Chief Health Strategists: How Public Health Leaders Can Be Successful Working Across the Health Landscape, Part II

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

Today, the second installment in our two-part series on the future of the public health discipline.

JOHN AUERBACH:
There was a team of people representing different organizations supported by the Robert Wood Johnson foundation that were brought together to think about the future of public health. They recognized that public health is changing.

MARY ANN COONEY:
The beauty of this model is that it gives the state health official the opportunity to stand as a leader and as a very knowledgeable leader about what makes people healthy.

JOHNSON:
Welcome to Public Health Review, a new podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we'll discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

On this episode, we finish our discussions about the concept known as Chief Health Strategists.

Last time we heard from one of the models’ architects, John Auerbach, president and CEO of the Trust for America's health.

AUERBACH:
The idea behind it was to step back from the practices that we had been involved in for decades and reflect on what were the current situations that were being faced around the country in regard to health and well-being.

JOHNSON:
Today, we offer the rest of our conversation with Mary Ann Cooney the Chief of ASTHO Center for Population Health Strategies. We've heard from John Auerbach about the concept of a Chief Health Strategist. To start, can you give ASTHO’s take on the concept?

COONEY:
Well, ASTHO right now is focusing a lot on building the leadership capacity building and advocacy around that model of the Chief Health Strategist. Inclusive of the public health 3.0, which looks at data, the emphasis of data multi-sector partnerships, and really focusing on the social determinants of health. We know so much more now than we ever did in terms of what really makes people healthy. And it's time now for public health to move a little more into the zone of stepping out of the comfort zone of what we've always done with public health and, you know, disease surveillance and disease control and look at really what makes people unhealthy and focus on that. And the health equity that is associated with health disparities.

JOHNSON:
When we spoke with John, we went through the entire concept, step one, through step six, explored every piece of it. It really does sound like the kind of thing that could push people out of their comfort zone.

COONEY:
Yes, very much so. Some handle it more than others. I think that those that have been in the public health world for a long time may struggle a little bit at first because they're very cultured to a certain way of acting or administrating or managing or even performing programs. But I think that the beauty of this model is that it gives the state health official and frankly, even their leadership team, you know, in their leadership team and all the way through the organization, the opportunity to stand as a leader and as a very knowledgeable leader about what makes people healthy and what are the programs, the evidence-based practices, the data that you have to collect and to promote that in such a way that, you know, they will act as the expert, which they are, but in a very different light. We tend to talk to the same players all the time.

We talk to each other a lot, and we talked to health care a little less, and we talked to social services even less. Well in the last several years, particularly when 3.0 started and we really looked at the Chief Health Strategists role. We now are having those conversations. We're not waiting anymore for somebody to invite us to a table if you will. The thing I like to say, and some others will say is, you know, we used to be invited as a table or be asked to invite, be invited to the table. Now I say the Chief Health Strategists sets the table they are the ones that are the convener they are the ones that lead the efforts and States for health systems transformation.

JOHNSON:
And when I got my briefing from John, this was the first time I had heard of the concept. So, I was very interested in it. But before that, I thought we were talking about a job title, a position, a person. He made it sound like it wasn't necessarily that at all, it was more a concept that needed to permeate the entire organization. So, we're not talking about finding $150,000 for an employee. We're talking about finding the internal mettle to go for it. Right?

COONEY:
Absolutely. And that's where I said that we work at ASTHO on a number of different levels with state health agencies. And, you know, there's the public health agencies. Some of the agencies and states are what we call mega-agencies, where they have a human service, the Medicaid programs in public health, all onto the same roof. But anyone of the folks in any one of those sections of an agency or an organization should see themselves as a leader, especially as it comes to transforming a health system in a state. Because what drives the health of individuals is really the way we start out in life.

