Chief Health Strategists: How Public Health Leaders Can Be Successful Working Across the Health Landscape, Part I

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

Today: part one of a two-part series on the future of the public health discipline.

JOHN AUERBACH:
Public health is critically important in this country. We need to be as strong, and robust, and effective as possible.

JOHNSON:
And the view that state health departments must rethink their approach if they want to remain effective in their communities.

MARY ANN COONEY:
Public health will die if it doesn't make these changes.

JOHNSON:
Welcome to Public Health Review, a new podcast brought to you by the Association of State and Territorial Health Officials.

With each episode, we'll discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

On this episode: the first of two discussions about the concept known as chief health strategists. How is it defined? How does it work? And is it simply a job description within a state health department or a role everyone on staff needs to adopt?

We start our conversation on the future of the public health practice with John Auerbach, president and CEO of the Trust for America's Health, headquartered here in Washington, D.C.

He explores with us the origin of the concept and tells us exactly how to think like a chief health strategist.

AUERBACH:
A few years ago, the Robert Wood Johnson Foundation brought together a number of different organizations and challenged us to think through the future of public health to help public health departments understand how they needed to change and adapt to the new conditions that they were facing at the local, state, and federal levels.

The idea of a chief health strategist was a vision for the future and, hopefully, a guide path for health departments to get there.

JOHNSON:
Can you explain the concept in detail?

AUERBACH:
The idea behind it was to step back from the practices that we have been involved in for decades and reflect on what were the current situations that were being faced around the country with regard to health and well-being.

And so, the idea was to consider the key steps that needed to be taken by a health department if they were going to be well-prepared for the challenges of the future.

JOHNSON:
How long have people been looking at this idea? How long has it been on the street?

AUERBACH:
The notion of chief health strategist has been in existence for about four years now. There was an initial publication that shared the idea fairly widely; and since then, there've been a number of other articles that have been written on it.

And lots of meetings around the country—when the state health departments would hold their annual meetings, they would often have a speaker who would explain the chief health strategist, and then there'd be a good deal of discussion about it.

JOHNSON:
Does it require a health department to do something different?

AUERBACH:
It does.

It requires a few steps—there are, in fact, are six steps that are outlined in the notion of a chief health strategist; and some of those will be familiar to health departments, but a number of them will be different than what health department officials have been accustomed to in the past.

JOHNSON:
Can we go through the steps?

AUERBACH:
Certainly.

The first one is to take a good hard look at the demographics and health indicators for a community. Health departments are funded in a restrictive way—they get their money to work on a particular health issue with a budget that limits their ability to be flexible.

I am a former state health official, former local health official, so I'm very familiar with those restrictions. And when they come, it tends to put something of blinders on a health official. They work on the activities they've been funded to do.

So, the first notion is to put that aside for a moment and just look at the data. Understand your community, understand who is in it, what the demographics are, what the trends are, and what the health issues are within the community. Get a full and complete understanding of that and use that as a basis for the work that you should be doing.

And, frankly, compare whether what you have been doing is consistent with what you should be doing, given the demographics and health needs in your community.

I can give an example of that.

JOHNSON:
Please.

AUERBACH:
We are seeing very clearly that the population is aging—the percentage of the population that are 65 years old or older is growing very rapidly—but health departments, for the most part, haven't been funded to provide services to that population.

The history of public health is more maternal and child health, more focused on infectious disease. So, when we have this growing population of older adults over 65 with lots of chronic ailments, the risks associated with sensory loss, and with dementia, health departments are not accustomed to addressing those issues, but they should be.

So, identifying that as a gap is part of that first step.

JOHNSON:
Step two.

AUERBACH:
Step two is to consider the interventions that have the strongest evidence of efficacy.

Here, too, public health practitioners care a lot about evidence, but we've often done public health a particular way, even if evidence is not so strong.

And so, step two says it's very important to take the time to study up, read the literature, understand what the evaluations say, and look at whether or not the practice of public health is consistent with what the evidence would say are the most effective activities.

So, know what works and be prepared to utilize those interventions.

JOHNSON:
The departments that are going through this, do they find a big disconnect when they get to step two?

AUERBACH:
They sometimes do. They sometimes do. One example of that I think I would offer is with tobacco.

So, with tobacco, we know exactly what we can do to reduce the use of tobacco. The most effective approach are price-related strategies—increasing the price of tobacco products. invariably reduces the utilization. So, relying on pricing strategies, relying on policies that limit the locations where smoking can take place, is an example of what we know works.

Sometimes those approaches are utilized. Sometimes they're not. That can be related to the political environment, but it may be related to whether or not the health departments are most familiar with what works the most effectively.

