ASTHO Profile of State and Territorial Public Health, Volume Four a Letter from the Executive Director

ASTHO OF STATE AND TERRITORIAL PROFILE PUBLIC HEALTH Contents

Acknowledgements II

A Letter from the Executive Director III

A Letter from the Centers for Disease Control and Prevention IV

A Letter from the Robert Wood Johnson Foundation V

Executive Summary VII

Top Findings VIII

Introduction XII

Part I—State Public Health: Who We Are 16

Chapter 1: State Health Agency Structure, Governance, and Priorities 17

Chapter 2: State Health Agency Workforce 35

Part II—State Public Health: What We Do 48

Chapter 3: State Health Agency Activities 49

Part III—State Public Health: How We Do It 76

Chapter 4: Planning and Quality Improvement 77

Chapter 5: Health Information Management 91

Chapter 6: State Health Agency Finance 103

Part IV—Insular Areas 118

Chapter 7: Insular Areas 119

Individual Agency Profiles 128 Acknowledgements

We are grateful to many colleagues for their substantial contributions to this report. Publication of this report was made possible with generous financial support from the Robert Wood Johnson Foundation (RWJF) and the Centers for Disease Control and Prevention (CDC). The vision and support provided by RWJF and CDC leaders has been invaluable to this effort.

The members of the Survey Advisory Workgroup provided thoughtful recommendations and useful suggestions for further improvement of the survey throughout the process.

There are a number of individuals and special skills needed to produce this publication and we offer many thanks for their efforts. Thank you to Katie Sellers, former chief of ASTHO’s science and strategy team, for her leadership, guidance, and dedication to the Profile. Emily Peterman and KaRon Campbell verified and cross-checked all of the data in the report. Maggie Carlin provided valuable contextual information on the U.S. territories and freely associated states. Jane Esworthy, Leslie Erdelack, and Virgie Townsend provided editorial support. Qualtrics programmed and hosted the web-based survey. Porter Novelli designed the publication, and Linemark printed it.

Most importantly, we would like to thank the staff of the 57 state and territorial health agencies that responded to the survey. Multiple staff members in each participating agency put a substantial amount of effort into answering the comprehensive questionnaire that forms the basis of this dataset. We appreciate their dedication to their work and their willingness to make time for this important effort.

Karl Ensign, MPP Elizabeth Harper, DrPH Chief Program Officer, erformanceP Senior Director, Research & Evaluation Improvement, Research & Evaluation ASTHO ASTHO

Rivka Liss-Levinson, PhD Alannah Kittle, MPH Director, Survey Research Senior Analyst, Survey Research ASTHO ASTHO

II ASTHO Profile of State and Territorial Public Health, Volume Four A Letter from the Executive Director

As we celebrate ASTHO’s 75th anniversary this year, I am especially honored to share the ASTHO Profile of State and Territorial Public Health, Volume Four, which provides a comprehensive look at the structures, functions, and resources of state and territorial health agencies. The report also details some exciting developments and continued challenges for state and territorial health agencies.

In this one of a kind report, you’ll learn specifics about state and territorial health officials and their tenure, health agency structures and priorities, and the public health workforce. You will also see the many activities that state and territorial health agencies oversee to promote population health—the span of activities is impressive and important. The report also highlights how health agencies operate and measure performance, and includes information about public health agencies in the U.S. territories and freely associated states.

We remain continuously grateful to ASTHO’s members for devoting their time and effort to completing this survey. The Profile report would not be possible without their generosity and willingness to share their experiences.

We welcome your feedback on this report and the survey. Please feel free to provide comments and suggestions on our survey scope, questions, or what future analyses would be most valuable to you. Reliable and comprehensive data is one of the best ways to demonstrate the value of public health to this nation. Thank you for reading and for supporting state and territorial public health.

Sincerely,

Michael R. Fraser, PhD, MS, CAE, FCPP Executive Director Association of State and Territorial Health Officials

ASTHO Profile of State and Territorial Public Health, Volume Four III A Letter from CDC

Dear Colleagues:

The Centers for Disease Control and Prevention (CDC) is pleased to have supported the Association of State and Territorial Health Officials (ASTHO) in its development of the ASTHO Profile of State and Territorial Public Health, Volume Four. CDC congratulates ASTHO on the release of this valuable resource, which contains comprehensive data about state and territorial health agency responsibilities, organization and structure, workforce, planning, and quality improvement activities.

We commend the state and territorial health agencies for completing the Profile Survey and for their dedication and contributions to public health. Their input significantly increases our understanding of the nation’s state and territorial health agencies and the important roles they play. We anticipate that the report will present policymakers, researchers, and public health practitioners at the federal, state, and local levels with many opportunities to inform policy, practice, and research, and will foster integration and collaboration among public health professionals to improve public health practice and population health outcomes.

Sincerely,

José T. Montero, MD, MHCDS Director, Office for State, Tribal, Local and Territorial Support Deputy Director, CDC

IV ASTHO Profile of State and Territorial Public Health, Volume Four A Letter from RWJF

Dear Colleagues:

We are pleased to support the ASTHO Profile of State and Territorial Public Health, Volume Four. This report provides the nation’s most comprehensive look at state and territorial public health services, providing critical support to public officials and policymakers seeking to collaborate across sectors for the benefit of America’s public health system.

The ASTHO Profile is key to sharing best practices across regions, and provides the most complete picture of governmental public health in the United States. While the Profile identifies and promotes best practices in the management, finance, and organization of public health services, we believe its impact goes far beyond practice.

This effort answers the most pressing questions in public health practice and policymaking. It envisions a more collaborative public health environment, where health becomes a greater cultural value among our leaders and the public. It fosters the kind of cross-sector thinking that will transform our health systems, integrate health within the decisions and opportunities presented to us each day, and ultimately make communities healthier.

Our sincere gratitude to the agencies and their staff who took the time, and were given the opportunity, to respond to the call for what works, and may work, in public health. ASTHO and its health officers serve a critical role in protecting our citizenry and ensuring that everyone who lives in America has a fair and just opportunity to live a healthy life. It is enough that you dedicate your passion to the wellbeing of others, but we are doubly grateful that you seed the future of public health practice. I look forward to continuing our work together building a national Culture of Health.

Sincerely,

Richard Besser, MD President and CEO Robert Wood Johnson Foundation

ASTHO Profile of State and Territorial Public Health, Volume Four V VI ASTHO Profile of State and Territorial Public Health, Volume Four Executive Summary

The ASTHO Profile of State and Territorial Public Health, Part II—State Public Health: What We Do outlines the public health Volume Four highlights findings from the 2016 ASTHO activities that state health agencies conduct. State health agencies Profile Survey. ASTHO is the national nonprofit organization promote population health by directly providing services such as representing public health agencies in the United States, disease treatment, maternal and child health services, and other clinical services. Agencies prevent disease by conducting screening its territories and freely associated states, the District of services and population-based primary prevention services. Columbia, and the more than 100,000 public health State health agencies also work to protect the public’s health by professionals that these 59 agencies employ. ASTHO conducting a number of laboratory services such as influenza typing, members, the chief health officials of these jurisdictions, maintaining disease registries, and conducting data collection for develop and influence public health policy and ensure epidemiologic activities, and disease surveillance. Additionally, this excellence in governmental public health practices. chapter includes information on various federal programs that state ASTHO’s primary function is to serve as an advocate health agencies have responsibility for, as well as the technical and voice for state and territorial public health agencies, assistance agencies provide to a number of different related parties. develop public health leadership at the executive level, and provide capacity building and technical assistance Part III—State Public Health: How We Do It is composed of three chapters that examine how state health agencies are able to to state and territorial health agencies. accomplish the myriad activities they perform by describing planning and quality improvement and health information management The ASTHO Profile is the only comprehensive source of at state health agencies, as well as state health agency finance. information on state and territorial public health agency The chapter on planning and quality improvement describes activities, structure, and resources. Launched in 2007 and states’ progress toward accreditation as well as the status of quality fielded every two to three years, the Profile Survey aims improvement and performance management in state health to define the scope of state and territorial public health agencies. The chapter on health information management discusses services, identify variations in practice among state and the status of informatics and health information exchanges at territorial public health agencies, and contribute agencies, as well as the electronic collection and dissemination to the development of best practices in governmental of data. The final chapter in this section, on state health agency finance, provides insight into the expenditure categories at state public health. health agencies, the various revenue and funding sources for public health, and funds distributed from state health agencies. This report describes the structures, functions, and resources of state and territorial health agencies from the 2016 ASTHO Part IV—Insular Areas provides an overview of the seven territories Profile Survey. When appropriate, it compares state health and freely associated states—collectively known as the insular agencies by governance classification, geographic region, areas—that responded to a modified version of the survey. This and state population size. Also, when applicable, it compares chapter provides information on their activities, workforce, structure, the 2016 findings for state health agencies with data from the quality improvement, and health information management efforts. 2012, 2010, and 2007 ASTHO Profile Surveys. Data from the territories and freely associated states—who responded to a Individual Agency Profiles provides a one-page summary of the governance structure, finances, relationship with local health modified version of the survey—are included in a separate departments, top priorities, workforce, and accreditation status for each chapter of the report. state and insular area health agency that responded to the survey.

Part I—State Public Health: Who We Are is comprised of two chapters. The first chapter describes the structure and governance To view or download the complete Profile report or request of state health agencies, including the number of local and regional access to Profile data, visit www.astho.org/profile. health departments in each state, and the appointment of the ASTHO thanks the Centers for Disease Control and Prevention health official. The second chapter provides a detailed picture of and the Robert Wood Johnson Foundation for their generous the roughly 97,000 employees at state health agencies, including support of the Profile. information on the positions, salaries, and demographics of state health agency workers, trends in retirements and vacancies, and Recommended citation: Association of State and Territorial Health Officials. ASTHO Profile of State and Territorial Public information about the qualifications of state health officials. Health, Volume Four. Arlington, VA: Association of State and Territorial Health Officials. 2017.

ASTHO Profile of State and Territorial Public Health, Volume Four VII Top Findings

The Top Findings consists of the most significant, timely, and relevant findings from the 2016 ASTHO Profile Survey.

VIII ASTHO Profile of State and Territorial Public Health, Volume Four State Public Health: Who We Are

Each state health agency (SHA) is led by a state health These levels of collaboration have remained largely stable official (SHO), often known as the state health secretary or from 2012 to 2016. However, there was a notable increase over commissioner of health. In 2016, 66 percent of SHOs were time in one area—the percentage of agencies that reported appointed by the governor, 14 percent were appointed by exchanging information with health insurers (72% in 2012, 92% a parent agency secretary, 10 percent were appointed by in 2016). This trend is undoubtedly partially attributable to the a board or commission, and 10 percent were appointed rapid increase in the number of states implementing All-Payer by another entity. Once appointed, 74 percent require Claims Databases (APCD). These are electronic systems that confirmation by the legislature, governor or a board or aggregate claims and administrative data from public and commission. private payers, allowing policymakers to identify and act upon trends. The APCD Council reports that 23 states have achieved SHO tenure is highly variable. As of September 2016, the some level of implementation and 12 more are investigating range in length of time SHOs had been in their position was this—up from 10 in 2014.1,2 Other contributing factors include two months to nearly 15 years. As of September 2016, SHOs’ implementation of the HiTECH Act and Affordable Care Act average tenure was 2.7 years (median=1.7 years). Since 2012, and concomitant federal and state regulation. average tenure decreased from 3.4 years while median tenure remained stable (1.8 years in 2012). The number of states sharing resources with other states on a continuous, recurring (non-emergency) basis has risen SHOs represent a variety of backgrounds. As of 2016, substantially, from 9 percent in 2012 to 27 percent in 2016. 64 percent of SHOs hold a medical degree, and 44 percent In both years, all-hazards response and epidemiology were the hold an MPH. This is a decrease from 2012, when 71 percent top two shared services and functions, laying the groundwork of SHOs held a medical degree and 48 percent held an MPH. for two areas that often require a multi-state response. Factors leading to this increase may reflect growing recognition of the In 2016, 29 state public health agencies (58%) were importance of Mutual Aid agreements of both a formalized freestanding/independent agencies, while 21 (42%) were and informal nature between states, and incentives produced a unit of a larger combined health and human services through supportive language inserted in cooperative organization—often referred to as an umbrella organization. agreement objectives issued by the federal government.

