Rural and Frontier Counties worked to improve public health for jurisdictions of every size...public health for everyone...How two public health nurses effected positive change in Montana

1. Creating a Sustainable Model of Public Health
for All of Montana: Strategies for Best Practices in
Innovative Policy Development:
The Journey of HB 173
Michele Sare, MSN, RN
Nurses for Nurses International
March 2011: AHEC
Spokane, WA

2. Prevents epidemics and the spread of
disease
Protects against environmental
hazards
Prevents injuries
Promotes and encourages healthy
behaviors
Responds to disasters and assists
communities in recovery
Assures the quality and accessibility
of health services
(*CDC slide)

3. Public Health has
some issues

4. 10 million children…18 each minute
1 million girls and women
32 million with HIV/AIDS
13 million with TB
27 million with malaria…most children
½ of the world‟s children will go to bed
hungry …again
Disparity - Inequity

5. 20% of our population
“If you’ve seen one PH
Department, you’ve seen
one PHD”

6. 7 days/week
HH care 2 – 3 x/d
No governance support for PH
Governance miss-management of funds
No cavalry
My Life as a LPHO

7. PH is a little broken…and has been neglected
Should not be ‘person-bound’….
A profession has guidelines, standards &
ethics
Concern for regionalization, loss of services
Sustainable Local Public Health?

8. Poor Health/Healthcare Hurts
25% > 65 by 2015 in MC
18% poverty rate in
MC….increasing
44% of all Montana children
uninsured (therefore do not
seek healthcare
appropriately)
High rates of obesity (40%) in
MC
Alcohol & drug abuse in MC
Leading causes of premature
death in MC are heart
disease, cancer & stroke – all
early prevention
MVA, resistant microbial
infections, STDs & other
preventable factors disable or
kill our citizens

9. Changing Paradigms
Evidence
Knowledge
Cultural Shifts
Collaboration 
„De-siloing‟
Accountability

10. WE ASKED:
“WHAT’S UP WITH
THIS?”

11. We Went Fishing…
Michele & Peggy & her crew – Mineral Co.
Dan & Gordon
MPHA, AMPHO & other Local HDs
DPHHS
___________
= HB 173

12. National & International
‘Mandates’ for PH
We ended Healthy People 2010
We’re headed toward a new set of national
health goals in Healthy People 2020 (HP 2020)
MDG -The United Nations – with the World
Health Organization (WHO)
http://www.un.org/millenniumgoals/

13. 1. End Poverty and Hunger
2. Universal Education
3. Gender Equality
4. Child Health
5. Maternal Health
6. Combat HIV/AIDS
7. Environmental Sustainability
8. Global Partnership
Millennium Development
Goals

14. Mission:
Promote Physical and
Mental Health
and
Prevent Disease,
Injury, and Disability
(*CDC slide)
Vision:
Healthy
People in
Healthy
Communities

15. National Trends…Others have been asking
“What’s up w/ this?”
HC reform nationally – cost, quality
and access
3,000 LHD nationwide…independent models
…‟made-up/person-bound‟
Not standardized – Old mantra = “If you‟ve seen
one LHD, you‟ve seen one LHD”
Dilution of services – vying for HC dollars
„Regionalization‟ and loss of services

16. National Guidelines
US DHHS CDC
PHAB
APHA
NACCHO, ASTHO & NALBOH
RWJF & W. K. Kellogg
Foundation

17. Institute of Medicine (IOM)
Reports
Tipped the HC world on its ear…
“Quality Chasms”
1988  PH Improvement came
assessment, policy development
& assurance
An update in 2003, The Future of the Public’s
Health in the 21st Century
Still not doing too well…

18. State Laws & Guidelines
Montana Code Annotated (MCA) – Title
50-2
(http://data.opi.state.mt.us/bills/mca_toc/50.htm
)
Administrative Rules of Montana (ARM)
– 37 – (http://www.mtrules.org)
MPHA
AMPHO
Local ordinances
MT Environmental Health Agencies
BON

