This transcript is auto-generated and may contain inaccuracies.

Brittan Williams:
Then you, of course, get the opportunity to hear from three specific states on strategies they’ve actually implemented. Starting here, I will work clockwise around this diagram, starting at the top, with identifying statewide documentation.

What we mean here is we can work with state health departments to identify if there’s any documentation in place at the state level that is applicable and used by most, if not all, local health departments in that state. What we would do is have the state package and submit that documentation to PHAB (Public Health Accreditation Board) once; PHAB would review it once; we would assess it once; and if the documentation is at least largely demonstrated, we wouldn’t have to reassess it. The local health departments in that state can then use that documentation as part of their own accreditation process for submission, thus reducing that documentation burden on the local health departments, and it’s also creating an efficiency in the review process for staff at PHAB.

Something else we’ve worked with states on is convening learning communities, including pathways cohorts. So you’ll hear a little bit about that from Montana today: how we’ve worked to convene specific Montana pathway cohorts within their state. Doesn’t have to be pathways cohorts, but any type of accreditation learning community we’re happy to support and engage with if they aren’t already in existence.

Then, exploring reciprocity between state requirements. Wisconsin comes to mind here. We worked with them to explore reciprocity for their local health departments that are accredited. They’re now exempt from some of the state reporting requirements, so that’s reducing that administrative burden on the local health department and incentivizing accreditation.

We can also help with establishing documentation libraries where the local health departments and the state and tribal in that state can submit documentation to share with other health departments as a kind of depository where they can pull from, even sharing templates with each other, so folks aren’t having to create documentation from scratch.

PHAB can help with supporting key plans and process development at the state level, creating that systems approach to how the state health department is working with the locals to get those major plans in place, if they aren’t already at a more system-level, and then conducting statewide assessments.

And you’ll hear Missouri talk a little bit about what we’ve done with them around doing a statewide readiness assessment. A statewide assessment to pull out trends and themes that they can then take back and work on those opportunities for improvement if they’ve noticed an area that is in need of growth amongst the locals.

Those are just some of the approaches. And what I’m noticing is not on here is Ohio’s approach, which is mandating accreditation. That’s actually not on here. So that’s another statewide approach that obviously could be explored. This is just a short list of some of the resources we have in place.

We have lots of tip sheets, Q&A documents, and key plan templates that are available. Talked about the readiness assessment, which is a tool that can help with supporting statewide approaches as well. And then the key plan templates that we have available, for example, are QI/PM (Quality Improvement/Performance Management) and a workforce development plan template that’s also available. So lots of resources are available.

If you hear about anything today that you might want to explore more, feel free to reach out. Including our inboxes. We have an ask PHAB and a PHAB technical assistance inbox, which I’ll share the contact emails for those on the next slide. So for the PHAB contacts, you’ll see mine and Reena’s email addresses here, as well as that Ask PHAB and PHAB Technical Assistance inbox. So, any accreditation-specific process or measure interpretation questions, you can send those to the Ask PHAB inbox.

If you have any statewide accreditation approach questions, you could really send them to either inbox, and whoever you email at PHAB will get it to the right person if it didn’t go to the correct email out of the gate, which is perfectly fine. And then just a reminder that, as you know, PHIG technical assistance should go through the PHIVE system.

I’m going to turn it over now to Mackenzie from Ohio, so you can hear the first example of implementation of a statewide accreditation approach.

Mackenzie Mays:
Hi everyone. My name is Mackenzie Mays. I’m the accreditation coordinator at the Ohio Department of Health (ODH) within our Center of Public Health Excellence.

Just to start off with some level setting, the state of Ohio has 88 counties, and we have 111 local health departments within our state. We are a decentralized home rule state, and as you can see, those little stars on the map indicate that we have a city health department as well as the county health department in some of our counties, which brings us to that 111.

Since 2013, Ohio statute has allowed for the ODH director to require accreditation for local health departments. The first Ohio locals were accredited in 2013, and we now have 102 out of our 111 local health departments that have achieved accreditation. Twenty-four of those have achieved reaccreditation, and we have eight that are still in process for their initial accreditation. We’ve only had one city, a small city health department, which has declined to pursue accreditation at this time.

In 2023, there was new statutory language from the Ohio legislature requiring that any city or local health department that serves a population of less than 50,000 may have to undergo a study to determine if they need to merge with their county health department. So departments that have achieved accreditation are exempt from this study if they are accredited by the end of this year. That would be something that the framework for that would be provided and developed by the state health department, looking at that recommendation, and then making a recommendation on whether we think that they would be better served by merging or not. So, since we have had that mandate for over a decade, we have gone through a number of different approaches to supporting our locals in their accreditation journeys.

One of the first early projects was the Local Public Health Accreditation Support Project, which was state-funded and given to the Ohio State University (OSU) Center for Public Health Practice in 2016. That started with doing readiness assessments in both 2016 and 2018 to see where our locals were in the accreditation process. And by 2018, when the second readiness assessment was done, 92% of local health departments in Ohio had either started or completed the accreditation process.

Through this project, all local health departments were able to apply for individual or small group training and technical assistance on a wide range of topics, such as workforce development, planning, strategic planning, quality improvement, performance management, facilitating community meetings, and really anything. They could submit an application for individual training from our partners at OSU to come to their health department and give them training or technical assistance on a topic that would help them be better prepared to apply for accreditation.