JOHNSON:
What's third on the list?

AUERBACH:
Third on the list relates to data, and it acknowledges that public health officials have often relied on a limited pool of data sources.

The golden data source for most public health officials is the CDC’s Behavioral Risk Factors Surveillance survey, but that comes out rather late, or about a year and a half to two years after the information is gathered. So, it isn't a timely data source.

We also know that, unlike 20 years ago, there is a lot more data sources: there are social media; and there's the private sector, which is gathering data; there are electronic medical records that didn't exist 20 years ago.

And public health hasn't always been able to tap into those very data sources so that it can get closer and closer to real-time information. If we have to rely on information that's a year and a half to two years old, that's not the best that we can do because health conditions change quickly.

So, we need to think about tapping into those data sources, pool them in a creative way, and share them with the public in a way that analyzes how they help us to understand the health of the community.

JOHNSON:
Why don't they use those other sources of data? Is it cost? Resources? People? All of the above?

AUERBACH:
All of the above. Some of it is cost.

I think some of it is that we weren't trained to understand those other data sources when we went to a public health school. Those are newer data sources that we were not as familiar with. We can't accurately assess which ones are, give us better insight than others.

So, there's lots of great work that's going on this around the country and there are health departments that are beginning to do this, but it requires having specialized staff who know what they're doing and know how to interact with people who are gathering that data, know how to filter out what's not so accurate and take what is accurate.

So, it is not easy to do. It's not easy to do. And sometimes it, of course, it does, it increases your budget that you have to put aside for data collection, but it's critically important, or else we'll be left on the sidelines. And we'll be reading about the studies that are coming out, the reports that are coming out on public health that are developed by people outside of the public health sector.

JOHNSON:
And the risk is your audience knows more about what's going on than you do.

AUERBACH:
That's one risk.

The other risk is you're targeting your work in the wrong direction because you're looking at information that's outdated, and since then conditions have changed, but you don't know it so you're not being as far as effective in terms of addressing a health problem as you might be.

JOHNSON:
What's number four?

AUERBACH:
Number four recognizes that public health needs to establish a close working relationship with the healthcare sector.

The healthcare sector is a sector that public health has long had connections to as we've immunized people and as we've treated different infectious diseases. But at this current time period, when we've seen the dramatic increase in terms of people who have insurance—20 million more people having insurance—many of the people we used to offer services to now get services in the healthcare sector, and we need to adapt our activities to recognize that we don't need to provide as many safety-net services as we used to.

But there are some things public health can do that the healthcare sector can't do. We're very good, for example, at complementing clinical care by working with families, individuals, and communities to do home visits or to think about the policy changes that, if put into place, would complement the clinical recommendations that doctors are making by creating healthier conditions in the community.

But it does require we work very closely with healthcare and we understand what they can pay for, what they can’t pay for, and how we can essentially work as a team to do all we can to maximize the health of the population.

JOHNSON:
Is that easier said than done?

AUERBACH:
It's not easy. The healthcare sector is quite diverse in any community. There might be multiple hospital systems, and there may be many different community health centers or private practitioners. So, for a health department that doesn't have a lot of excess resources, it's not always easy to determine, “Who should I work with?”

But health departments are diving into this, and they're figuring out where to begin. Sometimes you begin with one group—maybe it's the health centers—and you develop those connections, and you think about what you can do differently, what they can do differently, that's going to result in positive health outcomes.

JOHNSON:
Do you find that most health departments have the relationships with the health sector that are necessary to get this step accomplished on the checklist?

Or is there a lot of work to do just getting to know people?

AUERBACH:
Well, I think it's very uneven.

The state health department officials that I know, for example, don't always work closely with the state’s Medicaid programs—their fellow colleagues, often, in the governor's cabinet. When I was a state health official, I was friendly with a Medicaid director, but I didn't work with a Medicaid director.

That's an example of an opportunity that sometimes health departments, public health departments are able to take advantage of but can't always do it easily. People in Medicaid programs, commercial payers, the healthcare sector, sometimes speak a different language: they’re focused on actuarial reports; they're focused on looking at patient outcomes in a way that is different than how public health thinks.

So, training public health people to understand the culture, the language, the priorities that are being set in the healthcare sector is important. Similarly, training the healthcare sector to understand what public health does and the potential that we can offer. Something very valuable to them has to occur.

So, it—I think most health departments are working on this, but the current practice is uneven.

JOHNSON:
Step five.

AUERBACH:
Step five also thinks about the importance of partners, but it goes beyond healthcare.

