2017
Chapter 6
PROGRAM MANAGEMENT
The local health director is always in the middle: on one side are the assorted government agencies issuing health objectives and political promises; on the other are the people to whom these services must be delivered. Typically, the scope of national proposals and objectives is larger than a single department can manage, while the community's need exceeds its budgetary resources. The director's job, then, is to translate the promises to a form relevant to the community and the department's capacity. Also, to use the budget for those programs that promise the greatest measurable benefit to the community.
The key here is "measurable." The elected officials who provide the resources to the department have to make choices among many worthwhile programs every year. Many of the programs city councils or boards of supervisors are asked to fund sound laudable. Immunization of children against measles (to prevent measles encephalitis or death) can be measured by a drop in new infections, and subsequent disease and death. On the other hand, a program to teach children about the consequences of tobacco use, while laudable may not have any useful measurement other than a survey that most communities cannot afford, although the state BRFSS (Behavioral Risk Factor Surveillance System) for children is now able to give reasonable indicators. There are few valid measurements of how many children experiment with tobacco use, or don't start its use, other than response to surveys such as BRFSS. Reduction in tooth decay following use of fluorides in public water supplies is measurable. Use of condoms among teenagers after sex education classes cannot be validated by objective measurements other than a reduction in reported STDs. Successful public health programs are usually associated with clear objectives and valid replicable measurements of results.
Similarly, nationally, it is one thing for a president to declare war on cancer and quite another for physicians and scientists to devise specific procedures and strategies to deal with the many different forms of malignancies that attack man, and to track the results of those efforts. Sweeping pronouncements are politically attractive. Voters enjoy hearing them and politicians enjoy making them, but that does not necessarily make them workable. It remains for the local health director to apply common sense in developing procedures and strategies that might work locally and then track their results. A typical example is the 2016 “cancer moonshot” put forth by VP Joseph Biden.
Politics and health
The health director is not usually a research scientist and somehow above politics. To function, he/she must be aware of political realities, of competing interests, programs and agendas in pursuit of approval, votes and appropriations. The health director's best ally in that competition, however, is science. When a health director can demonstrate positive results with precision, it is easier to win approval for programs.
As the person responsible for the care of individuals, a local health director is in the best position to measure the effects of programs on people: to do the data gathering and thus to know what is really going on in the community. Paradoxically, some measurable successes of public health make it more, not less, difficult to convince voters and governmental agencies to continue their support. Fluoridation and other programs aimed at protecting the teeth of children have been so successful in the United States that the bulk of dental care has shifted to the middle aged and older. Children, in general, no longer have great numbers of cavities, except for those overindulging in carbohydrates and getting caries, or living in communities without fluoridated water supplies. People under 50 have not seen ‘iron lungs’ used to treat poliomyelitis patients, mental retardation from mumps or measles encephalitis, post-measles deafness and blindness or deaths from measles, diphtheria, and mumps. Most people do not realize that diseases which were common in the recent past are not "conquered" but merely held in check by routine public health measures, and that in the absence of these measures they can still be serious and life threatening.
Political challenges are by no means restricted to those of office holders; popular movements, with their penchant for confrontational tactics, can damage the credibility of any agency by simply capturing the attention of the media. A shouted slogan is a more dramatic "sound bite" than a reasoned response, as well as more memorable. Because many genuine public concerns are founded on poor science their value is often misunderstood. It is the health director's responsibility to provide a scientific base for public issues that will lead to a solution, if they are genuine, or to their dismissal if not. If politically astute, the director will work quietly to gather hard data and only then use the media to enlighten the public about issues engineered by others to fulfill some particular agenda. For example, there was a public outcry about the 'terrible side-effects of giving DTP vaccines' by small groups of vocal parents whose children had neurological problems temporally associated with use of the vaccine. It was only after the outcry, after lawsuits charging malpractice, and after congress had enacted laws to compensate parents that enough hard scientific data was accumulated to show that most, if not all, of these events did not have a genesis in administration of DTP vaccines. A current hot potato in 2015 is the requirement that girls and boys be required to accept HPV vaccination. Data from a national study suggests that about one in four U.S. females between the ages of 14 and 59 years may have the sexually transmitted infection HPV (JAMA. 2007;297:876-878) and that immunized young males have significantly less anal cancer and genital warts (NEJM 364;5 February 3, 2011). Data is starting to accumulate on the reduction in cervical cancer in women vaccinated against HPV.