Are we preventing the things that ultimately will cost more? And in public health, we get that. And we sometimes forget how much we know. In health care today, the folks that I've talked to in the health care arena, there are hungry for the information from public health, but they're like anyone else heads down sometimes in their most comfortable roles. And so, I think it's public health role to stand up and be that leader. And I was, you know, just talking to the other day to a chronic disease director and I was emphasizing the fact that they, no matter where you are in an organization, you have a voice, and finding your voice is so important.

And that's, that's the essence of the Chief Health Strategist, it is not a title. It's more of a culture that we develop within ourselves to believe that we are those people that can make that kind of change.

JOHNSON:
And now changing a culture is a lot easier said than done, right?

COONEY:
Yes, very much so.

JOHNSON:
And the model has many parts. So, if a state is out there thinking, and we ought to get on board with this, we need to, is it possible to just nibble before you buy it? Can you start anywhere in the model and get the ball rolling? Is a better to just do something here in this case?

COONEY:
Well, you know, there's, I think you can start just about anywhere in the model itself. But a Chief Health Strategist if what you're trying to do is, you know, use that big, hairy, audacious goal of transforming a health system, you can start very small and that is just picking up the phone and starting to establish those relationships with people who we don't always consider our essential partner. Now we know that health care is really important to the health of the public. We also know that prevention is a big role that primary care for instance plays in assuring the health of individuals, public health looks at any one of those individuals as a member of a larger community and helping the health care provider to navigate that kind of concept and to see public health as a partner in that it takes building that relationship.

And it can start with somebody saying, you know, you've got this project, you just have to go do it. What state health officials now are doing, they're picking up the phone and they're starting a conversation just to get to know people. And I think we all know that even in our personal lives if we want to establish a friendship, it isn't, it might start because of an issue that we're all interested in, but it's nurtured and it has to be nurtured and fed. And the identification of values is really important. So those are the things that are essential to get started.

JOHNSON:
And the recipients of these phone calls might be experiencing some big change too, right? I mean, they, they're not necessarily accustomed to being addressed.

COONEY:
Right. You know, there's a lot that's happened in the last 10 years, for instance, particularly since we've had changes in the affordable care act and you know, many, many changes within the health care arena. And the emphasis now on quality and value-based payments and assuring that you have outcomes. I'm talking about it in, not only the health care world but actually in public health as well, that that has created a much more urgent time or feeling that we have to work more closely together. So, I think that just in that alone, that, that starts the conversation from a sense of, we need to do this and how do we do it better?

And we can only do it better together, but they were other players that we are, we are now, you know, emphasizing. And those are the relationships, particularly in the governmental structure of departments, regardless of whether or not they have Medicaid in their shop or not. There are the human services side of the house, the areas with temporary aid to needy family’s kind of commonly call it welfare children, child welfare, child, and family services, transportation even, and other governmental agency that's outside of health and human services, housing. Those are the essential conversations that have to happen.

And those might be some of the toughest ones because it is so different from public health. Different in the way that there really is a mission that's for instance, the mission of housing is to house people. What public health wants to make sure is that people that don't have a house don't have a home, that they get one. One of the greatest indicators of somebody's health from a behavioral health perspective, particularly at a homeless individual, is if you give them a home and you provide case management to them, the success rate is through the roof, in terms of them getting back on their feet, getting a job, becoming healthy, taking their medication.

I mean, just think of it. How can you possibly even know where to pick up your prescription if you don't know where you're going to sleep that night?

JOHNSON:
Yeah, it's all related. I remember at the of transportation when I was there 10 years ago, maybe longer, the focus was on trying to connect transportation to all of those needs too, to understand that it's a network and you can't just focus on one piece. This sounds like the same thing.

COONEY:
Absolutely, it definitely is the same thing. And in communities where there's very limited transportation in the more rural communities where there aren't necessarily the public networks or the public infrastructure that can support transportation. The Chief Health Strategist or the local or state level, they play a very, very important role in identifying those areas where there are significant gaps where people cannot get to health care services. So, it's really up to all of us. And I can't imagine that anybody if you were working in transportation, you know what I'm talking about, your first mission is to meet the needs of the people within your state.

