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Learn how boundary spanning leadership can help develop more robust and productive public health workplaces.

As part of ASTHO’s Public Health - Hope, Equity, Resilience, and Opportunity initiative, we are using this post to highlight some acts of thanks for organization leaders and supervisors to consider.

Building a Culture of Care: Leadership in Public Health Agencies astho, association of state and territorial health officials, association of state and territorial health officials astho, state health official, public health official, territorial health official, island jurisdictions, state health, health department, public health, centers for disease control, creating a culture of care, public health workers, health equity, physical health, building a culture of care, health departments, public health professionals, training program, school of public health, mental health problems, public health leaders, public health workforce, mental well-being, culture of care, mental health, workforce development Chris Taylor ASHTO | A blog post highlighting three simple actions agencies can take to strengthen a culture of care. Throughout the COVID-19 pandemic response, many of us have witnessed or experienced increased feelings of exhaustion, mental distance from our work, negativism or cynicism related to our jobs, and reduced professional efficacy. The World Health Organization classifies these symptoms of burnout as an occupational phenomenon, rather than as a medical condition. For governmental public health agencies to successfully promote and protect the health of their communities, it is imperative that they support their staff to remain healthy and resilient. This blog provides information and considerations for state, territorial, tribal, and local health departments to identify and address work related causes of burnout, as well as build and maintain the health and mental wellbeing of their staff. Governmental public health continues to play a central role in the COVID-19 response, which for more than two years has created unprecedented and prolonged demands on staff. Beyond the COVID-19 response, there continue to be massive changes in how and where we do business, as well as how we interact with one another, contributing to additional organizational stress. In 2021, CDC surveyed state, territorial, tribal, and local public health staff to assess symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), and suicidal ideation. Among 26,174 public health staff who participated: 53.0% reported symptoms of at least one mental health condition in the preceding two weeks, including anxiety (30.3%), depression (32.0%), PTSD (36.8%), or suicidal ideation (8.4%). The highest prevalence of symptoms was among respondents 29 years or younger, as well as transgender or nonbinary persons (i.e., those who identified as neither male nor female) of all ages. Public health staff who reported being unable to take time off work were more likely to report adverse mental health symptoms. Severity of symptoms increased with increasing weekly work hours and percentage of work time dedicated to COVID-19 response activities. In a 2022 follow up survey, 75.5% of respondents did not think their employer had increased mental health support. Additionally, other recent surveys have indicated a trend of rising stress and burnout in the public health workforce, leading many to resign and more to consider leaving their agencies. While some support to the workforce may be available in government agencies, staff may feel they don’t have time, or feel supported to utilize these programs. This blog series will explore strategies that health department leadership may consider to strengthen a culture of care in their organization. Three Simple Actions You Can Take Today to Strengthen a Culture of Care Health department leaders can have a major impact on the behaviors and health of their workforce. Consider taking these actions: Practice and offer a model of your own commitment to self-care Self-care, which includes a healthy diet, adequate sleep, and regular exercise, are critically important for leaders in maintaining productivity and effectiveness, particularly during stressful periods. Other ways to practice self-care can include meditation or mindfulness practices, journaling, expressing gratitude or acts of kindness, or connecting with friends and loved ones. Send a message to your entire department discussing the importance of self-care and sharing examples of how you practice self-care. This not only demonstrates that your organization values and supports self-care, but also gives practical examples for staff to consider implementing. This would also be an excellent opportunity to highlight the availability of an employee assistance program (EAP) or employee wellness programs and benefits. Acknowledge the mental health effects of the COVID-19 response Share an example of how you (or someone you care about) has been impacted emotionally or psychologically by the COVID-19 pandemic. Your example can normalize the burnout and moral injury that some of your staff may be experiencing, as well as build trust and connectedness. Talking about mental health at work is important to reduce the stigma and create an environment that is more open and understanding about anxiety, depression, and other mental health issues that might show up in the workplace. This is also an opportunity to discuss mental health coverage in your health insurance plan(s), as well as resources available in the community, some which may be funded by your department. Exercise at the office or on the office grounds One well-proven approach to addressing stress and improving mental health is exercise. As a leader, you can model the importance of exercise to your agency. This can be as simple as taking the stairs rather than the elevator, incorporating stretching throughout the day, or walking during phone calls. Invite staff of all abilities to join you in a stretch, movement, or walk break. Consider a standing desk, replacing your chair with a stability ball, or keeping exercise equipment in the office for use during breaks. By prioritizing and modeling physical activity, you are sending a message that self-care is important. What Does a Culture of Care Mean for You? Has your organization prioritized a culture of health and well-being? Are there lessons learned for your organization’s support of staff during the COVID-19 response? How is your organization ensuring a manageable workload, particularly during times of emergency response? Speak with your employee wellness, workforce development, human resources, and/or professional development teams to ensure the organization is best meeting the health and wellness needs of employees. Based on the alarming findings of the CDC surveys, special emphasis should be placed on ensuring employees have additional information about, and are aware of, services/referrals to treat anxiety, depression, PTSD, and suicidal ideation. What’s to Come? Many employers and leaders have been creative in strengthening a culture of care in their organization. Over the coming months, ASTHO will highlight specific strategies to increase a culture of care in your organization. We’ll also share examples employed by health officials and other senior leaders within health organizations. Finally, we plan to curate a list of resources for executives, supervisors, and employees for creating a culture of care, stress reduction, self-care, and burnout prevention. Conclusion For public health systems to serve their communities most effectively, it is imperative that their staff are healthy, both physically and mentally. State, territorial, tribal, and local health departments should consider policies and programs that support the health and mental well-being of their staff – particularly in high stress emergency responses. We look forward to additional opportunities to discuss these important issues, hear how health department leaders are strengthening a culture of care, and learning how ASTHO can support your efforts. website yes

