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Collecting and sharing data are crucially important to improving health equity, because those datasets inform effective policymaking. Despite having some of the most challenging population health outcomes, the U.S. island areas are often absent within federal public health datasets.Federal, island, and nonprofit partners should prioritize efforts to increase their inclusion.

Learn how increasing the use of indirect cost rates in the territories and freely associated states can help improve public health financing in these jurisdictions.

This ASTHOReport serves as a primer for state and territorial health agencies seeking to assess the public health impacts of lead exposure in drinking water.

This report aims to highlight the unique vector-borne disease challenges faced by Island Areas and to dive into the key components of a mosquito control program, that are relevant to these unique jurisdictions.

This toolkit is designed to support public health leaders in leveraging the policy development process to achieve health equity in their jurisdiction.

Strengthening Leadership, Risk Communications, and Preparedness in the Islands Strengthening Public Health Preparedness in the Islands Sidnie Christian, Alyssa Boyea Key strategies in on leadership, risk communications, and preparedness, can help island jurisdictions prepare for and respond to emerging public health threats. ASTHO convened a two-day, in-person workshop in Honolulu from June 25 – 26, bringing together public health preparedness staff from American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, Hawaiʻi, the Republic of the Marshall Islands (RMI), and Palau, as well as federal partners from CDC, the Department of Homeland Security, and the Administration for Strategic Preparedness and Response. The workshop focused on leadership and workforce development, risk communications, administrative preparedness, and more to support island areas as they prepare for and respond to natural disasters and other emerging public health threats, of which emerged key learnings that can benefit all island jurisdictions. Leadership and Workforce Development Leading through change requires transparency, trust, and collaboration. Planned change involves assessing readiness for change, identifying resources needed, securing buy-in, and determining a path forward. However, sometimes change can leave little to no time for preparation. Island jurisdictions have encountered challenges in the face of change, with many workshop participants sharing firsthand challenges around retaining institutional knowledge, infrastructure, and receiving assistance from the mainland United States in a timely fashion. As such, change readiness, succession planning, and effective change management practices are of utmost importance in the islands. Key recommendations and takeaways include: Utilizing a reputable framework, such as Kotter 8-Step Change Model, is pivotal for improving change readiness and change management. Change management frameworks and methods can assist with different types of change including structural change, strategic operational change, people-centric change, etc. Trust is hard to build, but easy to lose. Participants spoke about characteristics of high trust relationships including open communication, consistency, good judgement or expertise, and cultural sensitivity, while low trust relationships characteristics include lack of communication, inconsistency, and lack of teamwork. Succession planning is important to ensure institutional knowledge and capabilities remain in the wake of staff turnover or retirement. Identifying the necessary expertise, skills, and capabilities for each role is vital in the case of unplanned changes in staffing. Promising practices include annual review of critical positions, conducting talent calibration sessions, defining action plans, and obtaining buy-in from leadership and relevant partners. Risk Communications The island jurisdictions face emergencies that require creative response efforts. Both Hawaiʻi and RMI demonstrated innovative approaches in risk communications during COVID-19, finding success in forming critical partnerships, utilizing trusted voices within the community, and bridging communication gaps: Hawaiʻi utilized social media to showcase individuals such as doctors, pastors, social media influencers, and even local sports teams getting vaccinated, and utilized trusted voices to deliver messages. Additionally, they translated their materials into three languages (Marshallese, Samoan, and Hawaiʻian), modeling that no one gets forgotten, the true meaning of “ohana.” RMI created a working group with a mix of partners that curated press releases, educational materials, and sitreps, and served as a liaison between RMI Ministry of Health and Human Services and the community. It also partnered with several media outlets (e.g., radio stations, local papers, and other private sectors) and