It thinks about the partnerships that are necessary in the sectors that don't initially sound like they have anything to do with health—sectors like transportation, education, public safety, recreational activities—that those sectors are very important in creating conditions, which can either encourage good health or discourage it.

For example, if the transportation systems are completely car-oriented, then it's going to make it much more difficult to encourage people to walk or ride their bicycles. If you can work with your transportation department—as more and more public health people are doing—with a notion of shared goals, it's possible to design a transportation system in many communities that encourage walking, biking, as well as making it easy for people to drive.

We've learned more and more that it's important to pay attention to what we refer to as the social determinants of health—the conditions in people's lives that are related to social, economic, psychological factors that influence whether or not the healthy behavior is the easier behavior or whether or not to adopt the healthier behavior. One has to overcome a number of different obstacles—and those obstacles can be economic, they can be physical obstacles—and the community paying attention to those by working in authentic partnerships with other sectors is an important step.

JOHNSON:
This sounds like the holistic step to me.

AUERBACH:
It is. I think that's a good way of putting it.

This is recognizing that our health isn't just about the 15 minutes that we may be in a doctor's office or the occasional involvement in a public health campaign. It's about where you go to school, where you work, where you live.

Those conditions have an enormous impact on the health of the public.

JOHNSON:
We're at step six—this was the final step, the one that brings it home.

AUERBACH:
Well, step six is based upon the notion that health departments need to be lean and effective organizations.

Many of us at—and include the departments that I oversaw—have systems that don't work as well as they could. We sometimes continue practices that have been done in the past without examining closely whether they're well-run, whether or not they're cost-effective.

The notion in the private sector of a total quality management, that it's important to put in place the systematic approaches that allow you to constantly examine is what you're doing working well.

Are there things that you can do better? That's the notion behind the sixth component of chief health strategists—that we've got to make sure that when taxpayers look at us and look at our departments, they see very effective organizations, not outdated ones that have a lot of not-so-useful activities.

JOHNSON:
What's been the reaction over the last for years to these concepts?

AUERBACH:
I'd say, in general, the reaction has been a positive one. Most health departments say this makes sense to them.

At the same time, there are health departments that will say, “This is not so easy. I live in a complicated environment where the governor may want me to work in a particular area or where my budget is under attack every year, and I've got to put all my energy into just defending the existing budget. I don't know if I can shift the budget if I propose putting money in an area where it isn't, where it hasn't been in the past, maybe lose some other funding.”

So, those are good concerns. Those are valid concerns, and ones that we need to take seriously. And so, there's an effort, I think, on the part of ASTHO, though, and many state health officials themselves, to pull together people with the shared interest in helping health departments evolve for the future.

And thinking through how to take the spirit of chief health strategists and adapted to the conditions that they are operating in, which may mean it—out of the six—that can work on only one of them. But it's important, I think, for us to be realistic that you can't change a system overnight. And so, beginning where it's possible to begin is a good step.

JOHNSON:
And it seems to me that you have overlapping jurisdictions just about everywhere. So, couldn't all of the health departments get together and work on this as a group to maybe share the burden deal with a cost is spread out the work.

Is that possible? Or does it not work that way?

AUERBACH:
In some cases, it's possible.

And again, I would say that ASTHO plays a critical role there because, through its board and through its membership, it’s able to look at whether there are policies—particularly at the national level—that would make it easier for health departments to change and adapt the new conditions.

Some of that can take place at the national level, and some of it has to take place state-by-state; ASTHO is very good at linking an individual state health officer with another state health officer who might have tried something that worked in their state and therefore offers a lesson to the other state health officer.

JOHNSON:
As you see this as your group put it together, is this something that really does need to be led by the state versus a city or county health department?

AUERBACH:
Well, states are incredibly important in terms of these changes, they have enormous influence—but that isn't to say that that's the only place that the changes should occur.

You're right. Local health departments need to be looking at the future as well and need to have a critical eye to the work they're doing the need to change.

That said, local health departments often looked to the state to give them guidance, sometimes permission, sometimes assistance with making the changes that are necessary. So, I consider the states critically important in terms of those changes.

The other thing I would say is that—given the national picture now and the fact that public health dollars are unlikely to be growing at the national level and the amount of innovation at the national level may be more limited than it's been in the past—increasingly there is a recognition that innovation comes from the states and that states should be trying new things, should be a laboratory for considering how public health can evolve in a new and productive way.

JOHNSON:
Are there states are doing this now? And, if so, can you talk about those?

AUERBACH:
Again, this is uneven.

