Local Health Department Services Research Articles

Identifying Areas with Disproportionate Local Health Department Services Relative to Opioid Overdose, HIV and Hepatitis C Diagnosis Rates: A Study of Rural Illinois.

Background: U.S. rural populations have been disproportionately affected by the syndemic of opioid-use disorder (OUD) and the associated increase in overdoses and risk of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission. Local health departments (LHDs) can play a critical role in the response to this syndemic. We utilized two geospatial approaches to identify areas of discordance between LHD service availability and disease burden to inform service prioritization in rural settings. Methods: We surveyed rural Illinois LHDs to assess their OUD-related services, and calculated county-level opioid overdose, HIV, and hepatitis C diagnosis rates. Bivariate choropleth maps were created to display LHD service provision relative to disease burden in rural Illinois counties. Results: Most rural LHDs provided limited OUD-related services, although many LHDs provided HIV and HCV testing. Bivariate mapping showed rural counties with limited OUD treatment and HIV services and with corresponding higher outcome/disease rates to be dispersed throughout Illinois. Additionally, rural counties with limited LHD-offered hepatitis C services and high hepatitis C diagnosis rates were geographically concentrated in southern Illinois. Conclusions: Bivariate mapping can enable geographic targeting of resources to address the opioid crisis and related infectious disease by identifying areas with low LHD services relative to high disease burden.

Fostering Local Health Department and Health System Collaboration Through Case Conferences for At-Risk and Vulnerable Populations.

In case conferences, health care providers work together to identify and address patients' complex social and medical needs. Public health nurses from the local health department joined case conference teams at federally qualified health center primary care sites to foster cross-sector collaboration, integration, and mutual learning. Public health nurse participation resulted in frequent referrals to local health department services, greater awareness of public health capabilities, and potential policy interventions to address social determinants of health.

Development of the PHAST model: generating standard public health services data and evidence for decision-making.

Standardized data regarding the distribution, quality, reach, and variation in public health services provided at the community level and in wide use across states and communities do not exist. This leaves a major gap in our nation's understanding of the value of prevention activities and, in particular, the contributions of our government public health agencies charged with assuring community health promotion and protection. Public health and community leaders, therefore, are eager for accessible and comparable data regarding preventive services that can inform policy decisions about where to invest resources. We used literature review and a practice-based approach, employing an iterative process to identify factors that facilitate data provision among public health practitioners. This paper describes the model, systematically developed by our research team and with input from practice partners, that guides our process toward maximizing the uptake and integration of these standardized measures into state and local data collection systems. The model we developed, using a dissemination and implementation science framework, is intended to foster greater interest in and accountability for data collection around local health department services and to facilitate spatial exploration and statistical analysis of local health department service distribution, change, and performance. Our model is the first of its kind to thoroughly develop a means to guide research and practice in realizing the National Academy of Medicine's recommendation for developing systems to measure and track state and local public health system contributions to population health.

Federally Qualified Health Center Substitution of Local Health Department Services

Strategic and budgetary considerations have shifted local health departments (LHDs) away from safety net clinical services and toward population-focused services. Federally Qualified Health Centers (FQHCs) play an increasing role in the safety net, and may complement or substitute for LHD clinical services. The authors examined the association between FQHC service levels in communities and the presence of specific LHD clinical services in 2010 and 2013. Data from LHD surveys and FQHC service data were merged for 2010 and 2013. Multivariate regression and instrumental variable methods were used to examine FQHC service levels that might predict related LHD service presence or discontinuation from 2010 to 2013. There were modest reductions in LHD service presence and increases in FQHC service volume over the time period. LHD primary care and dental service presence were inversely associated with higher related FQHC service volume. LHD prenatal care service presence, as well as a measure of change in general service approach, were not significantly associated with FQHC service volume. LHDs were less likely to provide certain clinical services where FQHCs provide a greater volume of services, suggesting a substitution effect. However, certain clinical services, such as prenatal care, may complement the public health mission-and LHDs may be strategically placed to continue to deliver these services.

Building the evidence for decision-making: the relationship between local public health capacity and community mortality.

We examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina. We analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality. Spending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births (P < .05). Provision of women and children's services was associated with a reduction of 1 to 2 infant deaths per 1000 live births (P < .05). Our findings, in the context of other studies, provide support for investment in local public health services to improve community health.

Measuring public health practice and outcomes in chronic disease: a call for coordination.