Public health agencies have an opportunity to recruit for and retain a diverse and skilled workforce. As new funding opportunities emerge ASTHO recommends a focus on proof, people, and processes.

The COVID-19 pandemic highlighted the importance of having in-house skills to respond to worldwide public health emergencies. Because of this, the American College of Preventive Medicine recommends that health departments consider bringing a board-certified preventive medicine physician on staff or to have one available to assist with preparedness and population health interventions.

To learn more about how the DELPH program has influenced our scholars’ leadership journey so far, ASTHO spoke with three leaders in the current cohort: Andrea Lowe, director of legislative services at the Nebraska Department of Health and Human Services; Tiffany Wilson, data analytics branch manager at the Alabama Department of Public Health; and Harold Gil, data science support unit supervisor at the Washington State Department of Health.

An issue that public health wrestles with is how to combat racism as we would any other public health emergency. ASTHO’s board of directors has declared structural racism a public health emergency. And health equity is the number one priority in ASTHO’s strategic plan, which means our staff will prioritize equity work as we support all aspects of our members’ technical assistance and capacity building needs.

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

Amid so much uncertainty, it might feel naïve to make any claims about what the future holds. But it is in these moments that it becomes more important than ever to have beacons to guide us and give us hope. As we look ahead to 2022, here are four priorities that must steer the public health course in the year to come.

Every year on Nov. 22, ASTHO—and countless other agencies and organizations worldwide—take a moment to acknowledge the public health workforce on Public Health Thank You Day. Like so many other days of recognition, it has become a blip on our yearly calendar. And, simply put, that’s just not enough. This year, ASTHO leadership took pen to paper to share some of our feelings, fears, and—yes, our thanks—for everything the public health workforce has always done to protect us.

In addition to the countless hours worked during the COVID-19 pandemic, many public health workers are also grappling with how to repay outstanding federal loans. In response, the U.S. Department of Education (DOE) recently announced temporary relief to current and future Public Service Loan Forgiveness (PSLF) program participants as a result of the COVID-19 pandemic.

Six questions with Scott Becker, CEO of the Association of Public Health Laboratories. Becker is active in national and international public health initiatives. He chairs the Governance Working Group for the Global Laboratory Leadership Program, a collaboration with the World Health Organization, CDC, and others to develop a competency-based curriculum for laboratory leaders. Additionally, Becker is a member of the Affiliate Council of ASTHO, which he formerly chaired.