There was also a component of this project that was looking at document reviews so locals could submit drafts of the five main plans, so their CHA (Community Health Assessment), CHIP (Community Health Improvement Plan), Strategic Plan, QI/PM (Quality Improvement/Performance Management) Plan and Workforce Development Plan, and it would be reviewed by a team of folks, compared against PHAB’s (Public Health Accreditation Board) criteria to see how what we thought.

Of course, that wasn’t an official recommendation, but we were able to review 285 documents through that process again. Any local around the state could submit that to see where they stood, since this was the first time that a lot of them were doing some of these plans.

Through this project, another thing that was started was the Accreditation Learning Community (ALC), and that still lives on today, even though the initial support project ended in 2020. So, as part of the accreditation learning community, it started as something that was just an annual convening in our state capital, once a year, around different topics.

And then during COVID, it became a virtual convening, of course. And then in the last few years, with PHIG (Public Health Infrastructure Grant) support, it has been revamped and really reworked to better meet the needs of our locals, especially with where they are now. So there’s been a big shift toward reaccreditation in the topics that are covered, since almost everyone is already initially accredited.

Based on evaluation feedback, we’ve updated a lot of the offerings, like location and format. So now we are doing a regional workshop method where we have a team of folks that meet in all five regions around the state, so that it is a lot closer for the locals to travel, instead of asking everyone to travel to Columbus. And then we’ve also tailored all of the topics that are covered at the ALC to be based on what our locals have asked for.

So specifically, this year’s trainings that just wrapped up this past week was a regional workshop on performance management led by Greg Chumney, who’s out there. He is our Performance Manager, and he went around to each of these five regions and held day-long trainings that were all about performance management and how to incorporate that into your work and how to set yourselves up for success in that way, since that was something our locals had been asking us about. And then again, based on evaluation, he has continued to modify the agenda throughout this summer, and has offered follow-up office hours because that was something our locals asked for.

The topic of performance management in general is something that our locals have asked about a lot and asked for a lot of support in that area since the beginning of the accreditation mandate in Ohio. So ODH does provide free licenses to Clear Impact performance management system for every local health department in our state, as well as that’s the system we use at the state level that really has allowed everyone to share best practices and support each other, help each other out.

It’s a lot easier if a local calls Greg or calls someone at ODH and asks them a question about how to do something that we’re all using the same system, even though we don’t mandate that they have to use that system. It really helps with that, with that sharing and working together.

And then we’ve also, as I mentioned, added a full-time dedicated Performance Manager, which has really helped allow us to provide more training, more technical assistance, more one-on-one help both for State Department employees as well as all of our locals.

Another way we have built out our team at the Center of Public Health Excellence post-COVID is through our regional staff. So before COVID, we had one liaison at ODH that provided support to all local health departments in the state, and it just wasn’t really enough to provide proactive support. Now we have, based on those five regions, they’re on the map that I showed at the beginning, we have a liaison that lives and works in each region, so they’re able to attend coalition meetings and one on one meetings at local health departments in the region that they work and live in, which has been really great, because a lot of that has been focused around things that support accreditation, such as going to CHA/CHIP meetings and things like that.

We also, in 2024, added one full-time member of our staff who is just focused on helping our locals get accredited. So a lot of his work initially was trying to get the last 20 or 30 across the line for initial accreditation. But he also helps support the accreditation learning communities, and is able to provide one-on-one assistance when people call him from the local departments with a question about accreditation, knowing that they have that safe person that they can call. And then, as far as financial support, that is a big topic that has come up a lot from our locals.

In addition to the allocation that we gave them initially from our PHIG funding to the locals, this past year, we also committed $50,000 to every local health department in the state that is specifically for accreditation or reaccreditation-related activities. We did not say what they had to use that for. It could be used for their PHAB annual fees to pay for their accreditation coordinator, or any activity that they could tie into accreditation. So any of those plans that they worked on, or if they hired a facilitator for CHIP meetings, anything that they could say helped them achieve accreditation, they could use that funding, which is really helpful.

And then we have always had a state subsidy for all local health departments in the state, and that subsidy is higher for health departments that are accredited. And so that’s been an incentive this whole time, since the mandate to achieve and maintain that accreditation, so that they get that annual subsidy at a higher rate. And then the final thing, as Brittan mentioned, and I know Montana will go into this more later, since they were the first to do it, but we have gotten three measures approved for statewide documentation. Really thankful that PHAB has that as an option, since so many of our locals are accredited, and hopefully will maintain that accreditation.

So we are working on getting more of those approved, and we hope that we can continue to do that and take that burden off of our locals for measures that they would all be answering in the same way. I think that was the end of my slides.

If anyone would like to reach out and talk about how this has gone in Ohio, I’d be happy to chat. My email address is on there, as well as the Assistant Chief of our Bureau, Laura, and our performance manager, Greg, who are both here this week for the meetings as well. So please feel free to reach out to any of us, and with that, I will turn it over to Missouri.

Brenna Davidson:
Did we fall down the stairs or up? I was worried about that. Hi everybody. I’m Brenda from Missouri. I am a lot of things in the Workforce Director. I run operational excellence. I do performance management accreditation.

