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

Learn how boundary spanning leadership can improve overdose prevention programs in this brief.

Health departments can use this guide to improve their public health accreditation efforts.

ASTHO engaged Oklahoma public health officials, members of the Oklahoma Harm Reduction Alliance, Health Minds Policy Initiative, and representatives of the Southern Plains Tribal Health Board, and others in a Boundary Spanning Leadership workshop.

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

The Eliminating Structural Racism to Achieve Health Equity Policy Academy fosters the development of governmental workforce policy development skills and boundary spanning leadership to advance policy, systems, and workforce changes to achieve health equity.

Advancing State Maternal and Child Health Policymaking Through Boundary Spanning Leadership ASTHO, Association of State and Territorial Health Officials, state policy, maternal and child health policy, maternal and child health, maternal health, public health, health equity, access to care, boundary spanning leadership, medicaid coverage, postpartum coverage, missouri department of health, department of health, prism learning community, mch policymaking, pregnancy risk, pregnancy realated death, socioeconomic disparities, pregnant and postpartum women, multi sector action network, improve partnerships, establish direction, strengthen relationships, mental health, community based organizations, public health agencies, shared barriers, elementary and secondary education, collaboration and coordination, key legislation Maria Gabriela Ruiz, Ramya Dronamraju ASTHO | Advancing State Maternal and Child Health Policymaking Through Boundary Spanning Leadership Missouri is addressing a critical maternal health crisis characterized by rising pregnancy-related deaths, socioeconomic disparities, and limited postpartum coverage. This challenge prompted a bipartisan push for Medicaid postpartum coverage extension and the need for a cohesive, comprehensive state system involving diverse stakeholders to improve outcomes for pregnant and postpartum women. As a result, the Missouri Department of Health and Senior Services (DHSS) team joined the Promoting Innovation in State and Territorial Maternal and Child Health (MCH) Policymaking (PRISM) Learning Community in 2021: a partnership between ASTHO and the Association of Maternal and Child Health Programs. Through PRISM, Missouri worked to increase access to quality health care for pregnant and postpartum women through innovative policy solutions. The team established three overarching goals based on state priorities: Advocate for extending postpartum Medicaid coverage to 12 months. Establish a multi-sector action network to provide a multidisciplinary system of care, promoting health equity and ensuring appropriate care coordination for women and mothers with mental health and substance use disorders. Improve access to quality health care for low-income pregnant and postnatal women, including Medicaid coverage of services provided by professional midwives, doulas, and community health workers. Boundary Spanning Leadership Training Overview As part of DHSS’ engagement with PRISM, Missouri participated in a Boundary Spanning Leadership to improve partnerships, develop solutions to address the emerging needs of the MCH population, and foster trust among partners dedicated to improving maternal and infant health in Missouri. Boundary spanning leadership (BSL) is defined as the capability to establish direction, alignment, and commitment across boundaries to achieve a higher vision or goal. The main vision of Missouri’s BSL training was to build momentum on their PRISM goals and improve MCH outcomes in the state by strengthening relationships with relevant stakeholders. BSL training participants included representatives from DHSS and Departments of Social Services, Mental Health, Elementary and Secondary Education, along with other critical partners from community-based organizations, academic institutions, and local public health agencies. BSL introduced tactical skills to create psychological safety as a cross-sector team and respect for the values and unique challenges of each team/organization represented. This space provided the direction, alignment, and commitment that participants to leverage in addressing challenges among the MCH population. Lessons Learned Recognizing Shared Barriers: A central aspect of the BSL training is for participants to align on shared barriers and concerns. Participants identified funding as a challenge when developing programmatic and policy initiatives, highlighting complex state and federal funding structures, bureaucracy, and sustainability. Collaboration and Coordination: Participants discussed the disconnect between the availability and accessibility of MCH services in Missouri, which results from fragmented communication between agencies, leading to duplication of efforts and straining already limited resources as well as personnel. Throughout the BSL training, participants discovered ways to work together to amplify available resources, coordinate programmatic efforts, and reduce barriers to access for MCH populations. Public Health Workforce Capacity: The COVID-19 pandemic resulted in workforce turnover and decreased capacity, leading to further disruptions in service delivery, quality, and efficiency. BSL participants highlighted acquisition, training, and staff retention as priorities to focus on moving forward. State Successes Enacting Key Legislation In May 2023, Missouri passed SB 45, which extended Medicaid for birthing people to 12 months postpartum, including coverage for mental health and substance use disorder treatment. The extension of coverage for 12 months after delivery is estimated to cover more than 4,000 women who would otherwise become uninsured two months after the end of pregnancy. Developing a Coordinated Approach Since the in-person BSL training in April, Missouri has developed interagency connections and relationships to bolster MCH progress in the state. One example is a partnership forged between the DHSS Office of Dental Health and leadership at Uzazi Village, a community-based health organization that provides “adjacent models of care” for Black and Brown childbearing families to restore health, vitality, and joy to communities of color during the perinatal period. These organizations collaborated to bring oral health care to pregnant and postpartum people without access to dental care services. The State Dental Director and MCH Director coordinated the donation and transport of the larger dental equipment and the purchase of smaller equipment and supplies needed for the clinic; the State Dental Director also connected Uzazi with a dental provider. Missouri is poised to capitalize on the connections established during this training and further enhance collaborative efforts to improve MCH outcomes. Next Steps Missouri achieved all three of their goals through engagement in PRISM, exemplifying a proactive approach to addressing critical maternal health challenges. The team has made significant progress in advancing policy initiatives to improve access to quality health care for pregnant and postpartum women. Developing a coordinated approach to addressing MCH issues remains a priority as Missouri continues to foster collaboration among diverse stakeholders. The team will be able to leverage its new connections to address emerging issues, such as the current, which is disproportionately affecting children and families. Moving forward, Missouri is well-positioned to build upon its successes and further strengthen interagency connections to continue making impactful strides in maternal and child health. Special Thanks-Blog - Advancing MCH Policymaking Through BSL website yes

Understanding boundary spanning principles helps public health practitioners recognize the types of boundaries that come naturally when navigating relationships that may involve managing up, down, and across.

ASTHO's Alice Schenall and Alyssa Merski talk about the role of boundary spanning leadership in strengthening Overdose Data to Action (OD2A) efforts.