Pharmacies have long been instrumental partners in providing lifesaving vaccines nationwide. As state and territorial health officials evaluate their COVID-19 response, planners must include input from the pharmacy community when identifying areas for improvement, as well as best vaccination practices in advance of future public health emergencies.

Though now an illegal practice, government contracts, policies, and practices have generally excluded women, and Black, Indigenous, and people of color. Still, practices and existing structures continue the inequitable distribution of all contracts. Governmental and non-governmental grants and funding should benefit the communities they serve while being proportionate to the communities' demographics. This is where inclusive contracting comes in.

As we head into Memorial Day weekend and honor the members of our armed forces who have made the ultimate sacrifice for our country and its freedoms, it is also important for us to give thanks to public health workers for being a shining example of what it means to lead in the face of a crisis.

When rural hospitals close, it increases the distance people must travel for essential healthcare services. The COVID-19 pandemic has highlighted and magnified the factors leading to rural hospital closures across the country. Many healthcare facilities suspended elective procedures to conserve critically needed personal protective equipment and reduce the risk of exposure to COVID-19 by patients and hospital staff. For many rural hospitals, however, the suspension of elective procedures with the reduced the use of non-urgent services by apprehensive patients meant a loss of revenue and the furloughed healthcare staff. Since the onset of the COVID-19 pandemic, approximately half of all rural hospitals are experiencing negative operating margins due to reduced outpatient revenue. The rate increases in states that have not expanded Medicaid. Unfortunately, these kinds of challenges are not new to rural hospitals.

Over the years evidence has expanded on community health workers (CHWs) improving outcomes and even reducing disparities in heart disease and many other public health priority areas. However, their presence in state and local public health workforce is still modest. A number of efforts have sought to expand the role of CHWs in medical care settings by developing reimbursement through third party payers, along with including them in managed care contracts and incorporating them in state Medicaid plans. The experience and lessons of the COVID-19 pandemic could substantially change the way we practice public health in the future, and provides opportunities to expand the role and presence of CHWs in the state and local public health workforce.