utilized mass text messaging to spread information quickly. The latter proved to resonate with most island jurisdictions who struggle with staying connected to hard-to-reach populations, namely those in more rural and disconnected communities. RMI was able to connect with these populations through WhatsApp to keep them updated throughout the COVID-19 response. Administrative Preparedness Improving administrative preparedness plans and processes ensure timely and efficient access to needed resources for a public health response. Most workshop participants are currently in the process of updating existing administrative preparedness plans, while some are working with other departments to create and implement new plans. Attendees discussed key partnerships for collaboration including other departments, Medical Reserve Corps, and other volunteer organizations. One common key challenge that emerged was around staffing (e.g., finding qualified people to fill vacancies, hiring process issues, making sure positions are competitive, etc.). To address this issue, island jurisdictions can work closely with other departments or jurisdictional agencies to streamline current processes, establish memorandums of understanding with different partners/facilities to assist with emergency procurement, and ensuring staffing vacancies are competitive and match public health classifications. Disease Forecasting A survey on state and territorial expertise and needs for infectious disease forecasts, models, and other outbreak analytic techniques—implemented by ASTHO with support from CDC’s Center for Forecasting and Outbreak Analytics—revealed that respondents from island jurisdictions experienced several barriers that led to limited use of infectious disease forecasts to inform communication and decision making. Challenges noted include limited software access, limited disease modeling capacity or skills, and lack of uniform reporting systems. Through a discussion-based exercise, workshop participants shared their challenges and considerations for ASTHO and CDC to assist with disease forecasting in the island jurisdictions moving forward. Challenges include but are not limited to: Delays with sending samples to labs and receiving results in a timely manner. Without timely results, it is challenging to take swift action. Lack of staff / staff wearing many hats with limited capacity. In most cases, there is no specific communication plan for disease forecasting within the departments. Communication can be challenging without clear processes and channels. Participants noted the desire for additional disease forecasting training and opportunities for collaboration. They suggested an integrated training session with island epidemiologists and other relevant staff to enhance disease forecasting knowledge and communication, as well as strengthen collaboration. Preparing for and Responding to Climate Events From hurricanes to typhoons to volcanic eruptions, the island jurisdictions are no strangers to the effects of changing climate. Willliam “Brandon” Aydlett, science and operations officer at the National Weather Service, and Shelbi Davis, Senior Analyst on the Environmental Health team at ASTHO, offer the following recommendations to island jurisdictions for preparing and responding to unprecedented climate events, as discussed with workshop participants: Create or update standard operating procedures for various climate related responses unique to the island. Always prepare for a category higher storm than is expected. Consider conducting regular vulnerability assessments to better understand areas where the island or its people may be most susceptible to adverse health impacts from climate events. Jurisdictions can learn from one another and find a sense of camaraderie in their preparedness efforts, much like the workshop participants. For example, one island jurisdiction noted that they currently do not have a warehouse to store equipment but are working on a plan to secure one; another jurisdiction, having recently revamped their warehouse, noted that they could assist their island neighbor in this endeavor and provide lessons learned as well as strategies to help secure a warehouse that will fit their needs. Looking Toward the Future Sharing lessons learned with one another and reflecting on how to apply those learnings in respective communities is crucial. Workshop participants shared their intent to share and utilize resources and information shared throughout the workshop with their leadership and team to begin implementing in their jurisdictions, as well as using strategies and skills learned to enhance partnerships. To all the participants and our Hawaiʻian hosts, we say mahalo. Related Resources Modernizing Infrastructure and Facilities for Readiness and Response | ASTHO PH-HERO Workforce Resource Center | ASTHO ASTHO STAR Center | ASTHO Evidence-Based Strategies to Enhance Public Health Emergency Preparedness and Response | JPHMP article yes

