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PHIG-Funded Local Health Agencies Model Strong Performance Management Systems Health Agencies with Strong Performance Management Programs Anna Bradley, Melissa Touma Performance management is essential in modern public health—learn about three local health agencies with strong performance management programs. Performance management (PM) systems are essential in modern public health, driving efficient service delivery, resource optimization, and transparency. By measuring and improving performance, public health agencies can enable data-driven decision making and communication, and support public health accreditation. With support from Big Cities Health Coalition, ASTHO conducted key informant interviews with performance management leaders from three accredited local health jurisdictions with Public Health Infrastructure Grant (PHIG) funding. These interviews highlight work by Columbus Public Health, Philadelphia Department of Public Health, and San Antonio Metropolitan Health District to build PM programs, create a culture of performance and quality improvement (QI), and ultimately enhance performance. In addition, they provide important insights to other health agencies. Visible Leadership Successful PM systems begin with strong leadership support. Visible leadership includes promoting a customer focus, transparency, strategic alignment, and a culture of quality within the organization. In each of the three health departments, PM programs sat directly under the health commissioner or an assistant director, ensuring the visibility and involvement necessary to drive PM efforts across the organization. Leadership involvement proved particularly important during periods of rapid growth and change, such as during the COVID-19 pandemic. All three jurisdictions experienced an increase in staff, programs, and funding, and leadership played a crucial role in championing the integral operational and administrative functions PM teams provided. For example: San Antonio prioritized growing the PM team as the agency grew to support agency operations as the “engine of the department.” Interviewees recalled that direct access to an assistant director was essential for team growth. As a result, the team expanded from three to seven people serving a department of 700 staff, for a ratio of 1:10. Columbus and Philadelphia also invested in expanding their PM programs. Funding for PM programs in these departments came largely from general funds, Medicaid waivers, and previous grants. However, PHIG funding went towards partial and full staff salaries as well as operational and programmatic dollars. One key informant reflected on the importance of this support, noting that prior to PHIG, the team felt shorthanded. Examples of the influence leadership had on a strong PM system included obtaining participation in QI councils, setting expectations for regular PM reviews, prioritizing PM among other projects, and advocating for increased resources. Performance Standards, Measures, and Reviews The importance of investing in a simple, manageable PM system and corresponding software tools cannot be overstated. When it comes to reporting on performance, the three jurisdictions favor methods that can provide progress snapshots, such as Balanced Score Cards. In Philadelphia, there is not a maximum or minimum required number of indicators per division, but there tends to only be six to 15 each. Keeping the number of metrics manageable and the format simple makes regular reviews between the PM staff and other agency teams easier to maintain. Columbus described a system with a similar focus on simplicity: Only one to two users per division have accounts within the performance management software for updating data. Conversations about performance management can focus less on learning how to use the software and more about how to decide on, analyze, and act on the resulting data. The three jurisdictions described ongoing discussions and training with programs around how many and what types of measures to collect. Relevant standards, indicators, goals, and targets naturally vary by jurisdiction: Philadelphia division directors review the Strategic Plan and the Community Health Improvement Plan and consider current needs of Philadelphians. Data are collected quarterly via Excel spreadsheets, which the Performance Management Unit maintains and distributes for use in quarterly reviews with the health commissioner. Columbus and San Antonio gather data quarterly using Insight Vision (Columbus) and VMSG (San Antonio) and condense it into Quarterly Data Reports for leadership review. Quality Improvement The three jurisdictions prioritize fostering a culture of QI over compliance by emphasizing one-on-one connections and coaching. The adoption of hybrid work environments and virtual communication platforms has opened more informal communication channels between PM/QI staff and other agency members. This allows staff to ask questions more frequently and identify “little QI” projects instead of only looking for larger, agency-wide, “big QI” projects. Hybrid environments also make it easier for staff from multiple locations to join in virtual trainings, meetings, and celebrations, ensuring broader engagement. These agencies also model QI by allowing their PM systems to adapt. They shared examples of how their QI Councils have periodically taken breaks to reassess scope and update group charter documents, membership, and participation requirements, ensuring the systems remain flexible and effective: Columbus recently changed their schedule from quarterly to monthly, with two months of one-on-one meetings between the QI team and members, and a group gathering in the third month. Membership includes the PM team, the Safety Officer, an epidemiologist, the Workforce Development Manager, a union representative, QA staff, and at least one representative from each division. Philadelphia is considering a matrix-style approach to their structure, in which the PM team would communicate with both QI Council members and individual division leadership to improve awareness of internal improvement opportunities and progress. Membership includes the PM team and representation from each division. San Antonio is planning to restructure the QI Council to be project-focused, potentially meeting every other month with less than 15 members representing each division, which is a reduction from 38 total staff. Membership includes upper leadership, frontline staff, and mid-level management from throughout the agency. PM teams can be champions and subject matter experts in change management. Getting ahead of change by communicating clearly, consistently, and with transparency is an important part of every strong workplace culture. Frameworks, such as NACCHO’s Roadmap to a Culture of Quality Improvement, can make change easier. Staff recognition and development are vital for embedding a QI culture. The three jurisdictions shared stories about celebrating and promoting QI by providing QI awards, staff symposiums, and partnering with academic institutions to display QI storyboards, in addition to leadership development programs that include QI projects and participation in the PM system or QI Council that empower staff and future leaders to confidently propose and discuss improvements with leadership. Key Recommendations for a Strong System Keep in mind that PM and QI are related and interdependent but not the same. Review the best practices available through PHAB standards and measures to fully develop and monitor the PM system, with QI as a critical component that uses PM data to prioritize agency-wide QI projects. Formalize processes, consider developing process flow maps to create consistency and clarity, and commit to transparent process improvement. Enhance training programs by making clear plans for training of different levels of staff. For example, differentiate the requirements for members of the QI Council, leadership, program managers, and agency wide opportunities. Also, include foundational elements of QI, the agency-specific PM system, the interaction of PM and QI, and how QI culture manifests. Engage staff of all levels through participation in the QI Council, training opportunities, and development and implementation of the PM system. Check out ASTHO’s online courses on QI and process improvement to refresh your memory on the basics and share them with peers. Schedule regular PM reviews with the highest levels of leadership, and use easy-to-adopt and at-a-glance tools to understand and report on performance. Get ahead of change management by using an established framework and developing a transparent internal communication plan. Operationalize health equity, including in PM systems. Connect with peers through online communities to share ideas, solicit feedback, and find inspiration. Managing public health organizations to improve quality and performance can be overwhelming—submit a PHIG TA request through the PHIVE system for support. Looking Ahead As health departments continue to evolve their PM systems, a focus on leadership participation, staff engagement, and change management is critical for driving improvements. By fostering a culture of continuous quality improvement and investing in infrastructure, public health agencies can ensure their PM systems not only meet accreditation standards but also contribute to better health outcomes for the communities they serve. OE22-2203 PHIG article yes

ASTHO’s 2024 resource roundup highlights essential public health tools, policy guides, and best practices for state and territorial health agencies.

