An Examination of State Laws and Policies Regarding Public Health Accreditation Prerequisites. State Summary Alabama

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1 Alabama Alabama does not have any legal or regulatory mandates for the prerequisites for national, voluntary accreditation. Alabama has a centralized public health system. Only Jefferson and Mobile counties have independent public health departments. The other 65 counties are part of the state system, and their director is the State Health Officer. There is some interest at the county level in pursuing accreditation, and the state central office is going forward with an intention to apply for accreditation, but it will take several years. The state does not have any of the prerequisites in place at this time. Some community transformation work has been done in 9 counties and will be expanding to 21 counties. This work will allow a foundation for a needs assessment and an improvement plan. A Performance Improvement Manager has been hired using the CDC National Public Health Infrastructure Initiative (NPHII) funding, and training is being offered on quality improvement and on accreditation. The central office has a website for county health status information which can be used for assessments when they are ready to begin them. Barriers include resources and the need to take one step at a time.

2 Alaska Alaska has a mandate based on a gubernatorial directive. The Governor of Alaska has charged each state department to pursue a performance management system which includes an annual strategic plan. Directives from the Office of Management and Budget of the Office of the Governor include the implementation of a comprehensive process designed to manage agency performance that includes strategic planning, purposeful budgeting, process design, and information based decision making. (June 16, 2011 Memo from Office of Management and Budget to Commissioners) Alaska does not have legal mandates that require the completion of the prerequisites for accreditation, although the statutes do include language that provides general authority for assessment and planning. These include assessment, surveillance, and review of the public health system. In addition, the Ten Essential Services of Public Health are in state statutes. Alaska is a centralized state, except for Anchorage and one small agency that does not provide comprehensive services. Alaska does have a different mandate. Alaska will have a strategic plan in 2011 and is in the conceptual stage of developing a state health assessment. No date has been set for the Statewide Health Improvement Plan (SHIP)or for applying for PHAB accreditation. National Public Health Infrastructure Initiative (NPHII) funding may support the development of the SHIP, if funding continues. Barriers include a lack of resources.

3 Arizona Arizona does not have any mandates for local or state completion of the accreditation prerequisites. The state uses broad authority for its work in assessment and planning. This general language does include planning as in: Encourage and assist in the adoption of practical methods of improving systems of comprehensive planning, of program planning, of priority setting and allocating resources. (ARS ) Arizona has completed the National Public Health Performance Standards and is working on a strategic plan with federal CDC National Public Health Improvement Initiative (NPHII) funding. It is also beginning a state health assessment process. Arizona intends to work on a statewide health improvement plan. There are 15 independent local health departments in the state and there is some interest, at the local level, in accreditation. One local health department and one tribal health agency were part of the beta testing for accreditation through the Public Health Accreditation Board (PHAB). Barriers include resources, as public health funding has been seriously reduced due to budget circumstances in Arizona. If not for Federal funding, Arizona Department of Health Services would not have the opportunity to move forward with the pre work to prepare for accreditation.

4 Arkansas Arkansas does not have any mandates in law or regulation for the prerequisites at the local or state level. However, the Director of the Department of Health has, through policy, mandated a state strategic plan every 3 years for the past 6 years. In addition, there are county profiles for the 75 counties. These profiles are part of community health assessments and allow counties to set priorities. Arkansas is using CDC Infrastructure funding to mobilize for a state health assessment, and has a history of using the National Public Health Performance Standards Program (NPHPSP). Arkansas sees the statewide health improvement plan as an outgrowth of the strategic plan. Arkansas is a centralized state with 94 offices in the 75 counties, all in 5 regions. They are likely to seek state accreditation prior to any local accreditation. Barriers to completing the prerequisites and applying for accreditation are largely time and money.

5 California California does not have mandates at the state or local level for the prerequisites for Public Health Accreditation. General authority exists in statute, but there is no specific language regarding health assessments or health improvement planning as required for the Public Health Accreditation process. The state may advise all local health authorities (CA HLTH &S ), but local health agencies are very autonomous in California. In preparation for Public Health Accreditation, the state health department is planning a meta analysis of related assessments that could be rolled up for a statewide assessment. Many programs have done extensive assessments and many local health departments have also done extensive assessments. San Diego Health Department was a beta test site for PHAB, and the western states are developing a western consortium to improve the knowledge and information of local and state officials about accreditation and quality improvement. Challenges for accreditation in California include the lack of specific authority for accreditation and the prerequisites, lack of general knowledge about the accreditation process, a need for training of the public health workforce around performance management and quality improvement necessary for accreditation and lack of specific funding to support accreditation activities.

