When Them Is Us and Us Is Them: Some Unique Features of State/Local Collaboration in Four Centralized States
By Michael Fraser, PhD
If you’ve seen one health department you’ve seen one health department. I have heard this statement from many local, state, and federal public health leaders over the years. And while there is a great deal of diversity across the country in terms of state and local public health there are also many similarities between public health agencies. The map provided by ASTHO on page 17 of this issue illustrates several ways public health services are provided in the states. According to ASTHO, in 13 states all local services are provided by the state health agency. In 17 states one or more localities receive all its public health services through the state health agency. The remaining states have autonomous, independent health departments working at the local level coordinating their efforts with the work of the state health agency.
A cross-section of four very different states – Maine, Florida, Alabama and Hawaii – provides a look at what MCH and CYSHCN programs look like in “centralized” states where most local public health services are directly provided by a unit of the state health agency. These states have unique models for providing public health services at the local level because the distinction between “local” and “state” is blurred. These cases illustrate the complexity of state-local collaboration required to improve maternal and child health outcomes even when the state is the “local” agency. As in public health overall collaboration and partnership are required to provide effective and efficient MCH services to all residents of a jurisdiction.
Maine: An Evolving State/Local System
Unlike many New England states, Maine has just two local health departments: Portland and Bangor. The state health department has traditionally responded to public needs in the other parts of the state and provided public health services directly through contracts with local service providers in towns and regions across the state. As a result of Turning Point, an initiative to examine the state/local public health infrastructure in Maine, and Governor Baldacci’s Dirigo Health Reform legislation, public health leaders engaged in a dialogue about the various roles of state and local public health authorities. Using the Ten Essential Services of Public Health as a framework, the conversation focused on which services would most effectively be provided at the local level and which would be most effectively provided at the state level.
The dialogue resulted in a shared recognition of the need for a “mid-level” district or regional entity for the purpose of coordinating services. The boundaries of the eight districts take into account population, geographic spread, hospital services areas and county borders. The establishment of the districts was designed to enhance effectiveness and efficiency of public health services by creating the geographic framework for greater consistency and equity in statewide delivery of the 10 essential public health services, providing a consistent basis for regional planning and coordinating across the public, nonprofit, and business sectors, and building sustainable infrastructure through regional co-location of Maine CDC and DHHS staff, “braided” funds, and the establishment of regional coordinating councils. To make this happen, Maine revamped its district infrastructure so that state government programs now all use the same district boundaries for all programs including EMS, Child Welfare, Food stamps, WIC, and TANF – a major feat when one considers all the players involved. Now when the Maine CDC has competitive funding the available funds are structured by districts. The Maine CDC is also working on braiding funding from more than one source into one contract when appropriate. The District Coordinating Councils are emerging as regional organizations by which to implement state programs at the local level, and proving to be an effective and efficient mechanism to build sustainable public health capacity throughout the state. As Maine moves forward with this new infrastructure, the state MCH program anticipates building upon these district organizations to implement programs, coordinate efforts, and reduce duplication and overlap in services at the local level.
Alabama: A Centralized System with Different MCH and CSHCN Agencies
In Alabama public health, including Title V services, is centralized under the authority of the State Health Officer for 65 of the 67 counties in the state. The CSHCN program is subcontracted out to a separate department that has its own Commissioner. The Alabama Department of Public Health (ADPH) is the Title V agency for the state, while Children’s Rehabilitation Service (CRS), a division of the Alabama Department of Rehabilitation Services, is the state’s CSHCN program. The state is divided into Public Health Areas with administrators who are organized under and supervised by the State Health Officer. For CSHCN, the state is divided into Districts with district supervisors who are supervised by the CSHCN Director.
The centralized structure makes it easier for the State Health Officer and CSHCN Director to directly influence what is happening in MCH operations for the state. This structure allows for alignment of state priorities, values, and the mission of each program at the local level in an efficient manner. It also improves consistency in service delivery and policy setting, and allows for easier data collection at the local office level. The centralized structure with local offices allows for community-based service delivery and a strong local presence. Having CSHCN in a separate agency that is entirely devoted to serving people with disabilities is helpful in that administration and service delivery is provided by experts in disability and special health care needs that are coordinated by one state entity. This expands the reach of MCH and the presence of public health in local communities. There is less of a sense of “crossing lines” as Alabamians receive services through the public health system, including CSHCN. For example, families with CSHCN can receive services at their local office, but can also choose another site if they prefer. External to the agency (ADPH and CRS), the MCH structure and organization makes it easier for the respective Directors to assume a leadership role in engaging in partnerships with other stakeholders and with other members of the system of care in the state.