Performance management systems can help public health agencies improve outcomes but choosing the right one can be tricky. Check out these tips to find the right system.

Missouri Takes Strategic Steps to Improve Policy Processes Colton Anderson Learn in this blog post how Missouri’s department of health is improving its internal policies and building a more robust agency by partnering with ASTHO. Why Strong Administrative Policies Matter For public health agencies, effective administrative policies are essential. They set clear expectations, support fair decision-making, and help agencies deliver consistent, high-quality services to the communities they serve. Recognizing this, the Missouri Department of Health and Senior Services (MO DHSS) partnered with ASTHO to improve its policy development and review process. ASTHO’s Role in Supporting Policy Improvements ASTHO provides tools and practical support to help public health agencies improve their internal policy processes. In 2023 – 2024, ASTHO launched a technical assistance program to help public health agencies enhance their administrative policy frameworks. This program, funded by the Public Health Infrastructure Grant, offered tailored support—including coaching sessions, resources, and on-site visits—aimed at giving agencies practical tools and guidance for a more efficient policy structure. ASTHO’s Guide on Conducting a Policy Assessment and Gap Analysis played a central role in this initiative, helping agencies learn about best practices, identify policy gaps, and prioritize areas needing attention. For MO DHSS, ASTHO’s support led to the creation of a policy review committee representing all divisions within the department. This structure promotes a more collaborative approach to policy development, ensuring that different perspectives within the agency are considered. MO DHSS’ Health Planning Coordinator Ashlyn Sherman said, “This work goes beyond preparing for reaccreditation cycles; it’s about embedding a continuous improvement mindset across MO DHSS.” Missouri’s On-Site Visit An on-site visit was a key component of Missouri’s technical assistance collaboration with ASTHO. Thanks to the thoughtful preparation by the MO DHSS team and funding support from the Public Health Infrastructure Grant, ASTHO facilitated a two-day visit to help Missouri improve their policy development process. During this visit, Missouri relaunched a policy review committee, established new by-laws, and used ASTHO’s policy and gap analysis tool to create an overview of existing and required administrative policies that guide the agency’s operations. Key Goals of ASTHO’s Technical Assistance Opportunity ASTHO designed this technical assistance opportunity with a few key goals in mind: Build capacity within public health agencies to systematically develop, review, and update critical policies. Encourage the use of quality improvement principles in policymaking. Provide tools for assessing policies and identifying gaps. Foster a community of agencies sharing best practices and lessons learned. How Other Health Agencies Are Advancing Policy Efforts MO DHSS isn’t the only one benefiting from ASTHO’s resources. Other public health agencies have also leveraged ASTHO’s support to rethink their policy development and review processes. For example, one health agency noted that ASTHO’s external perspective helped them re-launch and organize their approach with a fresh, structured strategy. Another agency received technical assistance in updating a process map and policy review team charter. All health agencies agree that the impartial facilitation and project management support from ASTHO helped them implement a more cohesive, comprehensive policy process that aligns with their organizational goals. To support these efforts, public health agencies are exploring additional areas for improving their policy processes, including establishing compliance units and incorporating AI into policy development. Recognizing the need for shared resources, ASTHO is building a library of administrative policy examples from public health agencies willing to share their work. This growing resource allows agencies to learn from each other, adapt successful policies, and reduce the time spent on creating new frameworks. Learn More and Take the Next Step If your public health agency is interested in improving its administrative policy process, explore ASTHO’s STAR Center or consider submitting a Public Health Infrastructure Virtual Engagement request to see how ASTHO’s programs might support your efforts. With ASTHO’s guidance and tools, public health agencies can take practical steps toward building a streamlined, effective policy process that supports their mission and the communities they serve. For more information, visit the ASTHO STAR Center. article yes

Learn about the various policies on vector-borne disease surveillance and control that states have considered to tackle rising threats.

Learn how strategic layering of state and federal funding maximizes reach and impact of critical suicide prevention programs.

Learn how congress is tackling public health preparedness, as the United States hosts the World Cup and gears up for the 2028 Summer Olympics.