6 An Examination of State Laws and Policies Regarding Public Health Accreditation Pre Requisites Colorado Colorado has statutory mandates for statewide health assessment, statewide health improvement plans, local health assessments and local or community health improvement plans due a public health law that passed in The Colorado Department of Public Health and Environment (CDPHE) is required to prepare a state health assessment and state health improvement plan every 5 years by law. The law articulates 17 items that are to be included in the state plan. The state completed its first state health improvement plan in Each county or district public health agency is required to prepare a local plan that is not inconsistent with the comprehensive, statewide public health improvement plan ( (1)) Local agencies are to prepare their plans as soon as practicable. The state agency has created incentives for the local agencies to complete community health assessments and plans by providing small grants to regions and to larger health departments. The local health departments have until 2013 to complete their plans, based on state directive. Colorado provides state general funds through per capita grants for local health departments. The contracts for this funding include a scope of work which states that the agencies will work on assessments and planning. In addition, National Public Health Infrastructure Initiative (NPHII) funding is supporting a data staff member in CDPHE s Center for Health and Environmental Information and Statistics to support local data needs. State agencies in Colorado are required by a new law to develop strategic plans that involve stakeholder input and measurable results. It is a 5 year plan with annual updates. Thus a mandate also exists for strategic plans at the state level. Colorado is well positioned for accreditation, but no commitments have been made regarding the timing. One county, El Paso, has made a commitment to apply for accreditation. Others have expressed interest, but are using the state timeline for development of the prerequisites. Barriers include resources and supporting small and rural agencies with the larger, historically more comprehensive local public health agencies.

7 An Examination of State Laws and Policies Regarding Public Health Accreditation Pre Requisites Connecticut In Connecticut, there is a legal requirement or mandate for a multi year statewide plan with assessments of the health of the population. The Department of Public Health has the authority to lead statewide public health planning and to assist communities in the development of collaborative health planning activities. These activities address public health issues on a regional basis or respond to public health needs with state wide significance. There are no mandates for the local public health agencies to complete the prerequisites for accreditation. The state s current plan is program driven, and an agency strategic plan is needed. Connecticut is working with the Association of State and Territorial Health Officials (ASTHO) for strategic effectiveness training. A Statewide Health Assessment is moving forward, starting with data collection and analysis. CDC National Public Health Infrastructure Initiative (NPHII) funding is available to support a position, but it was not filled as of August A previous gubernatorial directive established a council on local public health regionalization. The key finding was the embracing of local public health agency standards. The report from the council recommended that every health department and district department have the ability to align with standards for accreditation. A three year period was suggested to tie activities to the standards. Current law includes 8 programmatic duties for local health departments. One recommendation of the Council was to update the current 8 statutorily mandated functions with the 10 Essential Services. Some of the local agencies are expected to pursue accreditation. Some of the local agencies have the prerequisites in place, although they have not been required. Barriers have included delays in filling the new NPHII funded position, resources and the categorical nature of public health funding and public health infrastructure in Connecticut.

8 Delaware Delaware has general authority for the prerequisites for accreditation, but does not have legal mandates for accomplishing those tasks. The authority includes monitoring the health status of the population collection and analysis of data on health status. The 10 Essential Public Health Services are included in the statutes. With the support of the CDC National Public Health Infrastructure Initiative (NPHII) funding, Delaware is contracting for a statewide health assessment. Delaware is currently working on a strategic plan, strategic mapping, and setting priorities. The strategic plan and the state assessment will be done within a year, and Delaware will then develop a state health improvement plan. The state received a technical assistance grant through the Association of State and Territorial Health Officials (ASTHO) to help with strategic mapping, and has general plans to apply for accreditation in the next 5 years. Barriers are time, energy, fees, and generating enthusiasm. Performance improvement is new for many staff. Incentives have included ASTHO s technical assistance and training in Quality Improvement Tools through the Public Health Foundation.

