HomeMy WebLinkAbout04 BOHJoint CHScombined memo 8.2.16 AGENDA ITEM SUMMARY
WORK SESSION DATE: August 2, 2016
AGENDA ITEM TITLE: Joint Meeting between Pitkin County Board of Health and
Community Health Services Board of Directors
STAFF RESPONSIBLE: Liz Stark, Public Health Director
Nan Sundeen, Health and Human Services Director
ISSUE STATEMENT:
Today the Pitkin County Board of Health will hold a special joint meeting with the Board of
Directors of Community Health Services to review staff recommendations about how to move
forward with the development of a Pitkin County Public Health and Environment section.
BACKGROUND:
The landscape of the provision of public health policy and services, financing and administration
has evolved significantly over the past 30 years. While many aspects of our Pitkin County
Public Health system are working very well, the particular system we have built locally has
created confusion, redundancy and inefficiencies for staff and boards. This has resulted in
weakening our ability to protect the public and the environment.
For many years, CHS and Pitkin County staff have worked diligently to address the requirements
of the Public Health Act and provide the best public health services possible within the
constraints of a unique structure. However, it has become increasingly difficult for CHS to
effectively respond to the increasing demands of all the requirements and expectations for
"Population Health"while continuing to provide the same level of essential quality clinical
services. The current structure threatens the strength of the public and environmental health
protection(and potential response in an emergency) that Pitkin County residents and visitors
should be able to expect. The Pitkin County Public Health structure is not currently designed for
long-term sustainability in the current health care climate and needs adjustment.
The inefficiencies and redundancies of the current structure can be illustrated with these
examples:
• The Public Health Director for the County is not a county employee which creates
confusion when interpreting and implementing the authorities of this position. This
confusion has weakened our ability to build the highest level of public and environmental
protection possible.
• There is confusion about the authorities and responsibilities of the CHS Board and the
Board of Health which have been challenging to clarify.
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• Emergency preparedness and communicable disease surveillance have grown into a large
public health function with the increase in emerging infectious diseases. Currently the
CHS Director serves as the Emergency Preparedness Coordinator. This is an illustration
of the lack of capacity that currently exists in CHS to devote adequate resources to a vital
public health function.
The Public Health Act implementation, along with the City of Aspen's decision to deconstruct
it's formal public health structure, and Community Health Services acknowledgement that the
obligations of the Public Health Act have made it impossible for them to continue to effectively
provide both population health and clinical services, offered Pitkin County motivation and
opportunity to hire Keystone Policy Center, Public Health consultants, to evaluate the
governance, structure and services provided by public health.
On June 22 and 23rd Keystone Policy Center presented their findings to the CHS Board and Staff
and to the BOH. The key recommendations include:
1. Create a Public Health and Environment Section within Pitkin County(separate from a
Human Services Section). Broaden public health services to include the full spectrum of
essential public health services with a focus on long-lasting protective interventions,
changing the contact to make individuals' default choice the healthiest choice, and socio-
economic factors.
2. Hire a Public Health and Environment Director and two Public Health Planners in 2017
3. Separate "Population Health"public health functions from Community Health Services.
Ensure the provision of essential clinical services through CHS or through other
providers in the health care delivery system.
4. Integrate Environmental Health with Public Health in 2018
5. Create a new Board of Health comprised of subject matter experts
Since the Keystone presentation in June, staff from both organizations (including Public Health
and Human Services Directors, County finance, Human Resources, Business Information
Technology, Community Relations, CHS finance, CHS board, Public Health Advocate,
Environmental Health Manager and City of Aspen Environmental Health Manager)have been
working to develop a plan on how Pitkin County and CHS can successfully move forward with
the recommendations. Today staff will present"a path forward"to creating a Public Health and
Environment Section within Pitkin County. Mary Fox, CHS Board Chair will summarize CHS
board ideas about the strengths and challenges of the Keystone recommendations. There will be
significant time for BOH and CHS Board members to share their thoughts and identify
commonalities and differences. Attachment A is a proposed Agenda for this meeting.
Staff is looking to the BOH today to support the development of a Public Health and
Environment section in 2017 (with Phase I, hiring a Public Health and Environment Director and
two Public Health Planners in 2017) and to recommend that staff take the proposal through the
County's 2017 budget process.
As background to the provision of Public Health in Pitkin County, Attachment B is a detailed
history of provision of public health, the public health act, the core public health services, and
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the local public health priorities. This background is offered in order to allow participating board
members from each group the opportunity to focus on the Keystone recommendations and staff
ideas about how to move forward.
Attachment C is Keystone Policy Center's final report"Pitkin County Provision of Public Health
Assessment".
LINK TO STRATEGIC PLAN:
Livable and Supportive Community- Self Sufficient Individuals and Families
Prosperous Economy—Affordable and quality health care options
KEY DISCUSSION ITEMS:
1. Review staff recommendations on how to move forward with the Keystone Policy Center
recommendations
2. Consider CHS Board and BOH member concerns and ideas
3. Identify support for developing a Public and Environmental Health section and direct staff to
take the request through the 2017 budget process.
BUDGETARY IMPACT: $470,088 total startup costs for 2017 and 2018. These funds will be
drawn from the General Fund Balance with the intention that the full costs will be absorbed
within the Healthy Community Fund in 2019.
RECOMMENDED BOH ACTION: Direct staff to take the proposed plan through the
County's 2017 Budget Process
ATTACHMENTS:
A. Proposed Agenda for this Joint Meeting
B. History of Public Health in Pitkin County
C. Keystone Policy Center's Final Report- Pitkin County Provision of Public Health
Assessment
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(ATTACHMENT A)
Joint Meeting
Pitkin County Board of Health &
Community Health Services Board
August 2,2016
1-3pm
Meeting Goals
• Review Keystone Policy Center Recommendations and Staff Presentation about how to
move forward
• Explore the Community Health Services Board of Directors and Board of Health ideas,
concerns reactions to the presentation
• Conceptually approve the development of a Pitkin County Public Health and
Environment section and direct staff to propose the project through the 2017 budget
process
Proposed Agenda
Time Item
Ipm Introductions and meeting purpose
1:10-2pm Presentation on moving forward with the Keystone recommendations
2-10 Mary Fox, CHS Chair to summarize CHS feedback on Keystone
recommendations
2:10-2:45 Open discussion between the boards
2:45-3pm BOH direction for staff
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(ATTACHMENT B)
HISTORY OF PUBLIC HEALTH IN PITKIN COUNTY
Historically, two different types of public health agencies served Colorado's residents. Prior to
2008, agencies were categorized as either"Organized Health Departments" or"Nursing
Services". The primary difference between these two types of agencies was the scope of public
health services provided.
Prior to 2008, fifteen"Organized Health Departments," served twenty-four counties and 85% of
the state's population. These agencies were responsible for the provision of a broad scope of
public health services within their jurisdiction. These health departments were primarily located
in larger urban areas of Colorado.
In the remaining 40 counties, each local board of health was to assure the provision of public
health nursing services to areas within its jurisdiction. Public health nursing services meant only
those public health services deemed necessary or desirable for the public health by the local
board of health, and falling within the scope of the practice of nursing. These agencies were
generally located in the smaller, rural communities of Colorado.