For agencies housed under a larger umbrella agency, the States report many competing priorities, but chronic disease top three areas of responsibility for parent agencies in 2016 prevention, which includes activities such as heart disease, were Medicaid (91%), state mental health authority combined cancer, and tobacco prevention and control programs, with substance abuse (81%), public assistance (76%), and consistently emerges as the top priority of state health substance abuse (76%). There have been large increases agencies. This priority substantially increased from 14.5 percent from 2012 to 2016 for SHA responsibility for substance abuse in 2012 to 23.9 percent in 2016. (from 50% to 76%) and state mental health authority without substance abuse programs (from 30% to 57%). Other SHA priorities include clinical services/consumer care, which includes clinical programs such as TB treatment and The number of agencies governed by a board of health emergency medical services (11.4% in 2012, 9.4% in 2016) or similar entity has remained stable over time at just over and quality improvement/performance management, which 50 percent. In 2016, 18 SHAs (36%) reported having a board includes efforts to improve organizational performance and of health while nine (18%) reported having an entity that, efficiency (13.3% in 2012, 8.6% in 2016). while not called a board of health, performs similar functions. In 2012, these proportions were 45 percent and From 2012 to 2016, the estimated total number of FTEs for 8 percent, respectively. the public health workforce for the 50 states and District of Columbia decreased by 3 percent (from 100,468 to 97,230). SHAs collaborate with many different entities, including local Explanations for this decline include decreases in direct service public health departments, hospitals, and healthcare delivery provision, decreases in funding, and increases in the amount partners. In 2016, at least 90 percent of agencies reported of funding distributed as pass-throughs and grants/contracts to exchanging information and working together on projects with third parties, such as local health departments and nonprofits. hospitals, physician practices/medical groups, and community health centers. By 2020, SHAs expect the percentage of health agency employees who are eligible for retirement to increase from 17 percent to 25 percent.

The Source on Healthcare Price and Competition. “Issue Brief: All Payer Claims Databases.” Available at NOTES 1 sourceonhealthcare.org/legislative-topics-payer-claims-databases/. Accessed August 14, 2017.

2 APCD Council. “Standards.” Available at www.apcdcouncil.org/standards. Accessed August 14, 2017.

ASTHO Profile of State and Territorial Public Health, Volume Four IX State Public Health: What We Do

Nationwide, state and territorial health agencies engage in a directly performed by state health agencies; agencies may variety of activities to promote population health. These include: also be contracting out these activities to third parties in lieu of preventing diseases through screenings, primary prevention performing them directly. services, and vaccine management and inventory distribution; and conducting lab testing, collecting data in real-time, and The total number of environmental health activities directly engaging in other environmental health activities to protect performed by state health agencies has also decreased from the public’s health. an average of 42 percent in 2010 to 37 percent in 2016. Notable decreases in environmental health activities include Health promotion activities include: treatment for tuberculosis (60%), the number of state health agencies directly performing poison STDs (54%) and HIV/AIDS (32%); maternal and child health services control (decrease of 25% from 2010 to 2016) and vector control such as those for children and youth with special healthcare needs (decrease of 16% from 2010 to 2016). These changes are (54%), WIC (44%), and home visits (39%); and other clinical services probably due to funding cuts and transferring these services to such as oral health services (39%), substance abuse education/ local health departments and other state agencies. prevention services (37%), and pharmacy services (27%). SHAs continue to provide assistance and support through Prevention includes: screenings for diseases and conditions such technical assistance to a variety of partners and organizations. as newborn screenings (70%), HIV/AIDS (60%) and other STDs (60%); In 2016, technical assistance was frequently provided for quality population-based primary prevention services such as tobacco improvement, performance, and accreditation to hospitals (85%) prevention (84%), HIV prevention (82%), and STD counseling and and to local public health agencies (81%). These proportions are partner notification (82%); and vaccine management and inventory just slightly lower than those reported in 2012. distribution for childhood (96%) and adult immunizations (90%). The top federal initiatives administered by virtually all SHAs Activities aimed at health protection include: laboratory testing of in 2016 were: Maternal and Child Health/Title V, Preventive select agents and dangerous pathogens (92%) and foodborne Health and Health Services Block Grant, CDC Public Health illness (92%), influenza typing (92%), and vector-borne illness (90%); Emergency Preparedness cooperative agreement, Section 317 public health registry maintenance for childhood immunization Immunization Funding, and the Women Infants and Children (94%), birth defects (76%), and cancer (76%); other data (WIC) program. Participation in these programs has remained collection, epidemiology, and surveillance for foodborne illness very high since 2012. (100%), communicable/infectious disease (98%), and perinatal events or risk factors (98%); and other environmental health The total amount of federal funding appropriated to SHAs activities including environmental epidemiology (90%), food exceeded $14.3 billion in 2015. Nearly half of federal funding safety training and education (80%), and radiation control (70%). originates from USDA for the WIC program (45%); the next highest percentage comes from CDC (16%), followed From 2010 to 2016, states reported a marked decline in by Medicaid (14%), and HRSA (10%). directly performing many of these services and activities; for example, 17 of 18 clinical service activities surveyed have While SHAs vary widely in their reliance on federal funding, decreased, 12 of 14 maternal and child health surveyed have 80 percent of states receive more than 40 percent of their decreased, and 16 of 17 primary prevention activities surveyed funds from federal sources. In 2015, SHAs received an average have decreased. The increase in the number of individuals of $280 million in federal funding. States ranged from covered by Medicaid and insurance during this time is one a minimum of $26 million, to receiving a maximum possible explanation for these observed changes over time. of $1.8 billion in federal funding. In addition, these numbers only reflect decreases in activities

X ASTHO Profile of State and Territorial Public Health, Volume Four State Public Health: How We Do It Insular Areas

As of 2016, 20 out of 51 (40%) SHAs achieved accreditation The eight U.S. territories and freely associated states are through the Public Health Accreditation Board’s (PHAB) voluntary collectively referred to as the insular areas. The U.S. territories national accreditation program, and that number continues include three island jurisdictions in the Pacific—American to rise. Public health accreditation involves measuring health Samoa, Guam, and the Commonwealth of the Northern agency performance against a set of developed standards, and rewarding or recognizing health departments that meet Mariana Islands—and the two Caribbean territories of Puerto them. Since Profile data was collected in 2016, an additional Rico and the U.S. Virgin Islands. The remaining insular areas eight SHAs have become accredited; a majority of states include three sovereign nation states holding compacts 3 (56%) are now accredited. of free association with the United States, also known as compact nations: the Republic of Palau, the Federated Accredited states and those pursuing accreditation were most likely to report experiencing the following benefits: States of Micronesia, and the Republic of the Marshall Islands. 85 percent say accreditation stimulated quality and performance improvement opportunities, 82 percent say There is wide variability across these jurisdictions on many accreditation stimulated greater collaboration across measures. The uniqueness of each insular area (e.g., departments or units within their agency, and 76 percent geographic, socioeconomic, and systemic differences) say accreditation strengthened the culture of quality can explain much of this variation. Yet despite their individual improvement within their agency. diversity, the insular areas are collectively distinct from the On average, electronic data was most often collected state and D.C. health departments. Primary differences within a state system (90%), while 20 percent collected data include their remoteness, relatively close integration with through a health information exchange (HIE)—the electronic their healthcare systems, and challenges associated movement of health-related information among organizations with high incidences of both communicable and according to nationally recognized standards.4 From 2012 to 2016, the number of states collecting data electronically non-communicable diseases. increased across all areas surveyed—all agencies collect data electronically on lab results, reportable diseases, vital records, and newborn screening. Insular area health agencies reported performing primary prevention activities most frequently (92%), followed by data SHA total revenue fluctuated over time, from $29.1 billion collection, epidemiology, and surveillance activities (86%). in 2008 to $28.6 billion in 2015. The largest dip was seen between 2009 and 2010, when revenue decreased by In 2016, insular area health agencies reported a total of $3.4 billion. Between 2014 and 2015, there were decreases 6,523 FTEs. The occupational classification with the greatest in total revenue for federal funds, fees and fines, average number of staff was public health nurses (mean=216, and other state funds. median=32), followed by office and administrative support (mean=164, median=19), and behavioral health staff Between 2014 and 2015, the two largest spending categories (mean=150, median=17). as a proportion of states’ total budgets were clinical services/ consumer care and WIC. The average budget for insular area health agencies for 2014 was $59.5 million (median=$27.8 million), and the average In both 2014 and 2015, SHAs distributed approximately budget for 2015 was $61.5 million (median=$32.3 million). $6 billion (about 20% of their total budget) through contracts, In 2015, the average per capita expenditure on public grants, and awards to local and regional/district health health in the insular areas was $389 (median=$197). agencies, tribal health agencies, nonprofit organizations, and other governmental entities. In 2015, more than one-third of SHA contracts, grants, and awards were distributed to independent local health agencies (42%) and to community-based nonprofit organizations (40%).

NOTES 3 Public Health Accreditation Board. “Accreditation Activity as of September 19, 2017.” Available at www.phaboard.org/news-room/accreditation-activity/. Accessed October 1, 2017.

4 HIMSS. “The National Alliance for Health Information Technology Report to the Office of the National Coordinator for Health Information Technology on Defining Key Health Information Technology Terms.” Available at: www.himss.org/ national-alliance-health-information-technology-report-office-national-coordinator-health. Accessed June 6, 2017.

ASTHO Profile of State and Territorial Public Health, Volume Four XI Introduction

This report marks the 2017 release of the Association of State and Territorial Officials (ASTHO) Profile Survey. TheASTHO Profile of State and Territorial Public Health, Volume Four is the only comprehensive source of information about state, territorial, and freely associated state public health agency activities, structure, and resources. The Profile Survey aims to define the scope of state and territorial public health services, identify variations in practice among state and territorial public health agencies, and contribute to the development of best practices in governmental public health. The Profile drives improvement at state and territorial health agencies, educates policymakers, enables the sharing of best practices among state and territorial health agencies, and is a resource to the field of public health systems and services research (PHSSR).

This is the fourth survey in a series. State and territorial health agencies completed prior surveys in 2007, 2010, and 2012. In April 2016, ASTHO launched the fourth version, sending a link for the web-based survey to senior deputies from the 50 states, D.C., and eight territories and freely associated states. The 129-question instrument covered the following topic areas:

STRUCTURE, PLANNING HEALTH GOVERNANCE, WORKFORCE ACTIVITIES AND QUALITY INFORMATION FINANCE AND PRIORITIES IMPROVEMENT MANAGEMENT

Along with general instructions, senior deputies received states, territories, and freely associated states to complete recommendations on which staff and departments should the survey as possible. At the close of survey administration, complete each section of the survey. Multiple personnel the Profile Survey response rate was 98 percent among could complete the surveys in multiple sittings. ASTHO the 50 states and D.C., and 97 percent among all states, held question-and-answer webinars several weeks prior to territories, and freely associated states. the launch of the survey and midway through the survey administration period to clarify instructions, resolve technical ASTHO’s Survey Research team conducted extensive issues, and respond to item-specific questions. In addition, follow up with the states, territories, and freely associated ASTHO held individual phone calls with leadership from states through the remainder of 2016 to verify responses. each of the insular areas to provide clarification and When response errors were identified, ASTHO’s Survey assist in completion of the survey instrument. Research team worked with the agency to correct them. In instances where the state, territory, or freely associated Senior deputies were asked to complete the survey by state did not respond to multiple follow-up attempts, the May 31, 2016. However, the survey administration system Survey Research team used its expertise to determine remained open through September 2016 to allow as many whether or not to retain the data.