A strategic opportunity exists to coordinate public health systems and services researchers' efforts to develop local health department service delivery measures and the efforts of divisions within the Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) to establish outcome indicators for public health practice in chronic disease. Several sets of outcome indicators developed by divisions within NCCDPHP and intended for use by state programs can be tailored to assess outcomes of interventions within smaller geographic areas or intervention settings. Coordination of measurement efforts could potentially allow information to flow from the local to the state to the federal level, enhancing program planning, accountability, and even subsequent funding for public health practice.

Local public health department adoption and use of electronic health records.

Electronic health records (EHRs) may help local health departments (LHDs) to improve services and thereby promote and protect population health. Yet, little is known about nationwide trends and correlates of EHR use by LHDs. We examine relative contributions of LHD finances, leadership, and governance to EHR adoption and use from 2010 to 2013. The impact of LHD service provision and meaningful use factors on EHR use is explored in depth. Combining data from the National Association of County & City Health Officials Profile survey and the Area Health Resource File, logistic regression models were used to examine EHR use in 2013. Multinomial logistic models examined EHR adoption, use, or discontinuation from 2010 to 2013. EHR usage data were available for 514 and 488 LHDs in 2010 and 2013, respectively. A total of 117 LHDs had data for both 2010 and 2013. Outcomes included dichotomized measures of LHD self-reported use of EHRs in 2010 and 2013. For LHDs with 2 years of data, a 4-category variable measuring self-reported EHR use, nonuse, adoption, or discontinuation was analyzed. Overall LHD EHR use did not increase significantly between 2010 (19.3%) and 2013 (22.0%). While 15% of LHDs reported adopting EHRs from 2010 to 2013, another 8.5% reported discontinuing use of EHRs during this time. Likelihood of EHR use was strongly associated with LHD clinical service characteristics, per capita expenditures, and state governance structure. EHRs do not appear to be rapidly diffusing across LHDs, and retention of current systems may be a concern. Given trends away from clinical service provision and other pressing demands for LHD resources, the benefits of EHR adoption are unclear.

Classifying Local Health Departments on the Basis of the Constellation of Services They Provide

We explored service variation among local health departments (LHDs) nationally to allow systematic characterization of LHDs by patterns in the constellation of services they deliver. We conducted latent class analysis by using categorical variables derived from LHD service data collected in 2008 for the National Profile of Local Health Departments Survey and before service changes resulting from the national financial crisis. A 3-class solution produced the best fit for this data set of 2294 LHDs. The 3 configurations of LHD services depicted an interrelated set of narrow or limited service provision (limited), a comprehensive (core) set of key services provided, and a third class of core and expanded services (core plus), which often included rare services. The classes demonstrated high geographic variability and were weakly associated with expenditure quintile and urban or rural location. This empirically derived view of how LHDs organize their array of services is a unique approach to categorizing LHDs, providing an important tool for research and a gauge to monitor how changes in LHD service patterns occur.

Are Local Public Health Department Services Related to Racial Disparities in Mortality?

Our study aim was to determine whether local health department (LHD) services were associated with U.S. racial disparities in 1993-to-2005 mortality rates. In a national sample of LHDs, we examined 10 LHD service domains and gaps in Black–White all-cause mortality rates, drawing data from the National Association of County and City Health Officials’ National Profile of Local Health Departments surveys, as well as mortality and other public data files. Two service domains, maternal/child health and other activities, were significantly associated with decreases in the Black–White mortality gap for 15- to 44-year-olds. The health services domain approached significance in decreasing this gap. Screening was associated unexpectedly with a significant increase in the Black–White mortality gap for 15- to 44-year-olds. Selected LHD services that are provided directly to individuals and are allocated by need may have particular benefit for reducing Black–White mortality disparities for U.S. adults aged 15 to 44.

Assessing Gaps in the Maternal and Child Health Safety Net

The Patient Protection and Affordable Care Act of 2010 proposed sweeping changes to health insurance and health care delivery systems. As a result, local health departments, community health centers, and other safety net providers are expected to play a role in providing access to care for millions of individuals. This study examines the availability of population-based services by local health departments and community health centers in the Midwest/Great Lakes region. For this study, the authors used secondary data on location of community health centers collected by the Health Resources and Services Administration and local health department services delivery from the 2008 National Profile of Local Health Departments. To simultaneously examine the geospatial patterns of service delivery and location of community health centers, the geographic information system shape files of local health department jurisdictions were used to examine prenatal care services. Additionally, the effect of service availability was examined by analyzing the rate of low birth weight births within the service areas of these facilities. Results show large variation in the distribution of community health centers. Additionally, the analysis of local health department services shows that prenatal care services are not available in every jurisdiction. Furthermore, the rates of low birth weight births in these areas are significantly higher than in areas where prenatal care is available. Future studies are needed to examine the relationship between safety net providers as well as their role in improving population health.