The Boundary Spanning Leadership Framework’s Impact on Public Health Boundary Spanning Leadership's Impact on Public Health Alice Schenall, Tyrone Bethune, Alyssa Merski Explore three examples of Boundary Spanning Leadership's public health impact, from overdose to Alzheimer's to youth behavioral health. Since 2018, ASTHO has customized the Boundary Spanning Leadership (BSL) framework for the public health workforce. BSL develops leaders’ ability to create direction, alignment, and commitment (DAC) across both vertical and horizontal relationships within health departments and with community partners. The framework aims to work across differences in geography, demographics, leadership level, department, or unit. It’s designed for settings where the goal is not only to lead people but to lead across these differences, bridging agencies, sectors, levels of authority, and communities. In short, while many leadership models help individuals become more effective leaders, BSL equips public health professionals to mobilize collective leadership across systems, which is essential for addressing complex issues such as behavioral health and emergency response. Here are three examples of BSL’s impact and utility in public health, two of which are multi-state projects. Preventing and Responding to Overdose Overdose Data to Action (OD2A) leaders are faced with boundaries that can inhibit overdose surveillance and prevention activities without proper navigation. For example, partnership with community organizations to reduce overdose may not be effective without first exploring differences between the state health agency and community organization goals and working to build trust. Throughout BSL trainings, OD2A leaders have demonstrated many ways they bridge these boundaries and apply DAC in their overdose surveillance and prevention work. OD2A leaders may need to span boundaries… Between departments within the agencies in which they work. Between hierarchical levels within the organization. With external partners like community-based organizations. With diverse cultures, demographics, and populations with which they work like people who use drugs. Across rural/urban regions, states, or localities. Collaborating across these boundaries ensures stronger team relationships, exchange of perspectives, expertise, and experience, and alignment of vision and strategy to improve program impact. For example, BSL can help OD2A leaders secure critical health agency buy-in while meaningfully engaging people with lived experience in the planning, implementation, and evaluation of prevention programs. “This program allowed me to focus on specific skills and teach me things I had never learned before. My work will be significantly better because of this. I cannot tell you how important it has been to be able to network with the others as well.” — Participant of OD2A Reducing Risk for Alzheimer’s Disease and Related Dementias In 2025 and 2026, ASTHO and the Alzheimer’s Association hosted two BSL trainings for health departments and their partners throughout the Healthy Brain Initiative. These helped equip them with a dynamic approach to addressing Alzheimer’s disease and related dementias (ADRD) by aligning partners across public health, aging, and other sectors. Through DAC, participants engaged in dialogue that bridged boundaries to integrate brain health into chronic disease, injury prevention, and other public health initiatives. Applying BSL practices to brain health created synergies that addressed shared risk factors such as hypertension, obesity, and lack of physical activity. BSL enabled state and jurisdictional teams to adapt quickly to the latest science, engage nontraditional partners, and build the skills needed to navigate potential boundaries. These practices strengthened cross-sector collaboration and built sustainable systems of shared investment and learning, positioning brain health as a priority across the public health landscape. ASTHO selected the BSL training because leaders who effectively collaborate across boundaries are better positioned to address complex public health challenges such as ADRD, which requires interagency and multisector action. Public health leaders need solutions, and there is evidence to support and measure the usefulness of BSL concepts. Participants successfully met the expectations and objectives of the workshop: Breakthrough Innovations: Drove creative solutions that integrated culturally responsive care and brain health promotion across settings. Cross-Functional Learning: Built shared understanding between public health, aging services, and community stakeholders to address complex problems (e.g., ageism, risk reduction, caregiver burnout, access to care). Partnership Development: Leveraged cross-sector collaborations to expand age-friendly environments and relationships. The BSL training left a lasting impact on those who completed the workshop, with participants reporting increased knowledge of major boundary types and mechanisms needed to boost ADRD strategies. Participants shared their excitement to immediately implement BSL elements into their public health practice. As BSL gains momentum and attention across the field, we urge organizations to leverage the framework as a conduit to build the capacity needed to accelerate brain health strategies and beyond. “My participation in this BSL training will have a lasting impact by strengthening both my individual capacity and our team's ability to approach strategic planning, stakeholder engagement, and the development of sustainable. For my team, this will translate into stronger collaboration, clearer direction, and more cohesive implementation of our ADRD strategies.” — Participant of the Healthy Brain Initiative Building Bridges for Youth Behavioral Health in New Mexico In April 2026, leaders from New Mexico’s Departments of Health and Education came together — not just to coordinate but to truly collaborate. Partnering with ASTHO, they convened an in-person BSL training designed to move beyond siloed work and toward a shared vision for adolescent behavioral health in schools across the state. A total of 18 participants joined the training, representing a cross-sector mix of state agencies and community-based organizations. While the group brought diverse perspectives, they shared a common purpose: improving outcomes for young people across the state. The BSL framework offered them a structured way to navigate differences, build trust, and define collective direction. Throughout the workshop, participants deepened their understanding of the boundaries that often limit collaboration, whether structural, relational, or based on differences in processes and priorities. More importantly, they built the skills to identify and bridge those divides. For many, the experience shifted how they think about partnership — not as coordination across systems, but as intentional, interdependent, and relationship-driven leadership. The impact was immediate. Participants reported increased confidence in their ability to break down barriers and apply BSL strategies to advance adolescent behavioral health. Just as critical, they described forming authentic connections with colleagues across sectors, which laid the groundwork for more cohesive, aligned work ahead. Perhaps most telling: Every participant committed to using BSL strategies in the next 30 days to six months. This wasn’t a one-time training, it was the start of a new way of working. The group plans to continue meeting monthly to apply these tools, strengthening direction, alignment, and commitment in their shared efforts. “Addressing boundaries is a great practical step in all of the projects we will have going forward.” — Participant of New Mexico School-Based Health Program For public health professionals, the takeaway is clear. Complex challenges like youth behavioral health don’t sit neatly within one sector and they can’t be solved there either. Boundary spanning leadership offers a practical, human-centered approach to building the partnerships needed to create lasting change. Explore more of ASTHO's work in Boundary Spanning Leadership. article yes