9 Florida Florida has legal requirements for long range program plans for all state agencies (section , Florida Statutes and , Florida Statutes) which require mission, goals, objectives, trends and conditions. In addition, a mandate for the completion of the PHAB prerequisites is found in a directive from the Dr. Frank Farmer, State Surgeon General and the head of the Florida Department of Health. An communication to all departmental employees, dated May 23, 2011, states that over the next months, the department will: Conduct state and local health improvement planning to strategically identify health priorities with the highest potential for improving the health status of the state. Activities to support this statewide planning will include completing state and local public health system assessments, completing state and local status assessments, and developing state and local community health improvement plans. This directive implements a recommendation included in the Florida Department of Health Evaluation and Justification Review Report submitted March 1, 2011 to the Governor and State Legislature in response to Ch , 34, Laws of Florida. This recommendation in the report was: Recommendation 5: (That) the department develop and implement a state health improvement plan with priorities for statewide health improvement. Florida law provides general authority for the Department of Health to assess health status and the needs of the state through data collection and other appropriate means. Another form of directive assessing activities related to the prerequisites includes language in the Florida County Health Department Director or Administrator Performance Evaluation Form which includes the following Job Specific Expectations: Health Outcomes Demonstrates leadership in prioritizing, monitoring, and annually evaluating community interventions against key community health outcomes identified through a comprehensive community health assessment process. Performance Improvement Process Demonstrates participation and engagement in the CHD (County Health Department) performance improvement process annually to systematically assess, plan, manage, and evaluate CHD performance improvement. Uses employee QI monitoring team to assure continuous efforts are maintained and monitored. Florida anticipates completing a state level health status assessment in 2011, and the department may draft legislation for consideration on doing a state health improvement plan every 4 years. Florida has a history of supporting performance improvement and currently has an annual County Performance Snapshot of 57 measures, which includes three measures assessing county performance related to health improvement planning, strategic planning and quality improvement. Incentives for completion of the prerequisites include using the CDC National Public Health Infrastructure Initiative (NPHII) grant funding and the Multi state Learning Community funding to support county health departments with their assessments and community health improvement plans.

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11 Georgia Georgia does not have mandates for the prerequisites for PHAB recognition. The state has concluded that Georgia does not need any statutory authority to pursue accreditation and has not identified any barriers to prevent it from completing the prerequisites or applying for accreditation. Georgia has general authority to determine the health needs and resources of its jurisdiction by research and by collection, analysis, and evaluation of all data pertaining to the health of the community. (GA ) Georgia is in the process of developing a new state department of health, evolving from being part of an umbrella agency. They are proceeding with a strategic plan and have identified 6 priorities as part of their transition to an independent agency with a state board of health. This will lead to an agency strategic plan. Georgia is a hybrid or mixed state with local county boards of health and a mix of state and local employees operating the system of 159 counties in 18 districts. All employees are part of the state personnel system, regardless of whether their funding is local or state. Georgia is waiting for clarification regarding whether districts can be accredited. Current contracts with the counties do not address prerequisites or accreditation. The state does plan on working toward accreditation as there is a perceived benefit and they are positioning the state for a health assessment and health improvement plan after completion of the strategic plan.

12 Hawaii Hawaii does not have any mandates for the accreditation prerequisites. The state operates under general authority for assessments and planning. Hawaii has numerous assessments and plans at the program level, especially for programs with federal funding that requires assessments and plans. The state has a wide ranging set of services beyond traditional public health, including Mental Health and Developmental Disabilities. County hospitals are attached to the department, and the department operates a Certificate of Need Program. Hawaii conducts a needs assessment for the Certificate of Need (CON) Program, which supports health care investment decisions. Hawaii has not yet rolled the CON information into statewide assessments or plans. Hawaii has several assessments and plans that have been tied to consent decrees as court mandated actions. The programs that are outside of traditional public health have been the locus for class action lawsuits leading to consent decrees. Hawaii is a centralized system with all public health employees in the state personnel system. There is considerable experience with accreditation in related programs, such as Substance Abuse. The state also requires appropriate accreditation for many of the agencies and organizations with whom they contract. Hawaii will be developing a new strategic plan as part of a restructuring effort. They have hired a Performance Improvement Manager and will prepare an accreditation readiness in the next year. There are no current plans to seek PHAB accreditation. Barriers include extensive budget cuts, fragmented services, and the need to restructure the department to adjust for staff cuts.

13 Idaho Idaho has a statute that mandates that every state department has a strategic plan. The Department of Health and Welfare (DHW) strategic plan is for a 3 year period and is updated annually. This plan is short, visionary, and broad in scope. In addition, the Division of Public Health, within DHW, has developed an annual business plan, which has a closer alignment with the Public Health Accreditation Board pre requisite requirements than the statemandated strategic plan. The business plan includes measurable objectives with deadlines and is structured in the context of the Ten Essential Services of Public Health. At the state level, the policy decision is to not pursue the necessary prerequisites, including the statewide health assessment and the state health improvement plan at this time. Idaho has seven health districts that are autonomous and quasi governmental and include 4 7 counties each. These districts follow their own planning processes, and when necessary coordinate with the Division of Public Health. While not mandated, all do assessments because they recognize the importance of assessing the health of communities. Incentives for the districts include training and data. In addition, programs like MCH and health promotion require program assessments through contract language. The local health departments are considering accreditation. While the state agency is not currently pursuing accreditation, the agency is aligning itself for consideration in the future. Barriers to complete the prerequisites and prepare for accreditation include funding and capacity within the state.