Leadership Matters

The activities that local health departments (LHDs) conduct and their workforce characteristics change over time. We know little, however, about how changes among the services LHDs conduct are associated with the nature of LHD leadership and how these factors impact health. This study investigated changes in LHD services and leadership and how these changes are associated with mortality disparities. We conducted regression analyses of secondary data using an exploratory panel time series design. We used secondary data to investigate changes in LHD services and leadership and how these changes were associated with each other and with 1993 to 2005 changes in black-white mortality disparities. Local health department services were examined relative to change in breadth of services within each of 10 program domains between 1993 and 2005. LHD leadership was examined for discipline of the lead executive in 1993 and 2005. Our sample included 558 county or multicounty "common local areas," representing county-level data for LHDs and their jurisdictions. Significant beneficial relationships exist between having a clinician as lead executive in an LHD and reductions in black-white mortality disparities. Local health departments with a clinician (usually a nurse or physician) as their lead executive in 1993 and/or 2005 experienced a significant decrease in black-white mortality disparities for young adults (age 15-44 years) in their jurisdictions from 1993 to 2005 when compared with LHDs with nonclinician leaders. The discipline of an LHD's lead executive as a clinician appears to have a significant relationship with the impact of LHD practice on reducing black-white mortality disparities. This study suggests that the discipline of an LHD's leadership may be an important factor to consider in relation to local public health capacity to impact health disparities. Further research related to the mechanisms at play in these relationships is warranted.

Local Public Health Cost Study in Georgia

Development of a uniform cost study methodology for local health department services in Georgia began with a desire to negotiate cost-based reimbursement from Medicaid. Managed care and the Health Insurance Portability and Accountability Act requirements for common coding standards added impetus to Georgia's efforts to document the cost of local public health. With a determination that the result was achievable, the Division of Public Health contracted with a medical practice management firm. What followed included a major team effort with active working groups of county, district, and state representatives. A template was developed by the consultants to compile the cost report and automated applications were installed. Statewide training engaged the local public health workforce and led to a successful pilot project. This article describes the interactive process that led ultimately to the ability of every county in the state to produce a valid cost report. The cost of direct services provided for individuals by county health departments can now be calculated with a cost per relative value unit. The cost report also includes the cost of environmental health, dental health, population-based services and all other local public health services. A brief description of the methodology is presented.

Developing quality indicators for local health departments: Experience in Los Angeles County

Objectives To develop public health quality indicators for local health department (LHD) use. Methods An indicator development team utilized public health quality measurement concepts, reviewed existing quality measurement–related initiatives, and conducted interviews with LHD staff in order to identify and develop quality indicators for the Los Angeles County Health Department. Results Sixty-one recommended and 50 acceptable (i.e., scientifically sound but less useful) indicators were developed, with an emphasis on measuring process quality in services delivery. Pre-existing indicators from external sources, when available, were often not well suited to the Health Department's needs. The indicator development process clarified conceptual issues, highlighted strengths and limitations of potential indicators, and revealed implementation barriers. Conclusions A limited number of generally available, quantitative indicators of local public health quality exist. Indicators addressing the delivery of LHD services can be locally developed to fill an important gap in public health quality-improvement efforts. However, implementation of quality measurement is difficult due to limited evidence on public health practices, sparse data resources, unclear accountability, and inconsistent organizational motivation.

Research Article: Evaluation of the Capacity for Local Health Departments to Help the Public Address Poor Indoor Environmental Quality

The public is becoming aware of the role that the indoor environment plays on their overall health. Nationwide health objectives recommend that the local public health infrastructure provide resources and services to help the general public identify and address poor indoor environmental quality. The authors surveyed certified and non-certified municipal, local, and state regional health departments in Illinois to identify free publicly available resources to help the general public address indoor environmental quality in their homes, schools, and non-industrial workplaces. Most local health departments surveyed indicated that they are not capable of adequately addressing indoor environmental issues in their community. Available services in Illinois appear to be limited primarily to literature distribution and phone consultation in most of the health departments statewide. A general survey of state health departments indicated that Illinois is representative of a nationwide inability to adequately address indoor environmental quality issues through local health department services.