Partnership as the Foundation for Advancing Adolescent Health in American Samoa Partnership Advances Adolescent Health in American Samoa Gabby Ruiz Learn how American Samoa advances adolescent health in American Samoa through collaboration among state and local health and education agencies. Cross-sector partnerships are essential to advancing adolescent health, particularly in school-based settings. The intersection between public health, education, and clinical health is vital to the delivery of integrated services. In the United States, it is estimated that children in grades K-12 spend at least 1,231 hours each year in school, not including time dedicated to clubs or extracurricular activities. When schools function as trusted environments where health and learning meet, they become powerful access points for early identification of needs, preventive services, and supportive relationships. The public health sector brings expertise in prevention, population-level data, and community engagement. Meanwhile, the education sector provides youth engagement and the ability to creatively embed health into learning environments by leveraging diverse resources. When sectors work in isolation, resources are used inefficiently and adolescents may experience gaps in care, fragmented supports, and inconsistent access to essential services. With support from CDC’s Division of Adolescent and School Health, ASTHO leads the Leadership Exchange for Adolescent Health Promotion Plus Community of Practice, an initiative that promotes collaboration among state and local health and education agencies to strengthen health education, connect schools to services, and foster safe, supportive learning environments. This initiative provides a space for teams to share ideas, troubleshoot challenges, and build sustainable partnerships. Through this effort, the American Samoa team built a strong partnership between the Department of Health and the Department of Education to expand and enhance effective communication about sexual and reproductive health to reduce risk taking behaviors and promote protective factors. Peer-to-Peer Learning as a Catalyst for Youth Engagement Grounded in the belief that young people are often the most trusted messengers for their peers, the American Samoa team launched the Students Promoting Education, Awareness, and Knowledge (SPEAK) project: a student-led, peer mentor collaborative effort between the American Samoa Department of Education (ASDOE), the American Samoa Department of Health (ASDOH), and youth peer leaders. The project builds a network of trained peer educators who engage students on topics such as healthy relationships, personal responsibility, privacy, consent, HIV, STI, and pregnancy prevention. SPEAK peer leaders are students in grades 10 through 12, with two or more representatives from each grade level. High school counselors help identify students suited for this role, which includes: Co-creating educational materials that reflect their identities (i.e., their values, abilities, and lived experiences). Fostering safe spaces for support and dialogue. Managing online platforms that allow youth to ask questions anonymously. Collaborating with schools, communities, and health care providers to develop and promote educational campaigns through social media channels. SPEAK promotes student leadership, shared accountability, and open, stigma-free dialogue. Forging Strong Relationships Alignment and Sustainability From the beginning, ASDOH and ASDOE committed to building a unified team to support adolescent sexual and reproductive health. This collaboration became one of their greatest strengths. The team noted that establishing a shared vision early on helped them maintain momentum through challenges. Donation Ape, ASDOE Program Director, played a pivotal role in bridging agencies and strengthening the network that supported the project’s success. While Ape’s dedication and tenacity have been key to nurturing this partnership, both sides of the team are working to ensure that this partnership is sustainable. “With the right network, we were able to do it.” — Donation Ape, ASDOE Program Director Thoughtful Health Education In addition to coordinating across school systems and community partners, long-standing cultural values that emphasize privacy around family and personal matters made open discussion of adolescent health topics more challenging. Prior to SPEAK, students were not receiving structured health education in this area. ASDOE staff and leadership initially expressed understandable concerns about ensuring any peer-led approach would be age-appropriate, culturally respectful, and aligned with community standards. A key strategy for addressing these concerns was thoughtfully engaging youth alongside educators, families, and community stakeholders to help demonstrate the need and shape a solution to delivering health education. “When you see young people not just as children but as contributors to society, you start to see what’s possible.” — Fatih Seiuli, Health Educator, ASDOH Key Considerations for State and Territorial Health Agencies American Samoa’s experience offers key insights for other jurisdictions seeking to strengthen adolescent health through school-based partnerships: Integrate public health into education, clinical health, and mental and behavioral health to ensure a more holistic and sustainable cross-sector approach. Together, these sectors form a coordinated system that has the capacity to address pertinent adolescent health concerns. In addition, youth hold a critical role in their own care, and engaging them as part of these cross-sector partnerships is essential to adolescent health program uptake and understanding. Involve essential community voices by engaging key stakeholders and end users early on. Creating a peer educator network and creating space for youth-led engagement ensures programs reflect young people’s lived realities — increasing relevance and reach, and fostering trust and ownership among students who may otherwise feel disconnected from traditional health messages. Adapt curricula with cultural responsiveness. Integrate bilingual materials and tailor them to the unique needs of communities — expanding reach across cultural contexts and addressing stigma or other social and structural barriers. Additionally, ensure the framing of the program is appropriate for audiences and helps to overcome cultural barriers. Looking Ahead American Samoa’s journey demonstrates how intentional partnerships, youth leadership, and culturally grounded approaches can advance adolescent health in meaningful and sustainable ways. Their work reinforces that collaboration is a critical strategy that serves as the foundation for lasting impact. ASTHO will continue supporting jurisdictions through the Leadership Exchange for Adolescent Health Promotion Plus Community of Practice by fostering connections, strengthening multi-sector partnerships, and creating spaces where teams can learn from one another. As American Samoa’s experience shows, meaningful progress in adolescent health is possible when sectors and systems align around a shared purpose. Reviewed by - Akbarali, Mackie, Vance article yes