14 Illinois Illinois has a certification process for local health departments that has been in place through regulation since General authority in the law provides the basis for the regulation. While not technically a mandate, certification, which requires a self assessment and a health improvement plan every five years, is an implied mandate as certification is required to receive state funding. As the Illinois Department of Health website ( notes: The Illinois Project for Local Assessment of Needs (IPLAN) is a community health assessment and planning process that is conducted every five years by local health jurisdictions in Illinois. Based on the Assessment Protocol for Excellence in Public Health (APEX PH) model, IPLAN is grounded in the core functions of public health and addresses public health practice standards. The completion of IPLAN fulfills most of the requirements for Local Health Department certification under Illinois Administrative Code Section : Certified Local Health Department Code Public Health Practice Standards. The essential elements of IPLAN are: 1. an organizational capacity assessment; 2. a community health needs assessment; and 3. a community health plan, focusing on a minimum of three priority health problems. Because the Illinois IPLAN requires that local health departments that become certified complete CHAs and CHIPs, Illinois local health departments are well positioned for accreditation. A barrier could be the lack of strategic plans, although a strategic plan may be substituted for an organizational capacity assessment. The state health department completed a statewide health improvement plan (SHIP) in This was a mandate based on House Bill 4612, (P.A ) passed in The plan, which identified priorities and strategies to improve the health of the citizens of Illinois, went to the State Legislature and the Governor after extensive public input. The law requires a new SHIP every 4 years. A second SHIP was completed in The legislatively mandated SHIP Implementation Coordination Council convened in fall of An Illinois State Health System State Assessment was completed in 2009 through the Illinois Public Health Institute. HB 4612 reads: 10) TO DELIVER TO THE GOVERNOR FOR PRESENTATION TO THE GENERAL ASSEMBLY A STATE HEALTH IMPROVEMENT PLAN. THE FIRST AND SECOND SUCH PLANS SHALL BE DELIVERED TO THE GOVERNOR ON JANUARY 1, 2006 AND ON JANUARY 1, 2009 RESPECTIVELY, AND THEN EVERY 4 YEARS THEREAFTER. THE PLAN SHALL RECOMMEND PRIORITIES AND STRATEGIES TO IMPROVE THE PUBLIC HEALTH SYSTEM AND THE HEALTH STATUS OF ILLINOIS RESIDENTS, TAKING INTO CONSIDERATION NATIONAL HEALTH OBJECTIVES AND SYSTEM STANDARDS AS FRAMEWORKS FOR ASSESSMENT. THE PLAN SHALL ALSO TAKE INTO CONSIDERATION PRIORITIES AND STRATEGIES DEVELOPED AT THE COMMUNITY LEVEL THROUGH THE ILLINOIS PROJECT FOR LOCAL ASSESSMENT OF NEEDS (IPLAN) AND ANY REGIONAL HEALTH IMPROVEMENT PLANS THAT MAY BE DEVELOPED. THE PLAN SHALL FOCUS ON PREVENTION AS A KEY STRATEGY FOR LONG TERM HEALTH IMPROVEMENT IN ILLINOIS.

15 Illinois Page 2 The state agency has not indicated a plan for pursuing accreditation. The mandate of a SHIP and a SHA every 4 years provides a foundation for meeting the prerequisites. There is no state strategic plan at this time. Illinois considered a state accreditation program for local health departments but has decided not to pursue an Illinois model.

16 An Examination of State Laws and Policies Regarding Public Health Accreditation Pre Requisites Indiana Indiana does have a legal mandate to produce a 5 year state health assessment and a state health plan (Indiana Code ). The assessment and plan first to the Governor and then are forwarded to the General Assembly and includes mission, vision, and priorities based on data. The report has been structured to meet Public Health Accreditation Board (PHAB) pre requisite requirements. Indiana does not have a state strategic plan. Although the law (Indiana Code ) states that To qualify for financial support, a local board of health must submit an acceptable plan of community health services to the state department, this law has not been observed in recent years due to a lack of funding. Therefore, local public health departments do not currently have any mandates related to the pre requisites. Indiana has used the National Public Health Performance Standards to review the public health system at the state and local level. One incentive has been quality improvement training through Purdue University, using Lean Six Sigma as a framework. CDC National Public Health Infrastructure Initiative (NPHII) funding is supporting mini grants for quality improvement at a regional level. Indiana is also doing a statewide accreditation gap analysis. Seventy counties have indicated an interest in participating in the gap analysis with geo mapping how they meet each standard. Barriers include time, money and a lack of incentives for applying for accreditation.