Improving Public Health Communication for Effective STI Programs Improving Public Health Communication for Effective STI Programs Julia Greenspan Explore public health agencies' current STI communication practices and opportunities for improvement, based on needs assessment results. In spring 2026, ASTHO completed a needs assessment to better understand the strengths, gaps, and opportunities for communication about sexually transmitted infections (STI) from state and territorial health departments. Results highlight the important role that health department leadership plays in ensuring the success of STI and other public health programs through internal communication policies and culture. Major Findings The State of Communications STI communications for most jurisdictions have changed in the last three years, most notably due to an increase in digital and social media, updated messaging, and an increased focus on stigma reduction. This has had positive impacts, including: Increased public engagement. Higher engagement with priority populations. More inclusive and culturally appropriate language being used. However, there have also been additional approval processes — both within the health department and with external entities — and increased barriers to accessing materials for some populations. “Creating specific content that addresses unique barriers experienced by the priority populations [is vital].” — Needs Assessment Respondent Current Communication Approaches Jurisdictions most frequently use their health department website, printed brochures/flyers, and social media posts to communicate with key audiences. These materials raise routine awareness of priority STI issues, in targeted campaigns and during awareness weeks (like STI Awareness Week). They are used less frequently during outbreak response, in response to new data trends, or when new guidance is released. Most jurisdictions create STI communication materials from existing resources within the health agency. They reported the need to balance resources (financial and staff) with the desire to make relevant resources for their audience. Challenges to developing or adapting materials include limited funding and staff capacity, approval barriers, and a lack of culturally appropriate materials. “Budget constraints are the primary reasons we adopt [federal agency] campaigns.” — Needs Assessment Respondent Future Materials There is still a need for materials that cover basic facts around STIs, including transmission methods, signs and symptoms (i.e., asymptomatic spread), and new prevention tools. Diverse and culturally competent materials are also a priority. Jurisdictions prefer: Materials that are ready to use or require minimal editing. Short-form and succinct materials (e.g., infographics, one pagers, and social media ready content). “[…] the state of sexual health is not what we learned in high school sex ed. There have been so many advancements, but people don't know what they don't know.” — Needs Assessment Respondent Looking Ahead Staffing and additional funding was frequently mentioned as a requirement to improve future STI communications. Access to ready-to-use materials, technical assistance, translation services, and evaluation support would also be beneficial. Next Steps for Health Department Leadership Senior health department leadership can address several major themes from the needs assessment to support future public health communications. Minimizing Stigma Communication materials focused on topics that may be considered stigmatized or shameful still face additional scrutiny. Several respondents identified barriers both within and outside the health department preventing STI messages from being published. These barriers may have been minimized or non-existent for other public health topics. Leadership can play an important role in reducing stigma by promoting education around sensitive topics. Addressing Misinformation In addition to minimizing stigma, senior leadership can also address misinformation. Misinformation impacts many public health topics, including STIs. When there is a proliferation of misinformation, strained communication resources must be redirected to share factual information. By promoting evidence-based science and tailoring messaging to local contexts, leadership can minimize situations where resources must be diverted to respond to false or misleading information. Expanding Staff Capacity Finally, leadership can help address the major barrier of funding and staffing capacity. While grants and funding sources may have restrictions, aligning funds through braiding and layering can provide an opportunity to expand the capacity of staff. Encouraging partnerships within the health department can increase the impact of communication programs. Conclusion While the current needs and opportunities for STI communications are wide-ranging, state leadership plays an important role in setting the expectations and culture within the health department. Reviewed by - Allen, Petersen article yes

Prioritizing Community-Clinical Linkages to Prevent Falls in Older Adults Preventing Falls in Older Adults: Community-Clinical Linkages Amy Ciarlo Learn how health care providers and community-level evidence-based programs can help prevent falls in older adults. Falls among adults age 65 years and older are the leading cause of fatal and nonfatal injury, decreased independence, and health care costs across the United States. As the U.S. older adult population grows, falls are projected to increase. Moreover, older adults living in rural areas report 25% more falls than their urban counterparts, compounded by barriers including increased distance to care, fewer public transportation options, and limited health promotion services. Despite the statistics, falls are preventable — through the mobilization of health agencies, providers, communities, and older adults themselves. Evidence-Based Approaches Health care providers play a critical role in supporting the health and independence of older adults. CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative provides a coordinated approach to screen patients for fall risk, assess modifiable risk factors, and implement effective intervention strategies to reduce falls. STEADI translates complex guidance into actionable clinical workflows, including tools for gait and balance assessment, medication review, and patient education. Community-level evidence-based programs complement clinical care. Exercise programs such