Assessment of Staffing, Services, and Partnerships of Local Health Departments — United States, 2015

Beginning in 2008, the National Association of County and City Health Officials (NACCHO) periodically surveyed local health departments (LHDs) to assess the impact of the economic recession on jobs and budgets (1). In 2014, the survey was expanded to assess a wider range of factors affecting programs, services, and infrastructure in LHDs and renamed the Forces of Change survey (2). The survey was administered in to January–February 2015 to 948 LHDs across the United States to assess budget changes, job losses, changes in services, and collaboration with health care partners; 690 (73%) LHDs responded. Findings indicated a change in LHD infrastructure: compared with the previous fiscal year.* Overall, LHDs reported 3,400 jobs lost; 25% of LHDs reported budget decreases; 36% reported a reduction in at least one service area; and 35% reported serving fewer patients in clinics. In addition, up to 24% of LHDs reported expanding population-based prevention services, and LHDs reported exploring new collaborations with nonprofit hospitals and primary care providers (PCPs).

The public health and clinical care environment is evolving in part in response to the Patient Protection and Affordable Care Act (ACA). Section 501(r)(3) of the Patient Protection and Affordable Care Act (ACA) requires that nonprofit hospitals conduct and report on a community health needs assessment (CHNA) every 3 years to maintain their tax-exempt status (3). The ACA also requires that a CHNA take into account input from stakeholders that represent the broad interests of the community served by the hospital, including those with special knowledge or expertise in public health, such as LHDs. New systems of care with PCPs intended to improve patient outcomes and reduce costs have also been developed in recent years. These include State Innovation Models (state-based, multipayer health care payment and service delivery models), patient-centered medical homes (primary care delivery models that are patient-centered, comprehensive, team-based, accessible, and focused on quality and safety), and accountable care organizations (networks of health care providers voluntarily responsible for providing coordinated care to patients) (4).

An online survey was distributed during January–February 2015 to a statistically representative sample of 948 LHDs across all regions of the United States, representing approximately one third of all LHDs. LHDs were stratified by state and size of the population served (small [<50,000 persons], medium [50,000–499,999], and large [>500,000]). Hawaii and Rhode Island were excluded from the study because they have no LHDs. Survey topics were identified by NACCHO’s executive leadership, and several partner organizations provided input on the highest-priority topics, which included changes in LHD budgets, staffing, and services provided from the previous year; changes in clinical service delivery; third-party billing for clinical services; collaboration with nonprofit hospitals; and collaboration with PCPs (5). A survey instrument with 16 closed-ended questions was developed, reviewed by subject-matter experts, and piloted. Responses were self-reported and were not independently verified by NACCHO. Nationally representative estimates were weighted to account for sampling design and nonresponse. Information about the survey methods is available in the survey’s technical documentation (6).

The survey was completed by 690 (73%) top executives from 353 small, 271 medium, and 66 large LHDs. All surveyed areas except the District of Columbia and Massachusetts achieved a response rate of ≥50% (6). Overall, 23% of LHDs reported a lower budget in the current fiscal year compared with the preceding fiscal year, and 27% reported that they expected budget decreases to continue into the next fiscal year (Table). LHDs reported 3,400 jobs lost during 2014 (1,300 [38%] because of layoffs and 2,100 [62%] because of attrition). Since 2008, a total of 51,700 jobs have been lost. The number of lost jobs in 2014 was most marked among large LHDs: 61% of large LHDs reported at least one job lost, followed by 41% of medium LHDs and 26% of small LHDs. Approximately one third (36%) of LHDs reported reduced services in at least one program area during 2014. More LHDs reported reducing rather than expanding clinical services such as immunization (14% reducing versus 12% expanding), diabetes screening (14% versus 11%), or high blood pressure screening (11% versus 8%).

Approximately one third (35%) of LHDs reported serving fewer patients in their clinics during 2014 than 2013 (Table); this varied by state (Figure 1). However, a larger proportion of LHDs reported expanding population-based prevention services: 24% of LHDs expanded obesity prevention services, and 23% reported expanding tobacco, alcohol, and other drug prevention services.

During 2014, 38% of LHDs reported serving a higher percentage of insured patients than they had during 2013. Among sampled LHDs in 26 states that expanded Medicaid eligibility in 2015, 46% reported serving a higher percentage of patients with insurance, compared with 29% in states that did not expand Medicaid eligibility. Most LHDs (90%) bill third-party payers (i.e., Medicare, Medicaid, and private insurers) for some services; 66% of LHDs reported they billed both public and private payers for at least some services, and 23% reported they billed public payers only. Respondents reported that the cost and complexity of establishing billing, the existence of a trained workforce, and information technology capacity were most important in determining billing practices.