17 Iowa Iowa has both law and regulations that refer to voluntary public health accreditation, at the state level. There are Iowa standards and a process for accreditation for voluntary, state accreditation. It does not have mandates for the prerequisites, although these are included in the measures for the Iowa standards. The Iowa Accreditation Program is scheduled to begin in 2012, and there will be a pilot process in Iowa standards have been cross walked with Public Health Accreditation Board (PHAB) standards, showing a difference related to the research and quality improvement standards and measures. Iowa Standards have been revised to more closely match those areas. Iowa hopes that local health departments which receive Iowa Accreditation, which will be based on equivalency with the PHAB standards, will be recognized as accredited with PHAB. The state agency is currently working on a state health needs assessment and will move toward a state health improvement plan by February of The strategic plan will be done simultaneously. They participated in a beta test of the PHAB standards and process. The state intends to apply for both Iowa and PHAB accreditation. Local health departments are not mandated to do assessments and improvement plans, but they do them as an option under the state grant program every 5 years. This work is considered a bonus for which they receive an extra $800 per CHA and $800 per CHIP. It has become standard practice over a 20 year period. These local assessments are included in the state health assessment that is under development. Other incentives include technical assistance and use of the public health fund, 70% of which goes to local agencies. The rules for the fund state that one purpose is for providing grants to achieve and maintain voluntary accreditation in accordance with the Iowa public health standards. (I.C.A. 135A.8) Some of the Iowa local health departments may pursue PHAB recognition. Barriers include the need for training on strategic planning at the local level.

18 An Examination of State Laws and Policies Regarding Public Health Accreditation Pre Requisites Kansas Kansas has no mandates for the prerequisites for PHAB. The state and the county health departments operate under general authority and do not see any legal barriers related to completing the prerequisites or applying for PHAB recognition. Kansas has formed an innovative partnership through a joint resolution between the Kansas Hospital Association (KHA) and the Kansas Association of Local Health Directors (KALPHD), to jointly work on community health assessments and improvement plans. The Kansas Health Institute, the Kansas Department of Health and Environment, KHA and KALPHD are working together on a data system to support assessments. They have purchased the Health Community Network from the Berkeley School of Public Health which will link with services, best practices, and indicators. Kansas used funding from the Multi State Learning Community to support 10 regional teams, covering 64 counties, to work on community health assessments. The state also fielded a team. The state has a workgroup looking at accreditation and now has a performance improvement manager. There is interest in accreditation at the state level, perhaps in 3 5 years. They have not done the prerequisites. Barriers include the need for funding for the prerequisites and for preparing for accreditation.

19 Kentucky While Kentucky does not have mandates for the prerequisites, the law does address how a Kentucky Public Health Improvement Plan (KHIP) is to be used. The KHIP is intended to guide public health in activities and budgets, and guide local groups and coalitions in the development of innovative efforts to provide community assessment, policy development and assurance. (KRS 194A.001) The first plan was in 1998, and there are plans to develop one again. Healthy People, done every 10 years with a middecade review, provides benchmarks to follow key indicators. There are no mandates for local health departments to complete the accreditation prerequisites. HB 258, introduced in the 2010 General Assembly, would create a Kentucky Commission on Public Health within the Public Health Leadership Institute of the University of Kentucky. The Commission would ensure that all health departments in Kentucky achieve national accreditation and maintain accreditation by the Public Health Accreditation Board by 2019, and ensure that all health departments undertake quality improvement efforts to improve the efficiency and effectiveness of their services. The bill did not pass, but it is expected to be re introduced in the next legislative session. It was drafted and supported by local public health leadership. Kentucky has an Accreditation Readiness Team, an internal workgroup in the state health agency, which has a charter, logic model, and a planning guide to prepare for state agency accreditation with a target date of The Kentucky Health Department Association, a coalition of the 58 independent local health departments, holds a monthly meeting of local accreditation coordinators. There are local staff who are accreditation coordinators and attend monthly meetings. The Public Health Foundation has been providing QI training. Kentucky public health is working with the hospital association to encourage local public health and hospital collaboration on community assessments and plans. A National Public Health Improvement Initiative (NPHII) grant funds a Center for Performance Improvement, which focuses on Quality Improvement and supports state and local efforts toward accreditation. Barriers are funding and having the 58 independent local health departments see value in accreditation.

20 Louisiana Louisiana does not have mandates at the state or local level for the accreditation prerequisites. There are only 2 local health departments in this largely centralized state. Louisiana has been submitting annual Health Report Cards to the State Legislature through the Governor. These Health Report Cards are a foundation for a statewide health assessment. There is no sense that the lack of specific authority is an impediment to preparing the prerequisites or applying for accreditation. Louisiana is using the CDC National Public Health Infrastructure Initiative (NPHII) funding to do a readiness review for accreditation. They have a Health Improvement Support Unit and have hired a Performance Improvement Manager. The new Office will work on data collection and analysis and technical assistance. In the second year, they will work toward an assessment. Louisiana has received technical assistance from the Association of State and Territorial Health Officials (ASTHO) and from CDC. They would like to apply for accreditation in the future, perhaps Barriers include getting the right partners to the table and having sufficient resources.