Changing health and political realities
Standards that percolate down from the national level may be somewhat distant from local reality. Promoting Health--Preventing Disease: Objectives for the Nation (Objectives), published by the U.S. Department of Health and Human Services first in 1980, proposed goals to be achieved by 1990. The next such set of objectives, published in the summer of 1990, set goals for the year 2000. This was succeeded by the next 10 year plan – Healthy People 2000, and then by Healthy People 2010, and now the current plan identifying outcomes for 2020. 10 years may be seem a long a period for such health planning and objective setting, even at the national level, but a shorter period will make outcome data hard to accumulate. Changes in medical care, disease incidence or new technologies may modify perspectives or resource allocation. AIDS, for example, was not even mentioned in the 1980 objectives--it was then unknown. The political situation may also change. In Texas in 1980, for instance, no one could foresee the oil recession of the mid-decade that would hobble the state's programs. Recently we have had to deal with SARS and an expected H1N1 Flu Pandemic. It remains for the local health director not only to sort out and apply the objectives that work for his/her jurisdiction, but also to gather data to refine future sets of objectives. Though 10 years is a long period for health planning, planning based on evidence is better than none at all, and as shared information improves, so will the goals themselves. Part of the cost of planning is that of carrying out surveys to measure health status, and people’s behaviors and perceptions. The Public Health community must be more effective in helping legislators understand the value of such surveys, or health planning will continue to be out of step with the real world. Data is often out of date by the time it is published, due to poor methodology in aggregating data once gathered, but that is improving as computerized information networks across the health system had better linkage and coordination.
Adding to the complexity of dealing with various goals and the demands of various action groups (activists by cause) is the sheer number of responsibilities that have been imposed upon health departments. Besides gathering data and setting local objectives, the typical local health department is often charged with overseeing primary care clinical services to mothers, children and the indigent, and for intervention in genetic diseases and terminal illnesses. It is expected to develop and implement programs of general health for the public and to guard against the spread of infectious diseases. Local health departments are also regulatory agencies, “permitting” food handlers and septic tank sites, monitoring air and water quality, and dealing with occupational hazards. They often operate programs for particular conditions, such as hypertension. While this list is far from complete, it gives some notion of the scope of health department programs to be conducted with finite resources.
Programs and Data.
If politics is the art of the possible, the local health director must be a consummate artist. Information is the medium of this art form. With good data, health directors know which national standards are applicable to their communities, what programs save their communities money and people disability, what issues need attention, and what their departments must do to stay ahead of demands.
Data come from many sources;-physicians, hospitals, staff inspectors, school nurses and other governmental agencies. The data need to be processed into a single, comprehensive body to be useful. Fortunately, computerized databases make it possible to receive and process a vast amount of information while potentially eliminating duplication of effort. Once a piece of data is captured into an electronic database, it should never be necessary to capture it again. This database should be accessible, through networks or through the Internet. (Bioterrorism and unanticipated new diseases are driving database development in public health.) Staff at program sites should be able to enter new information about individuals and retrieve information about known patients already on file. The person registering a patient for an immunization program should be able to update a patient’s clinical history electronically. Timely information helps prevent patients from being given an incorrect vaccine. As an additional benefit, the system can print out vaccination certificates during each clinic visit. Simultaneously, the system records such details as the vaccine manufacturer, date of production, lot number, and the name of the person administering the vaccine. Current data from the American Academy of Family Physicians shows that less than 60% of physicians are using any electronic clinical database in their practices. With the new Affordable Care Act all medical organizations both institutional and private practice are required to develop effective electronic systems which, while seeming technically simple, are in fact a communication nightmare because of all the different organizations trying to develop them and lack of uniformity in labeling the various pieces of data to enable data exchange.
Families in most communities may have members living in the same household who visit more than one doctor, clinic or agency, and more than one family member may be visiting each agency, or participating in all the programs of one agency. As different agencies may also deliver services to a single household, the degree of overlap in both directions can be surprising. Not infrequently, the household members themselves get confused about who is looking after whom, and staff members can become entangled in the different eligibility requirements of the various programs, even within the same agency. Fortunately, nearly all agencies require similar financial data before determining the programs for which clients are eligible, and this, at least, may be shared between them all.