as Tai Chi, Matter of Balance, and Staying Active and Independent for Life improve balance, strength, and confidence among older adults. Additionally, programs offering home safety assessments help identify hazards and modifications to prevent falls. Research consistently shows that collaborative efforts linking clinical and community-based programs support sustainable falls prevention at scale. Efforts to establish these linkages are especially impactful in rural and underserved communities where program offerings are limited. ASTHO's guide to Expanding Falls Prevention Through Surveillance, Community-Clinical Linkages, and Strategic Planning and Evaluation helps health departments align and expand these efforts. It outlines three strategic steps: Assess the current falls prevention landscape. Identify opportunities to strengthen community-clinical linkages. Develop a plan to implement and sustain those linkages over time. State Health Agency Highlights Since 2023, ASTHO has partnered with CDC to build capacity among states to establish and strengthen community-clinical linkages for older adult falls prevention and expand the adoption of STEADI into clinical practices. The Iowa Department of Health and Human Services and Oklahoma State Department of Health participated in a multi-year pilot learning community. Through technical assistance, structured learning sessions, and action/evaluation planning, both states captured measurable progress in implementing STEADI and connecting clinical providers to community resources. Iowa: Building a Connected Ecosystem Iowa's strategy centered around the Iowa Community HUB (HUB), a community care hub that links networks of community-based organizations to the health care continuum through centralized infrastructure. Iowa has used the HUB to expand reach of evidence-based falls prevention programming. Key achievements from the Iowa pilot include: Embedding STEADI workflows into multiple partner clinics, including electronic referral orders within EHR systems linking patients directly to the HUB. Training numerous clinicians on STEADI principles. Expanding the Iowa Falls Prevention Coalition membership and building a broader statewide network of regional coalitions. Partnering with the University of Iowa Injury Prevention Research Center for evaluation support, using key informant interviews and the Consolidated Framework for Implementation Research. Establishing a Best Practice Advisory system to automate fall risk reminders for clinicians within EHR workflows. "STEADI is the tool that helped it all come together… Since partnering with the HUB, [our clinic] gained a trusted intervention option that addresses clinical and non-clinical needs." — Iowa-Based Clinicians Iowa also identified and filled gaps for state-specific falls prevention data and resources, procured multilingual materials to support diverse patient populations, and expanded marketing within clinical settings to raise awareness of available programs. Oklahoma: Scaling Through Practice Facilitation Oklahoma partnered with their state Medicaid agency, Oklahoma Health Care Authority, and contracted practice facilitators to integrate STEADI into primary care settings statewide. This reached more than 288 providers, with the following outcomes: 146 providers received education specifically on STEADI. 126 were actively screening patients for fall risk. 124 indicated they were intervening to reduce identified fall risk factors. 82 confirmed following up with patients who have identified fall risk factors. 69 had fully integrated STEADI into their practice workflow. Oklahoma expanded access to evidence-based programs across the state through instructor trainings of evidence-based programs, with Tai Chi and Matter of Balance being especially popular among participants. It also collaborated with county health departments to host programs in community settings such as libraries, faith communities, and senior centers. Participants in Oklahoma's community programs reported meaningful impact on their lives and independence. "Tai Chi has significantly improved my balance and flexibility... I feel Tai Chi has improved my ability to live independently for a longer time." — Oklahoma Tai Chi Program Participant Considerations for Implementation and Sustainability The ASTHO pilot learning community identified several high-value strategies for health agencies working to scale falls prevention efforts: Build localized and sustainable coalitions with support from statewide frameworks that are flexible and reflect community priorities. Leverage community care hubs and referral infrastructure to create durable pathways between clinical screening and community-based programs. Educate providers on falls prevention billing codes to incentivize screening and reduce time burden. Invest in Community Health Worker programs to expand capacity for environmental screenings in home and community settings, offer educational resources, and bridge the gap between clinical care and social needs. Use storytelling and qualitative data alongside numbers to demonstrate impact, appeal to policymakers, and source sustainable funding. Integrate falls prevention within broader efforts for promoting healthy aging and older adult health, brain health and caregiving, and physical activity to align priorities and reduce siloed programming. Expand culturally appropriate, evidence-based fall prevention programs in high-risk and rural communities through flexible telehealth and home-based delivery. Address potential workforce and partnership barriers through flexible scheduling, accommodating limited agency staffing, volunteer burnout, and rural resource gaps. Falls prevention is a strategic public health investment with a demonstrable return including reduced injury rates, lowered health care costs and burden, decrease in family caregiver strain, and improved quality of life. Considering flexible funding approaches for this work, such as braiding and layering federal, state, and local funds can help sustain falls prevention capacity. Health agencies are uniquely positioned to lead this work by convening cross-sector champions (e.g., health care, aging services, community organizations), supporting the implementation of STEADI, and tracking community-clinical referral pathways. ASTHO remains committed to supporting state health agencies in preventing older adult falls and will share details about future opportunities to continue this work. Reviewed by - Bayer, Grant, Mackie article yes