XII ASTHO Profile of State and Territorial Public Health, Volume Four Differences Between Surveys Adding a series of questions about the nature of collaborations with other agencies and organizations to collect more in-depth information about state health agency partnerships. In an effort to continuously improve the Profile Survey and the quality of the data, ASTHO made several notable Changing the occupational classifications in the workforce section to better reflect current jobs in state public health. changes to the survey from the 2012 version. ASTHO Each occupational classification definition included a convened a Survey Advisory Workgroup consisting of state description of the tasks associated with the position, as well health agency senior staff, researchers, ASTHO alumni, as common titles for individuals with the given position. representatives from national public health partner organizations, and ASTHO staff. The workgroup reviewed initial Modifying the planning and quality improvement section drafts of the survey instrument, made recommendations to ask additional questions about experienced and anticipated benefits of state health agency accreditation. on content, formatting, survey administration, and analyses, and pilot-tested the survey. Staff also leveraged the expertise Redesigning the health information management section of two of ASTHO’s peer networks, the Human Resources to collect the most useful information on health information and Workforce Development Directors Peer Network exchanges and Meaningful Use public health objectives. and the Chief Financial Officers Peer Network, in making Making small changes in expenditure and funding sources modifications to the workforce and finance sections of the definitions in the finance section for additional clarity. instrument. Findings from these meetings and the 2012 Profile Survey evaluation report were used to make revisions Including several evaluation questions (e.g., number of staff to the 2016 survey instrument, including the following: and estimate of time needed to complete the survey) at the end of the instrument for internal quality improvement purposes.

FIGURE 0.1 STATE POPULATION SIZE

SMALL (LESS THAN 2,100,000) MEDIUM (2,100,001-6,100,000) LARGE (6,100,001+) NO DATA

ASTHO Profile of State and Territorial Public Health, Volume Four XIII NEW ENGLAND SOUTH WEST MOUNTAINS/MIDWEST MID-ATLANTIC AND GREAT LAKES FIGURE 0.2 COMBINED HEALTH AND HUMAN SERVICES REGIONAL CLASSIFICATION

Structure of Report

The report is structured to provide a narrative of state and territorial health agencies, and has been divided into several sections:

Part I—State Public Health: Who We Are provides background on the When possible, 2016 data are compared with structure and composition of state public health agencies. Within this data from 2012, and in some instances, data section is Chapter 1: State Health Agency Structure, Governance, and from 2010 and 2007 as well. Care has been taken Priorities, and Chapter 2: State Health Agency Workforce. to include only those comparisons that represent Part II—State Public Health: What We Do describes the roles and meaningful differences between data from 2016 responsibilities of state health agencies and contains Chapter 3: and data collected in prior rounds of the survey. State Health Agency Activities. Although it is possible that some variations in

Part III—State Public Health: How We Do It reviews the mechanisms the data reported between 2007, 2010, 2012, state health agencies use to accomplish the activities described in and 2016 may be due to survey refinement or Part II. Chapters in this section include Chapter 4: Planning and Quality changes within the particular health agencies that Improvement, Chapter 5: Health Information Management, and responded to each question rather than actual Chapter 6: State Health Agency Finance. changes in health agency practices, we have Part IV—Insular Areas explores the activities, workforce, and tried to minimize this possibility in the development structure of the U.S. territories and freely associated states. of the questionnaire.

The final section of the report, Individual Agency Profiles, contains a one-page summary of key information about each agency from the report.

XIV ASTHO Profile of State and Territorial Public Health, Volume Four MIXED SHARED CENTRALIZED DECENTRALIZED LARGELY SHARED LARGELY CENTRALIZED FIGURE 0.3 GOVERNANCE CLASSIFICATIONS LARGELY DECENTRALIZED

When relevant, chapters also include discussion of notable Additional Information differences based on three organizational characteristics:

Size of population served. State health agencies were categorized as The ASTHO Profile of State and Territorial Public Health, small, medium, or large based on tertiles of the size of the population Volume Four is available online as a downloadable served. To estimate the size of the population served, 2016 population PDF on ASTHO’s website at http://www.astho.org/Profile. estimates from the U.S. Census Bureau5 were used. Figure 0.1 displays Also available on the page is additional information a map of states by population size. about the Profile Survey, including an interactive map with key data on state and territorial health agencies, Region of the United States. Regional classifications are based on HHS a downloadable questionnaire, codebook, individual 6 regions, which were paired into five regions to increase the number agency profiles, infographics, an animated video, and of state health agencies for comparison in each region. Figure 0.2 links to materials from prior rounds of the survey. ASTHO displays a map of states by HHS region. also encourages researchers who are interested in conducting analyses using Profile Survey data to visit State health agency governance. State health agencies classified http://www.astho.org/Research.aspx for details on how as centralized/largely centralized were compared with state health to request data and the process for obtaining a data agencies classified as decentralized/largely decentralized. Chapter 1 use agreement. General inquiries about the Profile provides more detailed information on governance categories. State Survey or this report may be sent to profi[email protected]. health agencies with a shared or mixed governance structure were not included in the governance comparisons. A map of states by governance structure is displayed in Figure 0.3.

U.S. Census Bureau. “Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: NOTES 5 April 1, 2010 to July 1, 2016 (NST-EST2016-01).” Available at www.census.gov/data/tables/2016/demo/popest/nation- total.html. Accessed February 14, 2017.

6 HHS. “Regional Offices.” Available at www.census.gov/data/tables/2016/demo/popest/nation-total.html. Accessed February 14, 2017.

ASTHO Profile of State and Territorial Public Health, Volume Four XV STRUCTURE, GOVERNANCE, AND PRIORITIES 16 ASTHO Profile ofStateand Territorial Public Health, Volume Four WHO WEARE STATE PUBLICHEALTH PART I STRUCTURE, GOVERNANCE, AND PRIORITIES 17 State health agencies collaborate with many different entities, including local public health departments, hospitals, and healthcare delivery partners. In 2016, at least 90 percent of state health agencies reported exchanging information and working together on projects with hospitals, physician practices/medical groups, and community health centers. In 2016, 66 percent of SHOs were appointed by the governor, 14 percent were appointed by a 10 percent parent agency secretary, were appointed by a board or and 10 percent were commission, appointed by another entity. Chronic disease has been the top priority for state health agencies from 2010 to 2016. The percentage of priorities related to chronic and treatment prevention disease substantially increased from 14.5 percent in 2012 to 23.9 percent in 2016. Other state health agency priorities include clinical services/ consumer care, and quality improvement/performance management. ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and In 2016, 29 state public health agencies (58%) were freestanding/ independent agencies, while (42%) were a unit of a larger 21 combined health and human services organization—often referred to as an umbrella organization. In 2016, 50 state public health agencies reported having a total of 2,795 local health departments and 312 regional or district offices. Eighteen state health agencies (36%) reported having a state board of health. An additional nine states (18%) reported having an entity that performs similar functions. Approximately one-quarter of state health agencies share resources with typically for all-hazards each other, preparedness and response (67%) and epidemiology or surveillance (52%). Both of these trends have been steadily rising since information leading Factors collection began. to this increase may reflect growing recognition of the importance of Mutual Aid agreements between states and incentives inserted in cooperative agreement objectives. KEY FINDINGS This chapter addresses the structure, governance, and priorities of state governance, the structure, This chapter addresses agency is manner in which a state health The public health agencies. are part of a larger agency, some state health agencies structured varies; vary States also in the extent of state governmental while others are not. the state health the rules surrounding authority over local health agencies, collaborations and the types of partnerships and official’s appointment, and nongovernmental entities. they engage in with other governmental comparing 2016 data of agencies, This chapter will explore the structure note differences and will when possible, with 2012, 2010, and 2007 data, when applicable. in structure by agency characteristics STATE HEALTH AGENCY STRUCTURE, STRUCTURE, AGENCY HEALTH STATE PRIORITIES AND GOVERNANCE, Chapter 1 Chapter STRUCTURE, GOVERNANCE, AND PRIORITIES 18 ASTHO Profile ofStateandTerritorial Public Health,Volume Four AGENCY STRUCTURE agency thatreporteddatain2007,2010,2012,and shows theothermajorareasofresponsibilityparent responsibility ofthestatepublichealthagency. Figure 1.1 responsibility fortheparentagencyversusstatutory umbrella agency(N=21)wereasked themajorareasof States thatreportedpublichealthwasunderan 77% oflargestates)thanstateswithsmallpopulations(31%). independent agencies(65%ofmedium-sizedstatesand large populationsaremorelikely tohavefreestanding/ under alargeragency(N=4).Stateswithmediumand are freestanding/independentagencies(N=9)than than twiceasmanystatehealthagenciesintheSouth independent agencies(64%and58%,respectively).More centralized 44% wereunderalargeragency).Centralized/largely 2010, 56%werefreestanding/independentagenciesand to thepercentagesfor2007and2010(inboth the sameasfor2012,andhaveremainedalmostidentical unit ofalargerumbrellaagency. Theseproportionsare freestanding/independent agencies, while21 (42%)werea In 2016,29statepublichealthagencies(58%)were largely decentralized public assistance, andsubstanceabusementalhealthservices. agency oftenresideinthatwithotherprogramssuchasMedicaidandMedicare, an umbrellaagencyorsuperagency. Statepublichealthagencieslocatedwithinalarger organization, alsoreferredtoas or aunitoflargercombinedhealthandhumanservices responsibility. Statepublichealthagenciescaneitherbefreestanding/independent will affecthowagenciesoperateintermsofbudgeting, decisionmaking, andprogrammatic departmental/organizational structureofthestate. Thelocationofthestatehealthagency placementwithinthelarger The structureofastatepublichealthagencyreferstotheagency’s NOTES 1 states areslightlymorelikely thandecentralized/ 1 2 2 statestohavefreestanding/ See page23 primarily leadlocalhealthunitsand thelocalgovernmentsretainauthorityovermostkey decisions. “Decentralized/largely decentralized” referstoagovernancestructureinwhichlocalgovernment employees and selectingthelocalhealthofficial. Seepage23 health unitsandthestateretainsauthorityovermostdecisionsrelated tothebudget,issuingpublichealthorders, “Centralized/largely centralized”referstoagovernancestructure inwhichstateemployeesprimarilyleadlocal for moredetailed informationaboutgovernance classifications. largely decentralizedagenciesdo). responsibility forthisfunction, while27%ofdecentralized/ protection (nocentralized/largelycentralizedagencieshave decentralized states, withtheexceptionofenvironmental thandecentralized/largely likely toprovideallservices services. Centralized/largelycentralizedstatesaremore number ofreasonslike cost-saving oradesiretostreamline likely duetoagencyrestructuring, whichcanoccurfora 2012 to2016.Thesechangesinareasofresponsibilityare other responsibilitieshaveshownsharpdecreasesfrom large increasesfrom2012to2016,long-term careand authority withoutsubstanceabuseprogramshaveshown responsibility forsubstanceabuseandstatementalhealth and substanceabuse(76%).Whilestatehealthagency with substanceabuse(81%),publicassistance(76%), Medicaid (91%),statementalhealthauthoritycombined 2016. In2016,thetopthreeareasofresponsibilitywere for moredetailedinformationabout governanceclassifications. STRUCTURE, GOVERNANCE, AND PRIORITIES 19 79% 100% 95% 57% 68% 76% 90% 81% 90% 81% 70% 91% 79% 71% 70% 76% 32% 43% 50% 76% 21% 43% 30% 57% 5% 24% 5% 14% 47% 67% 75% 14% 0% OTHER MEDICAID 10% LONG-TERM CARE LONG-TERM SUBSTANCE ABUSE SUBSTANCE PUBLIC ASSISTANCE 20% ENVIRONMENTAL PROTECTION ENVIRONMENTAL ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 30% 40% 50% STATE MENTAL HEALTH AUTHORITY WITH SUBSTANCE ABUSE SUBSTANCE AUTHORITY WITH HEALTH MENTAL STATE STATE MENTAL HEALTH AUTHORITY WITHOUT SUBSTANCE ABUSE AUTHORITY WITHOUT SUBSTANCE HEALTH MENTAL STATE 60% 70% 80% 90% 100% AGENCIES • 2007 • 2010 • 2012 • 2016 UMBRELLA OF LARGER (N=19-21) 2007-2016 FIGURE 1.1 FIGURE RESPONSIBILITIES RESPONSIBILITIES STRUCTURE, GOVERNANCE, AND PRIORITIES 20 ASTHO Profile ofStateand Territorial Public Health, Volume Four number ofindependentlocalhealthdepartments displays themean, median, minimum, andmaximum departments and298regionalordistrictoffices).Table 1.1 those reportedby48statesin2012(2,744localhealth or districtoffices. Thesenumbersarequitesimilarto a totalof2,795localhealthdepartmentsand312regional In 2016,50statepublichealthagenciesreportedhaving NUMBER ANDTYPESOFLOCAL HEALTH DEPARTMENTS TABLE 1.1 OF LOCALANDREGIONALHEALTH Independent localhealthdepartments State-run regionalordistrictoffices Independent regionalordistrictoffices State-run localhealthdepartments DEPARTMENTS BY STATE HEALTH AVERAGE NUMBEROFTYPES AGENCY CHARACTERISTIC NUMBER OFLOCALANDREGIONALHEALTH DEPARTMENTS, 2010-2016(N=48) TABLE 1.2 2010 11.25 20 44.40 Large Medium Medium Small Population Size(N=50) West Mountains/Midwest Mid-Atlantic andGreatLakes South New England New England Region (N=50) Governance (N=40) Decentralized/largely decentralized Centralized/largely centralized 4.29 0.92 EN EINMNMXMA MDA I A EN EINMNMAX MIN MEDIAN MEAN MAX MIN MEDIAN MEAN MAX MIN MEDIAN MEAN SHA Characteristic 0 0 0 0 0 0 0 5 37 19.50 43.79 351 346 1.50 4.60 33 1.60 20 413.38 94

