Partnerships & Capacity Building
Room: Triple Crown I, II, & III
Wednesday, April 22, 2015, 9:00 to 10:30 AM
Moderator: Susan Zahner, DrPH, MPH, RN
Rachel Hogg, DrPH, MA
Exploring the Impact of the Public Health System Network on Local Health Department Efficiency
Co-Investigator(s): Glen Mays, PhD, MPH & JS Butler, PhD
Background: Research around how efficiently Local Health Departments (LHDs) operate and deliver public health services is still an emerging body of work and much less is understood about what external factors impact efficiency. Because public health delivery does occur through the combined actions of multiple organizations in the community, the structure and network of the public health systems may have a relationship with how efficiently local health departments operate. Research Objective: This analysis seeks to understand the impact local public health system structure and other system characteristics have on how efficiently LHDs across the United States are delivering public health activities. Study Design: Results from panel stochastic frontier analysis (SFA) to generate local health department efficiency scores were merged with social network analysis (SNA) measures of average public health system degree centrality and density (n=729). Centrality captures the number of relationships that an organization maintains with other organizations in the network and density measures the proportion of total possible relationships that exist between organizations in the network. SFA is an econometric technique that uses an input/output ratio to estimate an ideal production frontier that can be used to generate measures of organization technical efficiency. Analysis: A multivariate regression model was used to estimate the impact of the SNA measures on the efficiency of public health service delivery. Information on agency and community characteristics serve as controls in the model. Data Sets and Sources: Inputs for the model consist of full time equivalent (FTE) employee data, lab capacity, and socioeconomic and demographic characteristics from the 1997, 2005, and 2010 waves of the National Association of County and City Health Officials (NACCHO) Profile. The composite output includes measures of public health service availability and perceived service effectiveness from the 1998, 2006, and 2012 waves of the National Longitudinal Survey of Public Health Systems (NLSPHS) and population served size. The NLSPHS follows a nationally-representative cohort of local public health systems over time (n=397), profiling the availability of 20 core public health services within their jurisdictions. Principal Findings: Technical efficiency ranges from a low of 1.5%, to a high of 88%. The average among LHDs is 0.50, meaning that the typical LHD in our sample operates with 50% inefficiency. Multivariate regression found a positive curvilinear association between public health system average degree centrality and density (p<0.001), with gains in efficiency decreasing after reaching a threshold. Conclusions: Local health department efficiency is positively impacted by increasing levels of overall network centrality and density, although evidence does suggest returns to scale exist. Implications for Public Health Practice and Policy: Strong local public health system network structures may have a positive impact on the level of LHD efficiency by bring more system partners into local public health and increasing the number of activities in which individual organizations participate. However, economies of scale exist with efficiency eventually decreasing. This may suggest that less efficient information sharing and problems with coordinating a large number of partners and organizations impacts the service production process.
J. Mac McCullough, PhD, MPH
Patterns and Correlates of Public Health Informatics Capacity Among Local Health Departments: An Empirical Typology
Co-Investigator(s): Kate Goodin, MPH
Background: Public health informatics and information systems have long been cited as a way to strengthen the work of public health departments. Yet little is known about the nationwide patterns in the use of public health informatics systems by local health departments (LHDs). For example, it is not known whether LHDs tend to possess informatics capacity across a broad range of information functionalities or for a narrower range of specific systems. Research Objective: This study created a novel, empirically-derived typology of LHD informatics capacities. This typology was then used to examine patterns and correlates of the presence of public health informatics functionalities within LHDs across the United States. Data Sets and Sources: Data came from the 2013 National Association of County and City Health Officials Profile (NACCHO) survey. Data were available for a total of 459 LHDs Study Design: 2013 NACCHO Profile survey data were used in this cross-sectional study of LHD informatics capacities. Analysis: An empirical typology was created through cluster analysis of six public health informatics functionalities: immunization registry, electronic disease registry, electronic lab reporting, electronic health records, health information exchange, and electronic syndromic surveillance system. Three-categories of usage emerged (Low, Mid, High). LHD financial, workforce, organization, governance, and leadership characteristics, and types of services provided were explored across categories. Principal Findings: According to our empirical typology, LHDs are clustered in three categories of informatics usage: Low (24.4%), Mid (20.4%), and High (55.6%). The LHDs with the lowest level of informatics usage had significantly lower levels of usage than high-capacity LHDs for all six functionalities assessed. Mid-informatics capacity LHDs had usage levels equivalent to high-capacity LHDs for the three most common functionalities and equivalent to low-capacity LHDs for the three least common functionalities. Informatics capacity was positively associated with service provision, especially for population-focused services. Conclusions: Informatics capacity is clustered within LHDs. Provision of population-focused services are highly correlated with higher informatics capacity. Increasing LHD informatics capacity may require LHDs with low levels of informatics capacity to adopt a range of functionalities, even taking into account their narrower service portfolio. LHDs with mid-level informatics capacity may need specialized support in enhancing capacity for less common technologies. Implications: National patterns in the use of public health informatics have been poorly understood to date. This study’s empirically-derived typology represents a novel conceptualization of department-wide informatics capacity. Our findings suggest two broad approaches to strengthen informatics capacity on a national level. First, LHDs with low informatics capacity may need broad support or technical assistance, with special consideration for how these LHDs can maximize the value of informatics to their work and their communities, given their lower levels of service provision. Second, for mid-level informatics capacity LHDs, strategies to promote adoption of less common technologies (e.g., electronic health records or health information exchange) may be most beneficial. These departments already have strong capacity for the more common informatics capacities, but targeted work is likely to be more beneficial than broad-based approaches. Consideration to state-level factors may be especially important for these LHDs.
