Reintegrating Health Care and Public Health

Over the past few years, there has been increasing attention on the opportunities for public health and primary care to work together to improve population health. This growing interest led the Association of State and Territorial Health Officials (ASTHO) to partner with the Institute of Medicine to convene primary care and public health experts to develop a strategic map.1 The map builds on the Institute of Medicine report, Primary Care and Public Health; Exploring Integration to Improve Population Health,2 and provides a framework for important next steps to work toward the recommendations of the Institute of Medicine report. It serves as a guiding document for the ASTHO-supported Primary Care and Public Health Collaborative currently composed of over 50 organizations and close to 100 people, and it sets priority areas of focus to improve population health through primary care and public health integration. It is also foundational to my challenge to state health official colleagues across the country. Each year, the ASTHO president issues a President's Challenge to his or her colleagues. For my ASTHO President's Challenge, I have called on state and territorial health officials to identify and share examples of collaboration, improved partnerships, or integration between public health and health care that have improved population health. Analyzing these examples will help us understand the key components that will sustain this work and accelerate the transformation of our system toward improved population health outcomes. Population health has become a commonly used phrase in health system improvement. Improved population health is the goal of primary care and public health integration and a shared vision for population health is foundational to the health system. This requires an understanding of both the complexity of the health system and the outcomes that determine the success or failure of this system. A shared vision for population health will take into account scientific and theoretical developments, practical applications of solutions at all levels, and individual capacity for health. This vision of population health considers the many levels at which health is influenced. It allows for dynamic interactions between persons, where and how they live, and how they interact with their health systems. Ignoring this multilevel dynamic of health has led to an erosion of health outcomes in the United States. For example, a lack of access to healthy foods, few community supports to sustain physical activity, and a treatment-focused health care approach has created an unprecedented public health epidemic—the obesity epidemic. Obesity affected 25% of the US population in 2012, more than double the rate of 10% of the population in 1990.3 The repercussions of these population health trends are also felt at the local level. Health systems are overutilized, and health care costs continue to rise. This has necessitated a more careful and strategic coordination between health care and public health, with population health as the center of focus. Public health is a core component of health system transformation, but it is often confused with population health. Population health is distinct and should be seen as both a conceptual framework and the factors that strongly influence health outcomes. This understanding allows us to link population health to the ongoing work of public health as state and local governments working with the federal government toward a national effort. This link between population health outcomes and public health reinforces the definition of public health offered by Roz Lasker. [Public health] focuses on ... assessing and monitoring health problems, informing the public and professionals about health issues, developing and enforcing health-protecting laws and regulations, implementing and evaluating population-based strategies to promote health and prevent disease, and assuring the provision of essential health services.4(p5) The graphic framework shown in the Figure illustrates how public health can play a role in transforming health systems and work toward the shared vision for population health. Public health has been framed in many ways, including the 10 essential services of public health within the 3 core functions of assessment, assurance, and policy development.5 Related to health system improvement and integration, it will be important to build out the work of public health and how integration with health care can help improve population health. This framework is best broken down by its components as follows:FIGURE: •. The Role of Public Health in Improving Population Health OutcomesPolicy Development One of the 2 overarching roles in public health is policy development. State health agencies communicate regularly with their state legislators, the governor's office, and other stakeholders involved in shaping public health policy. Public health works to create and inform policy to keep the population healthy and safe while reducing the cost burden. Program-related efforts remain an important part of the work of health agencies, but the broadest impact can be found in policy efforts. Some of the most significant victories in improving population health have come about as a result of policy efforts, including in motor vehicle injury (the use of seat belts) and work in tobacco cessation (taxes, regulation, and elimination of smoking spaces in public buildings). Regulatory Role Hand-in-hand with policy development, the regulatory role is the second overarching role of public health. Health agencies have broad authority to carry out public health functions in their jurisdictions. This authority includes, but is not limited to, the adoption and enforcement of rules, policies, and guidelines; data collection and analysis; emergency response; clinical services; and investigations. At the state level, many public health agencies regulate, license, and inspect a variety of health system partners that provide clinical services, including hospitals, clinics, and hospice facilities. Many state health agencies are also involved in the licensure and regulation of health care providers, including nurses, physicians, physician assistants, dentists, and pharmacists. Emergency Response Emergency response is 1 of 4 primary functions of public health. Public health emergency response activities have evolved in the past 12 years to the key role that we have today. Public health agencies participate throughout the cycle of preparedness, mitigation, response, and