21 Maine Maine has a most unusual responsibility under law. It is not a mandate for the prerequisites, but rather a requirement to report progress toward accreditation. Recent legislation states: The Statewide Coordinating Council for Public Health shall report annually to the joint standing committee of the Legislature having jurisdiction over health and human services matters and the Governor s office on progress made toward achieving and maintaining accreditation of the state public health system and on district wide and statewide streamlining and other strategies leading to improved efficiencies and effectiveness in the delivery of essential public health services. (22 MRSA 412) Maine is a centralized state with 9 districts, one of which constitutes the 5 tribes in the state. This substate structure co locates state staff and includes a voluntary coordinating council. The legislation came from a public health workgroup report of It is unique in the inclusion of tribes in all aspects of the law. There are also two autonomous local health departments. Local coalitions are tasked with developing comprehensive health assessments and improvement plans, using MAPP. The coalitions received funding by applying through a Healthy Maine Partnership RFA (Request for Application). The only link the coalitions have to government is through a contract. The law clearly states the broad range of participation that is needed for Health Maine Partnerships. Currently every district has a health improvement plan, but not all have assessments. Maine wants to be well positioned for public health accreditation. Maine has a state plan, but they do not think it will meet the Public Health Accreditation Board s (PHAB) criteria for a state health improvement plan. The state is in the process of conducting a state health assessment and state health improvement plan. The State Health Plan of 2008 and 2010 may meet the criteria for PHAB or be a basis for a satisfactory state health improvement plan. A strategic plan will also be developed. These activities are occurring as a policy decision, not a mandate.

22 Maryland Maryland has an executive branch mandate from the Governor to complete a state health improvement plan. It was included in the Governor s Report of Health Care Reform. Maryland completed a 10 year state health improvement plan in For the last 60 years, local health departments have received Core funding from the State, and as part of the requirement for this program, have been required to provide a plan consisting of an overview, local health needs assessment and statement of local priorities. However, due to severe reductions in the Core funding program, that requirement has been dropped. Current law stipulates the funding formula for local agencies through FY The level was reduced from $72 Million in FY 09 to $43 million in FY 10. The Department has written draft regulations to remove the annual plan requirement. Instead of requiring an annual plan, the State is encouraging local health departments to prepare for accreditation. The Maryland Department of Health and Mental Hygiene is in the process of preparing all Public Health Accreditation Board (PHAB) prerequisites, with a possible application date in That goal is dependent on continued CDC funding. Barriers are funding, should the CDC National Public Health Infrastructure Initiative (NPHII) Grants not continue.

23 An Examination of State Laws and Policies Regarding Public Health Accreditation Pre Requisites Massachusetts Massachusetts has no laws that mandate completion of the pre requisites for the state. There are two statutes that specifically refer to Boston and Cambridge. These laws (M. L. S. 111 App. 2 8 and 3 7) state that The annual public health assessment shall include an evaluation of existing local, state and federal programs and services to address the public health needs of the city. In Boston, the annual public health assessment includes neighborhood based public meetings where the health department supplies data from a robust surveillance system. There are 351 local jurisdictions with local health boards in Massachusetts. CDC National Public Health Infrastructure Initiative (NPHII) Component Two funding is supporting the formation of regional health districts. Phase I of the NPHII grant involved 11 groups encompassing over 100 municipalities. It is not clear how community health assessments for multiple jurisdictions will align with the Public Health Accreditation Board (PHAB) requirements. Massachusetts has a Determination of Need program. It requires 5% of the expenses that are being spent on capital projects to support community health needs in the community. This requirement, known as Factor 9 of DON, is an unusual mandate for the health care system. This is a valuable source of revenue for community health initiatives, often paid out over a 5 year period. Factor 9 is seen as aligning with the principles of PHAB. Community needs are often defined by processes such as the National Public Health Performance Standards Program or MAPP. Massachusetts is encouraging hospital community health assessments and public health assessments to align with each other. There is a statebased community benefit requirement for non profit hospitals in Massachusetts. The state is using ARRA funding, Putting Communities to Work, as well as NPHII funding and potentially Community Transformation Grant funding to support local health assessments. Local health assessments are also required in municipalities that receive grants through Mass in Motion, the state health department s signature initiative to reduce and prevent overweight and obesity. The state published a comprehensive health data and policy report in 2010 that will be updated in the process of completing a state health assessment for accreditation. Health planning is informed by annual regional dialogues, in which the state public health commissioner meets with local partners across the state. In the past four years, 40 regional dialogues have been held. Massachusetts does not yet have a statewide public health improvement plan that would meet PHAB standards, although they have elements of it in place. The state has strategy planning, but not a strategic plan. Incentives have included federal funding which is supporting local accreditation preparation. Massachusetts plans on applying for PHAB accreditation in Barriers include cuts in NPHII, Component Two funding from CDC.