We do cool stuff in the state of Missouri. So we’re going to go over some cool things that we do to support our locals. So you’re going to hear some topics that you heard in the opening remarks. Because, frankly, I wrote that speech, and I wanted to put it in there. So I’m gonna say a couple of things that you’ve already heard. But a little background of Missouri. So we are decentralized. So also, welcome to Missouri. We’re happy to have you.

We’re a decentralized system with 115 local public health agencies (LPHAs), which I’m probably just gonna say LPHA from now on. So that’s what that means. And from the state level, we knew we needed to support them on their journey to accreditation.

When we wrote PHIG, we really thought, wouldn’t it be cool if maybe one jurisdiction got accredited? We started with about 10, I think, that were accredited under PHAB at least, and we have made so much progress. So it’s pretty cool. But we always thought it was maybe someday. So that was one of my little nuggets that I like to say, because we really thought, like, when are you going to put down the immunization needle and go work on your CHIP?

You know, we have locals that have four, five people that work there, like, the administrator is the nurse, is the epidemiologist, is everything, right? So who’s going to do accreditation? So we know there are barriers there. There’s time, people, and money. What can we do at the state level to take those barriers away?

So I also am going to shout out Carter County. Again. She’s one of our favorites. So Carter County, Missouri, is down kind of in the boot heel, but not really the middle of nowhere. Let’s be honest. I think there are about 4000 people who live in that county. There are five people who work at that health department. They just got through their site visit in person. And the idea of having the site visitors come to Carter County is hilarious to me, because I don’t think there’s a hotel. There may not be a restaurant. One restaurant, all right, rock and roll, but that is my example of we have the support, if you have the energy and the tenacity to do this, you can do it. Accreditation is doable for anybody. So another big part of this is the partnerships that we build.

So I’m going to have Sarah talk about some cool stuff that she’s doing as our partner at the Institute.

Sarah Crosley:
All right. Good afternoon, everybody. Sarah Crosley, Missouri Public Health Institute. We’ve had a long organizational commitment to accreditation. We originally were formed as a membership association because local public health agencies across the state wanted to see more health departments accredited. In the state of Missouri, we have, obviously, PHAB and also a state version of accreditation that we’ll refer to as MICH (the Missouri Institute for Community Health, accrediting body for Missouri’s voluntary accreditation program for LPHAs). And really, our support and partnership with the state has rested on peer learning.

And I’m reminded a lot of what was just shared in our opening about some of the pieces around confidence and resilience. And really, one of the best things you can get out of a peer learning collaborative. We have one for MICH. We have one for PHAB. They’ve been in existence for a couple of years now. But frankly, just the idea that there’s somebody I can call and go, What the hell does this mean? And there’s also a group of people I can come to on a monthly basis and say, how do we approach this? What innovation did you use?

Carter County is a really great example. It does have one hotel slash/float, like canoe rental, and so they’ve made really great active use of our PHAB collaborative and frankly, the email list, these folks are not afraid to steal and copy and plagiarize and share, and that has been a really, really big resource.

But going back to that confidence, we had the opportunity to watch Michelle, sort of tentatively, first off, be thrown into the position of administrators. She was one of the administrators who started during the pandemic, because the original administrator left. So one of the 50% of administrators we lost during the Covid pandemic goes from, well, yeah, not so sure about this, to of course, I can accomplish it, and now I’m embarrassed my neighbors aren’t. And so she is sharing those resources within her region and within the peer learning community as well.

Something that we really specifically targeted, too, is the accreditation coordinators. That’s how I got my start in public health on January 28 of 2020. And they play a really special and critical role within a health department.

I don’t know that I need to explain that to this room, but we know that they face a significant amount of burnout, of stress, and in some ways, like isolation, they can play a kind of challenging role within an organization of pestering that person for documentation or explanation, or why aren’t you doing this right? So this year, we did our first round of accreditation coordinator retreats. Missouri has seven regions.

We’ve done four this year. We’ll do three next year, but these were day-long events hosted by a health department, limited to no more than 20 attendees. Most of them had around 10, maybe seven. So we could create a really intimate setting for accreditation coordinators who need peer connectivity, who need a safe space to say, I can’t get my team to do this. How have you made this happen? And then throughout that is a model that we hope other accreditation coordinators will be able to take back to their organizations, as we did wellness breaks throughout the day, right?

So we know this group of people really could benefit from that support. We created it, we modeled it, we gave them resources, and that’s really part of our sustainability for this project too: What are the relationships we can foster before our contract with the state ends?

I’ll leave my part here with a quote from one of our participants who shared that, as a suggestion, we need to continue to offer retreats on a regular basis, so that people from all stages of accreditation can benefit from this and receive support.

It is encouraging, and it is a great opportunity to reflect and offer support to others, wherever they are in this journey, which is the whole point of peer learning, right? And so we were really tickled by that, and we’ve been really pleased with how responsive folks have been to our accreditation coordinator retreats.

Brenna Davidson:
Thank you, Sarah, so I’m going to cover the last couple of points really quick.

So one of the big barriers is cost, right? It’s people, time, and money. Those are the things that keep people from achieving accreditation. So how can we remove those barriers as the state? So we built in support structures around the people, right? The Learning Communities, the time, meaning I will pay you for your time.