19. PH Drivers
• IOM - The Institute of
Medicine serves as adviser to
the nation to improve health.
• CDC – Overall lead for
coordination
• ASTHO – Develop and support
state instrument
• NACCHO – Develop and
support local instrument;
MAPP
• NALBOH – Develop and
support governance
instrument
• APHA –Marketing and
communications
• PHF- Performance improvement;
data collection and reporting
system
• NNPHI – Support through
institutes, training workshop and
user calls
• PHAB - In order to improve the
health of the public, the Public
Health Accreditation Board
(PHAB) is developing a national
voluntary accreditation program
for state, local, territorial and
tribal public health departments
(*from a CDC slide)

20. Strengthening systems,
improving the public’s health

21. History of the NPHPSP
Key Dates
– Began in 1998
– Version 1 instruments released in 2002
– 2002-2007 – Version 1 instruments used in more than 30
states
– Development of Version 2 instruments – 2005-2007
Comprehensive Development of Instruments
– Practice-driven development by CDC and ASTHO, NACCHO
and NALBOH Work Groups
– Field testing
–  Creation of PHAB – 2007
(*CDC slide)

22. Schools
Community
Centers
Employers
Transit
Elected
Officials
Doctors
EMS
Law
Enforcement
Nursing
Homes
Fire
Corrections
Mental
Health
Faith Institutions
Civic Groups
Non-Profit
Organizations
Neighborhood
Organizations
Laboratories
Home
Health
CHCs
Hospitals
Tribal Health
Drug
Treatment
Public Health
Agency
Public Health System
(*CDC slide)

23. Existing Tools

24. Tools to Implement 173
‘10 Essentials’
The ‘PH Wheel’ (10 Essentials)
NACCHO’s Operational Definition of a Functional Local
Health Department & Metric
NALBOH’s Local PH Governance Instrument, Version 2
PHAB Domains, Standards & Measures and
corresponding tools – in beta
ANA Scope & Standards of PHN….(& MCA & BON)
Evidenced Based Practice (EBP): research,
literature reviews, journals & current texts

26. Operational Definition of a Functional
Local Health Department:
NACCHO
+ Metrics

27. PHAB’s Purpose
“In order to improve the health of the
public, the Public Health Accreditation
Board (PHAB) is developing a national
voluntary accreditation program for state,
local, territorial and tribal public health
departments. The goal of the accreditation
program is to improve and protect the
health of every community by advancing
the quality and performance of public
health departments.” www.phaboard.org/

28. PHAB Draft Tools
(Based on the ’10 Essentials’)
Local Standards & Measures Self-
Assessment Tool
Health Department Readiness Checklist
Guide to National Voluntary Accreditation
Domains, Standards & Measures (final)

29. PHAB Beta Test: Paralleling 173
30 PH Departments
o 3 Tribal
o 8 State HD
o 19 Local HD
o Beta testing Domains, Standards & Measures
o Accreditation tools in draft form as beta test
continues
o Existing tools in-use
o Beta Test - October 2009 – December 2010

30. We are on the crest of a great wave of
change in public health….

31. So….How did we ‘do It’?
Tools  Synergy

32. Rule no. 1 to effecting a
positive policy change (and this is
the biggy – the foundation for all
others) – do your dandiest to
create a ‘win-win’
situation for all
stakeholders
11 Rules to Effective Policy Change

33. Infrastructure
Federal „HD‟ 
HHS
SHD
State Laws
LHD
Local Governance

34. RULE NO. 2 TO
POSITIVE POLICY CHANGE:
RECRUIT YOUR
LEGISLATIVE
CALVARY

35. RULE NO. 3:
EDUCATE,
EDUCATE,
EDUCATE!

36. RULE NO. 4: NEVER
CONSIDER ASKING
FOR MORE MONEY
FOR A PROGRAM IN A POOR
STATE THAT IS ALREADY
AWARDING TONS OF MONEY
(IN THE LEGISLATOR’S VIEW) TO
A PROGRAM THAT SOUNDS
AN AWFUL LOT LIKE
WHAT YOU’RE TRYING
TO DO