2012 notably overtime. local andregionalhealthdepartmentshasnotchanged offices (ledbystateemployees).Theaveragenumberof by non-stateemployees),andstate-runregionalordistrict government), independentregionalordistrictoffices(led local healthdepartments(ledbystaffemployedstate (led bystaffemployedlocalgovernment),state-run

Mean NumberofHealthDepartments Independent oa elhDprmnsRegionalHealthDepartments Local HealthDepartments 52 16.71 75.24 97 22.88 39.71 47.70 60 12.67 46.08 84 40.15 28.46 69.50 71.23 Local 9.31 0.64 21 0 0 0 0 0 0 State-Run 35.29 Local 1.19 1.8 0 0 0 5 20 14 42.06 351 34.44 33 1.80 21 413.84 94 2016 Independent Regional 1.71 1.47 2.25 0.17 .110.15 1.31 4.63 3.04 0.36 2.7 1 0 0 0 0 0 0 0 State-Run Regional 3.76 7.24 2.19 2.33 5.13 2.35 3.79 2.2 1 351 128 68 20 STRUCTURE, GOVERNANCE, AND PRIORITIES 21 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 0 1-10 49 11- 50- 99 100-199 200+ NO DATA YES NO NO DATA FIGURE 1.2 DEPARTMENTS MAP WITH NUMBER OF LOCAL HEALTH DEPARTMENTS AND Y/N REGIONAL HEALTH BY STATE DEPARTMENTS NUMBER OF LOCAL HEALTH DEPARTMENTS REGIONAL HEALTH The number of local and regional health departments shows an expected relationship with governance classification. Decentralized/largely decentralized states report many more independent local health departments than centralized/largely centralized while centralized/largely centralized states do, states report many more state-run local health departments This finding, than decentralized/largely decentralized states do. is displayed in along with regional and population trends, 1.2. Other notable findings include that the South has a Table greater average number of state-run local health departments (40.15) than all other regions (averages for the other four regions range from 0-12.67), and large states have significantly more independent local health departments on average (75.24) as compared with small (mean=9.31) and medium (mean=39.71) by state The number of local health departments states. 1.2. is displayed in Figure STRUCTURE, GOVERNANCE, AND PRIORITIES GOVERNANCE STRUCTURE 8 percentreportedhavingasimilarentity. Thereareno of agencies(45%)reportedhavingaboardhealth, while not calledaboardofhealth. In2012,agreaterproportion similarfunctions,an entitythatperforms eventhoughitis board ofhealth. Inaddition, ninestates(18%)reporthaving Eighteen statehealthagencies(36%)reporthavinga BOARD OFHEALTH primarily leadlocalhealthunitsandthestateretains centralized governancestructureinwhichstateemployees Nearly 30percentofstates(N=14)haveacentralized/largely according totheirgovernancestructure. to aidclassificationofstatesandtheDistrictColumbia The followingdecisiontreeinFigure 1.3wasdeveloped health agencyoperations, financing, andperformance. describe thewaysinwhichpublichealthstructureinfluences classification ofstatehealthagencygovernanceto the community. developedauniform, objective ASTHO providedwithin across levelsofgovernmentforservices understanding theroles, responsibilities, andauthorities services. Identifyingthesedifferencesisintegralto ofessentialpublichealth implications forthedelivery states. Thesestructuraldifferenceshaveimportant regional/local publichealthdepartmentsdiffersacross The relationshipbetweenstatehealthagenciesand (64% and59%,respectively)thanaresmallstates(37%). are morelikely tohaveaboardofhealthorsimilarentity structure orgeographicregion. Large andmediumstates notable differencesinboardofhealthstatusbyagency arrangement predominatesinthestate. others. Instateswithamixedgovernancestructure, noone local healthunits, whilelocalgovernmentemployeeslead governance structureinwhichstateemployeesleadsome key decisions. Ten percentofstates(N=5)haveamixed units whilethelocalgovernmentsretainauthorityovermost local governmentemployeesprimarilyleadhealth have adecentralized/largelydecentralizedsysteminwhich authority tomake key decisions. Overhalfofstates(N=27) health departmentsandthestateagencyhas shared governancesystem, localemployeeslead has theauthoritytomake key decisions. Instateswitha units. Ifstateemployeesleadthem, thelocalgovernment state orlocalgovernmentemployeesleadhealth Four states(8%)haveasharedgovernancesysteminwhich public healthorders, andselectingthelocalhealthofficial. authority overmostdecisionsrelatedtothebudget, issuing STRUCTURE, GOVERNANCE, AND PRIORITIES Mixed Shared FL, GA, KY GA, FL, NH, SD, VA SD, NH, UT, WA, WI, WV WI, WA, UT, Centralized Centralized governance governance governance governance governance MD Decentralized NV, TX governance NV, State has a mix of OR largely shared OR largely AL, LA, LA, governance AL, AK, ME, OK, PA, TN, WY TN, PA, OK, ME, AK, CLASSIFICATION CLASSIFICATION AZ, CA, CO, CT, IA, ID, IL, IL, ID, IA, CT, CO, CA, AZ, OF GOVERNANCE OR largely decentralized OR largely IN, KS, MA, MI, MN, MO, MT, MT, MO, MN, MI, MA, KS, IN, OR largely centralized centralized VT OR largely NC, ND, NE, NJ, NY, OH, OR, OR, OH, NY, NJ, NE, ND, NC, centralized,decentralized, and/or shared governance AR, DC, DE, HI, MS, NM, RI, SC, SC, RI, NM, MS, HI, DE, DC, AR, NO YES YES = State governmental entities have authority to make budgetaryState governmental entities have authority to make decisions government cannot establish taxes for public health nor establish Local More than 50% or less of local health unit budget is provided governmental entities cannot issue public health orders Local chief executives are appointed and approved by state officials Local WITH STATE GOVERNMENT WITH STATE • • fees for services OR this revenue goes to state government • by state public health agency • • NO NO AUTHORITIES Do health units meet Do health units meet with state government? with local government? three or more of the criteria three or more of the criteria for having shared authority for having shared authority + CRITERIA FOR STATE-LED HEALTH UNITS HAVING SHARED AUTHORITY UNITS HAVING HEALTH CRITERIA FOR STATE-LED YES YES NO NO YES STATE AND LOCAL HEALTH DEPARTMENT GOVERNANCE CLASSIFICATION SYSTEM CLASSIFICATION GOVERNANCE DEPARTMENT LOCAL HEALTH AND STATE population?* employee?* employee?* Does the state Is 75% or more Is 75% or more of the population of the population 75% of the state’s that serve at least HEALTH UNITS HEALTH unit led by a state unit led by a local have local health units served by a local health served by a local health * If the majority (75% or more) but not all of the state population meets this designation, * If the majority (75% or more) but not all of the state population meets this designation, then the state is largely centralized, decentralized, or shared. LEADERSHIP OF LOCAL OF LOCAL LEADERSHIP Local governmental entities have authority to make budgetary governmental entities have authority to make decisionsLocal government can establish taxes for public health or establish fees Local 50% or less of local health unit budget is provided governmental entities can issue public health orders Local chief executives are appointed and approved by local officials Local WITH LOCAL GOVERNMENT WITH LOCAL • • for services AND this revenue goes to local government • by state public health agency • • FIGURE 1.3 FIGURE STRUCTURE, GOVERNANCE, AND PRIORITIES 24 ASTHO Profile ofStateand Territorial Public Health, Volume Four RESOURCE SHARING (63% and71%,respectively) than smallstates(37%). are morelikely tohavelawsfacilitating resourcesharing decentralized states. Inaddition, mediumand largestates resource sharing, 68percentare decentralized/largely sharing ofresources. Ofthe28statesthathavelawsfacilitating 41 percentofstateshadlawsandregulationsthatfacilitate the resource sharing. Thisrepresentsanincreasefrom2012,when and 57percenthavelawsregulationsthatfacilitate sharing, fivestateshavelawsorregulationsrequiringsharing, basis, threestateshavelawsorregulationsthatprohibitsuch between localhealthdepartmentsonacontinuous, recurring not haveanylawsorregulationsrelatedtoresourcesharing states (47%).Whileapproximatelyone-third ofstates(35%)do 82%) aremorelikely tofacilitatelocalsharingthanaresmall With regardtopopulationsize, mediumandlargestates(both local healthdepartmentresourcesharing. sharing, whileonly29percentofstatesintheWest facilitate and Midwestfacilitatelocalhealthdepartmentresource South, theMid-Atlantic andGreatLakes, andintheMountains respectively). MorethanhalfofstatesinNewEngland, the with centralized/largelycentralizedstates(76%and57%, facilitating localsharingmorefrequentlyascompared States thataredecentralized/largelydecentralizedreport basis. Thispercentagehasremainedfairlystablesince2012. among localhealthdepartmentsonacontinuous, recurring of states(N=35)reportfacilitatingthesharingresources report sharingresourceswithotherstates, nearlythree-quarters While approximatelyone-quarterofstatehealthagencies than small(20%)andlarge(18%)states. Medium sizestatesaremorelikely toshareresources(41%) agreement objectivesissuedbythefederalgovernment. through supportivelanguageinsertedincooperative and informalnaturebetweenstates, andincentivesproduced importance ofMutualAidagreementsbothaformalized leading tothisincreasemayreflectgrowingrecognitionofthe only fourof46states(9%)reportedresourcesharing. Factors basis. Thisrepresentsasignificantincreasefrom2012,when with otherstatesonacontinuous, recurring(non-emergency) 49 respondingstatesin2016,13(27%)reportsharingresources collaboration betweenagenciesinotherareas. Ofthe moreefficiently,and providingservices andencourage effectively, canfillgapsinservices, assistwithrunningprograms local, ortribalhealthagencies. Resource sharing, whendone resources, suchasstaff, funding, orequipment, withotherstate, An increasinglypopulartopicinpublichealthisstatessharing STATE HEALTH AGENCIES,2012-2016(N=45-48) SHARED SERVICES ANDFUNCTIONSBETWEEN FIGURE 1.4 • 20122016 ALL-HAZARDS PREPAREDNESS ANDRESPONSE 70%80%90%100% 60% EPIDEMIOLOGY ORSURVEILLANCE ADMINISTRATIVE SERVICES NONE OFTHEABOVE CLINICAL SERVICES INSPECTIONS OTHER 0%10%20%30%40%50% 27% 38% 19% 16% 6% 2% 6% 7% 17% 7% 52% 36% 67% 58% STRUCTURE, GOVERNANCE, AND PRIORITIES 25 43% 43% 28% 43% 4% 17% 2% 19% 2% 6% 17% 6% 24% 15% 30% 34% 0%10%20%30%40%50% OTHER INSPECTIONS CLINICAL SERVICES NONE OF THE ABOVE ADMINISTRATIVE SERVICES SERVICES ADMINISTRATIVE NO TRIBES IN JURISDICTION EPIDEMIOLOGY OR SURVEILLANCE EPIDEMIOLOGY OR SURVEILLANCE 60% 70%80%90%100% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and ALL-HAZARDS PREPAREDNESS AND RESPONSE ALL-HAZARDS PREPAREDNESS • 2012 • 2016 FIGURE 1.5 FIGURE AND FUNCTIONS BETWEEN SHARED SERVICES AGENCIES AND TRIBES, 2012-2016 (N=46-47) HEALTH STATE In contrast to resource sharing among states, when states In contrast to resource sharing among states, to engage in share resources with tribes (N=25), they are likely some formal and some informal agreements (64%) followed written agreements (32%), and then informal by formal, 2012 to 2016, the percentage of agreements (4%). From written states sharing resources with tribes through formal, while the percentage agreements decreased by 20 percent, of states sharing resources with tribes through some formal and some informal agreements increased by 35 percent. Decentralized/largely decentralized states are significantly written to share resources with tribes through formal, more likely agreements than are centralized/largely centralized states (36% and 14%, respectively). Similar to trends for resource sharing among states, when states, Similar to trends for resource sharing among to they are most likely states share resources with tribes, response and do so for all-hazards preparedness and epidemiology and surveillance (both 43%). The percentage with tribes for a of state health agencies that share resources variety of functions and services 1.5. is displayed in Figure the percentage of As with sharing resources among states, states sharing resources for epidemiology and surveillance or inspections increased from 2012 to 2016; increases in sharing were noted in all but one category of services and functions. Among states that share resources with other states, 70 percent other states, Among states that share resources with Of the 35 states place. report having some sort of agreement in written 49 percent report formal, reporting agreements, 43 percent report some formal and some agreements, and 8 percent report having an informal informal agreements, to States in New England (71%) are more likely agreement. and some informal agreements than part in some formal take range from 29% agencies in the other four regions (values part to take more likely to 40%). Medium size states (77%) are than are small (36%) and large written agreements in formal, (27%) states. The services to states are most likely functions for which and 1.4. Figure are displayed in with other states share resources they are most resources with other states, When states do share and response (67%) to do so for all-hazards preparedness likely or surveillanceand epidemiology (52%), laying the groundwork These require a multi-state response. for two areas that often from 2012, when 58 percent shared represent increases preparedness and response and resources for all-hazards for epidemiology and 36 percent shared resources for inspections also rose Sharing resources surveillance. to 17 percent in 2016. from 7 percent in 2012 STRUCTURE, GOVERNANCE, AND PRIORITIES 26 ASTHO Profile ofStateand Territorial Public Health, Volume Four PARTNERSHIPS and 12 more are investigating this—up from10in2014. and 12moreareinvestigatingthis—up that 23stateshaveachievedsomelevelofimplementation to identifyandactupontrends. TheAPCDCouncilreports data frompublicandprivatepayers, allowingpolicymakers electronic systemsthataggregateclaimsandadministrative implementing All-Payer ClaimsDatabases(APCD).Theseare attributable totherapidincreaseinnumberofstates in 2012,92%2016).Thistrendisundoubtedlypartially reported exchanginginformationwithhealthinsurers(72% percentageofagenciesthat over timeinonearea—the from 2012to2016.However, therewasanotableincrease These levelsofcollaborationhaveremainedlargelystable the leadershiprolewithinthatparticularpartnership. resources totheseorganizationsandwhethertheyhave in whetherthestatehealthagencyprovidesfinancial high. Thereisalargevariation these organizationsisalsovery health agenciesthatreportworkingtogetheronprojectswith nursing), andlawenforcement. Thepercentageofstate media, continuingeducation(e.g., pharmacy, medical, (e.g., universities, medicalschools, communitycolleges), schools, community-based organizations, highereducation also reportexchanginginformationwithprimary/secondary insurers, andemergencyresponders. Atleast90percent practices/medical groups, communityhealthcenters, health report exchanginginformationwithhospitals, physician healthcare field. Atleast90percentofstatehealthagencies health agencies, hospitals, andmanyotherentitiesinthe agencies reportbeinghighlycollaborativewithlocalpublic are displayedinTableIn general, statehealth 1.3. collaborative activitieswithotheragencies/organizations nongovernmental agencies. Statehealthagency collaborate withmanytypesofgovernmentaland health departments, andtribes, statehealthagencies In additiontosharingresourceswithotherstates, local federal andstateregulation. HiTECH ActandAffordableCareconcomitant Other contributingfactorsincludeimplementationofthe NOTES 3 4 Accessed August 14, 2017. www.apcdcouncil.org/standards. APCD Council.“Standards.”Available at claims-databases/. AccessedAugust 14, 2017. www.sourceonhealthcare.org/legislative-topics-payer- “Issue Brief:AllPayer ClaimsDatabases.”Available at The SourceonHealthcarePrice andCompetition. 3,4