24 Michigan Michigan has a mandate for local public health departments to be accredited under the Michigan Public Health Accreditation Program through contracts. Local health agencies must be accredited to receive state contracts. State accreditation does not require that local health departments complete the prerequisites that are part of Public Health Accreditation Board (PHAB) accreditation. The state has a mandate in law to complete a state health assessment and set priorities which are provided through the appropriations process. The law states: The department, utilizing broad participation of, and providing ample opportunity for the submission of recommendations by, the individuals and organizations described in Section 2302, annually shall identify the priority health problems of this state utilizing state health plans and an assessment procedures based on data and statistics. (M.C.L.A ) It would likely meet PHAB requirements, as sections 2301 and 2302 include requirements for engagement of stakeholders and partners in the state health assessment process. Michigan is using National Public Health Infrastructure Initiative (NPHII) funding to update the statewide health assessment. The next step will be a statewide health improvement plan. The dashboard used by the Governor may lead to a strategic plan for the state. Incentives include using NPHII funding to help local health agencies prepare for completion of the prerequisites. Some local health departments have joined with local partners to complete community health assessments (CHAs) and community health improvement plans (CHIPs). There is a high level of interest in accreditation. The state will apply at some point. Barriers include the fee structure for PHAB, reduced budgets, and staff capacity.

25 Minnesota Local health departments in Minnesota have been completing community health assessments and improvement plans under a mandate since The law states: establish local public health priorities based on an assessment of community health needs and assets. (145.10) The CHA and CHIP are required every five years, and local health grants from the state are subject to their completion. The reporting system captures questions about community engagement, assessments, and planning. There is no requirement for a strategic plan. Although the law does not specifically address accreditation, the 10 Essential Services of Public Health are in the local public health law. In addition, the Commissioner of Health is required by law to set public health goals. Minnesota Statutes Chapter 62J.212 requires that: The commissioner shall establish specific public health goals including, but not limited to, increased delivery of prenatal care, improved birth outcomes, and expanded childhood immunizations. The commissioner shall consider the community public health goals and the input of the statewide advisory committee on community health in establishing the statewide goals. The statute does not specify how often goals must be set or updated. Minnesota is currently doing a state health assessment that is intended to meet Public Health Accreditation Board (PHAB) requirements. Incentives include using National Public Health Infrastructure Initiative (NPHII) funding to support local health departments with consulting assistance for strategic planning and for assessments against PHAB standards. There are guidelines, templates, and training for community health assessments. The Minnesota State Community Health Services Advisory Committee has issued a report on accreditation. The December 2010 report is titled: National Public Health Standards and Voluntary Accreditation: Implications and Opportunities for Public Health Performance Improvement in Minnesota. The report states that, The workgroup believes that achieving national standards will improve performance, and that improving performance will ultimately improve public health outcomes. (p.1). Barriers include the delays that necessarily occur when there is a change in administration.

26 Mississippi Mississippi does not have any legal mandates that directly support the fulfillment of the prerequisites for accreditation. The state agency largely operates under general public health authority. The State Board of Health is required to send a report to the State General Assembly each year with a statement of expenditures and any recommendations the board wishes to forward. A strategic plan is required by the State Legislature which includes program measures and is linked to the budget. That plan is in place for It is not seen as adequate for Public Health Accreditation Board (PHAB) requirements. Mississippi is a centralized state operating 82 local health departments, 14 full time clinics, 17 part time clinics, 9 home health agencies, and 9 health districts. All agencies report to the state health officers who report to the State Board of Health. The state plan addresses Certificate of Need, not what is required for PHAB prerequisites. Mississippi is on track to make their strategic plan more useful. It is working toward preparing for accreditation. Mississippi was a beta test site and did not meet any of the prerequisites during the beta test review. Barriers include the silos in the department. The Office of Performance Improvement is working toward creating cross cutting approaches.

27 Missouri Missouri does not have any mandates for the prerequisites in current law, however, this was not always true. Until 3 years ago, before budgetary cuts, the local health departments were required to complete all three prerequisites every three years to receive state funding. This was a mandate embedded in the contract between the state and the local health department. The state uses broad public health authority for its activities. Missouri has a state voluntary accreditation program, operated by the Missouri Public Health institute. This voluntary program requires all three prerequisites so those agencies that seek state accreditation complete them. The state has a long history of assessment and planning. The Missouri Foundation for Health has awarded agencies funds to prepare for accreditation. The foundation also gave some agencies a grant to apply for state accreditation on a regional basis. The state has provided county data and possible interventions for the local health departments which can support CHAs and CHIPs. The larger cities are likely to apply for Public Health Accreditation Board (PHAB) accreditation. The state health department has begun work on the statewide health assessment and a state health improvement plan. They have decided that accreditation is a priority. Barriers are financial, not legal. The PHAB fee structure is a barrier for smaller agencies. Budgets have all been reduced.

