|By the Innovations Exchange Team|
“Public health organizations are in transition with state budget cuts, changes in laws that govern public heath, accreditation of public health agencies, and the passage of the Affordable Care Act.” —Edward Baker, MD, MPH
The public health workforce is changing to meet new challenges. New national accreditation standards have been developed for local health departments, and nearly 100 departments have applied so far. Meanwhile, state budget cuts are reducing the size of public health agencies and, some would argue, their effectiveness. To explore the factors shaping the public health workforce, the Innovations Exchange interviewed these leading public health experts:
Edward Baker, MD, MPH
Director, North Carolina Institute for Public Health, University of North Carolina at Chapel Hill
Director, Public Health Leadership Institute
Kaye Bender, PhD, RN, FAAN
President and CEO
Public Health Accreditation Board
Shirley Orr, MHS, ARNP, NEA-BC
Public Health Consultant
Robert Wood Johnson Executive Nurse Fellow
Co-Director, Kansas Public Health Leadership Institute
Innovations Exchange: Please describe the public health workforce and the services provided by public health professionals.
Shirley Orr: Public health professionals work in the public and private sector at the national, state, and local (city and county), and tribal levels. Traditional employers include local public health departments, universities, and nonprofit organizations.
Public health is interdisciplinary and the workforce represents a wide range of professions, including nurses, social workers, physicians, epidemiologists, researchers, health educators, and laboratory technicians. Nurses make up the largest group of public health employees; an estimated 11,071 public health nurses were employed in 44 state and territorial health departments, according to a 2010 survey by the National Association of City and County Health Officials (NACCHO).
Local public health systems are expected to provide these 10 essential services for their communities, according to the Core Public Health Functions Steering Committee:
- Monitor health status to identify and solve community health problems.
- Diagnose and investigate health problems and health hazards in the community.
- Inform, educate, and empower people about health issues.
- Mobilize community partnerships and action to identify and solve health problems.
- Develop policies and plans that support individual and community health efforts.
- Enforce laws and regulations that protect health and ensure safety.
- Link people to needed personal health services and ensure the provision of health care when otherwise unavailable.
- Maintain a competent public and personal health care workforce.
- Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
- Conduct research to develop new insights and innovative solutions to health problems.
What are the major trends in the public health workforce?
Edward Baker: Public health organizations are in transition as a result of state budget cuts, changes in laws that govern public heath, accreditation of public health agencies, and the passage of the Affordable Care Act (ACA). The federal law has provisions related to disease prevention and health promotion, and some of those activities will be implemented by health care organizations and will change the way prevention is practiced.
Another implication of the ACA is an increasing emphasis on strengthening partnerships between public health agencies and heath care organizations, which should result in less isolation between government health agencies and the health care system.
Orr: A major trend is the elimination of a significant number of public health positions at the national, state, and local levels due to shrinking budgets during the past 3 years. The reduction has taken different forms, including attrition or layoffs. The downsizing has impaired the ability of state and local public health departments to maintain capacity and meet national accreditation standards.
Another trend is that more public health professionals may be working in nontraditional settings. As we work more closely with our partners in health care delivery systems and primary care organizations, I expect there will be more public health roles in those settings.
The organizational structure of local public health departments is also changing. Kansas, where I live, is a rural state with 3 million people spread across 105 counties, with a declining population and tax base. Our state is one of many that are looking at various models of cooperation, consolidation, and regionalization, which will have implications for leading a public health workforce that can work across geographic and operational boundaries. This will create a demand for employees who have the knowledge and skills necessary to work within the new models.
We are also seeing a new emphasis on standards and accreditation. The timing is critical because as agencies make difficult decisions about their future direction in light of budget reductions, the accreditation standards provide a framework for protecting the core public health functions.
Are community health worker programs increasing in number? Do they fill a gap or need within the public health workforce?
Orr: In general, it appears that these programs are increasing. Many public health agencies have looked at using health navigators, and many maternal–child health programs employ them for home visiting programs. They definitely have a role to play and a contribution to make within multidisciplinary teams. As members of their communities, lay health workers can be effective in ensuring that culturally competent services are provided and in making connections.