in allpartnerships. likely thansmall(0%)statestoreportacommonunderstanding in the partnersinvolvedinformalpartnerships, resultsvariedasshown population healthconcepts, definitions, andprinciplesacross When asked iftherewasacommonunderstandingof a designatedbodyandcharter. medium-sized states(13%)reportedthatallpartnershipshad their partnershipshadadesignatedbodyandcharter. Only percent ofrespondentswereunsurewhetherornotany that nonehadadesignatedbodyandcharter. Twelve 30 percentreportedthatfewdid, andonestatereported all did(17%).However, 38percentreportedthatsomedid, designated bodywithacharter, fewerreportedthatmostor When asked howmanyoftheirpartnershipshada 5 percentofstateswereunsure. had doneso; 19percentreportedthatfewhaddoneso; and all partnershipshaddoneso; 37percentreportedthatsome 38 percentofstatehealthagenciesreportedthatmostor partnerships hadadoptedastatementofmissionandgoals, formal partnerships. Whenasked howmanyoftheseformal health agencies(84%)reportedbeingpartofoneormore agency, education, andbusinessgroups).Amajorityofstate of publichealth(e.g., apartnershipamongthestatehealth written agreementinvolvingmorethanonesectoroutside was definedaspartnershipsgovernedbyanMOUorother collaborations thattheylistedwereformalpartnerships. This Respondents wereasked toindicatewhetheranyofthe partnerships; andspecifiedhealthobjectivestargets definitions, andprinciplesacrossthepartnersinformal a commonunderstandingofpopulationhealthconcepts, of understanding(MOUs);adesignatedbodywithcharter; elements key tosuccessfulcollaborations:memorandums they participate. Thesequestionswerebasedonareviewof questions aboutthenatureofcollaborationsinwhich asked respondentsanewseriesoffollow-upIn 2016,ASTHO Figure 1.6 5 Collaborating forhealthycommunities.” Pestronk RM,ElligersJJ, Laymon B.“Publichealth’srole: pubmed/23393725. 2013. 94(1):20-5.Available atwww.ncbi.nlm.nih.gov/ . Medium (19%) and large (21%) states were more Medium (19%)andlarge(21%)statesweremore . Health Prog. Health . 5