Rethinking “Soft” Leadership Skills in Public Health Rethinking “Soft” Leadership Skills in Public Health Angela Cochran, Jamilia J. Sherls Learn how public health leaders can leverage interpersonal skills to better navigate cross-sector partnerships in this blog post. Budget reductions, staff lay-offs, conflicting federal guidance, limited funding opportunities, being asked to do more with less — these are just some of the challenges public health professionals navigate. Public health’s goal to promote health, safety, and wellness across the nation is difficult to achieve while negotiating these challenges, often leading to stress and burnout. According to the 2024 Public Health Workforce Interests and Needs Survey, approximately 71% of state and local government public health workers are experiencing at least one symptom of burnout and about 20% are experiencing near-constant symptoms. When stress creeps into collaborative spaces, it can lead to frustration, misalignment, poor decisions, strained relationships, and weakened outcomes. As leaders work with internal teams and external partners to achieve public health goals, they must remain vigilant for signs of stress impacting the work. Stress often presents as irritability, conflict, errors, and stagnation. When stress gets in the way, it is critical for leaders to tap into their “soft” skills to alleviate pressures and create a clear path forward. Across sectors, communication, empathy, adaptability, and critical thinking are often grouped under the label “soft” leadership skills. Soft skills are considered foundational, interpersonal qualities or skills that help individuals interact with peers and navigate complex work environments. They may also increase resiliency, which is important in today’s ever-changing world. The term “soft skills” may sound neutral, but it carries an implicit assumption that these skills are easier, less rigorous, or secondary to technical expertise. These are, in fact, the skills that most define the quality of a leader. In practice, they are the very competencies that determine whether collaborative efforts succeed or stall. While there are many “soft” skills or leadership practices that can be helpful in stressful partnership situations and reducing conflict, there are three leadership habits especially critical to sustaining collaboration: Practice Intellectual Humility. Intentionally Build Psychological Safety. Anchor Communication in Values, Not Reaction. Each of these habits is learnable and, when applied with intention, can shift the entire energy of a room. Practice Intellectual Humility Collaborative leadership requires the ability to rethink assumptions without abandoning core values. In cross-sector work, leaders frequently navigate different perspectives, competing priorities, and incomplete information. Approaching these situations with a fixed mindset or rigid assumptions can limit progress, while intellectual humility creates space for better solutions. Practicing intellectual humility does not mean being easily persuaded or lacking confidence. It means remaining open to new information, asking thoughtful questions, and recognizing that no single perspective fully captures the complexity of the issue. Leaders who model this behavior create environments where others feel more comfortable contributing ideas, raising concerns, and engaging in meaningful dialogue. This becomes especially important when partnerships, both internal and external, are under strain. As expectations shift or challenges emerge, the ability to pause, reflect, and reconsider can prevent unnecessary conflict and support more productive problem-solving. For example, in cross-program initiatives where teams bring different priorities or funding requirements, taking time to understand competing perspectives before moving forward can prevent misalignment and strengthen long-term collaboration. Intentionally Build Psychological Safety Effective collaboration depends on trust, but trust does not develop passively. It must be built intentionally through leadership behaviors that create psychological safety. In practice, this includes clearly defining roles, maintaining open communication, and creating space for respectful disagreement. Proactive relationship management, such as regular check-ins and early disclosure of challenges, is essential to maintaining alignment and preventing breakdowns in collaboration. Without these efforts, stress can quickly erode trust and lead to disengagement. At the local level, building psychological safety often requires visible leadership behaviors that demonstrate support rather than control. This can include showing up alongside teams during outreach efforts when additional support is needed, not to direct the work but to reinforce shared ownership and trust. It also involves intentionally creating space for team members to share perspectives and acknowledging when or how those perspectives shift your own thinking. For example, when team members raise concerns or offer alternative approaches, responding with openness, such as acknowledging a perspective that had not been previously considered, can reinforce that you value their input. Over time, these behaviors help establish an environment where staff feel more comfortable speaking up early, allowing leaders and teams to address challenges before they escalate. Leaders play a critical role in shaping this environment by normalizing open dialogue and demonstrating that they value differing perspectives. Anchor Communication in Values, Not Reaction In fast-paced and often high-pressure environments, it can be easy for communication to become reactive. However, reactive leadership can create confusion, erode trust, and shift focus away from shared goals. Anchoring communication in shared values provides consistency and clarity, particularly when navigating uncertainty or competing demands. This means responding thoughtfully, aligning messaging with the broader mission, and maintaining transparency even when challenges arise. For example, during executive leadership discussions involving shared funding opportunities or cross-agency initiatives, leaders may face competing priorities and uncertainty around ownership of the work, responsibilities, or decision-making authority. In one discussion regarding a collaborative grant opportunity, a leadership team navigated tensions by grounding the conversation in organizational values that had been intentionally developed through prior team building, reflection, and difficult conversations around how the group wanted to lead and work together. Because there was already a shared understanding around values such as honesty, respect, integrity, trust, and clarity, team members felt comfortable asking difficult questions openly and respectfully. Rather than reacting defensively or avoiding tension, the leadership team was able to clarify expectations, define roles, and move forward with greater alignment and confidence. Listening to partners and stakeholders remains essential, but listening does not require immediate agreement or action. Leaders must balance openness with discernment, ensuring that decisions remain aligned with both evidence and organizational values. This approach reinforces stability within partnerships and helps to sustain collaboration over time, even when external pressures are high. Applying these three leadership habits the next time you feel the room get tense will significantly improve group dynamics, allowing the team to focus on the tasks at hand. It is important that leaders understand these practices require intention, consistency, and reflection. After an event, leaders should take time to think and reflect on how they used these practices, what the immediate outcomes were, and if there is anything different they would do the next time. These leadership habits do take practice, so leaders should be patient with themselves as they get more comfortable applying them in the heat of the moment. As the great philosopher Epictetus said, “It’s not what happens to you, but how you react to it that matters.” Public health is truly in unprecedented times, bringing with them unpredictable, challenging, and nuanced situations. Leadership calls for not only “technical” expertise, but for “soft” expertise as well to manage stress and complexity, provide clarity, and achieve the best possible outcomes in collaborative spaces. Resources PH WINS 2024 Findings by de Beamount Soft Skills Matter Now More Than Ever, According to New Research by Harvard Business Review Intellectual Humility by Character Lab Values-Based Communication (PDF) by TCC Group What Is Psychological Safety at Work? Here’s How to Start Creating It by APA Reviewed by - Mason, Prather article yes