So—and I would say many states are taking very seriously the ideas of becoming a chief health strategist—I would be surprised if any state is not trying some of this. There are some states that have the funding, the political environment, the state leadership in the governor's office or elsewhere, that allows them to be more innovative—and those include states like Washington state. The ASTHO Board president, John Wiseman, I think it does a terrific job in illustrating what a health department can do as it evolves for the conditions of the future.

But other states throughout the country are, as I said, are innovating and changing. And I would say they're even—where a state is facing tough conditions with regard to its funding, where funding may be going down, or where the legislature is rejecting a lot of proposals that the health department may be supportive of—even in those states, I've seen a terrific innovation and enthusiasm for improving the work of the department and taking on some of these new challenges.

JOHNSON:
The goal of all of this, of course, is to deliver better outcomes for the people that these departments serve, right?

AUERBACH:
Correct. That's the bottom line—we want the population to be healthier.

JOHNSON:
Do you have in this plan a way to measure that ultimately, or is that yet to be developed?

AUERBACH:
With regard to measuring whether or not health is improving, there are a variety of different goals that should be set.

I think this is very much relates to the second component of chief health strategists—making sure that you're tapping into the interventions that have been proven to be effective. If you're using interventions that are known to work, then you can measure how widely they're being adopted. And that can be a good surrogate marker for the outcome of better health because it's been proven to be connected.

The third component, the component that relates to you creatively using data, is also very important here because it's important that health departments have the ability to tap into the earliest evidence that health is improving.

And if we, for instance, we're trying to measure such things as the prescribing practices of opioids in primary care settings, and we could tap into the electronic medical records as is possible to do it and look in an aggregate about how many new prescriptions are being written for opioids. That also—that's an indication of something, that if those numbers go down, in all likelihood that will mean there are fewer future addictions.

And then, of course, the gold standard is the health indicator themselves. So if, for instance, we see less disease—whether it's infectious disease or chronic disease—then that shows us that our work is definitely effective. And there are, too, we need to think, “How are we tapping into the best ways of measuring whether or not those trends are occurring?”

JOHNSON:
What is your hope for the eventual adoption of this strategy, and how do you think that might take?

AUERBACH:
The chief health strategist is a concept, it's not anything that's carved in stone. But the idea behind it is to help health departments look at their own environments and consider what they need to do to adapt to the new and changing conditions. So, if it's helpful over time, that's great.

I suspect that we may find it needs to be adjusted, that the notion of chief health strategists five years from now may not be the best distillation of what health departments should be doing for the future.

I think we need to continually check in with the health department who are trying to make these changes to find out are they learning things that should help go back and inform the concept of a chief health strategist so that it can change if it needs to.

JOHNSON:
Where do people go for more information? How do they learn the details behind this? Is it online? Can they call someone?

AUERBACH:
You know, I'd always start, for a state health officer by saying talk to ASTHO; because ASTHO is an excellent resource of pulling together the key materials that people need. So, definitely check the ASTHO website and talk to the ASTHO leadership.

Independent of that, all you need to do is Google “chief health strategist” on any browser. If you just type that in, you'll get the documents that explain it. You'll probably get access to PowerPoint presentations, which you can use. So, I think the information is out there.

I'd also say people can always call the organization I oversee, Trust for America's Health. We're happy to be a resource as well; we have materials on our website, and we also have people who work at Trust who are available to come to speak to groups. We go to a number of different state public health annual meetings, for example, where we're asked to speak on the concept of it.

So, there are a number of different places where the information is available.

JOHNSON:
Good closing thoughts.

AUERBACH:
The closing thought is public health is critically important in this country. We need it to be as strong and robust and effective as possible. And to do that, we need to continually reflect on what we can do to be better. And, hopefully, the chief health strategist concept will help the health department as they are working to strengthen their activities in their states and locals.

JOHNSON:
Some states already are working on these reforms, while others may not have the resources to take on so much change overnight. If that's the case, what then?

Mary Ann Cooney, the chief of ASTHO's Center for Population Health Strategies, says there is an easy way to get started.

COONEY:
And if what you're trying to do is, you know, use that big, hairy, audacious goal of transforming a health system, you can start very small, and that is just picking up the phone and starting to establish those relationships with people who we don't always consider our essential partners.

JOHNSON:
For more information about the chief health strategists, check out the link to the ASTHO webpage in the show notes. You can also find links to the Trust for America's Health.

Next time on Public Health Review, we’ll hear more from Mary Ann Cooney. She'll offer some examples of this model already at work and tell you where you can get help if you want to move forward in your state.

Public Health Review is a production of the Association of State and Territorial Health Officials.

If you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

For Public Health Review, I'm Robert Johnson. Be well.