We have cost-reimbursement contracts that come from the state to the locals. Over two grant years, we’re getting ready for year 3 for this, even though we’re in year four of PHIG, you know how hard it is to get money out the door sometimes. You can hire, or you can pay existing staff time. You can contract. You can buy supplies, software, and things that you need with that money. It is like anything that is useful to you in the accreditation world will pay for it, right? It was first come first serve. The first year, I think we did 27 jurisdictions.

Second year, we did 23, and then we’re going to open it up again for a third round, so $50 million out to the locals to make it happen, Captain.

Also, there are GR or general revenue incentives that we have woven into our support structure. So a big part of what we’re doing is a novel approach. So thank you, PHAB, for your partnership for access to the readiness assessment.

So, if you’re not aware, the readiness assessment in the associated training is like the one-on-one kind of coaching and recommendations that come after that. Excellent resource if you are thinking about going for accreditation. We all know this, right? So we are one of the first, if not the first, state to straight up just contract with PHAB.

So we have 115 local public health agencies. The city of Kansas City is a recipient for PHIG so we wrote the contract for 114 so at a flat rate of like this is how much it’s going to be, and PHAB has been an excellent partner in having them do the trainings and collecting that data, we’ve seen 80% of our LPHAs have engaged in that resource, which is insane to think about. I thought like one would do something. So we got 80%, making progress, right? We didn’t want to tie all of this to achieving accreditation, because that really is a maybe Sunday thing. We wanted to tie it to making progress.

If you end up with a CHA and CHIP, I’m happy. You did something really good for your department, and it’s going to have lasting impacts. And maybe, just maybe, you’ll realize you can do more and then keep going, right?

The really cool thing about the readiness assessment, for me, is that at the end of the project, we’re going to get aggregated data from the findings. So Carter County went through it. I’m not going to know what Michelle said. I don’t need to know what Michelle said, but I didn’t know what everybody in her region said, or folks of her agency size, right? So we can find those areas of like, okay, let’s be real.

Domain nine is really hard for everybody. It was hard for me, and that’s my whole day job at the state, with all of the resources and support. I still struggled, so the locals are going to have trouble, too. So we’re going to use that aggregate data to combine with like PHWINS (Public Health Workforce Interest and Needs Survey) and our PHIG evaluation data to really get in FPHS (Foundational Public Health Services) costing capacity as well, to really understand how the system is doing. Where are the sore spots, and where can we put in more support from the state level to get those locals all elevated? That’s what we have for you. And now you get to hear from Carrie from Montana.

Kerry Pride:
All right. So hello everyone. I’m going to talk to you about what we’re doing in Montana, and I’m going to start with some small picture things and move to the larger picture as we go through this.

So, level-setting: Montana, we’re the fourth-largest state landmass, and we have just 1.1 million people total in the state. We have 60 local and tribal health jurisdictions, 52 of which are local and 8 are tribal. And what I want to point out here is that we look at them, we kind of break them up from frontier to small to medium to large. But when you look at the numbers, 38 of them are serving populations of under 10,000 people. And the other thing to look at here is the lower range of FTE. We’re talking really small health departments.

The one thing that we did, we talked about from Ohio, is that our accreditation coordinator, we were the first state to get approved statewide documentation, which is awesome. We did it for Measure 1.2.2, which is looking at that participation in data sharing with other entities, and we used our infectious disease reporting system. And he’s in the process of doing another for the second part of that measure. So we’ll get that done, and then a couple others.

It is something great to do for those who are initially accredited, reaccredited, or in pathways. Then ,the other thing, we kind of look at a tiered approach. Because, like, like you’ve heard from the other states, we all have very small departments. I don’t care, really, probably what state it is, there are always these smaller departments that struggle. So we want to think about how we can help them. And like they said, for Missouri, getting a CHA and a CHIP is huge, right?

So we have dedicated staff with PHIG funding that will go out and help with CHA, CHIP, and strategic planning. They’ll do the facilitation. Help them work through, like, what is the best form of primary data collection that’ll work for your community? We do the same with all of our tribal health departments. Then we also started a policy and procedure cohort.

And so what we mean by that is there’s no funding attached to it. It literally is. Here’s the year. This month, we’re going to talk about mission, vision, and values. So departments can join those calls. They can work with the staff at the state, and our Institute is also helping with that. The Montana Public Health Institute. There’s an online learning community. It’s a place for people to share, as we heard from others, like poach, copy, and make their own. So kind of going through, and this was the items that they worked on this year, and it’s been very well received. And like I say, if a department just wants to attend one, they can attend one. They want to attend all of them. They can attend all of them.

Then we started what we call pathways to recognition. We added that in there, because we over, I can’t think it was over at our state public health conference. We were sitting there with our fellow Montana Public Health Institute people, and we’re like, probably was over a beer, like, all right, what can we do to try to help?

When we were very excited when PHAB came out with this, and we thought, man, let’s create with PHIG funding this Learning Collaborative, we can do a partnership. We’ll do a two-year program. We’ll call it a program with this, we’ll give the health departments funding, we’ll have virtual meetings, we’ll have in person meetings, we’ll go ahead and go through all the standards and measures, and we’ll have this coordinated support, because both of the individuals that are in charge of this are both site visitors, and accreditation coordinators, and so going through this and using that virtual learning community so there can be this sharing. And so we did that.

