David Palm

Resource allocation and funding challenges for regional local health departments in Nebraska.

OBJECTIVEnThis study examined the mechanism of resource allocation among member counties and the funding challenges of regional health departments (RHDs) in Nebraska. DESIGN AND STUDY SETTING: In 2009, we conducted a qualitative case study of 2 Nebraska RHDs to gain insight into their experiences of making resource allocation decisions and confronting funding challenges. The 2 RHD sites were selected for this case study on the basis of their heterogeneity in terms of population distribution in member counties. Sixteen semistructured in-person interviews were conducted with RHD directors, staff, and board of health members. Interview data were coded and analyzed using NVivo qualitative analysis software (QSR International [Americas] Inc., Cambridge, MA).nnnRESULTSnOur findings suggested that the directors of RHDs play an integral role in making resource allocation decisions on the basis of community needs, not on a formula or on individual county population size. Interviewees also reported that the size of the vulnerable population served by the RHD had a significant impact on the level of resources for RHDs programs. The RHDs decisions about resource allocation were also dependent on the amount and type of resources received from the state. Interviewees identified inadequacy and instability of funding as the 2 main funding challenges for their RHD. These challenges negatively impacted workforce capacity and the long-term sustainability of some programs.nnnCONCLUSIONSnRegional health departments may not benefit from better leveraging resources and building a stronger structural capacity unless the issues of funding inadequacy and instability are addressed. Strategies that can be used by RHDs to address these funding challenges include seeking grants to support programs, leveraging existing resources, and building community partnerships to share resources. Future research is needed to identify RHDs optimal workforce capacity, required funding level, and potential funding mechanisms.

Effectiveness and challenges of regional public health partnerships in Nebraska.

OBJECTIVEnThe purpose of this study is to examine the effectiveness and challenges of regional public health partnerships by exploring the experiences of 2 multicounty LHDs in Nebraska.nnnSETTINGSnThe selection of the 2 local health department (LHD) sites was on the basis of the history of prior collaborative partnership in the LHD jurisdiction. Both regional LHD jurisdictions cover a service area of 9 counties.nnnDESIGNnA mixed method research design was used for this study. We first conducted an online survey to create an inventory of partnerships for each LHD site. Then, we collected quantitative data to measure the effectiveness of partnerships through a survey of community partners in both LHD sites. We also collected qualitative information through telephone interviews with community partners and LHD staff to examine the challenges for building an effective regional partnership.nnnRESULTSnRegional public health partnerships are most effective in efficiency, but less effective in the areas of management and resource sufficiency. More effort is still needed to maximize the collaborative potential for the majority of partnerships in both regions. In particular, geographic distance and work demand were identified as the 2 major challenges by community partners. The community health planning partnership in the LHD site with prior history of collaboration was more effective than its counterpart without such history.nnnCONCLUSIONSnPolicy makers should consider developing policies to assist multicounty LHDs with improving their management of regional partnerships and with providing sufficient resources to support their regional partnerships. If possible, the formation of regional community health planning partnership should follow the geographic boundaries where prior collaboration already existed.

A Comparison of the J-1 Visa Waiver and Loan Repayment Programs in the Recruitment and Retention of Physicians in Rural Nebraska

PURPOSEnThere is a dearth of literature evaluating the effectiveness of programs aimed at recruiting and retaining physicians in rural Nebraska. Taking advantage of the Nebraska Health Professional Tracking System, this study attempts to comparatively assess the effectiveness of the J-1 visa waiver and state loan repayment programs in the recruitment and retention of physicians in rural Nebraska.nnnMETHODSnA mixed methods approach was used. We tracked 240 physicians who enrolled in the J-1 visa waiver and state loan repayment programs between 1996 and 2012 until 2013. In addition, key informant interviews were conducted to obtain perspectives on the recruitment and retention of physicians in rural Nebraska through the 2 programs.nnnFINDINGSnResults from multilevel survival regression analysis indicated that physicians enrolled in the J-1 visa waiver program were more likely to leave rural Nebraska when compared with those enrolled in the state loan repayment program. Participants in the qualitative study, however, cautioned against declaring one program as superior over the other, given that the 2 programs addressed different needs for different communities. In addition, results suggested that fostering the integration of physicians and their families into rural communities might be a way of enhancing retention, regardless of program.nnnCONCLUSIONnThe findings from this study highlight the complexity of recruitment and retention issues in rural Nebraska and suggest the need for more holistic and family-centered approaches to addressing these issues.