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.

Both the Pacific and Caribbean are on the front lines of the dengue health security threat. As a result, many island areas, especially in the USAPI and Puerto Rico, are doing great work to combat dengue.

After years of advocacy, ASTHO and our partners are celebrating the recently signed Consolidated Appropriations Act.

ASTHO has several members from the territories and Freely Associated States—jurisdictions with unique challenges, and do not fall under the category of a state or federal district. This post is a brief look at some of the public health related legislation introduced during recent legislative sessions.

Each year, ASTHO tracks and analyzes key legislation that impacts public health, and highlights the emerging trends for our members. While the bulk of the tracked legislation arises in state legislatures, ASTHO also follows legislation from the territories and Freely Associated States, jurisdictions collectively referred to as the insular areas. The insular areas often face different challenges than the states, while also sharing many common concerns. This post contains a brief look at some of the public health related legislation introduced in the insular areas during their current legislative sessions.

U.S. Territories Face Healthcare Cuts if Congress Does Not Address Impending Medicaid Financing Cliff ARLINGTON, VA—Association of State and Territorial Health Officials (ASTHO) member Esther Muña, MHA, chief executive officer at the Northern Mariana Islands Commonwealth Health Corporation, and other territorial health leaders from Guam, Puerto Rico, America Samoa, and the U.S. Virgin Islands testified today before the United States House Committee on Natural Resources about the impact that cuts to Medicaid would have on U.S. territory populations. “On the heels of Super Typhoon Yutu, which devastated the Commonwealth of the Northern Mariana Islands’ economy and its people, we face another crisis – our Medicaid program is unable to sustain its operations with the low statutory cap on federal contributions,” says Muña. “Low federal contributions, coupled with the exhaustion of the Patient Protection and Affordable Care Act funds this year, creates a fiscal cliff for our Medicaid program. This fiscal cliff threatens to unweave our substantial improvements over the past ten years in the delivery of healthcare, further erodes our economy, and threatens the health and well-being of our people. “I strongly urge Congress to stabilize Medicaid financing for the territories by raising or eliminating the arbitrary cap on federal dollars to the program so I can continue my work to protect and promote the health our population,” Muña continues. Unless Congress acts, the U.S. territories’ Medicaid programs will become gravely underfunded. Federal funding for Medicaid in territories is capped and it is subject to a fixed federal matching rate. For more information about the hearing, visit the committee’s website. ASTHO Press Release Boilerplate website yes

As the Association of State and Territorial Health Officials, ASTHO is committed to the T in our name. The health officials from the territories and freely-associated states are valued members and we are committed to advocating for the unique policy needs and priorities of the Pacific and Atlantic jurisdictions. The insular areas face unique challenges locally but also require a specific strategy here in Washington, D.C. Funding approaches and requirements set for states do not always translate to the unique context of the insular areas.