And this is what’s cool. So in Montana, in 2014, our first health department became accredited. And I think Missoula City County was also one of the beta test group counties, I think, initially, for accreditation, and then by 2018, all of our larger jurisdictions were accredited, including the state. And then you kind of sit there, and I know there was a pandemic in the middle of this, but we also knew that we would probably have hit the wall for getting the rest accredited at that point, because it just seems so unattainable. And we were really hoping PHAB was going to come out with something to kind of help push that along that wouldn’t seem so unattainable. And so that’s where their pathways recognition program came out. And so with PHIG funding, we were able to do this.

And so our first cohort had five. Local health departments and one tribal health department, and the mean FTE was five, with the smallest being three and the largest being Butte Silver Bow. I think Butte Silver Bow had 30, but most of them were between three and five staff members. And what’s cool about this with PHAB is that five of six of these now are in pathways recognition, and they created a Montana-specific cohort. So not only did they complete their two years with us and get all ready, they all submitted their funding or fees, which were PHIG-funded, and now they’re going through it with PHAB.

We just started our second cohort, and we have seven in this, six local and one tribal, and so they’re in the end of year one in November. So we’ve learned a lot, and we’re going to talk about a lot of details about pathways tomorrow and the promising practice. So if you really want to get into the nitty-gritty of how we’ve done this and what we’ve learned, because we’ve learned a lot between the two cohorts, you know, come tomorrow, and we can talk about that.

And then the other thing, Montana, we joined the National 21c last year to try to think about, like everybody, with uncertain times, you know, and the reliance on federal funding, and looking at the great examples across our country of states that have been able to get dedicated public health funding. And so that’s our long-term goal with this.

We are literally in the infancy of this. And so we’re calling it Montana 21c Strengthening Public Health Together. And the first thing we did last year was a road trip around the state and a foundational public health services assessment. And so we looked at all the assessments done out there by all the different states, and looked at that to really be able to understand how those are being delivered across our state, where our strengths, where our gaps, and just kind of get a handle on that. And we did in-person interviews, and got 100% completion rate with all 16 local tribal health departments. And it’s really given us a baseline of where, where we’re at and where our challenges are, and not surprising, right?

Things that are funded and mandated, they do really well, and things they don’t, that aren’t right, they don’t do well. So no surprises. And so you can read about this, but really, we’re just trying to figure out how to create a very responsive public health system, right, that can be agile, and that’s our long-term goal, to get funding. But knowing that, when you look at the other states, we’re talking years, and that doesn’t mean there aren’t things we can do now that we’re in control of.

And so this Montana 21c is an umbrella over our key partners, and knowing that we’re going to have to engage, and we’re in the process of that, or other organizations, but the kind of the heart and soul of this is our Office of American Indian Health, Montana Public Health Association, the Association of Montana Public Health Officials, Montana Environmental Health Association, Montana State University, Office of Rural Health, University of Montana Public Health Training Center, the Montana Healthcare Foundation, Confluence Public Health Alliance, the state health department, and the Montana Public Health Institute.

And so it’s really these drivers, and we’re working like I say together to it’s not that we aren’t all rowing in the same direction we are, but we need to get where we’re rowing like those row boats right on the East Coast, you see them just all in time and unison going, that’s what we’re trying to do.

And so, as you all know, with any coalition work, that’s challenging, but we’re making a lot of progress, and we have it in different buckets. So I’m going to kind of start on the I guess it’d be on the visioning side, the opposite side that you normally would, but it’s really for us to have those conversations like, what does transforming public health in Montana mean for the State of Montana?

Montana has had a lot of challenges since COVID. We’re one of the states with, I think, the highest increase in home sales last year. It increased 121% in Montana. In Bozeman, Montana, the cheapest home is a million dollars, and when you look at wages, it doesn’t match. So we’re seeing there’s just a lot of big challenges coming on.

So what does that mean for our systems? We have 34 critical access hospitals. Over half of them are in immediate danger of closing. So there’s, like, all of these challenges that we’re like, okay, how are we going to be agile and think about this? And then, like, say that organizing the system? How do we really get rowing in unison? So we’re really committed to what we’re envisioning, and how are we going to get there? And then, really looking at that foundational public health services delivery, what does that mean for Montana? How are we going to fund that? And I’ll get into that in a little bit more detail.

And then, of course, the workforce, we hear so much about that. How do we really support our workforce? How do we ensure they have the tools needed to succeed? How do we do succession planning? How do we engage our youth so they’re interested in a career in public health, right? How do we do all of those things? And then also, the other part, then, is that policy and advocacy, and so beyond the funding piece of it, our statutes need updating. They’re antiquated when it comes to what is public health like, how do we get that now foundational public health services model into statute? So hopefully it’ll be easier to resource moving forward.

And just a couple of things about where we’re at, looking at this one, is that workforce survey. We do a statewide workforce assessment. So it’s done with a whole workforce group where the state and all the partners, they develop the survey, it goes to every local and tribal health department. We get this very big statewide picture of what are the training needs. Then each of those participating health departments gets its data back, so it can create its own workforce assessment. And then we’re doing the census tool. I don’t know if anybody’s in here from Indiana, but what’s based on Indiana, what they did for the costing of the foundational public health services. So it’s really understanding what each FTE does in the state, how much time is dedicated to those foundational services, and where it is being paid from right now?