Designing and building new local public health agencies in Nebraska.

Prior to 2001, the local public health system in Nebraska was weak, fragmented, and severely under funded. Local public health departments covered only 22 of the states 93 counties. The Turning Point project provided the impetus for change by allowing a diverse group of public health stakeholders to develop a strategic plan for strengthening and transforming the public health system. The plan acted as a catalyst to use some of the Nebraska Tobacco Settlement Funds to provide dedicated state funding to build the local public health system. By June 2002, 16 new local public health departments had been organized, ultimately covering all of the 93 counties in the state. Some of the keys to long-term sustainability are creating a network of community health partners that support collaborative decision making, continually seeking input from the community, developing and implementing an education and training plan for public health professionals and local board of health members, and demonstrating accountability by documenting results and communicating them to policy makers and the general public.

Measuring the Cost and Value of Quality Improvement Initiatives for Local Health Departments.

Objective: To demonstrate an approach to measuring the cost and value of quality improvement (QI) implementation in local health departments (LHDs). Design: We conducted cost estimation for 4 LHD QI projects and return-on-investment (ROI) analysis for 2 selected LHD QI projects. Setting and Participants: Four Nebraska LHDs varying in rurality and jurisdiction size. Main outcome measures: Total costs, unit costs, incremental cost-effectiveness ratios, and ROI. Results: The 4 QI projects vary significantly in their cost estimates. Estimated ROI ratios for 2 QI projects predicted significant savings in health care utilization for respective program participants. A QI project focused on improving breastfeeding rates in WIC (women, infants, and children) clients had a predicted ROI ratio of 3230% and a QI project for improving participation in a Chronic Disease Self-Management Program would need only 34 new participants to have a positive ROI. Conclusions: We demonstrated how data can be collected and analyzed for cost estimation and ROI analysis to quantify the economic value of QI for LHDs. Our ROI analysis shows that QI initiatives have great potential to enhance the value of LHDs public health services. A better understanding of the costs and value of QI will enable LHDs to appropriately allocate and utilize their limited resources for suitable QI initiatives.

The EDIC Method An Engaging and Comprehensive Approach for Creating Health Department Workforce Development Plans

In 2013, the Nebraska Department of Health & Human Services, Division of Public Health (Nebraska’s State Health Department); and the University of Nebraska Medical Center, College of Public Health developed a comprehensive approach to assess workforce training needs. This article outlines the method used to assess the education and training needs of Division staff, and develop comprehensive workforce development plans to address those needs. The EDIC method (Engage, Develop, Identify, and Create) includes the following four phases: (1) Engage Stakeholders, (2) Develop Assessment, (3) Identify Training Needs, and (4) Create Development Plans. The EDIC method provided a process grounded in science and practice, allowed input, and produced buy-in from staff at all levels throughout the Division of Public Health. This type of process provides greater assurance that the most important gaps in skills and competencies will be identified. Although it is a comprehensive approach, it can be replicated at the state or local level across the country.

Relationship between quality improvement implementation and accreditation seeking in local health departments.

OBJECTIVESnWe examined the relationship between quality improvement (QI) maturity and accreditation attributes of US local health departments (LHDs), specifically those in Nebraska.nnnMETHODSnUsing 2011 Nebraska LHD QI survey data, we conducted Spearman correlation analyses between QI maturity domains and accreditation attributes. Using the 2010 National Association of County and City Health Officials National Profile of LHDs, we conducted logistic regression analyses to examine the relationships between specific QI strategies and attitude toward seeking accreditation.nnnRESULTSnLeaders commitment to and length of time engaged in QI were positively associated with LHDs general attitude toward seeking accreditation. Use of QI strategies and integration of QI policies and practices were positively associated with LHDs confidence in their capacity to obtain accreditation. LHDs that had used at least 1 QI framework and at least 1 QI technique in the past year were more likely to agree that they would seek accreditation within 2 years of the national accreditation program.nnnCONCLUSIONSnExperience with and expertise in QI implementation play an important role in LHDs decision to seek accreditation, and their accreditation-seeking efforts may benefit from prior implementation of systematic QI strategies.