Information sharing
While public health information may not be made public, there is rarely any reason to withhold it from the various agencies with legitimate interests in the families they serve jointly. A community can and should decide which data, although confidential, should be available on a need-to-know basis to human service agencies funded and functioning within a single jurisdiction. Modern management techniques, using computerized databases, can provide information and restrict access to it, can ensure that essential services are provided with limited staffs and with far less paperwork. In this way, basic demographic data can be exchanged among health, welfare, mental health, education, rehabilitation and possibly charitable agencies. All agency staff needs to know such things as the names of family members, location of households and program identifiers such as departmental registration numbers. Whichever agency first contacts the eligible person should collect this data, and once that person is entered into the database by the first human service agency approached, there is no need to re-interview the person at the succeeding agencies. By developing a team of human service eligibility supervisors who can work together to determine data needs, communities can further maximize the efficiencies computers make possible. Under their guidance, individual agencies can identify the types of data each needs and can work together to install a common human services database, with the agency requiring the greatest amount of data keeping the permanent record. When clients move from one agency to another for primary services, protocols for stripping out the information not needed about them by the new agency are applied and the data are shared electronically. The eligibility system supervisors make eligibility decisions automatically available to any other agency to which a client is referred within the system, or to which the client goes independently.
Automated procedures not only perform a system eligibility function, but act as a referral mechanism to other agencies. A woman bringing in small children to be immunized, for instance, would be tagged electronically as eligible for WIC (a program providing supplemental food to pregnant women and young children), food stamps, and additional social services. Procedures for developing such interdepartmental data systems are discussed in another chapter.
Because medical data should be kept indefinitely it is good practice, in today's litigious environment, to store it in a remote site and make daily backup copies kept at 2-3 different sites simultaneously. Computers can make backups relatively easily, generating links to files required for audits while placing electronic copies of the records into permanent (archived) files. Data system improvements are among the most important advances to benefit public health in the past ten years. They allow us to track patients, analyze diseases, and evaluate the effectiveness and efficiency of our programs quickly and accurately. Congress has mandated that all health systems including doctor’s offices be computerized by 2014 which is an act in progress and more likely to be complete by 2020. The problem is that practices have been given the opportunity to access numerous different kinds of data systems that often fail to interact with each other so that the ability to analyze patient outcome among groups of physicians is still lacking. Further the medical records systems and doctor’ s offices currently fail to link with most hospital information systems or with local and state health agencies.
Health Education
If information is the medium of the health director's art, education is its message. Ordinary people who are well informed are quite capable of making intelligent decisions about their priorities while people who are ill informed tend to make poor ones. It is in everyone's best interest to be well informed, particularly in democratically governed communities.
It is seductively easy to rationalize the department's staff spending all their time in direct patient service rather than any in community education. Given the number of responsibilities a typical health department has, there is always a sense of urgency about getting on with the job or jobs at hand. Still, without community support a health department becomes moribund, and a department very busy doing things that are not well understood outside its offices can quickly lose community support. Particularly when the things it does are perceived as intrusive, painful and/or expensive, the health department may find itself cast in the role of adversary in times of confrontation by special interest groups.
On the other hand, when people generally understand what the department is doing and the principles underlying its programs, their support tends to be very strong indeed. Maintaining staff morale, funding continuing education, and obtaining additional staff all becomes much easier with such support, and the general health of the community improves. We should always devote a proportion of staff time to an effort to make people aware of programs and what they mean. Such activity pays off every time. The development of local health department web sites is increasingly important.
Communities that understand their health departments do not see them as an adversary or "just another bureaucracy". When there is an outbreak of disease, the health department is looked to for help rather than castigated for allowing it to happen. When infant death rates fail to drop, the community might ask what help it could give. During disagreements, especially when the federal or state government has made a policy announcement about health, the department's staff are often the nearest resource within reach. When trust and understanding have been built and maintained, channels of communication remain open.