STRUCTURE, GOVERNANCE, AND PRIORITIES 27 Organization Organization Does Not Exist in Jurisdiction No Relationship Yet ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and State Health State Health Agency Has Leadership in the Role Partnership State Health State Health Agency Provides Financial Resources Work Work Together on Projects N%N%N%N%N%N% 48 98% 49 100% 31 63% 24 49% 0 0% 0 0% 38 86% 38 86% 19 43% 13 30% 4 9% 0 0% 38 81% 44 94% 24 51% 12 26% 3 6% 0 0% 46 96% 48 100% 43 90% 31 65% 0 0% 0 0% 40 85% 41 87% 10 21% 7 15% 3 6% 0 0% 37 80% 36 78% 10 22% 5 11% 4 9% 1 2% 33 72% 34 74% 14 30% 6 13% 8 17% 2 4% 32 73% 34 77% 7 16% 6 14% 8 18% 0 0% 29 63% 36 78% 15 33% 6 13% 6 13% 2 4% 32 71% 30 67% 6 13% 4 9% 7 16% 3 7% 48 98% 47 96% 31 63% 27 55% 0 0% 0 0% 44 92% 43 90% 10 21% 9 19% 0 0% 1 2% 44 92% 45 94% 23 48% 19 40% 1 2% 0 0% 49 100% 49 100% 39 80% 26 53% 0 0% 0 0% Exchange Exchange Information * CONTINUES ON THE NEXT PAGE ON * CONTINUES (N=43-49) 2016 AGENCIES/ORGANIZATIONS, WITH OTHER IN COLLABORATION ACTIVITIES Higher education (e.g., universities, medical schools, community colleges) Other voluntary or nonprofit organizations (e.g., libraries) Faith communities Faith Community-based Community-based organizations Transportation Parks and recreation Parks Primary/secondary schools 44 92% 47 98% 28 58% 14 29% 0 0% 0 0% Cooperative extensions Environmental and conservation agencies Utility companies/agencies 21 48% 18 41% 4 9% 2 5% 17 39% 5 11% Housing agencies Economic and community development agencies Land use/planning agenciesLand 28 65% 27 63% 4 9% 3 7% 6 14% 3 7% Emergency responders Health insurers Other healthcare providers 41 89% 39 85% 23 50% 18 39% 1 2% 2 4% Community health centers 43 94% 45 98% 38 83% 19 41% 0 0% 0 0% Physician practices/medical Physician practices/medical groups Hospitals Local public health agencies public Local 43 88% 43 88% 42 86% 32 65% 0 0% 6 12% Collaborating Agencies/Organizations TABLE 1.3 TABLE STRUCTURE, GOVERNANCE, AND PRIORITIES 28 ASTHO Profile ofStateand Territorial Public Health, Volume Four other fourregions (valuesrangedfrom17-25%). specified inallpartnershipsthan werestatesinthe were morelikely toreportthatthe toolshadbeen States intheMid-Atlantic andGreat Lakes (50%) had inallpartnerships;twostates wereunsure. partnerships, while27percent reportedthatthey 71 percentreportedthattheyhadinsome track andmonitorprogresshavebeenspecified, Similarly, whenasked ifthetoolstheywilluseto (values inotherregionsrangedfrom13-17%). were statesintheotherthreegeographicregions had beenspecifiedinallformalpartnershipsthan likely toreportthatthehealthobjectivesandtargets Great Lakes (38%)andtheSouth(39%)weremore in allpartnerships. StatesintheMid-Atlantic and health objectivesandtargetshadbeenspecified Approximately one-quarter(27%)reportedthat objectives andtargetshavebeenspecified. in someformalpartnerships, boththeirhealth agencies withformalpartnershipsreportedthat, Approximately three-quarters(73%)ofstatehealth TABLE 1.3 Business Agencies/Organizations Collaborating Media other tribalcommunity Tribal governmentagenciesor pharmacy, medical,nursing) Continuing education(e.g., State boardsofhealth Local boardsofhealth Food banks Energy agencies Law enforcement Justice system ACTIVITIES INCOLLABORATION WITHOTHERAGENCIES/ORGANIZATIONS, 2016(N=43-49)*CONTINUED Information Exchange 58%3 8 22%92%25 0% 0 5% 2 21% 9 28% 12 88% 38 81% 35 29%3 8 12%51%00 0% 0 0% 0 11% 5 25% 11 68% 30 96% 42 16%3 7 24%1 0 %1 26% 12 4% 2 30% 14 48% 22 67% 31 67% 31 19%3 7 73%1 7 %12% 1 2% 1 27% 12 38% 17 87% 39 91% 41 06%3 5 22%91%00 633% 16 0% 0 19% 9 25% 12 65% 31 63% 30 36%2 2 73%1 7 %1 27% 13 2% 1 27% 13 35% 17 52% 25 69% 33 78%3 8 12%61%51%00% 0 11% 5 13% 6 24% 11 78% 35 82% 37 25%2 1 %25 53%37% 3 35% 15 5% 2 0% 0 51% 22 51% 22 59%4 6 9 7 %00% 0 2% 1 17% 8 19% 9 96% 45 96% 45 78%3 8 %1 2 %00% 0 9% 4 22% 10 9% 4 78% 36 80% 37 % N % N % N % N % N % N on Projects Together Work Yes, insomeofour CONCEPTS, DEFINITIONS,ANDPRINCIPLESACROSSPARTNERS, 2016(N=41) FORMAL PARTNERSHIPS WITHACOMMONUNDERSTANDING OFPOPULATION HEALTH FIGURE 1.6 partnerships there partnerships understanding among of thepartners understanding among some is acommon Yes, insomeofour partnerships there partnerships all ofthepartners 41% is acommon Resources Financial Provides Agency State Health 15% Partnership Role inthe Leadership Agency Has State Health Yet Relationship No understanding among some ofthepartners partnerships there partnerships there isacommon of our partnerships of ourpartnerships Yes, inallofour in Jurisdiction Does NotExist Organization is acommon understanding among allof the partners Yes, inall 29% 15% STRUCTURE, GOVERNANCE, AND PRIORITIES 29 . 48% 46% 46% 13% 15% 12% 0% 4% 6% 2% 2% 8% 4% 4% 2% 33% 28% 26% 0%10%20%30%40%50% OTHER GOVERNOR LEGISLATURE BOARD OR COMMISSION NO CONFIRMATION IS REQUIRED NO CONFIRMATION 60% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 70%80%90%100% STATE HEALTH AND HUMAN SERVICES SECRETARY AND HUMAN SERVICES HEALTH STATE • 2010 • 2012 • 2016 FIGURE 1.8 FIGURE OFFICIAL, 2010-2016 (N=46-50) HEALTH OF STATE CONFIRMATION Once the SHO is appointed, 74 percent of state health Once the SHO is appointed, agencies require confirmation of the appointment by the HHS secretary, board or commission, governor, legislature, The percentage of state health agenciesor another entity. that require confirmation of the SHO by each of these entities 1.8 displayed in Figure is 2016 and 2012, 2010, among states in Only decentralized/largely decentralized states (12%) report While having SHOs confirmed by the state HHS secretary. the entity responsible for confirming the SHO generally varies states that all seven Mountain and Midwest across regions, require confirmation of the SHO require it from the legislature. Confirmation by the governor is more often required in large states (24%) than in medium (12%) or small (0%) states. only eight states (16%) appoint When SHOs are appointed, 10 states appointed them In contrast, them to a specific term. 66% 74% 66% 19% 13% 14% 6% 6% 10% 2% 0% 0% 6% 6% 10% 0%10%20%30%40%50% OTHER GOVERNOR LEGISLATURE BOARD OR COMMISSION 60% 70%80%90%100% STATE HEALTH AND HUMAN SERVICES SECRETARY AND HUMAN SERVICES HEALTH STATE • 2010 • 2012 • 2016 FIGURE 1.7 OFFICIAL, 2010-2016 (N=47-50) HEALTH APPOINTMENT OF THE STATE Resource sharing, collaborations, and partnerships cannot and partnerships cannot collaborations, sharing, Resource state public highest level at a support from the occur without state health All state health official. health agency—the a state health official (SHO), also known agencies are led by as a state health secretary As or commissioner of health. health agencies (66%) report that of 2016, 33 of 50 state are appointed Other SHOs the SHO. the governor appoints and human servicesby the state health (HHS) secretary, While the proportion or legislature. boards or commissions, to 2012 by SHOs rose from 2010 of governor-appointed the proportion in 2016 reverted to 8 percentage points, showing who appointed the SHO in A graph 2010 levels. . SHOs in 1.7 2010, 2012, and 2016 is displayed in Figure to are more likely decentralized/largely decentralized states 50%). Only centralized/ be governors’ appointees (73% vs. in the South have largely centralized medium-sized states SHOs appointed by a board or commission. STATE HEALTH OFFICIALS HEALTH STATE STRUCTURE, GOVERNANCE, AND PRIORITIES 30 ASTHO Profile ofStateand Territorial Public Health, Volume Four 4.5 years, respectively)thandolarge states(average states havelongersetterms(average length=4.3yearsand term lengthsonaverage(3years). Smallandmedium-sized in theMid-Atlantic andGreatLakes havetheshortestset longest settermisintheSouthregion(6years),whilestates of 4.8yearsand3.5years, respectively).Thestatewiththe of decentralized/largelydecentralizedstates(anaverage SHOs withofficialtermlengthssomewhatlongerthanthose 2010 (4.5years).Centralized/largelycentralizedstateshave 2012 (3.9years),butstillshorterthantheaveragesetterm in 4.1 years. Thisisslightlylongerthantheaveragesettermin length variesfromtwotosixyears, withanaveragetermof When SHOsareappointedtoaspecificterm, theterm have SHOswithasetterm). (19% ofsmall, 24%ofmedium, and6%oflargestates SHOs toaspecifictermshowssomevariationbystatesize to aspecifictermin2010and2012.Theappointmentof STATE HEALTH OFFICIALDIRECTREPORT, 2010-2016(N=49-50) FIGURE 1.9 • 201020122016 SECRETARY OFSTATE HEALTH ANDHUMANSERVICES 70%80%90%100% 60% BOARD ORCOMMISSION GOVERNOR OTHER 0%10%20%30%40%50% 12% 8% 8% 8% 6% 6% 32% 33% 31% 48% 53% 55% remove theSHOinmedium-sized states(29%). Great Lakes; 8%).Aboardorcommissioncanonly or terminationofcontract(only intheMid-Atlantic and 38%), legislativeaction(only in NewEngland;13%), removed byboardorcommissionaction(onlyintheSouth; centralized states(64%).Insomeinstances, theSHOcanbe largely decentralizedstates(92%)thanincentralized/largely since 2010.Thisismoreoftenthecaseindecentralized/ states (84%).Thispercentagehasremainedfairlystable or herpositionatthewillofgovernorinmajority directly tothegovernor, theSHOcanberemovedfromhis Just astheSHOismostfrequentlyappointedbyandreports involved inthebudgetapprovalprocess. secretary small ormedium-sizedstatestohavethestateHHS HHS secretary, such thatlargestatesarelesslikely than approval process. Thereversetrendisfoundforthestate to havethestatebudgetofficeinvolvedin states aremorelikely thansmallormedium-sizedstates agencies in2012to86percentof2016.Large office’s involvement, whichincreasedfrom68percentof 2010 and2012,withtheexceptionofstatebudget (12%). Thisdistributionisfairlysimilartothedistributionsfor (34%),boardofhealth(2%),andother state HHSsecretary entities involvedinthebudgetapprovalprocessare office (86%)werethetopthreeentitiesselected. Other the legislature(92%),governor(88%),andstatebudget When asked whoisinvolvedinthebudgetapprovalprocess, and small(31%)states. report tothegovernor(65%)thanmedium(47%) (24%). Large statesaremorelikely tohaveSHOsthat have SHOsthatreportdirectlytoaboardorcommission inNewEngland. Onlymedium-sizedstates HHS secretary directly tothegovernor, while63percentreporttothestate the MountainandMidweststates, 70percentofSHOsreport the South(31%)reportdirectlytoaboardorcommission. In SHOs fromcentralized/largelycentralizedstates. OnlySHOsin twice aslikely toreportdirectlythegovernor(58%)as time. SHOsindecentralized/largelydecentralizedstatesare report tovariousentitieshasnotchangedsubstantivelyover As showninFigure 1.9,thepercentageofSHOsthatdirectly while aboutone-third (32%)reporttothestateHHSsecretary. Almost halfofSHOs(48%)reportdirectlytothegovernor, to aspecifictermhadthesetbylaw. than bycontract. In2012,all10stateswithSHOsappointed term, thetermissetbylawinsevenofeightstates, rather length=2 years).WhenSHOsareappointedtoaspecific STRUCTURE, GOVERNANCE, AND PRIORITIES 31 9 (3.5%) 12 (4.7%) 10 (3.9%) 1 (0.4%) 6 (2.4%)6 (2.4%) 6 (2.4%) 5 (2.0%) 6 (2.4%) 4 (1.6%) 7 (2.7%)0 (0.0%) 4 (1.6%) 1 (0.4%)8 (3.1%) 1 (0.4%) 6 (2.4%) 1 (0.4%) 22 (8.6%) 34 (13.3%) 22 (8.6%) 17 (6.7%) 9 (3.5%)13 (5.1%) 17 (6.7%) 16 (6.3%)15 (5.9%) 17 (6.7%) 12 (4.7%) 12 (4.7%) 13 (5.1%) 13 (5.1%)10 (3.9%) 8 (3.1%) 8 (3.1%) 8 (3.1%) 12 (4.7%) 9 (3.5%) 7 (2.7%) 18 (7.1%) 13 (5.1%) 6 (2.4%) 14 (5.5%) 18 (7.1%) 23 (9.0%) 45 (17.6%) 37 (14.5%) 61 (23.9%) 26 (10.2%) 29 (11.4%) 24 (9.4%) 2010: N (%)N (%) 2012: N (%) 2016: 255 (100%) 255 (100%) 255 (100%) ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and STATE HEALTH AGENCY TOP PRIORITIES, 2010-2016 TOP PRIORITIES, AGENCY HEALTH STATE Clinical services/ consumer care Quality improvement/ performance management Health data/health information technology General public health initiatives Infectious disease Health equity developmentWorkforce 8 (3.1%)All-hazards preparedness and response 12 (4.7%)Public health 9 (3.5%) infrastructure Environmental healthFunding 10 (3.9%) 2 (0.8%)Quality of health services 7 (2.7%) 4 (1.6%)Accreditation 5 (2.0%)Partnerships/ collaboration 6 (2.4%) Health and healthcare reform Injury prevention Health laboratory Communication Missing Total CATEGORY Chronic disease TABLE 1.4 TABLE