And so that’s going on, and then doing workforce calculators that PHAB has. That’s what we’re doing with each of the departments to really understand what are our gaps in our workforce. The other thing in Montana is that, and I’m sure other states have this challenge too, our environmental health. We struggle. We are really struggling with sanitarians. We are really struggling with the integration of the two, because in some counties, it is completely separate from public health. And so it’s pretty exciting.

We now have a work group that just stood up to look at this between Montana State, because that’s where our environmental health program is, the Montana Department of Environmental Health, the Montana Environmental Health Association, and the state. So they’re really going to look at trying to answer some of those questions moving forward.

We’re really trying to line these community health planning processes with the Office of Rural Health and our critical access hospitals, because I know everyone in the room struggles right with how to get health care and public health to work collaboratively to create something that meets both organizations’ needs.

And so, we’re really excited about some of the work that’s coming up along that. And the other thing we heard is a kind of a little bit of a preview. We don’t have all the details worked out yet, but when the things that we heard going around the state were, man, you know, I was born and raised in these communities.

We’re talking about little rural Montana towns, born-and-raised generations, and they’re like, some of my commissioners hate me. They hate public health. They don’t understand it. And all the stuff that’s happening nationally, the free branding that’s happening there doesn’t resonate like we have to figure out how to make this Montana, like, where they’re going to understand it. So the University of Montana Training Center has funding to go in and do what is public health in schools.

So there’s a whole campaign to go into schools and to talk to them about what is public health, and then they’re working with the health departments also give them the tools to go in and talk to schools. And what our hope is is that hopefully, maybe next year, we’re going to run a statewide campaign that will be a contest with all the schools across Montana to give kids, whether it be a poem, a letter, a picture, a video, to say, what does public health mean to you and your community? And run a contest across different school sizes, and then have the chosen ones work with our universities that do communications and media to develop a whole campaign based on what public health in Montana is, through the eyes of these kids around the state. We haven’t got it all figured out, but that’s our goal: to try to do that next year and help with that.

And then the other thing we’re working on that’ll start this fall, and it’ll be led not by the state. This is going to be led by our Association of Montana Public Health Officials. So really, our health department directors at the local and tribal level need to really go, okay, what makes sense for Montana with the foundational public health services, because then that can be used for what we’re hoping to change the statutes to, to hopefully be able to cost it. And it’s being driven by the people that are going to be asked to do it, with most of the changes in the conversation early on have been really to make sure behavioral mental health is included, because, like, I know most communities, right? That’s something that always rises in our CHIPs, right, is around that behavioral health piece. And how can we improve that connection?

So we’re looking at innovative models there, and something that has come out of that is our sister division, the Behavioral Health Division, and we’re trying to figure out how to break some of those silos and make sure some of that funding is now connected to some of the prevention efforts that are occurring at our state level. And then this shows you the work we still have to do.

When you look at the state of Montana, the western half is where our most populous counties are, minus I think you can see my pointer Billings there. So you look east, those are east in the High Line. Those are our very rural communities that struggle with capacity, funding, and other things. So we have some work to do there.

But the big orange county in the center is Garfield County. They have one point, not even one, not even one and a half. It’s like 1.4 FTEs. And they’re in pathways so that when they get through that, which we know they will, there’ll be no excuse for the rest of the counties, because they’re one of the smallest ones. They serve fewer than 1,000 people on that landmass. And a fun trivia fact about Garfield County, Montana, is where a T. rex named Sue and some of those other big T. rexes came from. And also it was infamous for the Freemen.

If anybody remembers the Freemen, I see some head shakes. They wanted to create their own government and secede. That was also in Garfield County. But so you can see it’s pretty cool that they decided to do that because they were actually asked by their commissioners. You know, it’s a pretty conservative county to be like, we need policies, procedures. We need to know what it means for public health. And so pathways will give them the path to do that. So pretty exciting. So with that, I’m going to turn it back over.

Reena Chudgar:
All right. Thank you all so much. Hopefully, y’all got a good sense of the swath of different ways you can approach statewide accreditation from our three states and from Brittan. We have plenty of time. Y’all flew through that for Q&A, so want to see what questions y’all have. Have a couple if we need for you start, but yeah, there we go.

Audience Member #1:
Thank you, everybody. I was just wondering, the person who presented first on Ohio, I realize Ohio actually requires every public health unit to have an epidemiologist on staff. Has to be one full. FTE. And I was wondering, how is that gone? Because it’s been about five years, plus, that has been the case. Is that overkill? Is it difficult to keep them on staff? I’m just curious.

Mackenzie Mays:
Yeah, I can answer. I’m from Ohio, so I wouldn’t say that it was overkill. There are plenty of things for them to be doing, especially, you know, post-pandemic and just all the new data modernization things we’re doing. It certainly has been a challenge for some communities, especially for small health departments or under-resourced communities.

We have many of the same problems that everyone else talked about with some small counties having a couple people on staff, but some of that has been resource sharing by working with other counties and working to, you know, recruit outside of that, or maybe there’s, there is one collaborative in our state that they all put money into that, and so then they get folks through that, but they’re hired through the collaborative versus hired through their department, even though they’re putting the money in for that. But then the HR service part of that for those epidemiologists is handled by a separate entity, so that takes some work off of the local health department. So there have been a few different approaches on that, but it was something that we thought was a priority.

Reena Chudgar:
Other questions.

