“Public health is everything outside our skin— individual health is everything within”.

The world around us impacts our health in countless ways. Each bite of food we take, sip of water we drink, the air we breathe, the condition of the house we live in, the safety of roads and sidewalks near our home, school, or work—all impact our own health and the health of our family, neighborhood, city, state, nation and the world we live in. A quick scan of the daily news brings home the fact that public health is a global issue–a measles case in New Delhi can travel by plane and expose a stream of travelers in major airports in London, New York, and Los Angeles in a single day. Within our own community, if we want to understand why two 4-year-olds with similar asthma severity have very different rates of hospitalization, medication compliance, and respiratory health outcomes, we must be willing to look beyond each child’s individual health condition, and explore factors in the home, family, neighborhood, and community. Addressing these factors requires different tools, skills and interventions.

Aligning Aims & Targets for Population Health Improvement

In the authorizing legislation in Section 5405 of the Affordable Care Act, Congress gives a principal charge to the Primary Care Extension Program (PCEP) to “assist primary care providers to implement a patient-centered medical home to improve the accessibility, quality, and efficiency of primaqry care services.” This charge emphasizes the role of the PCEP as a practice facilitator, providing technical assistance and coaching for practices to successfully implement innovations such as open access scheduling, the chornic care model, panel management, care coordination, team-oriented primary care models, and other redesign of workflows, organization, and processes to help practes to transform into high performing, patient-centered medical homes. While this charge falls in the domain of health care delivery, the authorizing legislation acknowledtged that limitng the scope of the PCEP to only reform of clinical health service delivery may be overly narrow. Section 5405 thus included a set of “discretionary activities” to allow the PCEP to expand its scope to encompass public health-oriented activities. One of the options is for PCEPs to “collaborate with local health departments, community health centers, tribes and tribal entities, and other community agencies to identify community health priorities and local health workforce needs, and participate in community-based efforts to address the social and primary determinants of health, strengthen the local primary care workforce, and eliminate health disparities.”

This expanded scope is taking on greater relevance as health care reform highlights the importance of a population health perspective. Accountable Care Organizations focus attention on improving health care value and health outcomes for a defined population. There is growing appreciation that the acute and chronic illnesses of patients seen in primary care, especially in underserved communities, is reflective of the “downstream” consequence of social and economic factors such as poverty, low educational attainment, poor housing, unsafe neighborhoods, unhealthy food choices and inadequate social support (Marmot, Woolf).

The Institute of Medicine Committee on the Integration of Primary Care and Public Health, released in March, 2012, stresses the need to develop a stronger partnership between primary care clinicians and public health departments to collaboratively address these fundamental determinants of health and illness and to improve population health. Health Extension agents can play a critical role in this endeavor.

Below is a video prepared by the Bernalillo County Health Council describing how these factors relate to health:

Interfaces with Public Health across Mission Areas

HEROs agents invest heavily in different social determinents, one of the most important is in the area of educational attainment. Local Agents encourage youth to complete high school and consider health careers. Such investment brings a triple community health benefit. A community’s rate of high school completion is one of the most important social determinants of community health—with youth earning power increased, and rates of acute and chronic illness decreased.(Woolf) In addition, encouragement of youth to enter health careers is a sound investment in terms of job security in light of high employment potential in the health field. Last year, in Taos County New Mexico (Taos being one of the state’s poorest), 65% of the new jobs were offered in the health sector. And finally, attracting health professionals into underserved areas, another role of Health Extension, yields an important contribution to local economic development. For example, every primary care doctor recruited to a rural community employs 18 people directly and indirectly, and generates $1 million in business each year—a large industry in a small town, attracting businesses, retirees and strengthening the school system and economic base.

HERO agents work with two programs of vital importance to primary care and public health. Agents work with their local Department of Health Offices to produce annual County Health Report Cards for each of the state’s 33 counties and uses these report cards to monitor progress towards state community health goals for 2020.

Another example of this bridging work has been HEROs’ promotion of the nation’s only 24/7 statewide nurse advice line (1-877-725-2552). The Line is supported by a public-private partnership. It receives 15,000 calls per month and has significantly reduced unnecessary ER visits, allowed rural primary care physicians to turn over their night telephone calls to the Line nurses, and allowed the New Mexico Department of Health to monitor on the Line’s web-based call data entries, patterns of symptoms across the state, picking up early warning symptoms of communicable disease symptoms.

Training the Health Workforce in Public Health

Imagine a workforce that protects our lives and promotes our health 24 hours per day, 7 days a week, 365 days per year–a workforce that assures air and water quality, a wholesome food supply, protection from deadly infectious diseases and other threats, including: terrorist attacks, natural disasters, drunken drivers, youth suicide, drug overdose deaths, car crashes, and workplace-related illness and death. This workforce also provides “safety net” health care for the poorest of the poor, medically-fragile developmentally disabled adults and children and the severely mentally ill, all for just 3 cents of each dollar spent on health care. Since there are virtually no training programs for front line workers in this system, all new “hires” must be trained on the job, placing an additional burden on existing staff. Now, imagine that workforce cut in half between 2000 and 2012, as a result of non-competitive salaries, retirement of the most experienced workers, and slashing of state and county budgets following the 2008 economic recession. Feeling a little worried about what comes next?

We should worry–a 2005 assessment of the public health workforce in six states by Health Resources and Services Administration (HRSA) before recession-related cuts in state and county budgets found that the public health workforce was understaffed, underpaid, lacking formal training in public health, and so diverse, it was difficult to generalize about a “fix”. Since that assessment, state and local health departments have weathered additional, substantial cuts in resources and staffing, while concurrently battling a global influenza H1N1 pandemic.

We believe it is time for a systemic solution, rather than a piecemeal approach to shortages in staffing, resources and training at multiple levels in each state. Whether they know it or not, every health care provider is a part of the public health system. If every training program for health care professionals provided a basic orientation to essential public health roles and training in basic competencies, the diverse U.S. health care workforce could begin to fulfill its essential public health roles in daily delivery of health care services. This would also expand the available pool of public health workers to staff health departments at all levels in all states, and assure a competent and capable public health system to protect our population from preventable disease and injury, and premature death. By including basic public health knowledge and related competencies in all board and licensure exams for health care professionals, we can begin to assure a competent public health workforce that includes all health care professionals.

At University of New Mexico School of Medicine (UNM SOM), this systemic solution has already begun. Since the fall of 2010, all medical students are required to complete course work for a public health certificate (17 credit hours) to receive an MD degree, and training in essential public health competencies is being integrated into ward rotations.

Related Literature & Tools

“The State of Health in New Mexico 2011”

“Public Health Workforce Development: Progress, Challenges, and Opportunities”

“Community Development Model for Public Health Applications: Overview of a Model to Eliminate Health Disparities”

“Public Health and Medicine: Where the Twain Shall Meet”

“Primary Care and Public Health: Exploring Integration to Improve Population Health”

“Educational Attainment in the United States”

Click below to access key primers and open-sources courses for public health workforce:

* Public Health Primer
* Roots of Health Inequity



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