6 National Center for Health Statistics. “Leading Causes of Death.” Available at www.cdc.gov/nchs/fastats/leading- Causes of Death.” Available National Center for Health Statistics. “Leading causes-of-death.htm. Updated March 17, 2017. Accessed August 8, 2017. 6 NOTES SHOs cannot address these priorities alone. In the next chapter, SHOs cannot address these priorities alone. In the next chapter, we will describe the men and women that comprise the state public health agency workforce and explore the integral role they play in the agency’s success. The percentage of priorities related to chronic disease The percentage of priorities related to chronic increased from prevention and treatment substantially 2016. In 2016, 14.5 percent in 2012 to 23.9 percent in clinical programs clinical services/consumer care (e.g., emergency such as tuberculosis (TB) treatment and medical services) and quality improvement/performance efforts to improve organizational management (e.g., performance and efficiency) were the second and third and 8.6 most frequently cited priorities at 9.4 percent displaying a decrease Priorities respectively. percent, health and in frequency over time included funding, Despite the fact communication. and healthcare reform, sharing among that there has been increased resource infectious disease and all-hazards preparedness states, and response have also both decreased as agency priorities during this time. * Please see pages 32-33 for definitions of state health agency priorities. Although responses varied by state, several common varied by state, Although responses chronic disease As in 2010 and 2012, themes emerged. most frequently cited categoryprevention was the of This largely reflects the greater public health focus priorities. diseases chronic on chronic diseases in the U.S.—where remain the and stroke cancer, such as heart disease, adults.leading preventable causes of death among The SHO’s portfolio is large and diverse. They must They must The SHO’s and diverse. portfolio is large that important topics and prioritize the many strategize Senior deputies, during their tenure. come to their attention Survey Profile who responded to the on the SHO’s behalf, their state public to list the top five priorities for were asked The most common current fiscal year. health agency for the 2012, and 2016 were categorized top priorities for 2010, 1.4. displayed in Table thematically and are STATE HEALTH AGENCY PRIORITIES AGENCY HEALTH STATE STRUCTURE, GOVERNANCE, AND PRIORITIES AGENCY PRIORITIES OF STATE HEALTH DEFINITION for Indianhealthcare. andearlychildhoodprograms.Alsoincludesfunds services, refugee preventivehealthprograms,student care,familyplanningdirectservices), child health,primary stateassistancetolocalhealthclinics(prenatal, genetic services, cancertreatment,TBemergencyhealthservices, cervical and abstinenceprograms,chronicrenaldisease,breast pregnancy outreachandcounseling,familyplanningeducation adult daycare,medicallyhandicappedchildren, AIDStreatment, disease, pharmaceutical assistanceprograms,Alzheimer’s Includes allclinicalprogramssuchasaccesstocare, Care Clinical Services/Consumer education (excludingWIC). education relatedtochronicdisease,andnutrition programs. Alsoincludessafeanddrug-freeschools,health disease investigation, screening,outreach,andhealtheducation as wellsubstanceabuseprevention. Theseareprovidedunder disease, cancer, andtobaccopreventioncontrolprograms, Includes chronicdiseasepreventionactivitiessuchasheart Chronic Disease health accidentsandinjuries, deathreporting. analysis), monitoringofdiseaseand registries,monitoringofchild production, report analysisofhealthdata(includingvitalstatistics andcollectionscosts, activities,data reports Includes surveillance Technology Information Health Data/Health strategic goals. processes thathelpanorganizationachieveitsmissionand equity andimprovecommunityhealth.Alsoincludessystematic orprocesses whichachieve other indicatorsofqualityinservices accountability,effectiveness, performance, outcomes,and toachievemeasurableimprovementsintheefficiency,efforts improving populationhealth.Includescontinuousandongoing focused onactivitiesthatareresponsivetocommunityneedsand Includes useofadeliberateanddefinedimprovementprocess Management Quality Improvement/Performance STRUCTURE, GOVERNANCE, AND PRIORITIES 33 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and Communication Includes both internal and external communications by and with state and territorial health agencies, disseminating information, and communicating the value of public health. Health and Healthcare ReformHealth and Healthcare Includes efforts and healthcare policy. to improve national health Injury Prevention safety Includes childhood safety and health programs, fire injury safety, firearm programs, consumer product safety, mine and cave safety, defensive driving, highway prevention, workplace violence onsite safety and health consultation, safety, occupational health, safe child abuse prevention, prevention, schools, and boating and recreational safety. Health Laboratory Includes costs related to the administration of the state or territorial health laboratory including chemistry lab, microbiology lab, laboratory building related costs, and supplies. administration, Quality of Health ServicesHealth of Quality regulatoryIncludes quality as health facility programs such (e.g., x-ray, equipment quality certification, licensure and systems emergency medical etc.), regulation of mammogram, or commissions health related boards designation, such as trauma loan and provider physician by the health agency, administered the and oversight when administered by programs, licensing boards quality reporting provider and facility and institution health agency, includes the financing of activities andcompliance audits. Also programs in this area. Accreditation of state health agency performanceIncludes measurement recognized, practice-focused and against a set of nationally in order to improve and protect evidenced-based standards and performancethe public’s health by advancing the quality of state health agencies. Partnerships/Collaboration working Includes two or more organizations or entities the public together to address emerging epidemics, develop information, health workforce, communicate public health effective public translate science to practice, and evaluate health services.

Includes state health agency efforts to maintain current levels of federal and non-federal funding, advocate for increased funding, and/or address budget cuts. Funding Includes lead poisoning programs, non-point source pollution solid and hazardous waste management, control, air quality, water quality and pollution hazardous materials training, radon, fishing advisories, and control (including safe drinking water, swimming), water and waste disposal systems, pesticide regulation includes food service Also power safety. and disposal, and nuclear and lodging inspections. Environmental Health Environmental Public Health Infrastructure frameworks, Includes utilizing the systems, competencies, public health relationships, and resources that enable state agencies to perform their core functions and essential services. organizational, Infrastructure categories encompass human, and fiscal resources. informational, legal, policy, Includes disaster preparedness programs, bioterrorism, disaster Includes disaster preparedness programs, costs associated with preparation and disaster response including and clinics, and response such as shelters, emergency hospitals clinics and distribution of medical countermeasures (vaccination points of distribution). All-Hazards Preparedness and Response Preparedness All-Hazards Includes efforts to improve health outcomes by enhancing the training, skills, and performance of state public health agency workers. Workforce Development Workforce Includes efforts that all people have full and equal to ensure access to opportunities that enable them to lead healthy lives. Includes efforts to reduce health disparities. Health Equity Includes immunization programs (including the cost of vaccinesIncludes immunization disease control, veterinaryand administration), infectious diseases and health education and communicationsaffecting human health, related to infectious disease. Infectious Disease Includes efforts outcomes and general health to improve targeted public health programming, wellness initiatives, delivered through worksite wellness programs. of health, and fostering cultures General Public Health Initiatives Health Public General STATE HEALTH AGENCY WORKFORCE 34 ASTHO Profile ofStateand Territorial Public Health, Volume Four STATE HEALTH AGENCY WORKFORCE 35 health agencies are female (70%), white (92%). (72%), and non-Hispanic/Latino There are some differences in the racial composition of state health agency staff, with Southern states having the highest proportion of black/African-American states employees (28%) and Western having the highest proportion of Asian employees (15%). at state health agencies are currently vacant. Of that 14 percent, however, active recruitment is occurring for only 25 percent of those vacancies. of state health agency employees who are eligible for retirement is expected to increase from 17 to 25 percent. development. More than three-quarters of state health agencies have a workforce development plan in place, and more than half have a workforce development director. The majority of employees at state On average, 14 percent of positions 2016 to 2020, the percentage From State health agencies prioritize workforce Demographics • and Retirement Vacancies • • Development Workforce • ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and

1 One survey respondent did not respond to this item. State population and the average number of FTEs per 100,000 population for their responses in 2010 and 2012 were used to estimate their number of FTEs for 2016. their positions is highly variable. As of September 2016, the range in length of time state health officials had been in their position was two months to nearly percent of SHOs hold 15 years. Sixty-four 52 percent also Of those, an MD or a DO. have an MPH. the greatest average number of staff are office and administrative support, business and financial operations, and behavioral health. state population size, so smaller states tend to have the lowest number of staff and FTEs and larger states tend to have the highest number of staff and FTEs. From 2012 to 2016, the estimated total From number of FTEs has decreased by more than 3,000. Explanations for this decline include decreases in direct service provision and decreases in funding. the public health workforce is estimated to be 97,230 full-time equivalents (FTEs) for the 50 states and District of Columbia. The length of time that SHOs have held The occupational classifications with The number of staff and FTEs is related to Based on the figures reported in 2016, 1 SHO Tenure and Educational Attainment and Educational SHO Tenure • • • Workforce and Occupational Trends Workforce • KEY NOTES FINDINGS This chapter describes the workforce of state public health agencies, detailing the health agencies, the workforce of state public This chapter describes demographics. and employee categories, salaries by occupational workforce’s size, retirements. and projected rates, turnover on vacancies, It includes information and salaries. tenures, describes state health officials’This chapter also qualifications, 2007 2016 data will be compared with 2012, 2010, and Throughout the chapter, health agency workforce and we will note differences in state data when possible, applicable. and state population size when region, by governance structure, CHAPTER 2 CHAPTER STATE HEALTH HEALTH STATE WORKFORCE AGENCY STATE HEALTH AGENCY WORKFORCE 36 ASTHO Profile ofStateand Territorial Public Health, Volume Four NUMBER OFSTATE HEALTH AGENCY EMPLOYEES number ofFTEsper100,000populationdecreases. As thesizeofpopulationincreases, theaverage small, medium,states thatserve andlargepopulations. the averagenumberofFTEsper100,000populationfor Table 2.2displaystheaveragenumberofFTEsand states tendtohavethehighestnumberofstaffandFTEs. have thelowestnumberofstaffandFTEs, whilelarger to statepopulationsizesuchthatsmallerstatestend raw dataalone, thenumberofstaffandFTEsisrelated have thelowestnumberofstaffandFTEs. Looking atthe on average, whilestatesintheMountainsandMidwest agency. SouthernstateshavethemoststaffandFTEs their includinglocalhealthdepartmentsaspartof decentralized/largely decentralizedstates, likely dueto centralized statestendtohavemorestaffandFTEsthan displayed inFigure 2.1.Onaverage, centralized/largely The numberofFTEsper100,000foreachstateis states Based onthereportedfigures, thetotalnumberofpublichealthFTEs forthe49responding andcontractworkers). of 96,902FTEsand101,009staffmembers(thisincludestemporary reportedatotal In 2016,the49statehealthagenciesthatrespondedtoProfile Survey and grants/contractstothirdparties, suchaslocalhealthdepartments andnonprofits. decreases infunding, andincreasesintheamountoffundingdistributedaspass-throughs shown inTable provision, 2.1.Explanationsforthisdeclineincludedecreasesindirectservice From 2012to2016,thetotalestimatednumberofFTEsdecreasedbyabout3,000as estimated numberofFTEsamongallstatesandD.C. decreasedbyapproximately6,000. TABLE 2.1 Number ofFTEs(N=50) NOTES 2 andtheDistrictofColumbiaisestimatedtobe97,230. ESTIMATED NUMBEROFSTATE HEALTH AGENCYFULL-TIMEEMPLOYEES,2010-2016 3 2 of FTEsfor2016. and 2012wereusedtoestimate theirnumber per 100,000populationfortheir responses in2010 State populationandtheaverage numberofFTEs respondentdidnotrespondtothisitem. One survey round,andsowasexcludedfromthisanalysis. survey One statedidnotrespondtothisquestioninany 2010 ,2 ,1 0,5 ,1 ,5 0,6 ,4 ,9 97,230 1,090 1,945 100,468 1,152 2,010 106,459 1,210 2,129 ENMDA OA ENMDA OA ENMDA TOTAL MEDIAN MEAN TOTAL MEDIAN MEAN TOTAL MEDIAN MEAN OF FTESPER100,000POPULATION BYSTATE SIZE(N=50) ESTIMATED AVERAGE NUMBEROFFTESANDAVERAGE NUMBER TABLE 2.2 2012 Medium (N=16) Small (N=16) Large (N=17) State Size 5 4 of FTEsfor2016. and 2012wereused toestimatetheirnumber per 100,000populationfortheirresponses in2010 State populationandtheaverage numberofFTEs respondentdidnotrespond tothisitem. One survey the numberofFTEsformissing datapoint. roundswereusedtoestimate other twosurvey per 100,000populationfortheirresponsesinthe state populationandtheaveragenumberofFTEs For statesthatdidnotrespondat a giventimepoint, 4

3 From 2010to2012,the Mean NumberofFTEs 3,085 1,833 853 2016 per 100,000Population 5 Mean Number of FTEs Mean NumberofFTEs