Audience Member #2:
Hi all, I’m a little biased because I’m from PHAB, so I’m going to just dig into your brains a little bit. Did you find that the accreditation process helped you identify any gaps in your agency’s data infrastructure? I heard you mention data modernization. So, through that process, did it inspire or help you direct any of those data modernization-related activities you all may have planned?

Brenna Davidson:
Well, okay, Susan, take note. So, Susan, my lead, yeah, I’m thinking the aggregate data that we’re going to get from the readiness assessment is going to be huge, right? Domain 1, exactly how you do in all your surveillance, right? So I’d like to see how what the local site, because some do have their own surveillance systems and some don’t, and so they rely, or most don’t. They rely on ours at the state level. So I know we were pursuing statewide documentation around, like our emergency operations and things that, like everybody uses that. So that’d be interesting to see. Because, combined with the FPHS capacity data that we have from 2020, we know that, like surveillance assessment and surveillance came out as one of our, we did a very visualizing image. That’s the red, yellow, and green indicators on the capacity assessment.

So it’s a stoplight system. It’s a much more complicated assessment. I’ll tell you that I just remember the picture. But everything on surveillance and assessment was pretty green, which I kind of want to, like, double click on that, be like, really, though.

So yeah, I think we would use the readiness assessment with the FPHS, and now that we’re getting into costing, we’ll understand how much it will take, which will feed into our DMI strategic plan, which is a statewide plan, along with our health data consortium that we put together across different agencies. So a lot of big words to tell you that I suspect that we could use more work than our 2020 assessment sets and we’ll use data to figure that out.

Kerry Pride:
And I would say the same thing, because none of our locals have their own surveillance systems. They’re all using ours. So when you look at how that was scored during the assessment, it’s all very high. But when I look at our systems, at the state, you go, oh, we have so much work to do. So, the same kind of answer.

Mackenzie Mays:
I’ll add two parts from Ohio. One, although the measures that we focus on for statewide documentation so far have been things related to our data systems, since they’re using our surveillance systems and things. And then on the other side of that, we have put a lot of time and money and energy into revamping a lot of our online data systems, so that’s both on the reporting and collecting end, but then also on making a lot more data available, and so that’s available publicly, but then our partners are able to use that with better dashboards and better tools to be able to get more up to date data that hopefully they can then use when they’re developing their CHAs or looking at other projects that are certainly related to accreditation.

Audience Member #3:
Appreciate the presentations from three very different states, geographically, culturally, everything else, but I’m kind of curious, as you’re talking about these aggregated views, especially at the state level, how are you thinking about the CHIP side of it, and what are like, what’s ideal state for what the state level could do with with lots of CHIP data coming in from your local jurisdictions.

Kerry Pride:
So, for us, with our State Health Assessment and State Health Improvement Plan (SHIP), we look at all the CHIPs out there.

And so we are looking at that as a data source, but we have also found, and I’m sure it’s no different anywhere else, that getting those documents right isn’t as big a deal as actually implementing them. We know even when we talk to our partners on the critical access hospital side, everybody struggles with yeah, great.

We get together every three years, we do our health improvement plan, and we don’t really do much with it. And so one thing that we’re looking at and toying with, because it came up, was how we could look at some of those more in a regional approach? Because when you look at what rises every year, it’s the same, and so, how can we look at that regionally? And so we have some areas looking at piloting something like that, and then having the strength to hopefully apply for grant funding as a cooperative unit to implement it. Because, as we know, the other challenge we’ve run into is that there is not usually funding for what rises.

It doesn’t fit into a categorical CDC, or even if it’s HRSA or SAMHSA, the right box to address. So that’s one thing that when we’ve looked at that data, and we have a dashboard where you can go search all the CHIPs and look at what rises that we really notice, like, oh my goodness, it’s really similar. So how can we decrease that burden? Still meet the needs of the Health Department and the hospitals, but looking at it in a regional approach. But, like I say, we do look at that, and it does inform our SHIP. And so that was the first time we did that. It was very eye-opening. That’s when the behavioral health piece really rose. We had not thought about it, because, as we all know, we cut the head off of a human and put that in another agency. And so when we did our SHIP, and it was 2017, I think that was the first realization, like, oh, okay, we have some challenges here. So it has informed quite a bit, but we’re looking at that next iteration.

Brenna Davidson:
Your question made me think of something really cool that I want to do now. So, Ohio, you provide access to performance management software. That’s a huge barrier for our locals, and we have an enterprise license; I’m not allowed to give it to everybody. I want to, real bad, but I’d like to see, like, get excited with me here. So what if we got some funding and I could provide the same platform to every local? They load their CHIP in there. I see all that. Well, this is me being like, power, but I see everything on how, like, how we’re doing, what progress we’re making, that informs the SHIP. It’s one system. It’s one pool of information. Like, I think that would be a really interesting way to go about this. Don’t know how I’d fund it, but thank you for the idea and the inspiration.

Mackenzie Mays:
Something I’ll add. So we still have a lot of ways that we can expand on this, but at the risk of sounding like Ohio mandates everything, another thing that we have in the Ohio Revised Code is that our locals do have to align their CHIPs to our SHIP in at least two spots, so they can choose that. And our SHIP includes a lot of different topics, so it hasn’t been hard for any of them to align, but they have to be able to tell us this was the topic area, this was the indicator, and this was the strategy that was in your SHIP at the state level, that is in our SHIP, so that we can see that alignment and see, like this, many counties in their CHIP have this indicator that they’re all working toward.