It is hard to measure the impact of efforts to educate the public and governmental officials, yet health departments, which make such efforts, prosper. In bad times, they seem to have the fewest cuts in personnel and programs of all community departments, and in good times their proposals tend to receive support. Because they address chronic needs, health departments rarely have first claim on community funds. More visible problems, like crumbling sewer systems, potholed roads or overcrowded schools are often first in line. But when tendency for neglected chronic problems to fulminate into acute ones is properly understood, health departments are not placed at the end of the line, either. It takes constant care to keep the public informed, but such public relations are as much a function of a successful agency as the clinical or environmental programs it operates. If the health department's services benefit the public, then it will be expected to continue providing them.
Public relations efforts take many forms at many levels. As a local health director, I sat on infection control and utilization review committees of local hospitals and met at least annually with the boards of directors of those hospitals. Being known personally to the medical community and making my views known to them was a necessary step in building my department's credibility and increasing the community's receptivity to my ideas. For example, because my staff and I met with the cancer society and hospital medical staffs we could link evaluation and treatment of women together when we found positive pap smears in our clinics. We worked closely with the local children's hospitals and were able to refer poor children to their specialty services by facilitating reimbursement from the state as well as enhancing pediatric residency training with hospital medical staff and residents working in our child health programs.
When good data is available it is possible to be more active in community education as opposed to working quietly to gather data when little is available. For instance one can help the community to understand and accept immunization programs better by meeting with community groups such as PTA, junior league, and churches. Staff can write information releases for newspapers, radio and TV, and work to get them in print or on the air. When dealing with more emotionally charged issues such as family planning, it is possible to work closely with such diverse groups as ministers from various faiths as well as advocates like Planned Parenthood. Additionally, the department's staff--nursing, environmental and support, can make a personal effort to educate friends, neighbors, their church congregations, and social groups. Because the newspaper owner and the senior staff of the local television and radio stations understood and supported the family planning program, they ran frequent notices and public service announcements in both English and Spanish.
Most of the funding battles for maternal and child health and immunization programs are won by ad hoc boards, appointed by the city and county officials. These are often composed of people from the school superintendent's office, educators, ministers, physicians, dentists, hospital auxiliaries, and persons from charitable agencies. Such boards should meet with the department staff regularly, tour the facilities, review all plans, help develop and critique policy, review annual program achievements and present the results to the relevant city and county boards. Invariably, they push for additional resources.
Finally, as chronic disease have become epidemic health department web sites need to be proactively engaged in helping people live healthy lifestyles with links to information.
Dealing with sensitive topics
Sexually transmitted diseases (STDs) are certainly an area of public health concern, yet one that poses difficulties. Many health departments handle STD information poorly because directors are often afraid of offending elected officials. Yet it is the diseases, rather than their transmission, that ought to be the focus. It is possible, proper and necessary to discuss these diseases epidemiologically without steamy details. The long term effects of Syphilis, Gonorrhea, Chlamydia, AIDS, HPV and pelvic inflammatory disease upon the population most at risk--young men and women--as well as the community's share of the consequences are tied to the health department's role in preventing them, by providing information people need to know. STDs are spread more by ignorance than any other type of disease, and that ignorance can be fought in schools, churches, recreation centers and the media without offense so long as care is taken to confine the discussion to the disease and its transmission rather than focusing on issues such as homosexual rights.
Recently, many city and state public health departments have improved their credibility by dealing with the HIV epidemic as a disease, using prior models for controlling tuberculosis and syphilis, rather than focusing attention on political actions, or trying to change individual morals. Coming to understand the disease and the needs of the patients has given us a new opportunity to plan the use of scarce resources, to integrate programs and to tell the public health story. Health departments emphasize education of both the general public and the medical profession about the limited ways in which the disease could be transmitted as well as use of condoms to prevent transmission of the virus in seminal fluids. They have continued motivating the public to be calm when faced with a new disease, as well as helping the media to provide useful medical information to the public.
Formulating health standards
The local health director is charged with developing and implementing local health goals and objectives for the various programs under his control. These should not conflict with state and national ones. However, not all national or even all state goals may be applicable to the situation the director or program manager faces. Goals for black lung disease, for instance, are useful only in jurisdictions containing coal mines. Particular demographics often dictate focusing attention on selected segments of the population rather than others. Some goals are more appropriately addressed by other agencies, such as environment or housing.