Huabin Luo, PhD
Factors Driving Local Health Department’s Collaboration with Other Organizations in the Provision of Personal Healthcare Services
Co-Investigators: Nancy Winterbauer, PhD; Ashley Tucker, MPH;& Gulzar Shah, PhD
Background: Recent work has highlighted the necessity of integrating primary care services and public health to improve quality and reduce the cost of healthcare. Research Objectives: To describe levels of partnership between local health departments (LHD) and other organizations in the community in the provision of personal healthcare services; and to assess LHD organizational characteristics and community factors that contribute to partnerships. Data Sets and Sources: Data were drawn from the 2013 NACCHO Profile Study (Module 1) and the Area Health Resource File. A total of 490 LHDs responded to Module 1, where LHDs were asked to describe the level of partnership for selected programs including three personal healthcare services—Maternal and Child Health (MCH), communicable/infectious disease control, and chronic disease prevention. The five levels of partnership were measured on an ordinal level from “not involved”, “networking”, “coordinating”, “cooperating”, to “collaborating”, with “collaborating” as the highest level of partnership. The level of partnership in these three personal healthcare services were the outcomes examined in this analysis. Covariates included both LHD organizational and community factors. Study Design: This is a cross-sectional study, based on secondary data from multiple sources, linked at the LHD as a unit of observation. Analysis: Three ordinal logistic regression models were run to assess factors associated with higher levels of partnership in the three personal healthcare programs. Data analyses were conducted using Stata 13 SVY procedures to account for the Profile Study’s survey design. Principal Findings: Overall, proportions of LHDs at the five levels of partnership—not involved, networking, coordinating, cooperating , and collaborating—for MCH were 11.8%, 12.4%, 28.3%, 24.9%, and 22.6%; for infectious disease control were 8.1%, 3.9%, 27.6%, 31.8%, and 28.9%; for chronic disease prevention were 10.4%, 14.2%, 37.7%, 21.2%, and 16.5%, respectively The proportion of LHDs engaged in collaboration, the highest level of partnership, increased with LHD jurisdiction population size. For MCH, 14.1% of LHDs with =500,000 people reported collaboration (p=500,000 reported collaboration with other organizations in the community (p<0.01). Ordinal logistic regression model results indicated that LHDs having a public health physician on staff were more likely to have engaged in higher levels of partnership in MCH (AOR=2.40, p<0.001), and in chronic disease prevention (AOR=2.57, p<0.001). Completion of a community health assessment was associated with higher levels of partnership in MCH (AOR=2.98, p=0.01), and in chronic disease prevention (AOR=4.57, p=0.03). Higher per capita expenditure was also associated with higher levels of partnership in MCH (AOR=1. 86, p<0.001), and in chronic disease prevention (AOR=1.40, p=0.03). Conclusion: Level of partnership varied across LHDs of different jurisdiction population sizes. And the level of partnership was highest for infectious disease control, and the lowest in chronic disease prevention. Implications for Public Health Practice and Policy: Factors that might promote LHD’s collaboration in the provision of personal health care services include having a public health physician on staff, higher per capita expenditure, and conducting a community health assessment.
Danielle Varda, PhD
Leveraging Resources in Cross Sector Collaboration: The Role That Nonprofits Play in Public Health Systems
Co-Investigator(s): Rachel Hogg, DrPH, MA& Carrie Chapman
Background: As demand for public health activities increases, public health agencies often turn to collaborative partnerships in order to relieve scarce resource burdens and achieve a broader range of outcomes than a single organization could facilitate independently. The transition to collaborative arrangements, a priority area in PHSSR, involving public, private, and nonprofit sector organizations poses unique challenges for organizations involved in the provision of public health activities. Resource contributions and mission objectives vary among partner agencies, and may affect the outcomes a collaborative seeks to achieve. Previous research has identified nonprofit organizations as a major contributor to public health activities, however very little empirical work has been done to evaluate the contributions these type of organizations typically provide. Research Objective: The analysis evaluates sector-based resource contributions and mission alignment in 170 public health networks to better understand the value that nonprofits bring to the public health system, and how the challenges of bringing diverse partners together may be overcome by practitioners in the public health community when their activities are informed by data. Datasets and Sources: Data for this analysis comes from the PARTNER (Program to Analyze, Record, and Track Networks to Enhance Relationships, www.partnertool.net) dataset. A sample of 170 public health collaboratives from around the US were selected and analyzed based on a set of common criteria. Study Design: This study is a secondary analysis of organizational level and whole network data. Analysis: Organizational level data were analyzed using one-way ANOVA tests to determine if significant differences in responses existed across sectors. Next, weighted least squares regression models determine how sector-based differences affect the number of outcomes a collaborative is able to achieve and agreement among collaborative members regarding the most important outcome. Principal Findings: The findings indicate that significant differences in resource contributions, perceptions of mission alignment, and the value of mission adherence to collaborative success exist across sectors. Compared to public and private organizations, nonprofit organizations were found to bring a greater number and diversity of resources to public health collaboratives, as well as being perceived by their public and private partners as having the strongest support of the collaborative’s mission. Conclusions: This study suggests that nonprofits, while contributing fewer financial resources than public organizations, are more likely to contribute additional resources. In particular, a greater number of nonprofits contributed volunteers, feedback, expertise, community connections/networking, and advocacy than either public or private organizations. Previous research indicates a high need for these resources in collaborative partnership, and nonprofits may be a more frequent source of their provision. Additionally, significant differences in perceptions of mission alignment indicate the need to develop innovative strategies aligning collaborative objectives. Implications: While benefits exist when engaging in collaborative partnerships in public health, challenges inevitably arise when organizations work across sectors. The findings from this study have both theoretic and practical implications. As public health service delivery increasingly relies on collaborative arrangements, it is critical to understand what practical challenges these collaboratives face, and to identify techniques for effectively managing intersectoral partnerships.