The current structure for providing Pitkin County's statutorily required public health services
started in 1971 when a non-profit visiting nurses association was formed. Community Health
Services-Visiting Nurse Association provided 6 major nursing service programs which included
home health and hospice, communicable disease control, immunizations, family planning,
maternal health, adult health and child health. Contractual agreements between Pitkin County
and the City of Aspen started at that time. Contracts between Community Health Services and
the Colorado Department of Public Health and Environment were also entered into to provide
program direction, compliance and fiscal support.
Over the years, the programs provided by CHS changed somewhat. Home care and hospice was
discontinued in 1989. The major CHS programs (Immunizations, Communicable Disease,
Nutrition, Family Planning and Prenatal) have been maintained although some activities within
each program area have changed depending on community need.
In the early 1980's, Pitkin County created the position of Health and Human Services Director in
an effort to establish, support and maintain a comprehensive set of social safety-net services for
the community. Since Community Health Services was providing"home health/hospice and
nursing services" as a separate non-profit, the county utilized it's Health and Human Services
and Environmental Health departments to advise the Board of County Commissioners,
sometimes serving as the Board of Health, in matters of public health and safety, fiscal
development for essential health services, and public health policy.
Recognizing the need for improvements in Colorado's public health system, legislators in 2008
passed Senate Bill 194, the Public Health Act. This legislation eliminated the statutory language
that created the two distinct agency types and established a uniform system of local public health
agencies. With this new uniform system of public health agencies established, the focus of
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improving public health in Colorado turned to providing standard public health services
throughout the state. The Public Health Act required the State Board of Health to establish, by
rule, core public health services to be assured or provided by each county public health agency.
Those Core Public Health Services are:
• Assessment and Planning
• Communicable Disease Prevention, Investigation and Control
• Prevention and Population Health Promotion
• Emergency Preparedness and Response
• Environmental Health
• Vital Records and Statistics
• Administration and Governance
One of the Core Public Health Services, Assessment and Planning, mandated that each local
public health agency perform a community health assessment every 5 years and submit a
Public Health Improvement Plan to the State. The plan is approved by the local Board of
Health prior to submission. Community Health Services completed the community health
assessment in late 2012 and submitted the Public Health Improvement Plan to the Pitkin
County Board of Health for final approval in January 2013. From there, the Plan was
submitted to the State. The Pitkin County public health priorities identified in the plan
include:
• Access to Care
• Mental Health and Substance abuse
• Needs of the aging population
• Radon awareness and mitigation
• Capacity building of Community Health Services to deliver the core public health
services.
The Public Health Act impacted the operations of CHS, Pitkin County Board of County
Commissioners and Pitkin County Health and Human Services significantly. Health Care reform
came shortly afterward, which has also had an impact on the operations of all three
organizations. The Public Health Act required that a local Board of Health be established(Pitkin
County Commissioners chose to appoint themselves as the Board of Health since they had been
serving in that capacity for many years), a Public Health Agency be formally named(Pitkin
County BOH chose themselves as the Public Health Agency, named themselves the Pitkin
County Public Health and Environment Agency in order to continue its subcontract with
Community Health Services, which is a contractor and not a county department) and a Public
Health Director be appointed by the Board of Health(the Pitkin County Board of Health
appointed Liz Stark, Executive Director of Community Health Services).
The Public Health Act requires counties to provide public health services through one of three
different structures: a county department or a regional health district. Pitkin, Rio Blanco, Moffat
and Routt are the only counties in Colorado to contract for public health from non-profit
agencies. The Act does not describe or dictate any of the roles and responsibilities of this more
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complicated type of relationship, so Pitkin County has been sub-contracting with Community
Health Services with no guidance from the State Department of Public Health and Environment.
Prior to the Public Health Act, the contract between Pitkin County and Community Health
Services identified very clearly the nursing services that Community Health Services was
providing and Pitkin County was procuring. However, after the Act, the contract between Pitkin
County and Community Health Services became broader and defined only"access to preventive
health care services for the most vulnerable population in the community, with a focus on
prevention and health promotion."
In 2011, additional financial resources were provided by the Pitkin County Healthy Community
Fund to allow CHS to add staff to address the Core Public Health Services, particularly the
Assessment and Planning function. Pitkin County provides about 31% of the overall CHS
budget, with the remaining income derived from grants and fees.
The Public Health Act also allowed municipalities to create their own board of health,public
health director and public health agency. The City of Aspen, through their Environmental Health
department, was one of only two municipalities in the state (including Denver)to implement this
option and they equipped themselves with their own infrastructure and conducted their own
Community Health Assessment and Public Health Improvement Plan. After five years of
implementing the Act and identifying local redundancies, the City of Aspen agreed in March,
2015, to deconstruct their Board of Health, Public Health Agency and Public Health Director in
favor of enhancing the Pitkin County structure. The process of expanding the Pitkin County
Board of Health with one new representative from Aspen City Council and one new
representative from the Town of Snowmass Village was complete in early 2015.
In 2015, CHS submitted a Healthy Community Fund grant request for a new 3 year partnership.
The request was substantially more than had been granted in the past due to the increased
expectations and demands being put upon the organization. This created an opportunity for the
county to explore more fully what the public health structure and function should be.
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(Attachment C)
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Pitkin County Provision of Public Health Assessment
Prepared by
Johanna Gibbs
Keystone Policy Center
jgibbs@keystone.org
970.513.5839
Dawn Joyce, MPH
Policies & Partnerships for Health
dioyce@alum.wellesley.edu
510.847.2900 ' KEYSTONE
Table of Contents
Executive Summary 3
Introduction 6
Federal, State, and Local Shifts 6
Process Aim 10
Assessment 10
Process 10
Findings 11
Strengths 11
Challenges & Opportunities 11
Community Values 12
Best Practices, Research, and Review 13
Process 13
Findings 14
Governance and Organizational Structure 14
Funding Strategies 14
Public Health Services 16
Recommendations 17
Public Health Services 19
Governance 19
Structure 21
Funding 21
The Path Forward 23
Additional Resources 25
Conclusions 25
Pitkin County Provision of Public Health Services Assessment 12/26
Executive Summary
Keystone Policy Center (Keystone), selected through a competitive
bidding process, worked to assess the provision of public health Keystone Policy Center
services in Pitkin County, review best practices, and recommend Keystone Policy Center brings
solutions. These recommendations included changes to the county's together crucial teams of
public health governance structure, direct services, and funding stakeholders who have
mechanisms necessary to ensure sustainable future for preventative diverse individual
and population health. perspectives but recognize a
common need to address
Process urgent issues with lasting
solutions. For more than 40
In order to inform the final recommendations, Keystone conducted years, Keystone has helped
an assessment through a series of key informant interviews with key leaders move beyond fixed
stakeholders and small group interviews as well as small group positions toward
meetings. This assessment was aimed at helping to better collaborative, action-oriented
understand the public health delivery system in Pitkin County and to approaches to problem-
solicit ideas on how the system can better safeguard and promote solving.
health in the future. These assessment interviews and meetings
were conducted between January and March 2016. During these 45- In an age of polarized debate
to 90-minute conversations, Keystone engaged interviewees in a on nearly every major topic in
series of facilitated discussions aligned with the process goals. public policy, Keystone offers
Interviewees were asked to openly share their expertise, thoughts, a refreshing yet proven
blueprint for progress. In
and ideas in confidence with Keystone with the understanding that more than four decades of
findings from the interviews would be shared in summary aggregate designing effective conflict
form. management strategies for
As the second phase of this process, Keystone conducted best complex, contentious issues,
practice research regarding the following topic areas: Keystone has built a portfolio
of substantive work in
• Public health services energy, environment,
• Funding strategies education, public health, and
• Governance and organizational structure agriculture.
To better understand best practices, Keystone conducted key
informant interviews with subject matter experts and public health directors from sample
communities, reviewed literature, and examined national standards and guidance. This process was
conducted between February and June 2016.
Pitkin County Provision of Public Health Services Assessment 13/26
Recommendations
The assessment and best practice research informed the formation of the following recommendation
to the Board of Health:
Public Health Services
• Broaden public health services to include the full spectrum of essential public health services
particularly the bottom three rows of the CDC's Health Impact Pyramid: long-lasting protective
interventions, changing the context to make individuals' default choice the healthiest choice,
and socio-economic factors.
• Expand emphasis on evidence-based population level health efforts.
• Continue to ensure access to clinical services, but focus services on long-lasting protective
interventions such as family planning and immunizations. Where possible, gradually shift direct
clinical services to the health care delivery system and focus public health's role on ensuring
that services are available rather than offering them directly.
Structure
• Establish the Pitkin County Public Health and Environment Section. This section will be
responsible for the full spectrum of public health services, including environmental health.
• Fully integrate environmental health and preserve a close strategic relationship with
Community Development.
• Separate the current Health and Human Services section so that there are two county sections:
(1) Public Health and Environment and (2) Human Services. Public Health and Human Services
require distinct expertise and should have a lateral relationship.
• Hire a county Public Health director with a Master's Degree in Public Health (MPH) and/or a
Doctorate in Public Health (DrPH). The director should report directly to the county manager.
• Expand Public Health and Environment staff to include additional staff members with formal
public health training, preferably with an MPH and experience with population level health
interventions. Key skill sets include: emergency preparedness, quality improvement, data,
analytics, and epidemiology.
Governance
• Create a new Board of Health (BOH) consisting of public health experts appointed by the Board
of County Commissioners (BOCC).
• The Board of Health should include five to seven members including reserved seats for at least
one MPH and at least one expert in environmental health.
Funding
• Increase opportunities to blend and braid multiple funding sources to meet public health needs
in the community.
• Increase focus on grant opportunities to maximize funding aligned with public health priorities.
• Data should drive funding priorities to ensure continuous movement toward public health
goals. Data should also continue to inform grant reports.
Pitkin County Provision of Public Health Services Assessment 14/26
• Add Public Health leadership to the Healthy Community Fund's strategic planning, grant-
making, and oversight processes. Utilize this funding to leverage a collective action approach
aligned with Public Health and Human Service priorities.
A phased approach to implementing this change over a three-year period is recommended to ensure a
successful transition. This carefully planned and phased approach will allow for opportunities from the
Public Health Act to be leveraged in a thoughtful manner including alignment with the Public Health
Improvement Plan's process.
Communities, including Pitkin County, will continue to face challenges in their efforts to ensure that
core services are maintained in an era of systematic shifts within public health, health care delivery and
policy. This process and accompanying recommendations provides Pitkin County with an independent
review of the public health system within the community and informs decision makers with
recommendations for a pathway forward to ensure that the system can better safeguard and promote
health in the future.
Pitkin County Provision of Public Health Services Assessment 15/26
Introduction
This report is intended to outline the process and major findings of the assessment and best practice
research as they informed the formulation of recommendations for Pitkin County's Board of Health's
consideration. This process took place between November 2015 and June 2016.
This report is not intended to be a comprehensive summary of all results, but rather a high-level
summary of key findings.
Federal, State, and Local Shifts
National, state, and local communities are in the midst of exciting, dynamic, and significant change as
public health transitions away from its emphasis on direct services and expands its efforts related to
prevention and population health. The Affordable Care Act (ACA), the State Innovation Model (SIM),
the Accountable Care Collaborative (ACC/RCCO/RAE), new formulas for Colorado Department of Public
Health and Environment (CDPHE) funding, new visions for foundation funding, and an increased
understanding of the social determinants of health are just some of the factors impacting the exciting
environment in which public health works. This exciting and shifting environment is not without
challenges as communities across the nation and state adapt their strategies and services to
complement systems that are continuing to evolve.
With the passage of health reform (the ACA), a large number of Pitkin County residents have access to
health insurance coverage that was not previously possible: since the implementation of the ACA, the
percentage of persons in Pitkin County that are uninsured dropped from 15 percent in 2013 to
8 percent in 2015 (EnrollAmerica.org). This nearly 50 percent decrease is due to Colorado's Medicaid
expansion coupled with enrollment through the health care exchange. Simply enrolling in coverage
alone, however, does not guarantee improved health outcomes. Although the ACA includes an
increased emphasis on preventive clinical care including all services that have received A or B rankings
by the U.S. Preventive Services Task Force (USPSTF), much still needs to be done to encourage clinical
settings and insurance entities to adopt this increased emphasis. Public Health can play a crucial role
helping the health care system leverage these changes to positively impact health. Public health's role
in this includes collaborating with the health care delivery system, strengthening the services that are
offered within a Medical Home or Medical Neighborhood, expanding the emphasis on primary
prevention, facilitating efforts that focus on health literacy and patient navigation, and working with
insurance companies to modify their benefit packages in order to maximize preventive health. As the
health care system continues to evolve, direct services previously provided within the Public Health
setting may be able to gradually shift to the health care setting thus allowing Public Health resources to
be focused on population level health instead.
While large numbers of Pitkin County residents have increased access to health coverage as a result of
the ACA, comprehensive health coverage still remains out of reach for many people in Pitkin County
due to the high cost of premiums. In particular, this impacts individuals and families above 400 percent
Pitkin County Provision of Public Health Services Assessment 16/26
of the federal poverty level' ($97,200 for a family of four) who work multiple jobs to make ends meet
but do not qualify for premium subsidies under the ACA. Given Pitkin County's high cost of living, these
individuals and families must frequently decide which core necessities to pursue and which to forego:
health coverage, health care, housing, nutrition, etc. In addition to high premiums, access to care also
is limited by high deductibles. This reality impacts Public Health services since it is responsible for
ensuring that all community members have access to essential health care, and preferably the full
spectrum of care they need to thrive.
Additional system-level changes that impact the environment in which Public Health works as well as
the strategies that it is best positioned to adopt include the State Innovation Model, which integrates
primary care and mental health care, as well as the Accountable Care Collaborative, which creates
opportunities for increased access to high quality care for Medicaid patients including case
management and navigation services. The Accountable Care Collaborative also addresses select
elements of payment reform. By engaging with these efforts through collaborative and strategic input
at the systemic level, Public Health can shape them in a manner that increases access to quality care,
including an emphasis on prevention.
The aforementioned health reform and health system level efforts — with all their strengths and
challenges — create a new environment in which Pitkin residents can increasingly access direct
services in new venues thus gradually giving Pitkin the opportunity to expand its focus on population
health. We envision a multi-year period during which Pitkin shifts the majority of the provision of direct
service to the health care system, plays a collaborative role to help ensure adequate access to high
quality clinical services, ensures patients are equipped to navigate the system, and grows its
population health focus. The Pitkin County public health system must ensure that all core Public health
services are delivered, but will work with partners to decipher how and who can most effectively
provide such services. With newly freed up and newly acquired resources, Pitkin will be able to
increasingly shift its strategies toward the bottom three rows of the public health pyramid (Figure 1).
1 https://aspe.hhs.gov/poverty-guidelines
Pitkin County Provision of Public Health Services Assessment 17/26
Figure 1: Public Health Pyramid
CDC Health Impact Pyramid
Factors that Affect Health
Examples
Smallest
Impact Eat healthy,be
Counseling physically active
Education
/ Rs for high blood
Clinical pressure,high
/ Interventions cholesterol,diabetes
Immunizations,
Long-lasting brief intervention,
Protective Interventions cessation treatment
colonoscop
Changing the Context Fluoridation.trans
to make individuals'default fat.smoke•free
decisions healthy laws.tobacco tax
Largest Poverty,education.
Impact Socioeconomic Factors housing,inequality
Check the Tarrant county Pubic Health web ade to learn more. /CDC
M,tp'tfl h Wranrcounty.nm `-
A shift toward the bottom of the public health pyramid will include adoption of preventive and
population health approaches within each of the 10 Essential Public Health Services':
1. Monitor health status to identify and solve community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships and action to identify and solve health problems.
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the provision of health care when
otherwise unavailable.
8. Assure competent public and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
10. Research for new insights and innovative solutions to health problems.
These essential services' combine to allow Public Health to meet its core functions'', as noted below
and illustrated in figure 2.
2 http://www.cdc.gov/nphpsp/essentialservices.html
3 http://iom.edu/Reports/1988/The-Future-of-Public-Health.aspx
4 http://www.health.gov/phfunctions/public.htm
Pitkin County Provision of Public Health Services Assessment 18/26
Core Public Health Functions
• Assessment: Monitoring health and collecting, analyzing, and tracking data to accurately
understand the health dynamics of the local community. This includes communicable disease
investigation.
• Policy Development: Working at the system's level to help make the public's default choices the
healthiest choices.
• Assurance: Ensuring that public health and health care services are available to the entirety of
the community. Mobilizing community partnerships to identify and solve health problems
together.
Public Health accomplishes this through strategic partnership and engagement with the broader
community. Public Health departments are directly responsible for select services and strategically rely
on the broader community for others. As illustrated in figure 3, together, the system as a whole
ensures the public's health.
Figure 2: Core & Essential Public Health Services
'QS
SF
S"
Evaluate Monitor �y
Health
Assure
Competent Man Diagnose
Workforce `eF aee4 &Investigate
Link a •Al w 1rn`ur,r.,
to/Provide
1
IA
Care
0
Mobilize •
Enforce Community
Laws Partnerships O�
Develop
Policies �C
ILO
Pitkin County Provision of Public Health Services Assessment 19/26
Figure 35:The Public Health System
•
111 Schools I'', Civic Groups Nursing
EMS Neighbor$d. Homes
Community
Orgs. Non ProfitCenters
Organizations
0
Hospitals t�l 1 0 Home-Health
Drug Pub li< HeathLabontories('
Treatment Agency
Doctors •
Mental Health
Law Faitls 0stit. • CI Enforcement
CHCs = Triba Heakh Flre Transit
I
Employee Elected Officials
Corrections
Process Aim
Keystone conducted a comprehensive study of the provision of Public Health in Pitkin County. This
effort included a study of the status of current organization and operations aimed at informing
recommendations to improve local commitment to providing the right level and type of services,
governance structure and funding strategies to ensure a sustainable future for priority public health
services. Deliverables included a written proposal and presentation of recommendations to the Pitkin
County Board of Health. To achieve this, Keystone developed a customized process that was carefully
and thoughtfully designed in consultation and coordination with key staff to achieve the project goal.
This process included an assessment and best practice research conducted from December 2015 to
June 2016.
Assessment
Process
The assessment process included engagement with more than 55 stakeholders through individual and
small group interviews as well as small group meetings. The assessment was aimed at helping to better
understand public health delivery system in Pitkin County and to solicit ideas on how the system can
better safeguard and promote health in the future. The goals for the interview processed included:
• Inform the current and future structure for public health services to Pitkin County residents.
5 http://www.cdc.gov/nphpsp/essentialservices.html
Pitkin County Provision of Public Health Services Assessment 110/26
• Understand the referral pipelines between entities.
• Identify opportunities for increased partnerships and opportunities for services to be shared or
delegated.
• Explore and identify the types of services Public Health could provide in order to most positively
impact health in Pitkin County. This may include services at all levels of the Health Impact
Pyramid (Figure 1).
• Identify potential sustainable funding mechanisms.
Keystone worked in cooperation with key staff to refine the assessment process including the
identification of key stakeholders to consult with for the assessment process and to refine assessment
questions.These assessment interviews and meetings were conducted between January and March
2016. During these 45-to 90-minute conversations, Keystone engaged interviewees in a series of
facilitated discussions aligned with the process goals. Interviewees were asked to openly share their
expertise, thoughts, and ideas in confidence with Keystone with the understanding that findings from
the interviews would be shared in summary aggregate form. A full list of assessment interviewees in
Appendix A.
Findings
The assessment key informational interviews and group meetings helped provide insight into the
landscape of health care and the provision of public health services within the community as well as to
highlight both the many strengths and challenges within the current system.
Strengths
Common strengths identified through the assessment interviews and meetings included the quality of
direct services being provided, community investment through the Healthy Community Fund and a
shared interest in adopting approaches that best serve the community.
Direct Services—Those served by the direct services currently offered by Community Health Services
(CHS) spoke to the quality of the services they receive and the caring nature in which those services are
delivered and accessed.
Community Investment—The community continues to safeguard and support the Healthy Community
Fund and the its commitment. This demonstrates taxpayers' commitment to services and
commitments realized through this fund.
Committed Leadership—Stakeholders identified the strong skills within leadership of CHS and the
county as strengths within the current system.
Challenges & Opportunities
Common challenges identified through the assessment interviews and meetings included provider
shortages, continued unmet need, ability to more effectively collaborative with health care partners
and facilities as well as governance structure.
Unmet needs— Despite the expansion of insurance coverage for many within the service area, there is
still inadequate access to health care services within the community due to a lack of providers, high
Pitkin County Provision of Public Health Services Assessment 111/26
insurance premium costs, high deductibles, and in some cases large geographic distances from where
services are offered.
Access to care—The lack of Medicare and Medicaid providers within Pitkin County continues to be a
challenge. Convening provider groups and facilities to identify incentives to attract current or new
providers to the area who are willing to accept Medicare and Medicaid is vital to being able to increase
the communities' abilities to meet the currently unmet health care needs in the community. Exploring
financial opportunities through the Federally Qualified Health Center is also key.
High cost of coverage— Pitkin County is a part of a region within the state that experiences the highest
cost of health insurance in the county. This high cost of insurance coverage is especially challenging for
those on the individual insurance market, where premiums are expected to rise substantially over the
short term.' For individuals with incomes above 400 percent of the federal poverty level, it is
exceptionally difficult to afford the entirety of these premiums without ACA subsidies.
Inadequate resources dedicated to population health—Currently resources are focused primarily on
direct services within CHS. These services address Public Health's role in "Linking To or Providing Care."
Limited resources are currently invested in the remaining Essential Public Health Services (figure 3).
Additional resources are needed to address the population health needs within the community.
Health care community relationships— Lack of strong relationships with providers and health care
facilities such as Aspen Valley Hospital serves as a barrier to pathways for collaboration and
partnerships. The Public Health Director does not currently sit on either of the Health Alliances.
Governance structure—Governance remains a challenge within the current structure. Confusion over
roles, reporting, communication pathways, and decision-making processes challenge the work that is
underway and prevents forward momentum of the public health system.
The assessment data helped to provide important grounding to understand the health care landscape
in Pitkin County as well as the strengths and challenges of the current system. The process also helped
to inform the identification of community values. These values can help to serve as an important
consideration when weighing and implementing the recommendations.
Community Values
Throughout the assessment process, common community values continued to be voiced by
interviewees and key stakeholder groups. These common community values included:
• Partnerships and collaboration
o Willingness to work as a community, including on a regional level, to meet community
needs.
6 https://www.colorado.gov/pacific/dora/news/division-insurance-releases-preliminary-2017-health-insurance-information
Pitkin County Provision of Public Health Services Assessment 112/26
• Community focused
o Desire to meet the needs within the community and at the forefront of thinking when
weighing considerations.
• Thirst for additional information
o Desire and willingness to understand best practice and data in order to make choices
and decisions from an informed place.
• Autonomy
o Interviewees valued CHS' independence from the county in that they believed it allowed
CHS to prioritize public health needs without needing to weigh those needs against
other county priorities.
• Agility and ability to adapt to change.
o The ability to be nimble and adapt strategies in times of change allowed high quality
services to continually be offered. This included time-appropriate innovation that
allowed systems to remain robust despite financial or political change.
Best Practices, Research, and Review
Process
Keystone, in coordination with key staff, built a research plan that included identification and
consultation with key subject matter experts, best practice research, and interviews with local public
health departments in a diverse array of communities around the state and country. Initial
communities were chosen based on profiles similar to Pitkin County (rural, resort community) or based
on expertise related to challenges that had been identified through interviews in Pitkin County, such as
experience guiding a public health system as it shifted from direct services toward prevention and
population-level health. In some cases, the process was iterative, with interviewees recommending
additional communities to speak with and resources to review. A full list of key subject matter experts
and sample communities consulted can be found in Appendix A.
Best practice research focused on the following areas:
• Public Health Services
o The provision of public health services in like sized communities as well as in counties
with similar health profiles and geography.
o Public health best practices within the state of Colorado.
o Public health best and promising practices nationwide focusing on the full spectrum of
Essential Public Health Services, including prevention and population health strategies.
• Funding Strategies
o Funding for public health services in like-sized counties.
o Funding options from CDPHE, state resources, and private foundation strategies. This
included a review of the Healthy Community Fund as a potential source of sustainable
public health funding.
Pitkin County Provision of Public Health Services Assessment 113/26
• Governance and Organizational Structure
o Governance structure of public health agencies in like sized counties including size,
subject matter expertise, bylaws, and term limits of boards of health.
o National best practice regarding local boards of health.
o Organizational structure including governmental entities, non-governmental non-profit
organizations, and hybrid structures.
o Organizational relationship between Public Health, Human Services, and Environmental
Health.
o Personnel including number of staff, areas of focus, and educational requirements as
well as preferred educational background and expertise (MPH/DrPH).
This research and interview process was conducted between February and June 2016. Interviews with
key subject matter experts and sample communities were conducted with the understanding that
information gathered would be used to help both understand best practice and shape
recommendations for Pitkin County. All information was shared under the agreement that it would be
reported in the aggregate and sources would remain confidential in order to allow them to be fully
transparent regarding the strengths and weaknesses of their existing systems.
Findings
Governance and Organizational Structure
Pitkin County's public health structure is complicated — which poses challenges for the strategic
development and execution of service delivery and community health outcomes. Public health services
are currently provided and managed by a separate non-profit entity. Support for this non-profit as well
as others in the community is provided by the Healthy Community Fund.This funding process creates
additional challenges as increasing demands for prevention, population health, and emergency
preparedness in the community expand and more insured individuals seek to access care.
The assessment identified governance as a clear challenge. Unclear and cumbersome channels of
reporting and decision-making pathways deliver unnecessary confusion and inefficiency in the system.
Clear organizational structure and a strong governance model can help to move the public health
system move forward to better meet the long-term needs of Pitkin County.
Funding Strategies
Community Health Services currently receives funding from the Healthy Community Fund to address
direct clinical service, population health, prevention and preparedness responsibilities. Additional
funding is received through local grants and regional commitments as well as state grant funding.
Expansion of insurance coverage has increased the number of individuals seeking care, combined with
evolving pressures to expand prevention, population health and preparedness strategy, and reach is
creating the need for the community to better understand current investment, how those investments
align with demands and how best to seek adequate funding to sustain needed direct services while
building the additional capacity for the broader public health needs in the community today and in the
future.
Pitkin County Provision of Public Health Services Assessment 114/26
Blending and braiding multiple funding sources to meet public health needs is common. It is also an art
that requires expertise in the funding arena. Having experts on staff that can conduct grant writing and
advise public health on strategies to maximize funding aligned with priorities is key to success. Sources
of funding that are often blended and braided include local, state, and federal government funding,
foundation grants, and direct charges.
Scans of other health departments indicate that many communities have a higher level of grant
funding to support their work. This includes foundation as well as government grant funding to support
programs, particularly those with an emphasis on the lower three rows of the Health Impact Pyramid
which address population level health. Successfully securing grant funding requires alignment with the
grant goals as well as grant writing and reporting resources. Many public health departments have
grant writers that are either on staff or hired on a contract basis; other public health department staff
write the grants themselves, which can require a large time investment.
Figure 4 demonstrates the funding sources of local rural health departments in Colorado aligned with
the current funding for CHS. Rural public health department data is based on 2013 NACCHO
community profile data; CHS data is from FY2015.7
Figure 4.
bo%o 6
90% 22 •Healthy Community Fund
s0%o 17
70io •State (Fed pass-thru)
21 19
60% •Insurance
50%
40% 5 20 33 _Local Contracts and Grants
200/ •Federal (direct)
30%
20%
10% ■Other
0%
CHS CO Rural LPH
Funding priorities within foundations such as The Colorado Health Foundation are continually evolving
in accordance with best practice research and the demonstrated needs within communities. Public
health departments with the greatest grant writing success tend to track this information closely and
develop relationships with Program Officers in order to learn from one another. The Colorado Health
Foundation, for example, will soon be adding an emphasis on rural health and health care which has
the potential to increase opportunities for Pitkin County.
Updated data requested from CDPHE Office of Planning and Partnerships
Pitkin County Provision of Public Health Services Assessment 115/26
Public Health Services
As described in figure 2, the Institute of Medicine (IOM) and the Centers for Disease Control (CDC),
provide a guiding framework for public health's service provision: 10 Essential Public Health Services
(figure 2) within three core functional areas: (1) Assessment, (2) Policy Development, and (3)
Assurance. Pitkin County may rely on the state public health department (CDPHE) and other partners
to provide some of these services.
Currently, the majority of the public health services offered through CHS are focused on direct services,
most of which fall into the "Link to/Provide Care" category. Limited resources are invested in the other
Essential Services and an additional investment, potentially coupled with a reallocation of existing
resources, is needed. Reallocating resources to additional population level strategies or non-clinical
Essential Services would require shifting current clinical services to the health care system.
Additional areas in which resources are currently allocated, albeit in amounts not yet meeting the
need, include monitoring health, diagnosis and investigation, assuring competent workforce, and
mobilizing community partnerships. Although the level of need varies and should be determined
through the Public Health Improvement and other strategic planning processes, additional resources
are needed in all areas except "Link to/Provide Care."
Best practice research shows that Public Health's role in clinical service delivery is to ensure that all
populations have adequate access to high quality health care services, including prevention. Public
Health identifies gaps in access to care and facilitates efforts to shift the health care system so that it
focuses on prevention and meets the entirety of the population's needs. When the health care system
is not meeting the entirety of the need, Public Health provides core clinical services directly. As Public
Health effectively helps the health care system evolve to meet the full population's needs, however,
the direct provision of services should ideally be shifted back into the health care system so that
patients access health services within the context of a Medical Home or Medical Neighborhood.
Three important areas in which Public Health plays a particularly key role ensuring the availability of
clinical services, and providing such services when necessary include:
1) Immunizations
2) Family Planning
3) Maternal and Child Health, Including Prenatal Care
All of these are long-lasting protective interventions, as emphasized in the middle row of the CDC's
Health Impact Pyramid. When these clinical services are not available in a reliable, sustainable, high
quality manner within the community or when evaluation of the local health care system determines
that they are best offered by Public Health, then the local public health department steps in to offer
them.
Pitkin County currently faces a shortage in access to care within the areas emphasized above:
immunizations, family planning, and prenatal care. The current gap includes inadequate access to
primary care for Medicaid adults and Medicare seniors. Having recognized this gap, CHS is currently
playing a crucial role providing these clinical services directly.
Pitkin County Provision of Public Health Services Assessment 116/26
Strategic, outcome-based conversations — ideally facilitated by Public Health — are needed with the
medical community to further understand the providers' willingness to address the shortages within
the community. Such conversations must aim to find solutions that will both increase access to care
and work toward creating a health neighborhood for patients while preserving the current high quality
of care that patients are being given.
Recommendations
The following recommendations were developed in consultation with information gathered in the
community during the assessment and best practice research gathered as a part of this process as well
as additional financial and timing considerations. Through best practice research, we found common
elements of highly effective public health department to include the following:
• Board of Health with public health expertise
• Community integration, collaboration, and partnerships
• Clear governance and structure
• Integration with environmental health
• Strategic planning alignment with human services, community development, and other efforts
These elements as well as key community values articulated during the assessments are reflected in
the recommendations for Pitkin County.
Recommendations should be adopted fully to ensure that Pitkin County is moving their public health
system forward to better meet the needs of the community for the future. In order for change to be
implemented in the most thoughtful and sustained manner, we recommend that the county shift
incrementally to realize this change.
Recommendations to the Pitkin County Board of Health are as follows:
Public Health Services
• Broaden public health services to include the full spectrum of essential public health services
with strategies adopted within the bottom three rows of the CDC's Health Impact Pyramid.
• Expand emphasis on population level health efforts.
• Continue to ensure access to clinical services but focus services on long-lasting protective
interventions such as family planning and immunizations.
• Gradually shift direct clinical services to the health care delivery system, where possible, and
ensure that high quality services are available. Prenatal care, in particular, should be fully
integrated into the healthcare system. Actively explore the possibility of shifting family planning
and immunizations to the health care delivery system. If health care providers can offer these
services in a sustainable, accessible, high quality manner, support their shift to the delivery
system and continue to hold responsibility for tracking data to ensure services are accessible,
and working from the population level to increase utilization of prevention services.
• Utilize the Public Health Improvement process outlined by the Public Health Act to establish,
implement, and evaluate your strategies utilizing five-year cycles.
Pitkin County Provision of Public Health Services Assessment 117/26
Structure
• Establish a new county section: Pitkin County Public Health and Environment. This section will
be responsible for the full spectrum of public health services, including Environmental Health.
• Fully integrate Environmental Health and preserve a close strategic relationship with
Community Development.
• Separate the current Health and Human Services section so that there are two county sections:
(1) Public Health and Environment and (2) Human Services. Public Health and Human Services
require distinct expertise and should have a lateral relationship. Align strategic planning efforts
so that they complement one another.
• Hire a county Public Health Director with a Master's Degree in Public Health (MPH) and/or a
Doctorate in Public Health (DrPH). The Director should report directly to the County Manager.
• Expand Public Health and Environment staffing to include additional staff members with formal
public health training, preferably with an MPH and experience with population level health
interventions. Key skill sets include: quality improvement, data, analytics, epidemiology, and
emergency preparedness.
Governance
• Establish a Board of Health (BOH) of public health experts appointed by the Board of County
Commissioners (BOCC).
• Five to seven members including reserved seats for at least one Masters in Public Health (MPH)
and at least one expert in Environmental Health.
Pitkin County Provision of Public Health Services Assessment 118/26
Funding
• Increase opportunities to blend and braid multiple funding sources to meet public health needs
in the community.
• Increase focus on grant funding opportunities to maximize funding aligned with public health
priorities.
• Continue to invest in the collection of accurate data regarding public health in Pitkin County.
Such data should inform public health priorities and is an essential component of grant
applications and grant reports.
• Add Public Health leadership to the Healthy Community Fund's strategic planning, grant-
making, and oversight processes. Utilize this funding to leverage a collective action approach
aligned with Public Health and Human Service priorities.
Public Health Services
As described above, Public Health services should include the full spectrum of Essential Public Health
Services. Priorities should be data-driven and identified through the Public Health Improvement
Process. Strategies should include interventions at all levels of the Health Impact Pyramid, with an
ever-growing emphasis on the lowest three rows that focus on population level health.
Public Health should facilitate strategic conversations with health care providers including the hospital,
Health Alliance, and Mountain Family Health Center (Federal Qualified Health Center) to determine the
level of ability, interest, and willingness to offer all or some of the direct services currently offered by
CHS within the health care system instead. CHS's leadership will determine its ongoing role as a direct
service provider, ideally in collaboration with Public Health and the remaining health care system
players. Existing clinical services are high quality and are exceptionally important. The process of
exploring potential shifts in delivery must ensure that quality services are available in an ongoing,
sustainable manner.
As Public Health shifts direct services into the health care system, additional resources should be
shifted toward additional evidence-based prevention and population level interventions.
Pending a sustainable funding model, CHS could continue to serve as a direct service provider. CHS
leadership may wish to explore the feasibility of this as a branch of the federally qualified health center
given the enhanced financial reimbursement available through such entities. Public Health could play a
facilitation and/or research role to support this conversation and exploration. As an example, Summit
County shifted its direct clinical services into what used to be a community clinic and a now newly
designed FQHC.
Governance
Recommendations include strengthening the Board of Health's (BOH) role by reviewing and clarifying
the roles and responsibilities of the Board through revisions to the bylaws including articulating
communication protocols, decision making process and term limits. Clear bylaws and decision making
criteria strengthens the governance structure and creates clear authority.
It is important to implement a straight forward process, guided by bylaws, for appointment of new
members to the BOH. Term limits should be staggered initially so that long term only one to two BOH
Pitkin County Provision of Public Health Services Assessment 119/26
members change each year thus ensuring a retention of organizational history within the BOH. In the
communities consulted through best practice research, the Public Health director frequently advised
the BOCC on BOH appointments in order to align the BOH expertise with Public Health strategies
thereby positioning the BOH for the greatest impact.
BOHs with representation of substantive public health experts provide unmatched value to the
important and vital decisions for the health of the community. It is recommended that Pitkin County
create a new BOH that is appointed by the BOCC and includes substantive expertise in both Public
Health and Environmental Health. It is recommended that the BOH include five to seven members
appointed by the BOCC. Two of the seats should be reserved for expertise that should be required
within the BOH's bylaws: at least one BOH member with a Master of Public Health and at least one
BOH member that is an Environmental Health expert. The other three to five members of the board
would include individuals representing one or more areas of recommended expertise: key partners,
representative from local health care facilities, dental, mental health, education, foundation or other
funding entity, a representative from one of Pitkin County's vulnerable communities, regional
representation (Aspen and Snowmass as well as potentially Basalt and El Jebel), and local government
expertise (members of the BOCC). The BOCC may choose to reserve one to two seats on the BOH for a
BOCC member. This would ensure a strong link between the BOH and BOCC that some communities
have found to be very valuable. The bridge between the two ensures policy expertise on the BOH and
allows public health to better shape the BOCC's actions including their legislative advocacy efforts
related to public health. Needed expertise should align with the strategy outlined in the Public Health
Improvement Plan. Each BOH member is likely to help fulfill multiple recommended areas of expertise.
Given that recent changes created geographic representation on the BOH, we recommend maintaining
geographic representation in either the short or long term. While the current board includes members
appointed by Snowmass and Aspen, we recommend considering representation from all areas of Pitkin
County. As mentioned with recommended expertise, BOH members would represent multiple areas of
subject matter knowledge including geographic needs as well as one or more of the other
recommended or required areas.
Communities nationwide found that appointing members to their BOH created bridges among
organizations that benefitted broader collective impact action. This is something to consider when
appoint Pitkin County's BOH. The bridges built or strengthened should align with current or future
Public Health Improvement Plan strategies.
Select communities around the country have chosen to form advisory committees to their Boards of
Health. These advisory committees primarily server as liaisons between the community and the Board.
Committees assist the Board in providing additional public health focus and feedback from the
community-at-large. We recommend considering advisory committees only if needed, and for a limited
duration of time as required by specific deliverables. Such committees can help with strategic input but
also create a more complicated arrangement.
Pitkin County Provision of Public Health Services Assessment 120/26
Structure
We recommend the creation of the Pitkin County Public Health and Environment Section that fully
integrates public health and environmental health. This section should be a part of the county and
should be led by a Director of Public Health and Environment that has either a Master or Doctorate of
Public Health (MPH or DrPH). The Director of Public Health and Environment should report directly to
the County Manager and work in close partnership with the Board of Health that is composed of
substantive expertise including public health, environmental health, and additional areas aligned with
current and future public health strategies.
The Public Health and Environment Section should have a lateral relationship with both Human
Services and Community Development. Collaborative strategic planning, and when possible co-
location, will enhance the opportunity for alignment and collective impact.
Best practice research in sample communities demonstrates the need for clear governance models to
ensure clear understanding of decision making responsibility as well as structure that most efficiently
allows for effective decision making and joint strategy development. In order to allow public health to
be a greater part of strategy within the county, to allow the county to directly shape the public health
services it is responsible for, and to provide more effective and efficient strategy development,
budgeting and reporting across county sections, we recommend the creation of a county section
dedicated to Public Health and Environment.
Environmental Health is a core discipline of public health and best practice emphasizes the importance
of their integration. When environmental health is integrated with the remainder of public health
services, strategies are strengthened: environmental health then impacts public health strategies and
vice versa. Integration allows a public health lens to be brought to environmental health and an
environmental lens to be brought to public health. This is important with respect to a multitude of
areas of public health: healthy eating and active living (obesity prevention), the build environment,
disease surveillance, emergency preparedness, and more. Public health and environmental health
must work together as one entity to address the health of the community.
The continued development of regionalism should be emphasized through shared staff, regional
strategies and opportunities for regional grant funding requests. The ground work for increased
regionalism is being developed through the regional approach to the Public Health Improve Plan which
is currently underway.
Funding
Core, stable funding is key and Pitkin County is uniquely positioned to leverage funding through the
Healthy Community Fund to impact the health of the community in a strategic, collaborative way by
leveraging partnerships within the community and also providing services directly. In order to best
meet community needs, community investment must align with strategy. Opportunity exists to align
data gathering and outcomes reporting, community investment and grant requests with the strategy
outlined within the Pitkin County's Public Health Improvement Plan. This type of strategic alignment
will help to further leverage funding and positively impact the health of the community.
Pitkin County Provision of Public Health Services Assessment 121/26
It is recommended that the Director of Public Health and Environment be added to the leadership
group that oversees the strategic planning and grant award process for the Healthy Community Fund.
In collaboration with the oversight and public input processes that currently exist for the HCF, we
recommend that Public Health and Environment jointly manage the strategic direction of the fund in
partnership with Human Services. Specifically, it is recommended that Public Health and Environment
partner with Human Services to develop funding strategies, outcome measures, and reporting
processes for Healthy Community Fund that utilize a collective action approach to advances public
health and human service goals including the social determinants of health.
Best practice from other communities illustrates that most Local Public Health Departments are funded
by multiple sources: county and city dollars, state funding, healthy community tax revenue, and
foundation grants. Similarly, it is recommended that Pitkin County Public Health and Environment be
funded through a blending and braiding of multiple funding sources. Seeking and utilizing multiple
funding sources requires expertise in this arena. Additional staffing is likely needed to ensure this
expertise. Staff could exist within the Public Health and Environment Section or within another area of
county government in which the individual served multiple sections at once. Grant writing may be
conducted either utilizing internal resources or contract resources. Additional resources are needed,
however, in order to pursue such funding. Such requests should be based on alignment between
funding opportunities and public health strategies.