Discover how cross-sector partnerships can strengthen overdose prevention efforts and improve outcomes.

Learn how state health agencies are using policy to strengthen preparedness and supply chain resilience.

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2026 State Legislative Session Update 2026 State Legislative Session Update Learn about state legislation from FY26 focused on hot public health topics in this Health Policy Update. ASTHO’s 2026 Legislative Prospectus Series announced the top five public health state policy issues to watch this year. With at least 30 states scheduled to conclude their legislative sessions by the end of May, state legislatures focused on many of these public health topics. Expanding Access to Care As expected, a number of states considered legislation to expand access to care, including policies that promote community-based services and rural health care access. Doula birthing support services continue to be a topic for state legislatures with at least a dozen states considering legislation to expand coverage or access. Oregon enacted SB 1568, expanding coverage for birth and postpartum doulas and lactation counselors. Virginia enacted two bills that support access to doulas: HB 328 requires the Bureau of Insurance to select a new essential health benefits benchmark plan that includes doula care coverage starting in 2029, while HB 838 expands Medicaid coverage to include incentive payments for doulas to provide linkage to care visits in the postpartum period. For other licensed health care professionals, interstate compacts allow health care professionals licensed in one member state to practice in another without additional credentials. This year, legislatures have considered more than 100 health care professional compact bills so far, with at least six states enacting legislation: Arizona (HB 2190), North Dakota (HB 1622), and South Dakota (HB 1146) adopted the Physician Assistant Licensure Compact. New Mexico adopted the Interstate Medical Licensure Compact (SB 1) and the Social Work Licensure Compact (HB 50). Mississippi (SB 2543) adopted the Dentist and Dental Hygienist Compact. Washington (HB 2088) adopted the Dietitian Licensure Compact. Finally, at least two states enacted legislation to expand telehealth. Virginia HB 1284 specifies that its Medicaid provider-to-provider consultation provision includes services provided via telehealth, and Kentucky HB 424 eases the requirements for social worker telehealth practice. Behavioral Health Legislatures are also continuing to explore policies that address mental health and substance misuse. This includes legislation that supports people across the care continuum, explores the use of psychoactive substances in mental health treatment, and regulates emerging substances. At least seven states have enacted legislation to establish or enhance the continuity of care for people in a behavioral health crisis. This includes Maine LD 1216, which requires the Department of Health and Human Services to establish crisis intervention support services in all counties. Virginia enacted HB 453, which specifically allows amendments to the state’s Marcus Alert plan supporting the state’s comprehensive crisis system and requires state agencies and local partners to align their policies accordingly. States also continue to promote the availability of opioid reversal drugs through legislative action. Virginia SB 257/HB795 requires certain health insurance plans to include at least one opioid antagonist with limited cost-sharing on their drug formularies. Kansas HB 2534 requires schools to stock naloxone and establish polices to support its administration, and Utah SB 87 clarified its immunity provisions for administering opioid antagonists and will allow expired — but still effective — opioid antagonists to be dispensed and administered in certain situations. Another trend this legislative session is the legalization and regulation of use, medical study, and reclassification of certain psychedelic drugs for therapeutic purposes. Several states considered legislation to allow psilocybin for therapeutic purposes, including Oregon HB 4040, which already allows psilocybin service centers and expanded its licensing criteria for psilocybin service facilitators. At least 23 states considered, and five states (Mississippi SB 2056, South Dakota HB 1099, Utah SB 83, Virginia SB 379, and West Virginia SB 906) enacted legislation that would automatically reschedule psilocybin or certain formulations, pending federal approval and/or rescheduling. Finally, at least 10 states considered bills to support access or research into ibogaine, which is being studied in relation to PTSD and substance use disorder. States include Washington (SB 5204), Oregon (HB 4110), Tennessee (SB 2149/HB 2075), Louisiana (SB 43), Oklahoma (HB 3834), and Georgia (HB 1296), with Mississippi enacting HB 314 to allow the state health department to participate in a consortium supporting clinical trials for ibogaine drug development. A number of states are also taking action to address kratom, a plant-based substance with the potential for serious side effects, including substance use disorder and withdrawal symptoms. As of January 2026, 31 jurisdictions regulate kratom, with at least five states enacting legislation this year. New York (A 9472/S 8814), Virginia (HB 360), and West Virginia (SB 985) established or enhanced prohibitions on selling kratom to people under 21, while Nebraska (LB 901) enacted an excise tax on kratom products. Utah enacted two bills (HB 385 and SB 45) that regulate processors and retailers and New York mandated warning labels on certain kratom products (A 9443/S 8780). Healthy Food and Chronic Disease States continue to prioritize chronic disease by advancing policies recognizing the importance of prevention and how food impacts health. In 2026, a number of states considered legislation to address food insecurity, improve school nutrition, and promote chronic disease screening and prevention. At least 10 states considered legislation to limit ultra-processed foods or promote access to healthy foods, with Nebraska LB 940 prohibiting public schools from offering foods that contain certain color additives and Tennessee SB 2423/HB 1853 taking a similar approach but for any artificial food dye. States are also exploring ways to accommodate student dietary preferences. Minnesota (SF 2970), New Jersey (S 1676), New York (A 1834), and Washington (S 5878) introduced legislation that would mandate plant-based options in school cafeterias. Illinois enacted HB 1607, creating a health department task force to review state efforts to eliminate food deserts and requiring a report with recommendations by January 2028. Finally, state legislatures are taking action to support access to early detection and chronic disease management through insurance regulation. Mississippi enacted HB 565 to require Medicaid and other health plans to cover biomarker testing for the diagnosis, treatment, management, or monitoring of patients when supported by medical evidence. Additionally, Oregon enacted SB 1527, which limits out of pocket costs for medically necessary cervical cancer screenings and follow-up examinations. Finally, Alabama (SB 19) will prohibit certain insurance plans from imposing cost-sharing for prostate cancer screening of all men over 50 and younger men at high risk. Infectious Disease Prevention With recent changes to the membership and recommendations of the Advisory Committee on Immunization Practices (ACIP), a number of state legislatures have considered changes to vaccine policy in 2026. Several states enacted legislation to modify the role of ACIP, including Colorado (SB 26-032), Connecticut (HB 5044), Maine (LD 2146), Maryland (HB 637), New Mexico (HB 156), Oregon (SB 1598), Vermont (H 545), and Washington (HB 2242). Many of these bills address other components of vaccine policy, including: Vaccine Schedule Recommendations: Colorado, Connecticut, Maryland, New Mexico, Vermont, and Washington substitute or add state health agencies and/or organizations like the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and American College of Physicians as sources for vaccine recommendations. Insurance Coverage: Connecticut, Maryland, New Mexico, Oregon, Vermont, and Washington require health insurance plans to cover vaccines recommended by health agencies or other organizations, rather than ACIP alone. Pharmacist Scope of Practice: Maryland and Vermont substitute or remove ACIP recommendations as an authority for pharmacists to administer vaccines, and Colorado allows pharmacists to prescribe vaccines independently. Funding: Colorado, Maine, and Vermont expand vaccine purchasing programs to include vaccines recommended by bodies other than ACIP. Liability Protections: Colorado, Maine, and Vermont include liability protections for certain providers administering vaccines according to state or medical organization recommendations. Public Health Funding Legislatures in thirty-one states, the District of Columbia, and three U.S. territories will enact budgets for the 2027 fiscal year, while legislatures in three more states will enact biennial budgets for the 2027 and 2028 fiscal years. With reductions in federal funding, states continue to find ways to leverage state funds to invest in public health and public health infrastructure while adhering to balanced budget requirements. Eleven states have enacted FY 2027 budgets and three states enacted biennial budgets for FY 2027-FY 2028, with several states increasing public health funding, including Kansas (HB 2513), New Mexico (HB 2), and Wyoming (SF 0001). Additionally, three states passed FY 2027 supplemental budgets featuring public health provisions: Maine LD 2212 appropriates funding to support access to affordable prescription drugs in rural and underserved areas, Washington SB 6003 increases funding for the state’s Drinking Water State Revolving Fund, and Nebraska LB 1071 shifts funds to children’s health insurance, community-based aging services, and mental health operations. States have also