37. RULE NO. 5:
CLEARLY DEFINE
THE ROLES AND
RESPONSIBILITIES
OF STAKEHOLDERS

38. Partners & Stakeholders
Montana Legislature
Taxpayers – Mineral County
citizens, governance & HC
entities
Representative Gordon
Hendrick & Education
Policy Advisor Dan Villa
DPHHS – PH Improvement
group
NWCPHP
PHAB & MLC III
PHSITF
HB 0173 Pilot Projects
BON, ANA, NLN +
National PH Agencies

39. RULE NO. 6 OF
POLICY CHANGE: IT IS
‘S-L-O-W’, BE PATIENT
AND THOROUGH (THIS 18
MONTHS WAS ACTUALLY
PRETTY SPEEDY!

40. RULE NO. 7: CREATE
A COMPELLING
PURPOSE THAT EVERYONE
CAN UNDERSTAND –
‘BRAND’ IT.

41. RULE NO. 8: CREATE
BUY-IN BY MAKING
SURE THAT IT ISN’T
ABOUT ‘YOU’ IT IS
ABOUT THE GREATER
GOOD

42. RULE NO. 9: BE A
MASTER
COMMUNICATOR
AND LEAVE NO
ROCK UN-TURNED
WHEN COMMUNICATING!

43. RULE NO. 10:
BELIEVE IN YOUR
POLICY ‘PRODUCT’
AND LEARN THE BUSINESS OF
‘SALES’!

44. RULE NO. 11 IS AN
‘EXTRA’ – IT IS WHAT
YOU BECOME WHEN YOU
WORK TO CREATE A WIN-
WIN – NO. 11 IS A BENEFIT
– GAINING A SENSE OF
GROWTH AND
CONTRIBUTION

45. HB 0173 Sites
1. Butte-Silverbow
2. Yellowstone (Riverstone)
3. Richland
4. Mineral
5. Cascade
6. Hill
7. Prairie

46. Purpose
1. Determine what it takes to create a
sustainable model of a local PHD in our
frontier setting
2. Determine what it takes to create a
sustainable model of an accredited local PHD
in our frontier setting

47. 4 Over-Riding Tasks
1. Conduct a Self-assessment based on the PHAB Self-
Assessment Tool
2. Conduct a Community Health Assessment (CHA)
3. Develop a Community Health Improvement Plan
(CHIP)
4. Develop a PH Strategic Plan (PHSP)

48. Who We Are Accountable To
(who is watching us, wants reports & where the
money came from)
ARRA – The American Recovery & Reinvestment Act:
Montana RRA $
“ARRA funds are targeted toward rebuilding infrastructure
and positioning the country to grow the next
generation economy”.

49. Also Accountable To:
Legislators & Legislative Interim
Committee
Local Governance
DPHHS PH Improvement group
PHITF
Bruce & Jack (contractors to DPHHS –
from NWCPHP)
PHAB
Little cross-over w/ RWJF & the MLC III

50. Project Schedule
Began 11/1/2009
Self-assessment 1/2010 – 4/30/2010
Began Community Health Assessment (CHA)
9/2010
Report to Legislative Interim Committee August
24, 2010
Year 1 – completed 6/30/2010
Year 2 – 7/1/2010 – 6/30/2011
Year 2 – CHA, CHIP & PHSP

51. MEASURING ACCOUNTABILITY:
Based on the
language of
HB 0173
http://data.opi.mt.gov/bills
/2009/billhtml/HB0173.htm

52. Role of DPHHS & PHITF
Oversight of HB 0173 progress
Guidance materials and assistance
Resource
Technical assistance

53. Guidance
PHAB
CDC
NACCHO
Interpret & facilitate the guidance:
NWCPHP
PHSITF
DPHHS

54. The New Public Health
Together - We have work to
do!

55. The End… …References
• CDC: http://www.cdc.gov/od/ocphp/nphpsp/
• PHAB: http://www.phaboard.org/
• NACCHO: http://www.naccho.org/
• IOM: http://www.iom.edu/
• MAPP:
http://www.naccho.org/topics/infrastructure/MAPP/
index.cfm
• PDSA:
http://www.valuebasedmanagement.net/methods_d
emingcycle.html
• NFNI: http://www.nursesfornursesinternational.com