co. $ -0- /yr Medical: $ 7,500/yr Environ Eng: $13,000/yr $20,500/yr CDC PHAP Associate Benefit Provided and paid for by CDC to assist with research /analysis $21,843/yr $43,686/yr Shared Transportation Savings Joint RFP for 3-5 Preschool and Early Intervention Transportation $ -0- /yr $107,295/yr TOTAL$428,588/yr

28. What Is Next?  Focus on implementation:  Measuring effectiveness (i.e., changes in quality/quantity of services) AND efficiency (i.e., ROO)  Moving from anecdotes to evidence  Is what we learned applicable to CJS involving:  States?  Tribes?  System-wide changes?  Public-private and public-non profit collaborations?  What are fiscal implications?  Cost of sharing services:  We need to measure costs before we measure savings  Apportionment

29. A New Resource

30. www.PHSharing.org PHSharing@KHI.org (855) 476-3671 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.