The relationship between county variation in macro contextual factors and the performance of public health practice in regional public health systems in Nebraska

OBJECTIVEnThis study examined the relationship between county variation in macro contextual variables and the performance of public health practice in regional local health departments (LHDs) in Nebraska. DESIGN AND MAIN OUTCOMES MEASURES: County-level data from the US Census Bureau, the Nebraska Department of Health and Human Services, and the University of Nebraska Medical Centers Health Professions Tracking Services were used to create macro context variables (eg, demographic, geographic, social, economic, population health status). The public health performance data were collected through a mail survey of the directors of regional LHDs in Nebraska in 2008. Public health performance measures were created to indicate LHDs general performance as well as core function specific performance (ie, assessment, assurance, policy development). The coefficients of variation were estimated and used to categorize each regional LHD into either a larger county variation group or a smaller county variation group for each domain of macro context variables. Statistical comparisons of public health performance measures were then made between these 2 groups for each domain.nnnRESULTSnThe results suggest that the county variation in macro contextual variables within a regional public health district, in general, is negatively associated with the performance of public health practice in regional LHDs. The regional LHDs performance in specific public health core function (eg, assurance) is negatively associated with the county variation in specific types of macro context factors (eg, geographic factors such as land size and population density).nnnCONCLUSIONSnRegional LHDs may design and implement their public health programs on the basis of the type and degree of heterogeneity among the member counties within their jurisdiction. The formation of regional LHDs, if possible, should follow geographic boundaries that minimize the heterogeneity of county composition in terms of macro contextual factors.

Longitudinal Evaluation of Quality Improvement and Public Health Accreditation Readiness in Nebraska Local Health Departments, 2011-2016:

Objectives: Public health accreditation is intended to improve the performance of public health departments, and quality improvement (QI) is an important component of the Public Health Accreditation Board process. The objective of this study was to evaluate the QI maturity and accreditation readiness of local health departments (LHDs) in Nebraska during a 6-year period that included several statewide initiatives to progress readiness, including funding and technical assistance. Methods: We used a mixed-methods approach that consisted of both online surveys and key informant interviews to assess QI maturity and accreditation readiness. Nineteen of Nebraska’s 21 LHDs completed the survey in 2011 and 2013, 20 of 20 LHDs completed the survey in 2015, and 19 of 20 LHDs completed the survey in 2016. We facilitated a large group discussion with staff members from 16 LHDs in 2011, and we conducted key informant interviews with staff members from 4 LHDs in 2015. Results: Both QI maturity and accreditation readiness improved from 2011 to 2016. In 2011, of 19 LHDs, only 6 LHD directors agreed that their LHD had a culture that focused on QI, but this number increased every year up to 12 in 2016. The number of LHDs that had a high capacity to engage in QI efforts improved from 3 in 2011 to 8 in 2016. The number of LHDs with a QI plan increased from 3 in 2011 to 10 in 2016. The number of LHDs that were confident in their ability to obtain Public Health Accreditation Board accreditation improved from 6 in 2011 to 13 in 2016. Although their QI maturity generally increased over time, LHDs interviewed in 2015 still faced challenges adopting a formal QI system. External financial and technical support helped LHDs build their QI maturity and accreditation readiness. Conclusion: Funding and technical assistance can improve LHDs’ QI maturity and accreditation readiness. Improvement takes time and sustained efforts by LHDs, and support from external partners (eg, state health departments) helps build LHDs’ QI maturity and accreditation readiness.

Fewer immigrants have preventable emergency department visits in the United States.

Objective: The aim of this study is to examine differences in having preventable emergency department (ED) visits between noncitizens, naturalized and US‐born citizens in the United States. Methods: We linked the 2008–2012 Medical Expenditure Panel Survey with National Health Interview Survey data to draw a nationally representative sample of US adults. Univariate analysis described distribution of preventable ED visits identified by the Prevention Quality Indicators across immigration status. We also assessed the association between preventable ED visits and immigration status, controlling for demographics, socioeconomic status, health service utilization, and health status. We finally applied the Oaxaca‐Blinder decomposition method to measure the contribution of each covariate to differences in preventable ED services utilization between US natives, naturalized citizens, and noncitizens. Results: Of US natives, 2.1% had any preventable ED visits within the past years as compared to 1.0% of noncitizens and 1.5% of naturalized citizens. Multivariate results also revealed that immigrants groups had significantly lower odds (adjusted OR: naturalized citizen 0.77 [0.61–0.96], noncitizen 0.62 [0.48–0.80]) of having preventable ED visits than natives. Further stratified analysis by insurance status showed these differences were only significant among the uninsured and public insurance groups. Race/ethnicity and health insurance explained about 68% of the difference in preventable ED service utilization between natives and noncitizens. Conclusion: Our study documents the existing differences in preventable ED visits across immigration status, and highlights the necessity to explore unmet health needs among immigrants and eliminate disparities.