recovery, working collaboratively with emergency management, law enforcement, and health care providers (eg, hospital preparedness). Through the investment in developing improved capabilities, training, planning, and exercises, public health agencies are an essential partner with these first-responder agencies. Public health can leverage subject matter expertise, a coordinating role with the health care system, well-developed communication systems, and planning capabilities. The public health system has been challenged by a wide range of emergencies, both naturally occurring and man-made, and has demonstrated the ability to respond competently and professionally. Clinical and Population Data Another key function for state health agencies is to provide support for population assessment to determine medically underserved areas, medically underserved populations, and health care professional shortage areas. These assessments allow public health to work with the federal government in workforce distribution and safety net component placement. Public health works to coordinate services between private practice providers and other clinicians to improve access to care. It also works through legislation to build the primary care workforce within their jurisdictions, which includes administering a number of data collection efforts, including surveys and vital statistics, in coordination with local and federal agencies. Clinical Services Many public health agencies offer clinical services, including access to care for rural populations and other areas with clinical workforce shortages. Public health agencies are a vital part of the safety net and work with other components of the safety net, such as retail clinics and health centers, to improve access to services. There is also a careful coordination with hospital systems to ensure adequate reach and quality of services to underserved populations. Public health also provides specialized clinics both to treat tuberculosis and AIDS and to offer family planning and other services. Patient Safety Public health is responsible for protecting patients across the health care system and serves as a bridge between health care and the community. It leads the response to widespread outbreaks originating in health care settings, including collecting community-level data on trends and patterns, detecting and identifying problems, and working with facilities to address and prevent further infections. The recent fungal meningitis outbreak is a good example of what public health brings to patient safety—an individual physician knows his or her patient has an infection, and the hospital may detect a pattern, but public health can investigate across facilities and jurisdictions to determine how widespread the problem is and take quick action to contain the outbreak. According to the ASTHO Profile of State Public Health,6 health agencies spent 6% of fiscal year 2009 expenditures on a range of activities related to quality of health services, including hospital licensure (42 states). In recent years, public health entities have scaled up efforts to address several critical areas of patient safety: health care–associated infections, antimicrobial resistance, injection safety, health care worker vaccination, and injury prevention. Patient and Community Engagement An important tool used by the public health enterprise is enabling people to make informed choices about their health by informing individuals and communities about healthy practices and leading community health assessments. They also often serve as conveners for multipartner collaboration on community improvement. Public health brings a key interest in this work without a bias toward anything other than a healthy population. The public health official is often seen as a subject matter expert on health who is expected to provide education and expert opinion to inform the community and state policy makers. This expertise has the capacity to inform more national efforts, including actions within the scope of the US Congress and the Executive Administration related to the overall public health enterprise. Several public health officials have testified before Congress or advised other parts of the federal government. Bully Pulpit Public health leaders have unique responsibility and opportunity to inform and advance the health of population in the public forum. Governmental public health leaders are highly educated and experienced health care professionals. Most have a terminal degree in a health-related field, and many are, by statute, physicians. This background with their role in public service allows them to speak with authority on health-related issues to inform policy and to appeal, from the executive branch of state governments to the policies and programs that work toward a healthy population. They speak with legislators and the governors in their jurisdictions as well as directly to the public and media. Total Population Access Equal access to care will be a part of any effort to improve health outcomes. This means both considering the needs of people at all socioecological levels in their interaction with the health system and the opportunity to live a healthy lifestyle. Public health works with other health system components to reduce health disparities related to everyone's access to care, including partnering with several components of the safety net to improve access and working to improve the health care workforce with policy-level initiatives to recruit and retain primary care practitioners. This improved access is accompanied by work to promote access to healthy environments and to help ensure that, for the public, the healthy choices are the easiest choices. These components of public health demonstrate the important role health agencies play in improving population health. Health officials work at several levels, both within and outside the health care system, to improve health outcomes. We are now at a point in our health system improvement that we can take steps to further integrate public health and health care. There is, at once, both precedent and promise. We must continue our work to claim the successful steps taken to date, demonstrate the profitability of this integration, and work to resource it while collecting data that can be used to create and inform solid policy decisions. These steps toward improvement will allow us to work both toward a transformed health system and toward improved outcomes for population health.

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