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In the current legislative cycle, there are several policy strategies that support the development and integration of community health workers into the public health workforce, including dedicated federal funding and state laws supporting workforce development programs, certification standards, and Medicaid coverage.

This brief examines the ways states can support certification for community health workers.

Several states and territories, as well as many local governments, are going beyond recommendations and requiring individuals to wear face coverings when they are in public settings and spaces (i.e. grocery stores, retail stores, restaurants, public and private transportation services, parks, etc.). Ongoing research and evidence suggests the relationship between mandatory face coverings and declines in daily COVID-19 growth rates is statistically significant.

State and territorial health agencies continue to be challenged by the opioid epidemic, which has been exacerbated by the COVID-19 pandemic. Addressing the opioid crisis requires a robust public health response, which could be helped by resources from pending and future opioid settlement funds.

The 2020 holiday season is coinciding with a nationwide surge of COVID-19 cases. With great concern that holiday travel to see loved ones may exacerbate community spread of the virus, many states are increasing public health measures before the winter holiday season. As of November 16, 2020, 13 states and D.C. had a quarantine requirement for out-of-state travelers. The U.S. territories also have instituted travel restrictions to limit the spread of COVID-19.

ASTHO staff identified a range of evidence-supported policies considered by state legislatures that could prevent ACEs. This report synthesizes these research and policy proposals and is intended for public health practitioners and policymakers who are considering adopting similar policies.

States Stay Prepared by Supporting the Public Health Workforce Margaret Nilz, Christina Severin Learn how states use policy to support emergency preparedness and bolster the public health workforce. Public health — particularly public health preparedness — continues to experience workforce shortages, driven by longstanding systemic challenges such as chronic underfunding, high turnover, limited recruitment, and an aging workforce. While some jurisdictions report increased capacity to hire and train public health staff in recent years, they often rely on short-term or temporary funding streams, which limit long-term sustainability. State, local, tribal, and territorial health agencies have varying capacities to respond to public health emergencies, particularly in rural and underserved communities. Because a limited workforce can inhibit emergency preparedness efforts, jurisdictions recognize the importance of cultivating a resilient public health preparedness workforce to respond to future emergencies. In recent years, jurisdictions have pursued several policy interventions to bolster the public health preparedness workforce such as legislation supporting front-line clinical staff and first responders, and rulemaking and other executive powers to provide structural and financial support to critical personnel. Legislative Efforts Legislative efforts to increase benefits and support for health care and public health workers can help address the root causes of workforce challenges and lay the groundwork for sustainable, long-term investment in public health preparedness. Laws that establish standards and expectations for the preparedness workforce, including expansions of benefits or additional training, support workforce growth and retention. Since 2024, several jurisdictions expanded mental health benefits and related support for first responders and other preparedness personnel. Both Alaska (SB 103) and California (AB 2859) enacted legislation that allows peer support programs for emergency service personnel. In Alaska, the bill creates programs for entities such as law enforcement agencies, firefighters, and emergency dispatchers, while California’s bill creates programs to serve a variety of health care providers involved in emergency medical care, including physicians, nurses, paramedics, and emergency medical technicians (EMTs). Utah enacted HB 378, which requires the Department of Public Safety to annually distribute information about its critical incident stress management program to first responder agencies. The bill also requires first responder agencies to annually notify employees about the availability of mental health resources, including periodic screenings for employees and continued support for retired or separated first responders and their spouses. On a broader scale, Hawaii SB 3279 recently established a well-being project tasked with mental health trainings and support for several community organizations, including first responders, hospitals, and medical staff. In Washington, HB 2311 directs the state’s Criminal Justice Training Commission to develop resources for first responder wellness, including a peer support network for active and retired first responders and their families. States have also enacted legislation expanding traditional employment-related benefits, including Colorado (HB 24-1219), which expanded certain health benefits for firefighters to include part-time and volunteer firefighters, and Idaho HB 55, which allows retired public employees to volunteer with public employers without it being considered reemployment. In addition, Georgia HB 451 requires state and local entities to provide disability benefits for first responders who experience occupational or volunteer-related post-traumatic stress disorder. Finally, several jurisdictions enacted legislation to support education and training for their public health and health care workforce. For example, Kentucky HB 484 established an emergency medical service education grant program that provides tuition support for students pursuing paramedic certification, wage reimbursement to ambulance providers whose employees pursue certification, and funding for institutions planning to offer EMT, advanced EMT, and paramedic programs. Oklahoma HB 1696 expands eligibility for the Oklahoma Medical Loan Repayment program to include certified nurse practitioners. Two new laws in Puerto Rico require police officers with the Puerto Rico Police Bureau to be certified in first aid or immediate rescue (PC 0859) and adds seminars on sign language, suicide prevention, and conflict mediation to the Bureau’s continuing education training (PC 0543). Other Policy Levers: Beyond the Legislature Jurisdictions can also use non-legislative policy tools to enhance workforce capacity in public health preparedness. This includes rulemaking, where executive agencies use existing legal authority to adopt or amend regulations. Regulations have the force of law and can help support the public health workforce by establishing licensure standards, training requirements, and operational protocols. Wisconsin, following the enactment of AB 576 in 2024, is developing rules to establish a program for peer support and critical stress management teams in the state. And Utah recently adopted rules for its first responder mental health services grant, which helps these professionals pursue a degree or certification as a mental health provider. Government agencies can also leverage grants and contracts to fund and otherwise direct workforce development initiatives, support training programs, and expand capacity in targeted areas. Jurisdictions can strategically direct funds to address skill gaps and assist local, state, tribal, and territorial agencies build a more resilient workforce. One example of this is in Michigan, where in 2024 the state health agency issued a request for grant proposals to award up to $9 million in EMS workforce grants, building on similar awards to address EMS shortages in 2023. Executive orders are another policy option for jurisdictions to consider as they explore different pathways to workforce sustainability. Executive orders are issued by a jurisdiction’s chief executive (often the governor) and direct certain policy actions or activities. Generally, the power to issue an executive order comes from existing law or a jurisdiction’s constitution and, in most cases, does not require legislative approval or review. Several states have leveraged executive orders to advance the public health workforce and support preparedness activities more specifically. For example, Vermont and New Jersey have recently used executive orders to create or extend advisory councils on issues pertinent to public health preparedness. In 2024, Virginia’s governor issued an executive order formalizing the Office of First Responder Wellness, which provides training, counseling, and other resources to first responders in Virginia. In 2023, the governor of Maryland issued an executive order establishing a State of Preparedness directive if there is a risk of public emergency, and the actions state agencies must undertake to promote improved coordination and hazard planning. Key Takeaways Addressing public health emergency preparedness workforce challenges demands strategic, long-term policy solutions, but several implementation options are available. Health agencies can pursue a variety of policy interventions to support and prepare their public health workforce for future emergencies. ASTHO will continue to monitor this important issue and provide updates as appropriate. article yes