Approximately half (58%) of LHDs reported that they were currently collaborating with nonprofit hospitals to conduct CHNAs. A smaller percentage (9%) of LHDs were considering future collaboration, and some (12%) were not engaged in discussions to collaborate. The remaining LHDs (21%) did not report having a nonprofit hospital serving their jurisdiction. In addition, among LHDs with a nonprofit hospital serving their jurisdiction, 60% were involved in a nonprofit hospital’s implementation plan for the CHNA. Among these, 47% were listed as a partner in the plan, 41% participated in developing the plan, 20% reported that they were conducting an activity in the plan, and 10% of LHDs reported using the same implementation plan as the hospital.

LHDs also reported collaborating with PCPs. Approximately half (61%) of LHDs actively encouraged PCPs to use evidence-based public health services, such as interventions to reduce asthma triggers in children’s homes; 47% provided population health statistics to PCPs; and 23% used clinical data from PCPs. Overall, less than 10% of LHDs were actively engaged in new systems of care with PCPs including State Innovation Models, patient-centered medical homes, or accountable care organizations. This engagement also varied across states (Figure 2).

Corresponding author: Sarah J. Newman, snewman@naccho.org, 202-640-4923.

¹National Association of County and City Health Officials, Washington, D.C. ²Office of State, Tribal, Local and Territorial Support, CDC.

References

1. Ye J, Leep C, Newman S. Reductions of budgets, staffing, and programs among local health departments: results from NACCHO’s economic surveillance surveys, 2009–2013. J Public Health Manag Pract 2015;21:126–33. CrossRef PubMed
2. Newman S, Leep C, Ye J, Robin N. The changing public health landscape: findings from the 2015 forces of change survey. Washington DC: National Association of County and City Health Officials; 2015. http://nacchoprofilestudy.org/wp-content/uploads/2015/04/2015-Forces-of-Change-Slidedoc-Final.pdf
3. Internal Revenue Service. New requirements for 501(c)(3) hospitals under the Affordable Care Act. Washington, DC: US Department of Treasury, Internal Revenue Service; 2016. https://www.irs.gov/charities-non-profits/charitable-organizations/new-requirements-for-501c3-hospitals-under-the-affordable-care-act
4. Centers for Medicare & Medicaid Services. Innovation models. Baltimore, MD: US Department of Health and Human Services, Centers for Medicare & Medicaid Services; 2016. http://innovation.cms.gov/initiatives
5. National Association of County and City Health Officials. Forces of change. Methods. 2015 forces of change survey instrument. Washington DC: National Association of County and City Health Officials; 2015. http://nacchoprofilestudy.org/forces-of-change
6. National Association of County and City Health Officials. 2015 Forces of change. Technical documentation. Washington DC: National Association of County and City Health Officials; 2015. http://nacchoprofilestudy.org/wp-content/uploads/2015/04/Forces-of-Change-Technical-Documentation-Final.pdf
7. Public Health Leadership Forum. The high achieving governmental health department in 2020 as the community chief health strategist. http://www.resolv.org/site-healthleadershipforum/files/2014/05/The-High-Achieving-Governmental-Health-Department-as-the-Chief-Health-Strategist-by-2020-Final1.pdf

TABLE. Number and percentage of 690 local health departments (LHDs) reporting recent budget changes, job losses, changes in services, third party billing practices, and collaboration with nonprofit hospitals and primary care providers, by size of population served — National Association of County and City Health Officials Forces of Change survey, United States,* 2015

* Hawaii and Rhode Island not included.
^† Number of LHDs responding is smaller than total number of respondents (n = 690) because of missing values and/or because respondents could skip questions based on their responses to screening questions.
^§Small: serve <50,000 persons (n = 353 LHDs); medium: serve 50,000–499,999 persons (n = 271); large: serve >500,000 persons (n = 66).

FIGURE 1. State* percentage of local health departments serving fewer patients in their clinics in 2014 compared with 2013 — United States

* Hawaii and Rhode Island excluded because they have no local health departments. Data from states with insufficient response rates (Alaska, Arizona, District of Columbia, Maine, New Hampshire, and Utah) not shown.

FIGURE 2. State* percentage of local health departments actively engaged with primary care providers on State Innovation Models, accountable care organizations, or patient-centered medical homes — United States, 2014

* Hawaii and Rhode Island excluded because they have no local health departments. Data from states with insufficient response rates (Alaska, District of Columbia, New Hampshire, Oklahoma, and Utah) not shown.