28 Montana The Montana Department of Public Health and Human Services does have a legal mandate to do a strategic plan every five years (MCA ). That requirement is for the umbrella agency, in which the Division of Public Health sits. Accreditation was addressed in House Bill 173, which created a pilot program to assist local public health agencies in the preparation for national accreditation by using nationally recognized public health standards and guidelines that are based on the 10 Essential Services. This pilot program was completed in June The law was written and supported by local public health nurses and implemented through an RFP competitive process. The 7 pilot agencies, all of which received a $25,000 grant each year for 2 years, now have their prerequisites in place. They did readiness reviews, assessments, improvement plans and strategic plans. Another bill was introduced in 2011 to continue the pilot program, but it did not pass. Montana also used Preventive Block funding to support three larger health departments in the preparation of their community health assessments. They each received $15,000. As a member of the Multi State Learning Community, Montana was also able to provide training and technical assistance in Quality Improvement through Purdue University. The state health assessment will be completed during A state health improvement plan will be developed next, and the strategic plan will be updated. Barriers are financial and staffing. Many agencies are very small.

29 Nebraska Nebraska is rich in incentives for the prerequisites. There are no mandates at the state or local level. Statutory language includes core functions and authorizes the state to contract with local health departments to deliver core functions, meaning that duties at the local health departments include assessments and policy development. The state agency, which is part of an umbrella department, has provided funding to local health departments to complete comprehensive needs assessments. Most of the agencies have completed them twice, starting in 2005 and repeating every 3 5 years. The state combined funding from numerous grants to support this work. The current cycle of funding is competitive and is called Healthy Communities Grants and provides funding to improve one priority area, using evidence based strategies that lead to policy, systems, or environmental changes. Most local agencies use MAPP. In addition, the state is offering $15,000 to each local health department to prepare for accreditation. They can use the funding for MAPP, community health improvement plans, quality improvement, or to close gaps in capacity. Nebraska has a State Health Improvement Plan, which was updated in 2008.The state is currently doing a formal state health assessment (SHA), and will follow the SHA with a state health improvement plan and a strategic plan. Nebraska is committed to moving toward accreditation with a focus on completing the prerequisites. The goal is to be accredited by 2015 and for local health departments to achieve accreditation as well. The Nebraska Rural Health Association is engaging rural hospitals, public health departments, the Nebraska Office of Rural Health, the Nebraska Office Community Health and Performance Management, rural health networks and other community health organization in collaborative efforts to assist hospitals in complying with their IRS community benefit obligations regarding community health assessments.

30 Nevada Nevada does not have any mandates for the prerequisites. They operate under general authority and are part of an umbrella department. There are only 3 local health departments in the state. They have a goal toward accreditation and are focusing on quality improvement and doing a gap analysis of the standards. They have not completed the prerequisites. Carson City, one of the three local health departments, was a beta test site and may wish to apply for accreditation. Barriers include funding and marketing to staff, partners, legislators and local government how accreditation will be useful.

31 New Hampshire New Hampshire has a statute that requires a bi annual statewide health assessment, but an assessment has not recently been conducted. A Public Health Improvement Services Council was established in legislation in 2007 to develop and monitor public health improvement plans. The 2007 legislation called for the development and monitoring of a public health improvement plan. The plan for New Hampshire, developed in 2008, was based on the National Public Health Performance Standards assessment. There is a high level group of state health partners involved in the discussion phase relative to the development of a state plan. It is unclear at this time if a state health improvement plan (SHIP) will be a part of this work or a separate initiative. New Hampshire recently completed a State Health Profile. This report on 38 health indicators uses a social determinants of health model. This will serve as a foundation for a SHIP, with next steps including stakeholder input and other components of the MAPP process. This process will take place during The University of New Hampshire and the state health agency are collaborating to make data more readily available and timely through a web based system. The state Division of Public Health Services (DPHS) developed an agency strategic plan that is in year two of implementation. The DPHS anticipates applying for accreditation in 2013 or The state contracts with various agencies to conduct Emergency Preparedness work. Those agencies are asked to look at Public Health Accreditation Board standards as they relate to EPR and how they measure themselves against those standards and measures. New Hampshire is divided into 15 public health geographic regions. Two of those have comprehensive local public health departments which would be eligible to seek accreditation independently, and both are interested in applying. In the other regions, most public health services are delivered through nongovernmental agencies. All regions have conducted a capacity assessment based on the National Association of County and City Health Officials Operational Definition for local health departments. These assessments identified gaps in local public health capacity and resources, which will be used for planning purposes. Barriers to completion of the prerequisites include time and money.