Learn how strengthening collaboration and utilization of opioid settlement funds can help address overdose.

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

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

16 recommendations for states as they set up mobile and drive-through COVID-19 test sites.

In this infographic, ASTHO highlights some of the biggest takeaways, successes, and data collected from the Breastfeeding Learning Community.

Approximately 700 women die annually in the U.S. between 2007-2016 as a result of pregnancy or its complications, according to CDC data. This is one of the highest maternal mortality rates in the developed world. On top of that, there are stark disparities along racial lines, with Black and American Indian/Alaska Native women having higher rates of pregnancy-related deaths compared to white women.

The need for food and nutritional assistance is growing. Based on Feeding America’s food insecurity projections released in March, it is anticipated that 42 million people may experience food insecurity this year—up from 35 million pre-pandemic. The job loss in communities as businesses had to shut down or reduce capacity has left many families across the country relying on food banks. In fact, food banks in the Feeding America network distributed 6.1 billion meals to individuals and families during this pandemic, an increase of 43% from 2019. Many of the people who have fallen into food insecurity are experiencing it for the first time in their lives, as our food pantry partners across the country report that 35% or more of the people they’re serving today had never received charitable food prior to the pandemic.

As the number of COVID-19 vaccinations grows, some states are looking at their vaccination rates to determine when to loosen measures that mitigate the spread of COVID-19, such as venue capacity limits, business closure times, and masking requirements. As vaccinations allow businesses to reopen and customers to return, questions have arisen about whether venues or services—especially those that bring people in close contact for long periods of times—such as retail stores, concert venues, entertainment venues, air travel, cruise ships, etc., can require patrons or customers to verify that they received a COVID-19 vaccine. So far, state policy makers have had mixed views on the issue.

Continuing ASTHO’s Legislative Prospectus series—which highlights the top 10 public health policy issues for 2022—this post focuses on mental and behavioral health, as well as supporting the public health workforce.

State efforts to reduce firearm injury and death with safe storage policies.