Centralizing Administrative Functions, with Lessons Learned from Guam Megan Drake-Pereyra Centralizing administrative functions, such as procurement or grants management, is a strategy many organizations utilize. Having administrative functions concentrated with a specific team rather than dispersed or managed within separate teams can work well. There is potential for standardized processes and procedures, increased efficiency and quality, more control and accountability, and consistent data collection and monitoring. This brief details how health departments can utilize existing, evidence-based frameworks to centralize administrative functions and build off lessons learned from others, such as the Guam Department of Public Health and Social Services (Guam DPHSS). Getting Started Considerations When transitioning from a decentralized structure to a centralized structure, it is important to clearly outline the what, why, how, and benefits. Consider the following components to kickstart success: Leadership vision: Start with the leader’s visionary perspective. When the leader allocates sufficient time and consistently reinforces the vision, it allows for the necessary decisions, trust, and support to be established during the transition. Data-driven design: Use data and existing information, such as current standard operating procedures or process diagrams, to understand the decentralized process differences/similarities, and guide effective centralized processes and procedures. Role clarity: Clearly outline and define the new centralized infrastructure, purpose, roles, responsibilities, expectations, and procedures. This helps everyone understand and follow the new processes more consistently, with better results. Performance measures: Establish and use performance measures from the outset (e.g., team knowledge, skills, competency, process time and quality, outcomes, impact, etc.), for insight into the value, or return on investment, of the centralized model. This will help indicate the quantity, quality, and impact of programs/processes. Documentation: Capture and share decisions, vision, goals, structure, standard operating procedures, and relevant details in writing for new team members and users of the centralized functions. Communication: Transparently share plans, timelines, and additional knowledge to maximize utilization and value. Additionally, anticipate and proactively address resistance to change to help everyone embrace and adhere to the new, centralized approach. The Plan-Do-Study-Act Method Change management, quality planning, and process improvement models can also support organizational and process change. For example, the quality improvement methodology, Plan-Do-Study-Act (PDSA), offers an effective framework for centralizing administrative functions and complements many of the aforementioned considerations: Step one, plan, relies on leaders to decide the vision, scope, structure, roles/responsibilities, goals, and purpose of the centralized team. Here leaders establish and reinforce the leadership vision, using existing data to guide the design of the new centralized team. Step two, do, is dedicated to onboarding centralized team members, defining their work processes and procedures, and ensuring effective communication with all stakeholders. This requires thorough documentation and strong communications plans. Step three, study—an often overlooked but crucial building step—is for testing the processes, procedures, roles, and responsibilities, to confirm and build confidence that this centralized structure will yield the desired results. Performance measures provide clarity into what is working well and what is not. Step four, act, is for launching and rolling out the structure, ongoing monitoring of performance, and continuing to educate and coach for successful, sustainable improvements. Lessons Learned from Guam Guam DPHSS, a joint health and social services agency, is working to centralize its administrative functions to reduce inefficiencies and redundancies as well as improve quality and consistency. This has been a big change for Guam DPHSS, but leadership vision, documentation, role clarity, and communication have proven to be key throughout the process. In 2021, Guam DPHSS established a centralized Office of Grants Management (OGM). In its early stages, programmatic teams saw OGM as a regulatory body that would audit and direct their work, while OGM’s true objective was to provide support and ease administrative burden, allowing program staff to focus on accomplishing their goals and deliverables. By clarifying and documenting the vision, roles, and responsibilities as well as focusing on communication, the OGM built trust, addressed specific concerns, and established a shared vision of their role as supportive and helpful. In 2023, Guam DPHSS began the process of establishing a centralized Procurement Management Office (PMO). While Guam DPHSS reorganized and co-located staff into the new, centralized PMO, Guam was undergoing a governmentwide business process improvement (BPI) project focused on procurement—presenting an opportunity for Guam DPHSS to involve new PMO staff and other key DPHSS team members in improving its functions and centralizing the procurement process. Through the BPI project, which utilized PDSA, DPHSS clarified roles and responsibilities, defined work processes and procedures, and developed training and communications plans that supported process improvement and centralization of procurement functions. Guam DPHSS has learned many lessons throughout their journey to create a centralized OGM and PMO, including that change of this magnitude is hard—more specifically, balancing change management while ensuring maintenance of key operations. Ultimately, they found that the aforementioned considerations and methods for getting started were critical in supporting the change to centralized administrative functions. Establishing the Ideal Structure for Administrative Functions Determining if and how centralized administrative functions will work for an organization is multifaceted. An organization’s culture, size, infrastructure (including technology and systems), and workforce and skills all play crucial roles in shaping the ideal structure. The methods and considerations noted previously can help health departments determine and support the best path forward for each unique organization. ASTHO has several additional resources and tools that can support administrative change and improvement. Visit the ASTHO STAR Center to learn more. website yes

Leveraging Medicaid to Support Community Health Workers astho, association of state and territorial health officials, community health workers, health equity, medicaid coverage, chw workforce, social service, public health, health care system, improve health, individual and community, mental health, achieving health equity, social determinants of health, underserved communities, united states, health disparities, medicaid program, state Medicaid, advance health equity, highest level of health, people of color, community they serve, improve access, people living, increased health Vanessa Finisse, Madison Hluchan How to leverage Medicaid to support community health workers. Community health workers (CHWs) are pivotal in advancing health equity and improving population health, especially for marginalized communities. Today, there is increasing federal investment to better integrate CHWs into the health care system, spurred by post-COVID-19 federal legislation. While the benefits of CHW integration are well-documented, sustainable funding remains a challenge. This brief, developed in partnership with the Center for Health Care Strategies (CHCS), explores Medicaid coverage for CHW-led services and highlights opportunities for state and territorial health agencies (S/THAs) to collaborate with Medicaid to support CHWs. Key Considerations Medicaid-Funded CHW-Led Services Medicaid authorities can finance CHW-led services, such as state plan amendments (SPAs), section 1115 demonstrations (1115 waivers), and managed care flexibilities. States can pick a pathway depending on their goals, timeline, and administrative capacity. As compared to SPAs, 1115 waivers provide states with more flexibility to waive federal Medicaid rules to test innovative approaches (see Table 1). website yes

Explore key actions, indicators, and supports to enhance workforce recruitment and hiring in governmental public health.