In preparing for the Robert Wood Johnson Foundation (RWJF) Forum on the Future of Public Health Nursing, I heard optimism and concern about community health workers. Public health nursing directors mentioned that nurses in some states were being replaced by less expensive paraprofessionals. In other states, nurses were viewed as an investment because their professional training could be used in several roles within the public health agency.
What other gaps exist in the public health workforce, and how are they being addressed?
Orr: Some issues are tied to the emerging functions of the public health system and efforts to advance the quality of public health. To apply for accreditation, public health departments must meet three prerequisites: a community health assessment, a community health improvement plan, and an agency strategic plan that they submit with their application.
Large health departments have the resources and staff needed to complete these prerequisites, so they find it easier to become accredited. In contrast, small rural county health departments are resource challenged, which makes it more difficult for them to conduct community health assessments and improvement planning.
Most rural counties that face capacity and funding challenges rely on partnerships with state health departments to gain access to needed staff, such as epidemiologists who play an important public health role.
Baker: Many public health workers do not receive training in informatics, which is essential for efficient management of information systems. Given the growing use of electronic health record systems and health information exchanges, we face a critical need for public health workers who have informatics training. The two main challenges to providing such training are the lack of available programs and the limited role of public health departments in controlling information systems. One organization that is trying to fill the gap in informatics training is the Public Health Informatics Institute in Decatur, GA, which provides training and collaborates on projects with public heath organizations.
Another gap in public health training is in the area of management and leadership. I have observed that public health agencies promote employees to management positions based almost entirely on their medical and technical background or expertise.
Some university schools of public health, including the University of North Carolina, are providing management and leadership training to students. The National Public Health Leadership Development Network, funded by a cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the Association of Schools of Public Health and Saint Louis University School of Public Health, also operates some excellent programs. But several programs have closed, and we still face a shortage of management and leadership training.
Are public health departments partnering with community-based organizations?
Orr: Historically, public health agencies have worked with community-based organizations. There is also a need for individuals to work collaboratively to facilitate diverse, broad-based partnerships. When new emergency preparedness programs were created about a decade ago, those programs partnered with law enforcement and emergency management agencies.
The new national accreditation standards for community health assessments provide an opportunity for public health departments to partner with their local hospitals to coordinate and assess community resources.
Is quality improvement an important focus of the workforce?
Kaye Bender: Quality improvement (QI) in public health is still such a new concept that applications of QI models and practices, and the adoption of a QI culture, remain challenging for many public health professionals. Yet QI has become a part of health care and of most major businesses in recent years, and public health needs to catch up. The general public as well as policy makers expect government to become more accountable and transparent, and those goals also apply to public health. Public health is expected to embrace QI and to have a workforce skilled in using QI models to improve their practices. This needs to be a major focus for the public health workforce.
How has accreditation and training changed in the last 5 to 10 years?
Bender: Since the Institute of Medicine’s 2003 report recommending increased attention to accreditation, there has been growing support for the concept. In 2004, the CDC identified accreditation as a key strategy for strengthening the public health infrastructure. The Public Health Accreditation Board (PHAB) was incorporated in 2007 and launched in September 2011. The actual decision to accredit public health departments came from the practice community in public health, with a lot of support from the public health academic community. The RWJF and the CDC responded by providing fiscal and technical support to PHAB and other national partners, such as the Association of State and Territorial Health Officials and NACCHO, to help health departments achieve accreditation. PHAB has seen many health departments use the accreditation readiness process to provide a framework for transforming their health departments in these tough times of budget cuts.
What is required for accreditation of public health departments?
Bender: PHAB has developed a practice-driven accreditation process that measures health department performance against a set of nationally recognized, practice-focused, and evidenced-based standards, and recognizes achievement of accreditation within a specified timeframe. The accreditation process requires the continual development, revision, and distribution of public health standards.
PHAB views accreditation as an important step along the QI continuum. After submitting a community health assessment, a community health improvement plan, and an agency strategic plan, health departments submit documentation for each of the measures associated with standards in 12 domains. The 12 domains are based on the 10 essential public health services, plus one domain for administration/management and one for governance. The process also includes a site visit. All reviews are done by peers. Once accreditation has been granted, it’s good for 5 years.
Orr: One of the accreditation standards focuses on workforce development. The requirements include ensuring a sufficient number of public health staff, assessing staff competencies, and addressing gaps by enabling organizational and individual training. Public health departments also must demonstrate collaboration with partners, such as schools of public health and other academic institutions, to educate students about professional careers.