Florida: A Statewide System with Local Roots
In Florida, the state Department of Health administers 67 County Health Departments (CHDs) which act as the foundation of the state’s public health care system, providing critical detection, treatment and prevention services that protect Floridians from disease and injury. Every person, living in every community in Florida, benefits from the public health services provided by the local county health departments. As the implementation arm of Florida’s public health care system, the CHDs have the responsibility to prevent and treat infectious diseases of public health significance; monitor and regulate activities to prevent disease of environmental origin including rabies, West Nile virus, food and waterborne diseases; partner with other community organizations to ensure access to basic primary care medical services and serve as one of Florida’s largest safety net providers for the uninsured and Medicaid populations; promote healthy lifestyles by focusing on wellness and prevention services such as smoking cessation, school health services, and encouraging healthy behaviors to reduce the incidence of chronic diseases; prepare for and respond to natural and man-made disasters, and other modern public health emergencies. CHDs are among the largest providers of clinical care in the state providing over 3.3 million visits to over 1.0 million patients annually.
FDOH also encompasses Children’s Medical Services (CMS) which is an integrated statewide network of providers who deliver care to children with special health care needs. The foundation of CMS was to form partnerships at the local, regional and state level to assure quality health care for children with special health care needs. In 1996, CMS became a Medicaid plan and in 1998 a state children's health insurance plan for CSHCN. In addition to its service delivery responsibilities it is also responsible for the tracking and follow-up component of newborn screening, high risk perinatal care through regional centers, early intervention for infants and toddlers, medical services to confirm child abuse, a statewide poison control network, and child abuse death reviews. Children's Medical Services has line authority over its 22 area offices arranged in regions. The central office has responsibility for certain functions such as policy development, standards setting, financial and contract management, as well as quality assurance, provider management and credentialing, enrollment processing and tracking, and training.
Some benefits of the Florida model include a seamless integration of state and local policy development, with CHDs acting as the implementation arm of the department. The state also has a statewide performance improvement process that uses shared measures across the state. Florida’s Healthy Start Coalitions (single county and regional organizations) work as the statutorily designated entities responsible for needs assessment, planning, and purchasing the delivery of MCH services at the local level—these are contracted entities from the state health office that work with the local county health departments and other providers to leverage resources and assure services.
Partnership in Paradise: State and Local Public Health in Hawaii
Hawaii has a centralized public health system and there are no county funded or local health departments within the state. District Health Offices are managed by a District Health Officer within each county and all personnel are state Department of Health employees. Except for the Office of Rural Health which is located on the “Big Island” (the Island of Hawaii), all division and administrative heads are housed on Oahu as 70% of the state’s population resides there.
The majority of direct and enabling services are delivered through contracts with private sector health and human services organizations on each of the Hawaiian islands. Clinic based services are contracted with Community Health Centers. Placement of community resources at the “grass roots” level is an essential component in linking successful partnerships among policymakers, health care providers, families, the general public and others to identify and solve maternal and child health issues and concerns in the state. MCH infrastructure building and population based services are managed through the strategic placement of MCH and Family Health Services Division (FHSD) Coordinators and CSHCN staff on the neighbor islands and this allows for collaborative partnerships and mobilizations of Title V/FHSD initiatives and programs. Neighbor island coordinators and staff actively participate in both local and statewide coalitions and advisory groups which provides for open communication and recognition of varied cultural values and practices. Provision of MCH services to culturally and linguistically diverse populations and addressing racial and ethnic disparities in the health of women of reproductive age is a challenge for many states, including Hawaii. To address these issues, programs and community health centers actively recruit and retain staff that are culturally competent and linguistically capable of interpreting various languages.
Hawaii’s centralized structure allows for a focus on priority MCH needs statewide and activation of a unified approach in provision of MCH/CSHCN services. Local area MCH/CSHCN, FHSD representation acts as a catalyst on each neighbor islands to assure quality preventative and protective health care. The procurement of direct and enabling services through contracting also assures that there is a continuity of service delivery throughout the entire state and allows the division to implement a standard of care.
Hawaii’s Title V Director, Loretta Fuddy, believes the major difference between centralized and other public health systems is that the centralized system limits the number of competing agendas and priorities. State and counties alike have a common goal and purpose “to protect and improve the health and environment for all people in Hawai’i.”
All four of these states demonstrate that even when the state is the local, and the local is the state, collaboration with partners at the community level is required to carry out critical MCH services. As states look to address MCH challenges an examination of how the state health agency is organized, and what services are provided by which level of government, may provide an opportunity to improve program performance and more efficiently provide services within our diverse states and territories.
Thanks to the following individuals for their input in this article: Valerie Ricker (Maine), Julie Preskitt, Chris Haag, and Melinda Davis (Alabama), Annette Phelps and Phyllis Sloyer (Florida), and Loretta Fuddy (Hawaii).