Privatization and the scope of public health: a national survey of local health department directors.

This study sought to obtain and analyze nationally representative data on (1) privatization of local health department services, (2) local health department directors' beliefs and perspectives on the desirable role and focus of health departments, and (3) the influence of these views on privatization practices. A stratified representative national sample of 380 local health department directors was drawn, and 347 directors were interviewed by telephone. Logistic regression established the independent effects of various factors on decisions to privatize. Almost three quarters (73%) of the local health departments privatized public health services of some type. The 12% of the directors who believed that local health departments should be restricted to the core public health functions and move entirely out of direct provision of personal health care were more likely to privatize services. The 77% of the directors who believed that local health departments should be involved in an increasing array of social problems were more likely to privatize. Privatization has quietly and quickly become commonplace in public health, and privatization practices are intimately related to divergent conceptions of public health and the role of local health departments.

Privatization of local health department services: effects on the practice of health education.

Local health departments (LHDs) are changing service delivery mechanisms to accommodate changes in health care financing and decreased public support for governmental services. This study examined the extent to which North Carolina LHDs privatized and contracted out services and the effects on the time spent on core functions of public health and activities of health educators. Questionnaires were mailed to the senior health educators in all LHDs. Sixty-nine responded, and 68% of LHDs had not privatized any services other than laboratory and home health. Clinical services were more commonly privatized than nonclinical services. Respondents perceived that privatization produces more time for LHDs to address the core public health functions and for health educators to engage in appropriate professional activities. Health educators in LHDs that had not privatized were more likely to be concerned about potential negative effects. This study suggests that privatization has generally had a positive effect on the roles of health educators in North Carolina LHDs.

Findings from case studies of state and local immunization programs

Background: As part of its examination of federal support for immunization services during the past decade, the Institute of Medicine (IOM) Committee on Immunization Finance Policies and Practices (IFPP) commissioned eight case studies of the states of Alabama, Maine, Michigan, New Jersey, North Carolina, Texas, and Washington; and a two-county study of Los Angeles and San Diego in California. Specifically, the IOM Committee and these studies reviewed the use of Section 317 grants by the states. Section 317 is a discretionary grant program that supports vaccine purchase and other immunization-related program activities. These studies afforded the Committee an in-depth look at local policy choices, the performance of immunization programs, and federal and state spending for immunization during the past decade. Methods: The case-study reports were developed through interviews with state and local health department officials, including immunization program directors, Medicaid agency staff, budget analysts, and Centers for Disease Control and Prevention public health advisors to the jurisdiction. Other sources included state and federal administrative records and secondary sources on background factors and state-level trends. The case studies were supplemented by site visits to Detroit, Houston, Los Angeles, Newark, and San Diego. Observations: The nature of immunization “infrastructure” supported by the Section 317 program is shifting from primarily service delivery to a broader set of roles that puts the public effort at the head of a broad immunization partnership among public health, health financing, and other entities in both the public and private sectors. The rate and intensity of transition vary across the case-study areas. In the emerging pattern, service delivery increasingly takes place in the private sector and is related to managed care. “Infrastructure” is moving beyond supporting a core state staff and local health department service delivery to include such activities as immunization registries, quality improvement, and coordination with programs outside public health agencies. At the same time, the recent decline in federal Section 317 support is forcing difficult choices between old and new activities at the state and local levels. Conclusions: Immunization programs function as an organic component of the local health care financing and delivery systems of which they are a part. Immunization efforts are organized and conducted within distinctive state and local fiscal, economic, and health care contexts. Section 317 Financial Assistance grants, while playing a vital role in supporting immunization “infrastructure,” have been too unstable and unpredictable to elicit the strategic planning, programming, and own-source spending that would be optimal for state and local programs. The predominant immunization function of state and local public health agencies is becoming assurance of age-appropriate immunization throughout the lifespan. To be successful in this emerging role, the health agencies must be supported with appropriate staffing, interagency collaboration, and clearly articulated authority.

An epidemiological model applied to planning and evaluation of local health department services

Utilizing epidemiological methods in the planning process, the Georgia Department of Human Resources, Division of Public Health, focuses on community-based and patient-based standards. These standards are identified and applied in the evaluation of local health department programs.

Local Health Department Services for Long-Term Patients

Local Health Department Services for Long-Term Patients

The Local Health Department—Services and Responsibilities

The Local Health Department—Services and Responsibilities