What has the impact been of federal policies requiring Accountable Care Organizations (ACOs), medical homes, and patient-centered care?
Orr: It’s been trickling down. Health departments are trying to determine what these policies mean for them. Due to state budget cuts and a desire to fulfill core public health functions, many health departments are moving away from providing primary care services, relinquishing that function to other community partners, including community health clinics and rural health clinics that might pursue medical home or ACO status.
For example, the director of the public health department in Kane County IL, analyzed the availability of primary care services in his community about 2 years ago, and transitioned all of them to community-based primary care providers. This move reduced the department’s overall budget and number of employees. When the primary care services were transferred, public health employees providing those services left to work in community clinics.
However, if there are no primary care providers readily available in the community, which is increasingly likely with the looming primary care shortage, public health departments may have to look elsewhere.
What impact have state budget cuts had on the state’s ability to maintain an adequate public health workforce and promote public health?
Baker: Public health workers face more daunting challenges and instability than they did 10 years ago. There have been widespread layoffs and attrition through retirement. As a result, fewer employees are available to get the work done, which means that one person often performs the job of two or more people. With a large number of “baby boomers” retiring and not being replaced, there is a loss of institutional memory and knowledge. As a result, public health workers without adequate expertise are taking on new tasks such as outreach to communities and public–private partnerships.
Orr: When budget cuts are required, funds for training and education are among the first areas to be cut. For example, Kansas suspended its Public Health Leadership Institute and Core Public Health Program due to a lack of funds to support their operations.
Budget cuts also create new challenges for providing the education required to develop current and future workforce competencies. Those of us involved in the RWJF project for public health nursing are exploring ways to ensure that public health nurses will have programs to train them to learn new competencies. With fewer staff positions, the challenge is to maintain essential services and to ensure that agencies throughout the country can meet the new national accreditation standards.
What policies need to be implemented at the federal, state, and local level to shore up the public health workforce and ensure that is effective and efficient?
Baker: The most important policy issue is how funds are allocated to cover the costs of training and professional development to strengthen workforce competencies. A key challenge for the public health workforce is communicating the value of what we do. Because our focus is on preventing disease and injuries, the results of our work tend to be invisible, and people take it for granted. Clinical treatment receives far more attention than prevention from policymakers, and therefore receives a larger share of the federal budget.
Orr: There is a broad consensus within the public heath workforce that a huge policy challenge is securing sufficient funding to ensure that programs are available to build employee capacity and new competencies.
We also need to develop an evidence base to help us plan how we should organize and structure public health services in the future. That is the missing link: We have the new national standards, we know the essential functions that should be provided, but we don’t have an evidence base that tells us how to translate those goals into a staffing model and workforce development.
Organizations that are on the leading edge of the public health workforce transition, such as Kane County in Illinois, can be a model for understanding current and future staffing needs. Evidence from such efforts will help us decide how to staff public health departments in the future.
About Edward Baker, MD, MPH: Dr. Baker is a Research Professor in the Department of Health Policy and Management at the University of the North Carolina Gillings School of Global Public Health. Prior to coming to UNC, he served as Assistant Surgeon General in the U.S. Public Health Service and Director of CDC’s Public Heath Practice Program Office since 1990. In that role, he led national initiatives to strengthen the public health infrastructure by improving workforce competency, enhancing information systems, improving access to practice-relevant knowledge, building organizational capacity, and supporting extramural prevention research.
About Kaye Bender, PhD, RN, FAAN: She is the President and CEO of the Public Health Accreditation Board, a position she has held since 2009. Dr. Bender has more than 26 years experience in public health, working at both the state and local levels within the Mississippi Department of Health. Her last position there was as Deputy State Health Officer.
About Shirley Orr, MHS, ARNP, NEA-BC: She is a public health consultant and a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow (2009 to 2012). Her focus is on helping states meet new national public health standards and supporting a new RWJF project to develop a shared vision and agenda for the future of public health nursing.
Disclosure Statement: Dr. Edward Baker, Dr. Kaye Bender, and Ms. Shirley Orr reported having no financial interests or business/professional affiliations relevant to the work described in this article.