So how do you do that? You don't, if you don't know what you don't know, you're not going to address it. So, when public health can pick up the phone and talk to the department of transportation and say, I have a whole community that is completely off the grid, but yet I've got many, many people there that have diabetes and can get to their doctors. Well, that's a partnership that I can only imagine would be solid and everybody working towards the same goal.

JOHNSON:
So, this makes total sense to the guy who is not a public health professional. That to me. How is it resonating with public health professionals?

COONEY:
Well, that's a great question. And I have one, I have a couple of examples. One, in particular, that is about our incoming president for our board president and Dr. Nicole Alexander Scott, and she's in Rhode Island. Of course, I'm in New England. So, I tend to find, the find the people, the gyms in my area a little bit, but she started to have conversations with the department of agriculture in her state. We all know obesity is an issue, food insecurity, amenity of the communities now.

And you think, and you think Rhode Island is small and there are any rural or hotspots where there might be a problem with access. There are, of course, there are food access issues. So, she talked to the department of agriculture, and she talked to the local community leaders. And what they have started now is a full, comprehensive approach to addressing the food needs within communities. All the way from providing fresh fruits and vegetables to including the snap program, things such as. Well, they provide bonuses if you will. So, if somebody uses their snap benefits for fresh farm, fresh produce, they'll get a $2 back.

So that's a great way of incentivizing people to eat more healthily. And that takes work. And that's the part of the chief health strategists. Here's this, you know very, you know, dedicated woman who has been a physician worked in work as a, in private practice. I don't know if it was private enough, but now she's picking up the phone, talking to the department of agriculture to set up standards for the state to help people become more healthy.

JOHNSON:
Are most states tackling this in one way or the other, or is this still a very new idea for people?

COONEY:
I would say in the 10 years ago, eight years ago, that would be a really big new idea. But right now, I'm finding, we're finding places throughout the country where the departments of transportation, housing, and public health are working together to address social determinants of health. Another example for a really big policy change, that one, you know, if you look at it and we know that income is an important piece. Well, Dr. Ed Ehlinger, who was our president a couple of years ago from Minnesota. He wants pointed to his greatest public health accomplishment and helping to pass a minimum wage increase. Now has nothing to do with disease control surveillance, but it certainly has a huge impact on somebody's health.

If they can lift themselves up out of poverty, start to address healthy food, maybe even walking paths, buy a new come to a new apartment that they may never have had the ability to have their children live in their own bedrooms. So those are the things that we know to improve health and, and other state health officials are right there with him on that.

JOHNSON:
And this sounds exciting because if you've been in the business a long time, this could be the thing that gets you interested in coming to work again each day. Are there any obstacles? Is there pushback at all? If so, what is it?

COONEY:
So, I would say, you know I was once the state health official, so I can say I can look back on my own days of the pushback. And this was some time ago when we were looking at developing an integrated policy with our child welfare system about home visiting programs. So, the pushback may not be necessarily the individual in another agency, but the regulations that we have to work under. So, we have the maternal child health program, robust, wonderful home visiting programs, and then child welfare focuses on home visiting for children that are in their system. It may be even prevention services that they're offering.

It doesn't have to be a child that's either been from the home, but certainly doesn't it make sense instead of having to people to go into the home after a child is born to have one person go in. And so how do we make sure that we're not duplicating services? It's really important from a financial perspective to be a good steward of public funds, but sometimes those regulations from the feds tend to inhibit our ability to be that creative State health officials now work directly with their federal agencies and say, look, I know that I can do this at a lower cost. If you give me just a little bit of a room and that's what's happening now. So that could be a barrier.

JOHNSON:
This model of Chief Health Strategist I think has been around about four years or so. Yeah. Do you sense that it's catching fire across the States or are there still States that maybe are on the sidelines thinking about?