ASTHO and NAMD Letter Urging Congress to Fully Fund Medicaid and CHIP in U.S. Territories Dear Chair Wyden, Chair Rodgers, Ranking Member Crapo, and Ranking Member Pallone: Strong, sustainably funded Medicaid and Children's Health Insurance Programs (CHIP) are crucial to addressing health care challenges in the U.S. territories. On behalf of the Association of State and Territorial Health Officials (ASTHO) and the National Association of Medicaid Directors (NAMD), we urge Congress to ensure the fiscal stability of the territories’ Medicaid programs by lifting the annual Section 1108(g) allotment cap for all territories and authorizing a permanent 83% Federal Medical Assistance Percentage (FMAP) for Puerto Rico. Robust Medicaid and CHIP are critical components of strong and resilient territorial health systems. The five U.S. territories—American Samoa, Guam, the Commonwealth of the Northern Mariana Islands (CNMI), Puerto Rico, and the U.S. Virgin Islands (USVI)—vary dramatically in population, health care system capacity, and Medicaid program structure. Despite these differences, they share common challenges, including significantly higher rates of poverty (ranging from 16.8 percent in Guam to 54.6 percent in American Samoa in 2019, compared to 10.5 percent in the United States), higher rates of chronic health conditions, and a lack of health care infrastructure. Medicaid and CHIP programs are crucial to addressing these challenges. Chronic underfunding has impaired territories’ capacity to serve their residents, who are U.S. citizens or U.S. nationals. Historically, the territories have faced two statutory funding challenges: 1) A low, fixed FMAP rate that is not tied to per capita income (as is the case in the states), and 2) Annual funding caps. Prior to FY 2023, Congress supplemented low annual funding amounts with short-term additional investments. The short-term nature of this funding limited territories’ ability to plan, undertake large investments, and efficiently deliver services. In the Consolidated Appropriations Act of 2023, Congress permanently increased the FMAP for American Samoa, Guam, USVI, and CNMI to 83% and authorized a 76% FMAP for Puerto Rico through 2027. NAMD and ASTHO applaud and fully support this structural means of addressing longstanding needs. Congress should continue to build on this foundation by extending the permanent 83% FMAP to Puerto Rico to ensure all U.S. territories have access to sustainable Medicaid and CHIP funding. Over and above this FMAP adjustment, Congress must also address the constraints caused by the allotment cap on the territories’ Medicaid and CHIP funding, established by Section 1108(g) of the Social Security Act. When a territory reaches this cap, they are responsible for funding their Medicaid agency solely with local dollars. Due to challenges generating sufficient local funds, many territories have been forced to cut services after reaching these allotment caps, drastically limiting their ability to offer services and destabilizing local health care providers. For example, CNMI expects to hit its FY 2024 cap by July, leaving the CNMI government with more than two months of unmatched Medicaid costs. Congress should eliminate the annual Section 1108(g) allotment cap to ensure sustained access to high-quality public health and health care services in the U.S. territories. Sustainable, equitable funding will allow territorial programs to make long-term, cost-effective investments that support high-quality and innovative Medicaid programs. The Consolidated Appropriations Act of 2023 directed American Samoa, Guam, CNMI, and USVI to develop four-year strategic plans focused on workforce, program integrity, systems development, and financing. The four territories developed comprehensive plans with ambitious goals, including developing electronic eligibility and enrollment, MMIS, and T-MSIS systems, launching initiatives to expand local provider workforces and territory administrative capacity, and strengthening program integrity processes. These plans are evidence of the momentum and energy that territory leaders bring to their reform agendas. Technical assistance from CMS and other agencies will remain a critical resource for capacity-building efforts in the territories. In addition to lifting the statutory allotment cap and providing Puerto Rico with a permanent 83% FMAP, Congress should also consider providing the territories with targeted, project-specific enhancements to their administrative match rates to facilitate necessary technical assistance and change management. These structural improvements will strengthen the impact of Medicaid dollars allotted to the territories. Thank you for your previous support of the Medicaid programs in the U.S. territories and your ongoing attention to this important issue. If you have any questions or require additional information, please reach out to Jeffrey Ekoma (senior director of government affairs at ASTHO, jekoma@astho.org) and Jack Rollins (director of federal policy at NAMD, Jack.Rollins@MedicaidDirectors.org). Sincerely, Joseph Kanter, MD, MPH Chief Executive Officer, ASTHO Kate McEvoy, Esq. Executive Director, NAMD website yes

Learn about recent public health legislation in the islands areas related to access to nutritional foods, deterring substance use, and promoting healthy aging.

The PLF was developed in close consultation with expert legal drafters and health policy experts in Pacific Island countries (including the U.S. Affiliated Pacific Islands), along with development partners and academic institutions. The tool was finalized in 2021, and is intended to help strengthen jurisdiction laws that regulate NCD risk factors.