The Public Health Response to Hantavirus: Key Actions, Perspectives, and Takeaways Public Health Response to Hantavirus: Key Takeaways Ericka McGowan, Sidnie Christian, Margaret Nilz Learn about the hantavirus outbreak from the MV Hondius and the ongoing public health response — including the important work of state and local health departments. On May 2, the World Health Organization (WHO) received notification of an international hantavirus cluster linked to passengers aboard the MV Hondius cruise ship, following reports of severe acute respiratory illness. Subsequent laboratory testing confirmed infection with the Andes strain of hantavirus, a rare zoonotic virus associated with hantavirus pulmonary syndrome. The event drew international public health attention because of the distinct challenges posed by the cruise ship setting, the need for multi-country coordination as exposed passengers returned home, and the involvement of the Andes virus — which can be transmitted person to person unlike other strains of hantavirus. In response, WHO and U.S. health authorities initiated contact tracing and surveillance to monitor for additional cases. Despite international attention, the risk to the public is low at this time. However, it remains crucial for state and territorial health officials to stay up to date on this developing threat, which serves as an important reminder that public health preparedness is more critical than ever. What Is Hantavirus? Hantaviruses belong to the family Hantaviridae within the order Bunyavirales and are primarily spread through contact with infected rodents (i.e., via exposure to their urine, droppings, saliva, or contaminated surfaces). Various strains exist globally, including the Sin Nombre virus, predominant in North America, and the Andes virus, predominant in South America. In humans, clinical signs are non-specific, including fever, fatigue, muscle aches, headache, and gastrointestinal symptoms. In severe cases, infection may progress to hantavirus pulmonary syndrome, with rapid onset of cough, shortness of breath, and fluid accumulation in the lungs. The recent cases raised concerns as the cruise ship setting likely facilitated exposure among passengers and crew. Additionally, the expedition's international nature meant potential exposure across multiple countries, with passengers disembarking before confirmation that illnesses on board were due to Andes virus — thus requiring coordinated surveillance, contact tracing, and risk communication among national health agencies. The particularly long incubation period of the Andes virus, 4-42 days after exposure, further complicates monitoring. MV Hondius Hantavirus Outbreak: Key Insights Timeline In early April, the MV Hondius ship departed Argentina. On April 11, the first case died on board, and a close contact died shortly after. On April 28, a passenger experienced onset of symptoms, later presenting with pneumonia, and died on May 2. On May 2, the United Kingdom reported a cluster of passengers with severe respiratory illness to WHO. At the time of reporting, 147 passengers and crew were on board while 34 passengers had disembarked. On May 2, PCR testing confirmed hantavirus infection of a probable case. On May 10, the MV Hondius was permitted to dock and let passengers disembark in the Canary Islands off the coast of Spain. Passengers were then transported to their home countries via non-commercial means. On May 11, U.S. passengers arrived at the National Quarantine Unit (NQU) in Nebraska for evaluation and monitoring. WHO and CDC continue to provide updates as the situation evolves. Risk to the Public While the risk to the public remains low, it is important for public health authorities to assess and monitor contacts closely during the 42-day period for symptoms, as deterioration can occur quickly. Monitoring and assessment are collaborative efforts supported by CDC and led by state and local health departments. CDC released interim risk assessment guidance to support health departments in managing people with potential exposure related to the MV Hondius. It provides definitions of high- and low-risk contacts, recommended care, monitoring, and guidance to reduce the risk of transmission and exposure. A Coordinated Public Health Response This outbreak punctuates the importance of international and federal agencies, state and local health departments, laboratories, health care systems, and specialized treatment centers working together to manage emerging threats. Shared guidance and regulations were necessary to help standardize monitoring and response efforts. WHO coordinated with 10 countries to ensure timely information sharing, response, repatriation, and contact tracing. Domestically, the U.S. Department of State, Health and Human Services Administration of Strategic Preparedness and Response (ASPR), and CDC coordinated to form the domestic hantavirus taskforce. Together, the agencies have managed: U.S. passenger transport and repatriation. International coordination and communications. Access to health care and treatment structure. Quarantine and preparedness assets. Disease surveillance. Epidemiologic support. Risk assessment. Public communication. Coordination with state and local public health departments. This response highlights the expertise, logistics, and coordination required to manage high-consequence public health threats. Specialized Response Systems Responses to high-consequence infectious diseases (HCID) often require specialized infrastructure beyond routine health care. During events like this Hantavirus cluster, quarantine facilities, treatment centers, and coordinated health care networks help safely manage potentially exposed travelers while supporting health care system readiness. Together, these specialized preparedness systems help ensure that patients can be safely evaluated and treated while minimizing disruption to broader health care operations during HCID emergencies: The NQU at the University of Nebraska Medical Center and the Global Center for Health Security is a key component of this infrastructure. This unit is specifically designed to support quarantine and individuals exposed to HCIDs. U.S. passengers returning from the cruise ship were transported to Nebraska for assessment and monitoring, including one asymptomatic passenger who was admitted to the Medical Center’s Biocontainment Unit for further evaluation but has since been cleared to return back to the NQU. Regional Emerging Special Pathogen Treatment Centers (RESPTCs) serve as specialized hubs within the National Special Pathogen System. ASPR funds 13 RESPTCs in the United States to support management of care related to high consequence pathogens. The system is designed to distribute specialized care, offset operational burden, and maintain national surge capacity during complex infectious disease responses. ASPR’s Hospital Preparedness Program provided additional preparedness aid. This program supports health care coalitions and strengthens coordination among hospitals, emergency management agencies, public health departments, and health care partners. By advancing planning, training, exercises, and regional coordination, it helps health care systems maintain surge capacity and preparedness for complex emergencies. The Laboratory Response Network, which supports responses to biological threats, emerging infectious diseases, and other public health emergencies, plays a role in public health responses by supporting epidemiologic investigations and providing timely laboratory information to guide monitoring and response activities. In response to this Hantavirus cluster, the Association of Public Health Laboratories activated its Incident Command System to help support a coordinated laboratory response to the Andes virus. The Role of State and Local Health Departments State, territorial, and local public health agencies play a central role in infectious disease responses, especially when exposed travelers cross jurisdictional boundaries. For this response, agencies coordinated contact tracing, symptom monitoring, health care communication and preparation, laboratory coordination, and public risk communication. State and Territorial State and territorial health agencies serve as the primary lead for investigating and managing public health emergencies within their jurisdictions. In addition to coordinating with federal partners, health care systems, and laboratories, state and territorial health agencies may exercise legal authorities (i.e., isolation and quarantine) when necessary to help contain infectious disease threats. Their role helps translate national guidance into coordinated, jurisdiction-specific response activities. Local Local health departments also play a multifaceted role in outbreak response through community-level coordination, health care access, communication, and follow-up for potentially exposed individuals. In some states, local health departments also have the authority related to quarantine and isolation to prevent spread of public health threats. Local health departments help connect public health agencies, health care, emergency management partners, and community organizations to facilitate operational coordination and timely information sharing. Support from the Public Health Emergency Preparedness Cooperative Agreement Many of these preparedness and response capabilities are supported by the Public Health Emergency Preparedness cooperative agreement, which has helped health departments across the country strengthen their ability to respond to infectious disease outbreaks, natural disasters, and other public health emergencies since 2002. It supports surveillance capacity, emergency coordination, epidemiology staffing, and risk communication capabilities while helping jurisdictions build flexible and adaptable preparedness systems before emergencies occur. Events like this recent Hantavirus

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