COONEY:
Well, I think it's caught fire and it's burning I'm in some states, it might be a slower burn than others, where there is to use a metaphor, the flame is huge, but ASTHO focuses a lot these days and we have always in the past, but right now it's part of the language that we use consistently. You know, how do we as an organization whose primary role is to provide capacity building, to assist state health officials in becoming the leaders that they want to be and giving them the tools that they need to become that state health Strategists, chief health strategist in this state and it trickles down to their, their folks at work with them. When they see it, they're a leader acting in a certain way that it, like you said, it makes people want to come to work during the day.

JOHNSON:
And what kind of support do you offer states and the people working out there, if they need help on this?

COONEY:
Great, well, there's one major component of our program and that's the ASTHO leadership Institute. And I don't think there is a state health official out there today that doesn't really want to be part of the leadership Institute because it, you know, they know they're going to be able to not only network with their colleagues, but they have an opportunity to, to learn. So, there's the leadership Institute. We used the center for creative leadership, I believe. And we are implementing a program that they have developed called boundary-spanning leadership. And that sounds pretty awesome. And it is because it's exactly what it's talking about. It's expanding boundaries.

Some of the other things that we do, we provide frequent opportunities for state health officials to network together. To become, have close relationships meetings, couple of times a year. It's just them in the room. And so that they can share with each other what's going on. And obviously, we work with the centers for disease control and Robert Wood Johnson. And our fund is to make sure that we're implementing evidence-based practices, we're promoting evidence-based practices with our state health officials. Some of them only have a very, you know, like a short window of time.

Some of them might be two to four years. Others may last longer, but during that time, they really want to make an impact. And the way to make an impact is to use evidence-based strategies. So, all that, what we do is focused on that. We provide that information to state health officials in their teams, and we provide you know, opportunities for learning communities and onsite technical assistance.

JOHNSON:
What are you learning from the feedback on these efforts? I assume that people are reporting how they're going. Is the regulation obstacle. One of those things that came back to you. You, you know, that might be one. What else?

COONEY:
The other obstacles that could very well be challenging a Chief Health Strategist is a time. You know, do I have time? Some of them have limited resources as it is. Some states are smaller than others. The chief, one of the state health officials may not even have a deputy. So that means that their time is spent, you know, meeting with the governor, meeting with a legislature, talking to the finance offices. So, what are the things that ASTHO can do is give them, what of those, you know, glimpses of opportunity where you can break out of that routine or break out of that. And try to find that, you know, one moment in time, perhaps to create a relationship with somebody else outside of an organization. Those are the barriers that state health officials face.

JOHNSON:
Final question, is the market basically going to demand this approach across the board?

COONEY:
Yes.

JOHNSON:
You can't really, I mean, you got to do this.

COONEY:
Absolutely, absolutely.

Public health will die if it doesn't make these changes. So, all of, you know, the state health officials know that it's a matter of getting it done. You know, what we are faced with now are just a continuation of somewhat subtle emergencies in States where we have a chronic disease increasing. I'm one of the members of the silver tsunami, I call it. Where the baby boomers are going to start to be the ones that are showing chronic disease and having health concerns that on a much larger scale from a population perspective. Well, if you were not closely aligned with health care, if we're not really tied to the community-based agencies and organizations out there that are going to help us to that problem, then public health has missed its mark and really is lost, lost an opportunity.

So rather than waiting for this to occur, this is a time where they develop those relationships in. So many of them are already doing that.

JOHNSON:
For more information about the Chief Health Strategist concept, check out the link to the ASTHO webpage in the show notes. You can also find links to the Trust for America Health. Next time on Public Health Review we'll hear about a telehealth program in Alaska with the results so impressive, you'll find them hard to believe.

Public Health Review is a production of the Association of State and Territorial Health Officials.

If you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

For Public Health Review, I'm Robert Johnson. Be well.