Model Standards
National health guidelines were initiated as PL95-83, the Health Services Extension Act of 1977, which called for standards to "identify populations in need of preventive or protective health services," to "establish model standards with respect to preventive health services in communities," and to "maintain community-oriented preventive health programs." A work group composed of representatives from the Centers for Disease Control, the Association of State and Territorial Health Officials, the National Association of City and County Health Officials, and the American Public Health Association had seen the need for such standards, worked for the passage of the law and subsequently produced Model Standards for Community Preventive Health Services (Model Standards) in August, 1979 (Second Edition, 1985). Finally incorporated into the healthy people programs is HP 2020 which is the most recent publication.
The publication has a major set of prevention strategies:
Each of which has numerous objectives such as those that focus on the current epidemic of chronic diseases.
Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions
Multiple chronic conditions (MCC) pose a significant and increasing burden on the health of Americans. As part of its efforts to reduce the burden and suffering from MCC, the US Department of Health and Human Services (HHS) supports a large number of programs to prevent and manage multiple chronic conditions MCC. HHS also provides leadership for improving the health of individuals with MCC.
The HHS material on chronic diseases and other noninfectious diseases has been supplemented by the "Guidelines for Community Preventive Services" The new material focuses on evidence-based decisions. The HP 2020 document is further supported by recommended public health standards which can be used by state and local health departments and is available at the National Public Health Performance Standards web site.
2020 Objectives
Over the last 30 years the model standards have morphed into the healthy people objectives which have improved each year from the 1990 objectives all "pie-in-the-sky" to the 2020 objectives which are more realistic and have a reasonable opportunity of being achieved. The subject is can be found online and should be examined to look at “focus areas” which have been extended to a great number of objectives, which will look good on paper at the national level but there prescriptive value tends to fall apart except when state program directors tried to select from them to determine what is best to use at the community level. See Healthy People 2020. Further the CDC’s Office of Public Health Practices has developed a whole set of model practices which are discussed in the planning chapter.
Applying the Objectives.
Texas, Virginia and other states and localities really started using the healthy people project with HP 2000 to derive state & local goals from these national agenda. The approaches used by two different two states such as Virginia and Texas are different from each related to the population makeup in the two states. In Texas, a steering council of 30 members, representing government, private health professionals and businesses, assisted by an advisory committee of program specialists from the state agency, used a modified version (one that better reflected the needs of Texas) of the national objectives to formulate their own set. In Virginia, a "Health Congress" was formed of members from state agencies, local health departments, voluntary non-profit agencies, health care providers, educators and the state legislature. After several days of intense effort, this group identified the major health priorities of concern within the state. Afterwards, local departments, with these priorities in mind, compiled their own objectives based on the HP 2000 recommendations and their own knowledge of local health needs, met and unmet. In a "bottom upwards" process, these local objectives were then consolidated into regional objectives and the regional objectives into objectives for the state.
Although the final Virginia objectives were developed four years later they were similar to those from Texas. They included all the areas covered by 2010 Objectives, plus additional programs important to Virginia. The outcomes from these two very different approaches were essentially the same, yet both plans contained state-specific elements, and the process of formulating them helped all the participants to improve their understanding of their respective states.
All have been updated to incorporate the Healthy People 2020.
The next three essays will demonstrate the mechanics of making local health programs work in the areas of disease control, disease prevention and clinical services. The specific topics are selected to provide the reader with examples of program goals and objectives selected from the Healthy People documents. The selected goals and objectives are used to describe methods to combine local health department resources with those of other public, private and non-profit health care and human service agencies to provide effective and efficient programs of service to the community. The selected objectives are ones that have been used in different places at different times, over the last twenty years. The techniques used to attain these objectives are aimed to help readers understand the value of the objectives. These techniques can be applied to the myriad other objectives found in 'Healthy People'.
When reading next three chapters remember that goals reflect broad areas of national policy that may seem utopian for local health departments. This is emphasized to remind you that the local department must modify these goals to reflect local long-range goals. It will also be necessary to revise the objectives, which in both documents are national objectives, to reflect local conditions. In some communities the local objectives may already surpass national goals, but still not be satisfactory to that community. In others, the national objectives may be too ambitious for a locality. When reviewing the material in the next three chapters you will find it helps to keep the 'Healthy People' documents available.
Recommended Reading: