Ready, Set, Go: Costing the Prerequisites

1. Ready, Set, Go:Costing the Prerequisites Presentation to the Open Forum September 16, 2010 Lee Thielen, MPA

2. Costs of the Prerequisites for National Voluntary Accreditation Community/Statewide Health Assessment Community/Statewide Health Improvement Plan Agency Strategic Plan Supported by the Robert Wood Johnson Foundation

3. Three required components

4. As Mark Twain said, “The secret to getting ahead is getting started.” For public health, that is assessment.

5. Definitions: A Community or State Health Assessment is: “collecting, analyzing and using data to educate and mobilize communities, develop priorities, garner resources, and plan actions to improve public health.” (PHAB Newsletter April 2010)

6. Planning: “You may be disappointed if you fail, but you are doomed if you don’t try.” Beverly Sills

7. Community or State Health Improvement Plan Definition: “A long-term systematic effort to address issues identified by the assessment and community health improvement process. It is broader than the health department agency and should include partners…” Source: PHAB Newsletter, May 2010

8. Strategic Plan Definition: A strategic plan is internal to the public health agency and guides the health department in fulfilling its obligations from the Health Improvement Plan.

9. Methodology Sources: Interviews with approximately 40 public health individuals to date. NACCHO Profile Data 2010 Tribal Public Health Profile ASTHO Chartbook of State Public Health

10. Prerequisites: What’s Been Done

11. State Public Health Agencies • State health assessment – Not asked • 24% have done a state health improvement plan • 75% have done a strategic plan ASTHO Chartbook of State Public Health, 2010

12. Tribal Health Organizations • 44% have done a community health assessment • Not clear what percentage have done community health improvement plan or strategic plans 2010 Tribal Public Health Profile

13. Local Public Health Agencies • 63% have done community health assessments • 49% have done community health improvement plans • 61% have done strategic plans 2008 NACCHO survey data

14. States: Some are doing well. • 10 states – 80% or more of LPHAs have completed CHA • 4 states - 80% or more LPHAs have completed CHIP • 3 states –80% or more LPHAs have done both 2008 NACCHO survey data

15. Factors associated with completing CHA’s and CHIP’s • Population size • Expenditures per capita • Type of governance • Staff: epidemiologist/health educator • Data sets available: BRFSS, hospital discharge • Partnerships with higher education 2008 NACCHO survey data

16. Multivariable Analysis: What continues to be important. • Staff ---- epidemiologist/health educator • Availability of data ---- BRFSS • Partnership with academic institutions --- Having had faculty/staff from an institution conduct a program evaluation

17. Other Major Findings 1. Assessment vs Plan: Agencies do not always see a sharp distinction between the Community Health Assessment process and documentation and the Community Health Improvement Plan. Instead it is a continuous process that needs continuous investment.

18. Findings Cont. 2. Document or Information: The concept of a “document” to be shown to PHAB does not work for some agencies. Some agencies made it very clear that they see little value in printing a community health assessment. The agencies with greatest capacity share their results using on-line information with specific reports as needed as the best approach. Large agencies (over 1,000,000) do not find community input useful, unless done at the neighborhood level.

19. Findings Cont. 3. Public Health Makes Do. While specific ranges of costs can be noted for an assessment, agencies also “make do”. There are great examples of using faculty and students from the schools of public health, schools of nursing, etc. to obtain adequate assessments for minimal costs.

20. Incentives Work “I’m going to make him an offer he can’t refuse.”- The Godfather, 1972

21. Findings Cont. 4. Incentives work. Local Agencies respond to even modest “incentive grants”, even though it doesn’t include the full cost of producing an assessment or a plan. Examples: $10,000 $20,000 $30,000

22. Findings Cont. 5. A Continuous Process: The more experienced (sophisticated or well-resourced) agencies do not see assessment and planning as something that is done as a 3 or 5 year obligation, but rather as a continuous investment with dedicated staff and dedicated systems.

23. Findings Cont. 6. The Role of the State Agency with Local Results: The state agency can support local health agencies, especially in data collection and analysis, including rates and identifying outliers. The state agency can provide incentive funding, often using Preventive Health Block or sources such as Tobacco Settlement funds. The state agency can provide technical assistance.

24. Findings Cont. 7. Costs of Assessments and Plans: There is convergence on costs. Although it may be assessment only or may include plan as well. In a summary: Less than 50,000: $20,000 to $50,000 (One agency with a population of 8700 did assessment for $1000 plus 100 hours of director’s time, using graduate and nursing students and faculty) 50,000-500,000: $69,000 to $130,000 (One 6 county region, population 80,000 did it for $32,000) Over 500,000: $109,000 to $500,000

25. Finding 7 Cont. Agencies find it hard to break out costs of assessment versus planning. They range from 62/28 to 80/20. Usually the assessment is considered 75-80 of the cost.

26. Findings Cont. 8. Strategic Plans can be done for a low cost: Strategic Plans are in the range of $3,000 to $30,000, depending on cost of facilitator and if vetting in public meetings. Some communities use volunteer facilitators and have negligible costs.

27. Findings Cont. 9. State Agency Data: States are investing 2.5 to 4 FTE for assessment and planning. One centralized state estimates that for $500,000 to $800,000 all districts would have assessments and plans. Note: This is small sample.

28. Findings Cont. 10. Hospital Relationship Can Help. Some agencies have received funding for community health surveys. One LHA had a $18,000 community survey supported. Another received $120,000 to do a Health Indicators Report. The hospitals satisfy their community benefit requirements.

29. In Summary 1.PHAB should rethink document versus information availability of information and engagement. 2.Assessments and improvement plans are seen as a continual process with no beginning and no end by some agencies. 3. Incentives matter. Public health continues to “make do”.

30. Always available for more discussion leethielen@aol.com

31. Joyce Marshall, MPH Director, Office of Performance Management Oklahoma State Department of Health September 16, 2010 Oklahoma QI Collaborative:Stepping up and Preparing the Way to Accreditation

32. Accreditation Prerequisites Health assessment Health improvement plan Agency strategic plan Three required components

33. The Way It Was . . .We are They and They are We

34. County Pilot Site Selection • Geography • Size • QI Knowledge/Experience • Demonstrated Commitment/Resources • Knowledge of MAPP Process • Active Turning Point/Community Health Improvement Coalition • Accreditation Readiness Efforts

35. Oklahoma Quality Improvement Collaborative Washington County Logan County Okfuskee County Cleveland County Comanche County

36. Collaborative Overall Goal • By March 2011, the county health department teams involved in the Oklahoma Quality Improvement Collaborative will improve community engagement and the health improvement planning process in their counties and make significant progress towards completion of the three core components for accreditation including a community health assess-ment, health improvement plan and strategic plan that are aligned to the state strategic plan and health improvement plan using proven quality improvement tools and processes.

37. Learning Session Trainings

38. Collaborative Schedule

39. Step UP: a cycle of Plan-Do-Check-Act(PDCA) Plan Set Standards Reporting Act Adopt, modify or drop the change Implement the change Do Quality Improvement Measure Performance Check How did it go?

40. Performance Measures • Pre/post test of community engagement • Pre/post test of health improvement planning process • Progress towards completion of local community assessment, health improvement plan, and strategic plan • Shared successful processes and tools

41. The Better Way . . . Tying It All Together OSDH Performance Management & Quality Improvement Model National State Agency Service Area & County Health Department Individual Employee Healthy People 2010/2020 Strategic Plan Tool – Strategic Map 3 Core Functions Strategic Targeted Action Teams/Plans Tool – Step Up 10 Essential Public Health Functions Accreditation Community Health Improvement Plans Tool – Mobilizing for Action through Planning and Partnerships (MAPP) Turning Point & Step UP Oklahoma Health Improvement Plan Individual Performance Appraisal Tool – Agency Individual Performance Management Process (PMP) Evaluations Program Area/CHD Strategic Plans Tool – Step Up Core Services Document Tool – Business Plan United Health Foundation & Commonwealth Fund Community

42. MLC Kansas – Paving the Road for Accreditation Gianfranco Pezzino, M.D., M.P.H. Senior Fellow Kansas Health Institute

43. Follow the Yellow Brick Road…?

44. Goal: To improve public health services by implementing quality improvement practices. Strong emphasis on: Quality Improvement (QI) Preparedness for accreditation Based on collaborative projects For Kansas: regional model MLC-3

45. Functional Regionalization • Since 2002 • Voluntary • You pick your partners • At least 3 contiguous counties • Inter-local agreement • Approved by County Commissions • Filed with Attorney General • Governance • Each county has one member on Board

46. Functional Regionalization Source: U.S. Census Bureau, Census 2000

47. MLC-3 Kansas Target Areas Health Status Capacity

48. Want to Apply? First You Need These Documents….

49. Community Health Assessments in Kansas • Last broad state health assessment done in the ‘90s • No action plan • Not updated • No legal requirements • No standardized approach • Little collective knowledge and experience

50. Challenge #1 How to apply Breakthrough Series and Quality Improvement to a new activity?