And like I said, that’s still a work in process that we’re talking about how we better harness that information, because right now, it’s a little bit that just we have that information and we are requiring that alignment, but we’re not necessarily doing taking a lot of next steps, but we hope to do that with our next SHIP cycle, which will hopefully our next ship will hopefully be released in this coming year, and then we’ll be able to be a little bit more intentional about that collective impact.

Sarah Crosley:
I’ll add also, from like a Missouri TA perspective, while we’re not at this sort of, like golden vision that Brenna just laid out that we amazing, and what a phenomenal, like goal post that we should be driving toward. But something that I’m, like, the most frequent hand-wringing we see around the start of a CHIP is the policy requirement, and so we’ve been, like, building publicly available repositories of counties that have adopted this policy. And here’s a strategy we’ve pulled from this place, and that’s been kind of helpful in getting us closer to a statewide picture of us moving in a similar direction, but we’re starting from a place where, honestly, we’re just excited when an LPJ (local public health jurisdiction) is like, yes, I want to do a CHIP, right? That’s like, we’re like, okay, cool. And we can do a lot with enthusiasm. We could do a lot more with a system. I’ll say that.

Kerry Pride:
I just wanted to add to kind of make that connection between DMI and accreditation, one of the things I was thinking of when you asked your question, and then when Brenna was talking, was that with the CHIPs that the locals need, they need data, right? That data comes many times from the state, and what we found was that we had one of our systems that provides a lot of data to the local health departments, regional local data to them. At the time it was developed, of course, it was state-of-the-art, but now not so much. So we kind of identified through that that we need to do better with sharing data with them, so they can then do better with their assessments in their own community. So we are both enhancing with this path here and replacing this path over here, the main one of the main systems where they get some of their statewide data. So I think that connection was well-connected.

Reena Chudgar:
Other questions? I had a question for Britain. hat do you see as kind of the benefits of thinking about this statewide approach versus kind of every individual health department doing their thing? What are some of the ways that these approaches can really benefit thinking about individual health departments and the system?

Brittan Williams:
Well, I think it’s just not taking that one-to-one approach. It’s putting that system-level approach in place that can help advance more than one health department, right? And trying to create efficiencies. So I feel like that’s what you’ve heard all of these folks talk about today, the system level approaches they’ve taken to create, either reduce documentation, burden, support with ta funding, a lot of funding I’ve heard today, which I’m so impressed with the amount of funding put towards us, which I know PHIG was a big helper there. Thank you, PHIG. Plug for PHIG. But I think it’s just driving at a larger level, versus just assisting one department, helping move and advance as a state together. And I think doing it as a larger group together. I think y’all talked a little bit about the peer learning that happens. You’re all kind of working towards the same thing together. Thanks.

Reena Chudgar:
That made me think of another question, while folks are thinking. In thinking about funding and the kind of resources that support this, and thinking about resource shifts happening, kind of overall, what are some of the conversations maybe that y’all have been having about how to, like, prioritize this work and keep it moving forward despite larger resource shifts, if any?

Sarah Crosley:
One of the roles the Missouri Public Health Institute plays as a nonprofit is that we get to say things that our state partner may not be able to. So we love playing that role. It’s a treasured role, and this is very much in line with what Director Willson was sharing earlier, about how we cannot have a reliance on federal funding. Missouri’s state per capita funding is $7 a person, or the price of the latte I bought on my way here. And that cannot continue. And at the beginning of this year, our organization conducted a statewide poll on public health trust. And we keep hearing all these national narratives about Americans not trusting public health, so we asked the question, well, do Missourians trust their local public health agencies?

60% of Missourians trust their local public health agencies, and after experiencing a service from their local public health agency, that number rises to 73%. 83% of poll participants said they would support increased funding for public health. I’ve never seen 83% of Missourians do anything together ever.

And so for us, like really, the focus is like, for whatever work it may be, whether it’s accreditation or DMI or epi or just the future of public health in our state, it’s get local, get partnered, get focused. Because those numbers are astounding, and that is a very easy thing to hand to a decision maker and say, these are your constituents who trust this agency. And that’s a really strong foot in the door for our advocacy efforts around FPHS and protecting the public health budget in our state.

Kerry Pride:
And I was just going to add, that’s why we’re looking at how to rebrand public health specific for Montana, to try to get that because it is a similar response, right? When people actually go to the agency, they learn, they like, oh, wow, you do. This is awesome. So how do we capitalize on that? And then how do we also, that’s why the public health in schools program too, right? To get people to understand at a younger age the value of public health, too.

Reena Chudgar:
All right, any other questions? Think we grilled y’all enough. All right. Well, thank you all so much. I have a couple of closing remarks before we give our speakers a hand. Please join us in 15 minutes for a welcome reception and poster session, generously supported by Inductive Health. There are many poster presentations throughout the fourth floor. So please take a moment to visit with the poster presenters about their work, and then tomorrow, breakfast starts at 8 am inthe Grand Ballroom on the fourth floor. Closing reminders for y’all and thank you all again to our presenters. Really appreciate y’all sharing your experience, expertise, and for all of y’all for being in here. Thanks.