The advantage of foundation funding is that it often allows Public Health Departments to implement
key strategies and interventions that funding is not otherwise available for; the disadvantage is that
such funding is not permanent. A combination of foundation dollars, Health Community Fund dollars,
governmental contracts, county and city dollars, and local contributions could work together to jointly
fund the full spectrum of public health services in Pitkin County.
Additional investment by the county will likely be needed during this period of transition in order to
guarantee that the public health system is ensuring that community needs are being met while the
system moves to address population health within the community.
Data helps to drive strategy and strategy should drive funding priorities. Increased data collection and
analysis will help to increase the likelihood of securing additional grant and foundation funding
sources. Ensuring that staff have experience in data collection and analysis as well as the ability to
conduct grant writing activities that align with strategies to maximize funding is key. Grant writing and
reporting may be conducted by internal staff or by a contractor.
Select communities such as Denver have found that it is financially helpful to have a non-profit arm for
fundraising purposes. Some grantors are interested in funding governmental entities; others prefer to
fund non-governmental entities. By creating or partnering with a non-profit entity, Pitkin County Public
Health and Environment could pursue additional funding opportunities.
Additional funding opportunities can also be pursued on a regional basis in partnership with other
Local Public Health Departments or local entities. Applying as a broader body could leverage greater
impact and also better position the grant request for success in the bidding process.
Pitkin County Provision of Public Health Services Assessment 122/26
The Path Forward
A planned phased approach to implementing this change is recommended to ensure the success of this
transition. This phased approach will allow for opportunities from the Public Health Act to be leveraged
in a thoughtful manner including alignment with the Public Health Improvement Plan's process.
Pitkin County Provision of Public Health Services Assessment 123/26
Suggestions for this phased incremental change can be found below.
Phase I: Development of Structure Shift Summer and Fall
• Budgeting process 2016
• Development of job descriptions
• Planning for shift of Public Health from Human Services
Section.
Phase II: Hire new Public Health and Environment Section Director January 2017
Key director responsibilities include:
• Direct service assessment
• Regional PHIP
• Strategic community conversations and partnership
development
• Strategic planning with DHS
• Develop integration plan for Environmental Health
• Initiate new BOH transition Spring 2017
Hire key initial Public Health and Environment Section staff
Phase III: • Establish new BOH 2O18
• Adoption of new bylaws
• Expansion of Public Health and Environment staff based
on the Public Health Improvement Plan
• Final Integration of Environmental Health into section
Pitkin County will benefit greatly in allocating time and resources to strengthening relationships
between public health and the provider and facility community within Pitkin County. Structural
changes will help aid in strengthening these relationships by creating systematic pathways for
communication, collaboration and joint strategic planning. Specific attention and strategy should be
developed strengthen the relationship with Aspen Valley Hospital and other health care providers in
the community.
Pitkin County should continue to look for ways to regionally engage with partners and look for ways to
be the convener of key public health conversations within in the Roaring Folk Valley and regionally.
There may be opportunity to leverage resources through regional grant funding requests.
Additional next steps to help move elevate the role of Public Health in the community and strategically
shift to a more integrated public health system in the community, it is recommended that Pitkin
County address the following:
• Develop funding strategies, outcome measures, and reporting process for Healthy Community
Fund to align with public health strategies and priorities. Additional analysis of similar
community funding mechanisms in other localities would be helpful.
Pitkin County Provision of Public Health Services Assessment 124/26
• Develop communication protocols and bylaws for the BOH and Dept. of Public Health and
Environment.
• Research and feasibility study of Title 10 funding within FQHC to understand the feasibility of
how these services could be provided in other locations by other providers.
• Integrate the new Director of Public Health and Environment into representation on Health
Alliance.
• BOH may benefit from site visits to or presentations regarding sample public health
departments to gain additional understanding of structure, strategic focus and population
based health interventions.
Additional Resources
Additional resources to assist Pitkin County to support this shift include state agencies and
membership organizations: CDPHE Office of Planning, Partnerships, and Improvement, Colorado
Association of Local Public Health Officials (CALPHO), sample communities that were consulted for this
work, and national resource centers such as the Public Health National Center for Innovation
(www.phaboard.org/phnci). Additionally, many health departments around the country are using
the Public Health Accreditation Measures as guidance for their work (www.phaboard.org). It is
recommended that Pitkin use these measures to guide their selection of public health services and to
ensure that all public health services are available within the community. Last, it is recommended that
the BOCC, Pitkin County staff, CHS, and other key stakeholders continue to develop an understanding
of evidence based population level health interventions, such as those recommended in The
Community Guide to Prevention, Oregon Guide, and the Australian Guide.
Conclusions
Communities across the country and within Colorado are readjusting their strategies as the ACA is
implemented, Medicaid is expanded, social determinants of health are better understood, the Public
Health Act is implemented, and Public Health's emphasis shifts toward population health. This evolving
environment creates enormous opportunity for increased impact and also creates challenges.
This process provides Pitkin County with an independent review of the public health system within the
county and aims at providing decision makers with recommendations for a pathway forward to ensure
that the public health system within the county can best safeguard and promote health in the future.
In order for change to be implemented in the most thoughtful and sustained manner, we recommend
that the county shift incrementally, as outlined in this report.
Pitkin County Provision of Public Health Services Assessment 125/26
Appendix A: List of Assessment Interviewees and Group Meetings and Best Practice Research
Assessment Phase Members of Pitkin County Health and Human
Interviews Services Non-profits (POD)
Aspen Community Foundation
Tom Heald,Aspen School District Best Practice Research Phase
Jennifer Ludwig, Eagle County Public Health Subject Matter Experts Consulted
Yvonne Long, Garfield County Public Health Patrick Gordon, Rocky Mountain Health Plans
Dr. Kim Levin, Medical Officer, Pitkin County Steve Holloway, Colorado Department of Health
Board of Health and Environment
Jon Peacock, Pitkin County Government Rachel Hutson, Colorado Department of Health
and Environment
Liz Stark, Community Health Services
Kathleen Matthews, Colorado Department of
Nan Sundeen, Pitkin County Government Health and Environment
Jon Redmond, Pitkin County Government Lisa VanRaemdonck, Colorado Association of
Dr. Kim Scheuer,Aspen Medical Care Local Public Health Officials
Jordana Sabella, Community Health Services
Kathleen Lyons, Eagle County Department of Sample Communities
Human Services Eagle County Colorado
Fremont County Colorado
Small Group Meetings Mesa County Colorado
Community Health Services Board Northwest Colorado Health (formerly
Community Health Services Staff Northwest Colorado Visiting Nurse Association)
Department of Health and Human Services— San Juan Basin Health Department
Managers Seattle-King County, Washington
Mountain Family Health Executive Team Summit County Colorado
Valley Settlement Project Summit County Utah
Environmental Health, Community Teton County Wyoming
Development and City of Aspen Environmental
Health
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