Strengthening Long-Term Care Capacity in Island Jurisdictions Through Policy Using Policy to Strengthen Islands' Long-Term Care Capacity Lana McKinney Explore policy levers island jurisdictions can use to strengthen long-term care capacity like payment flexibilities, workforce, and collaborative partnerships. Acute care facilities in U.S. territories and freely associated states experience significant strains on capacity, driven by: Difficulty transitioning medically stable patients to the next appropriate level of care. Insufficient staff to meet patient needs. Limited transitional or extended care facilities. This creates a bottleneck that compromises the efficiency and stability of health systems. However, there are policy levers available to island jurisdictions that can support appropriate care for patients requiring institutional or home-based services and supports. These include payment flexibilities, workforce initiatives, and collaborative partnerships. Current State Infrastructure Island jurisdictions have limited hospital and long-term care (LTC) facility capacity. While many have government-run hospitals, three jurisdictions — American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), and Palau — have only one hospital, the Federated States of Micronesia has one hospital per state, and the Republic of the Marshall Islands and the U.S. Virgin Islands (USVI) each operate one hospital in both of their most populous islands. Additionally, Guam has just one Medicare-certified skilled nursing facility with 40 Medicare beds, operated by the Guam Memorial Hospital Authority, while Puerto Rico has nine Medicare-certified nursing homes for a population of more than three million people. Without LTC facility capacity, hospitals lack appropriate options for discharge. Geographic isolation, difficulties with recruitment and retention of sufficiently skilled staff (i.e., nursing staff), and supply chain challenges are additional obstacles to establishing and maintaining LTC capacity. Reimbursement Federal health care programs also influence the availability of LTC services in the territories. Medicare and Medicaid may cover LTC services under different circumstances; however, federal funding restrictions limit Medicaid in the territories compared to the states. Unlike the annually calculated, income-based Federal Medical Assistance Percentage (FMAP) for states, the territories have a fixed FMAP. The current permanent FMAP for American Samoa, Guam, CNMI, and USVI is 83%, while Puerto Rico’s is 76% through FY2027. Medicaid funding for the territories also operates under a statutory cap allotment, meaning once the federal allotment is exhausted, the territory must cover all subsequent service costs with local funds. This frequently results in territories expending federal funding mid-year, which leads to service restrictions for residents and financial instability for providers. Finally, while the territories have additional financing restrictions, CNMI and American Samoa are able to operate their Medicaid programs under a special waiver authority. Policy Strategies A number of policy strategies may limit the strain on acute care facilities, address LTC needs, and support the provision of appropriate levels of care in island jurisdictions: Workforce Development Recruitment and retention of health care workers is a challenge in island jurisdictions, but public health and rural health care workforce strategies may help address staffing needs and capacity. Encourage employers and educational institutions to partner with local colleges, vocational schools, and community centers to develop apprenticeship programs and formal career pathways that support skills development, professional advancement, and patient and community needs. Identify available educational programs across the region to support a pipeline for students entering medical, nursing, pharmacy, and behavioral health careers. Promote and support dedicated in person recruitment opportunities as well as broader strategies that support local candidates and students. Develop cross-jurisdictional workforce agreements that allow training completed in one island jurisdiction to be recognized in another. Explore workforce training opportunities through commissions (e.g., Western Interstate Commission for Higher Education), universities (e.g., the Pacific Islands Geriatric Workforce Enhancement Program), and public health associations (e.g., Equipping Community Health Workers to Address Alzheimer’s) as well as curriculum exchange and workgroups (e.g., USAPI Health Workforce Development Technical Working Group). Support partnerships among island jurisdictions to share resources and learnings related to facility development, financial models, and reimbursement strategies. For public employers, decentralize HR functions to create a more efficient hiring process. For jurisdictions with professional schools and programs, develop additional training models (i.e., short-term or extended rural placements) or blended learning. Medicaid and Other Federal Health Programs U.S. territories can also consider Medicaid policies that encourage community supports over institutional care or pursue other program flexibilities through waivers or state plan amendments. For example, states and territories can provide Home and Community-Based Services and use different authorities to achieve their policy goals. Implementing a Section 1115 demonstration allows for significant flexibility but must be budget neutral. In addition, the Money Follows the Person demonstration supports community-based services over institutional care. CMS awarded time-limited planning grants to Puerto Rico and American Samoa for this initiative. Additionally, the Program of All-Inclusive Care for the Elderly helps older adults remain at home and offers comprehensive medical and social services to eligible individuals. Supported Care Transitions Several models support patients moving from hospital to home to control chronic conditions, limit readmissions and emergency department visits, reduce costs, and improve outcomes overall. This includes the Care Transitions Intervention, a short-term training program for patients and caregivers to navigate the move home. The coach’s credentials are flexible and can include nurses, social workers, community health workers, or other professionals. Meanwhile, the Transitional Care Model, provides ongoing care management and is led by an advanced practice nurse. Collaboration Strategic partnerships can drive policies that support healthy aging or aging in place. For example, USVI established a commission on aging, while Guam enacted a senior citizens housing task force, both with multi-sector representation. And in December 2025, American Samoa’s Governor issued an Executive Order establishing a Home and Community-Based Services Commission as part of its Money Follows the Person plan, which includes representatives from a number of governmental agencies and areas of expertise. Legislation Island legislatures have also explored strategies that support older adults and those with complex health care needs and their families: Guam (No. 31-38 (COR)) would establish a regulatory framework for assisted living facilities with the goal of facilitating their development and operation. In 2023, USVI 35-0119 authorized mobile integrated health programs to leverage health care personnel for in-home services and prevent costly hospital readmissions. CNMI considered a resolution to explore several policy strategies, including leveraging Medicaid flexibilities, and prioritizing collaboration and financial support to meet the needs of elderly residents. In 2026, Puerto Rico enacted legislation to improve access to information about the benefits and services available to older adults. Reviewed by - Baker-White, Kearly, Sands Leavitt, Wheatley article yes

Learn about public health in American Samoa, including key health priorities, challenges, and ASTHO’s support for strengthening systems and improving outcomes.

This blog describes the island areas COVID-19 successes and their cultural and historical context.