23 41 76 STATE HEALTH AGENCY WORKFORCE 37 MEAN MEDIAN MIN MAX N 41 146 3838 2 1,05722 2,426 876 1,15231 15 58 4,201 748 0 180 10,213 0 9,397 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 1-10 11- 50 51-100 101- 200 200+ NO DATA FTEs PER 100,000 Employment Category/Assignment Hourly/temporary or as-needed Part-time workersPart-time Assigned to the 44central office 119Assigned to local health departments 34Assigned to regional or district offices 0 823 TABLE 2.3 TABLE AND ASSIGNMENT AGENCY EMPLOYEES BY CATEGORY HEALTH NUMBER OF STATE Improvements to the clarity of the question allowed for more responses to be retained in 2016 than in 2010 and 2012. 6 There are no trends in union membership 6 PER 100,000 BY STATE NOTES by governance classification or state size. Union membership rates vary In 2016, across states. union membership in state health agencies ranged from Of the a low of 0 percent to a high of 100 percent. 46 states reporting percentages for collective bargaining, 43 percent of employees have union representation. New England states have the greatest average percentage of employees represented by unions (90%), while Southern states have the lowest percentage (14%). Although the average union membership percentage for 2016 appears much lower than union membership due to the increased in 2010 and 2012 (73%), this is likely response rate. Respondents were also asked to classify workers by to classify workers asked were also Respondents worker) hourly part-time, employment category (e.g., or district regional, central office, and assignment (e.g., 2.3. in Table Results are displayed office). FIGURE 2.1 MAP OF FTEs STATE HEALTH AGENCY WORKFORCE 38 ASTHO Profile ofStateand Territorial Public Health, Volume Four * Pleaseseepages46-47fordescriptionsandexamplesofoccupationalclassifications. rangeforeachposition. classifications instatepublichealthagenciesandtheaveragesalary Table 2.4displaystheaveragenumberofFTEsformostcommonoccupational State healthagencyemployeesfulfillavarietyofrolesthatspanoccupationalclassifications. RANGES ANDSALARY CLASSIFICATIONS STATE HEALTH AGENCY EMPLOYEE OCCUPATIONAL TABLE 2.4 Office andadministrativesupport Physician assistant Public informationspecialist Quality improvementspecialist Oral healthprofessional Public healthphysician Preparedness staff Public healthinformaticsspecialist Nurse practitioner Agency leadership Nutritionist Health educator Epidemiologist/statistician Lab worker Environmental healthworker Public healthnurse Behavioral healthstaff Business andfinancialoperations OCCUPATIONAL CLASSIFICATION AVERAGE NUMBEROFFTEsANDSALARY RANGEBYSTATE HEALTH AGENCYOCCUPATIONAL CLASSIFICATION HEALTH AGENCYLEADERSHIP SALARY RANGEOFSTATE 55.8 6.5 45 13.9 44 15.4 45 20.1 43 23.4 46 35.1 44 43.3 42 49.3 46 51.6 46 63.5 83 34 46 143.3 46 157.7 46 230.9 46 276.7 45 310.2 46 46 10.6 41 N TABLE 2.5 MEAN NUMBER MEAN NUMBER OF FTEs MEDIAN NUMBER MEDIAN NUMBER Local healthdepartment liaison State labdirector State epidemiologist Chief informationofficer Chief financialofficer Chief scienceofficer Chief medicalofficer Senior deputy OCCUPATIONAL CLASSIFICATION OF FTEs 85$71,488-$175,617 18.5 $45,829-$84,969 $31,737-$102,077 56.5 90.6 6 $23,642-$64,455 160 . $52,836-$88,417 2.5 $44,468-$83,241 6.5 8$43,353-$95,121 18 $59,227-$73,880 $37,519-$66,661 $40,733-$97,498 17 $29,606-$88,680 27 $37,436-$92,183 46 58 61 0 4 3 4 0 0 $116,042-$176,715 $51,582-$111,267 $76,477-$102,023 $64,251-$95,311 $47,607-$80,127 $33,450-$78,749 MEAN SALARY RANGE staff memberonaverage. officer wasthehighestpaid positions, thechiefmedical as in2012,amongallleadership are showninTable 2.5.In2016, the SHO).Responses fromstates for leadershipstaff(otherthan rangeinformation provide salary States werealsoasked to and oralhealthprofessionals. physicians, agencyleadership, professionals werepublichealth paid statepublichealthagency health staff. In2016,thehighest financial operations, andbehavioral administrative support, businessand health agencieswereofficeand number ofemployeesatstate classifications withthegreatest In 2016,theoccupational 0$84,664-$117,807 $91,274-$124,841 $114,576-$154,019 30 $87,407-$130,048 40 $80,462-$120,878 45 35 $153,168-$194,867 42 $104,136-$145,928 39 47 6 N $119,107-$150,647 MEAN SALARY RANGE STATE HEALTH AGENCY WORKFORCE 39 4% 4% 0% 4% 4% 2% 0% 2% 2% 0% 0% 0% 0% 0% 0% 0% 13% 17% 25% 34% 65% 65% 71% 60% 35% 40% 48% 44% 15% 17% 31% 14% 17% 17% 23% 20% 2% 2% 6% 4% 6% 6% 4% 4% 6% 0% 2% 2% 6% 8% 2% 0% 0% 0% 2% 4% 10% 6% 2% 12% 0%10%20%30%40% BS JD BA RN DO MD PhD BSN DDS MSN MBA DVM MPH DrPH OTHER • 2016 50%60%70%80% • 2012 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and • 2010 90% • 2007 100% FIGURE 2.2 Although the average SHO tenure Although the average 7 Since December 6, 2016,18 new SHOs have been appointed. 7 NOTES In 2016, 64 percent of SHOs had an MD or DO. Of those, Of those, In 2016, 64 percent of SHOs had an MD or DO. percent of SHOs 48 Overall, 52 percent also had an MPH. The percentage of SHOs with an had an MPH or a DrPH. from 71 percent in 2012 to MD decreased by 11 percent, 60 percent in 2016; the percentage of SHOs with an MPH decreased from 48 percent in 2012 to 44 percent in 2016. ASTHO has been tracking SHOs’ levels of educational qualifications of theattainment since 2007. The educational . Nearly one-quartercurrent SHO are displayed in Figure 2.2 of states (24%) report no statutory requirements for the SHO’s than half of states (52%) have the More education level. official statutory that the SHO possess an MD requirement this. only one state requires In the West, or DO. The average number of years of public health experienceThe average number of years of public This represents a before becoming a SHO is 11.8 years. when the averagesignificant decline from 2010 and 2012, was 15.9 yearsnumber of years of public health experience A total of 96 percent of SHOs respectively. and 16.9 years, before becominghad executive management experience a percentage that has remained fairly the state health official, stable over time. has decreased by more than a year from 2012 (3.4 years),has decreased by more remained similar (median tenurethe median tenure has SHOs in the Mountains and Midwestof 1.8 years in 2012). longest tenures (almost 4 years), whiletended to have the tended to have the shortest tenuresSHOs in New England SHOs have average). On average, (almost 1.5 years on SHOs in profession for 14.2 years. been in the public health states tend to have been incentralized/largely centralized for fewer years than SHOs fromthe public health profession (11.8 anddecentralized/largely decentralized states respectively). 16.1 years, As of September 2016, SHOs’ average tenure was 2.7 years, 2016, SHOs’As of September tenure was 2.7 years, average from two and the range was tenure was 1.7 years, the median years. months to nearly 15 STATE HEALTH OFFICIALS OFFICIALS HEALTH STATE STATE HEALTH OFFICIAL EDUCATIONAL QUALIFICATIONS, 2007-2016 (N=48-50) QUALIFICATIONS, OFFICIAL EDUCATIONAL HEALTH STATE STATE HEALTH AGENCY WORKFORCE 40 ASTHO Profile ofStateand Territorial Public Health, Volume Four England mean=25%;otherregions rangefrom42-60%). to determineSHOsalariesthan thoseinotherregions(New state payscale. GovernorsinNew England arelesslikely SHO salariesaredeterminedbythe decentralized states’ while agreaterpercentageofdecentralized/largely determined bythestatelegislature, board, orcommission, SHOsalariesare of centralized/largelycentralizedstates’ governor decreasedby9percent. Agreaterpercentage 9 percenteach, whilethepercentagedeterminedby state legislatureorpayscaledeterminedincreased by From 2012to2016,thepercentageofSHOsalariesthat method (10%). state payscale(34%),boardorcommission(12%),another discretion(46%),statelegislature’s(38%), governor’s salariesaredeterminedthroughoneofseveralmethods: SHOs’ forhavingamedicaldegree). salary differential(anincreased 16 percentofstatesprovideasalary than SHOsfromsmallorlargestates. For SHOsthathaveanMD, medium-sized statestendtoreceiveahigheraveragesalary receive thelowestsalaries, asshowninTable 2.6.SHOsfrom the Southreceivehighestsalaries, whileSHOsinNewEngland in2012.SHOs is nearly$18,000lessthanthemaximumsalary that than in2012,whilethehighestpaidSHOreceivesasalary the lowestpaidSHOisbeingapproximately$5,000more has becomenarroweratboththehighandlowendsuchthat has increasedbyabout$5,500since2012,therangeofsalaries of $99,216toamaximum$250,000.Whiletheaveragesalary SHOsalariesrangefromaminimum (median salary=$170,002). of$167,815 On average, SHOsin2016werepaidasalary AVERAGE SHOSALARY BYU.S.REGION(N=48) TABLE 2.6 West and Midwest Mountains and GreatLakes Mid-Atlantic South South New England REGION ENSOSLR MEDIANSHOSALARY MEAN SHOSALARY $181,342.43 $186,336 $186,336 $181,342.43 $158,443.90 $155,570 $155,570 $158,443.90 $161,520.41 $161,000 $161,000 $161,520.41 $186,980.23 $189,000 $189,000 $186,980.23 $143,641.38 $138,000 $138,000 $143,641.38 STATE HEALTH AGENCY WORKFORCE 41 MEAN PERCENTAGE N 4241 72.0% 39 16.6% 41 0.9% 22 5.0% 34 0.4% 21 3.8% 0.8% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and The average number of years of service by a state 9 RACIAL CATEGORY White Black/African-American NativeAmerican Indian/Alaska Asian Native Hawaiian/Other Pacific Islander Another race or more races Two health agency employee is 12. These findings are consistenthealth agency employee is 12. These findings ASTHOwith results from the 2007, 2010, and 2012 Surveys. Profile and average number median age, age of employees, Average of years of service do not vary substantially by governance the average age of employees is fairly While classification. tend to have the employees in the West constant across regions, fewest years of service (average=10 years), while employees in years). ThereNew England tend to have the most (average=14 by state size suchare also trends in average age of employees older employeesthat medium and large states tend to have than small states. about the average age of current In addition to being asked to report the average agencies were also asked employees, the fiscal years, Over the past three age of new employees. average age of new state health agency employees was 41 (2013), 40 (2014), and 39 (2015). States in New England have the oldest average new employees (mean age = 42), while states in the Mountains and Midwest have the youngest (mean age=38). Smaller states tend to have younger new employees (mean age=37) than medium and large states (mean age=40 for both). These numbers are almost identical to the average ages inThese numbers are almost identical to the workforce is generally2010 and 2012. The state health agency which has a median age workforce, older than the average U.S. of 42 years. TABLE 2.7 TABLE 2016 BY RACIAL CATEGORY, AGENCY STAFF HEALTH OF STATE MEAN PERCENTAGE N=47, as two states did not respond to this item. Survey.” Statistics from the Current Population Force Statistics. “Labor Bureau of Labor U.S. Department of Labor, March 3, 2017. Accessed at www.bls.gov/cps/cpsaat11b.htm. Available 8 9 This percentage is almost equivalent to the is almost equivalent This percentage 8 NOTES In 2016, 70 percent of state health agency employees percent of state health In 2016, 70 were female. State health agencies report that the average age of employees is 47 and the median age of employees is 48. State health agencies were also asked about their State health agencies were also asked Of the responding agencies employees’ ethnicities. (N=39-42), 7 percent of employees in 2016 were States in New England and the South Hispanic/Latino. employees had the greatest percentage of Hispanic/Latino and Great Lakes (both 10%), while states in the Mid-Atlantic had the fewest (2%). Small (9%) and large (7%) states had employees a greater percentage of Hispanic/Latino than medium states (3%). State health agencies were asked to provide the to provide were asked State health agencies are Responses by racial category. percentage of staff of all state. Nearly three-quarters 2.7 presented in Table with the next largest are white, health agency employees (16.6%). percentage being black/African-American compositionThe state health agency workforce’s racial Employees inremained fairly stable from 2012 to 2016. to are more likely decentralized/largely decentralized states centralized statesbe white than those in centralized/largely (78.2% versus 62.3%). Employees at centralized/largely to be black/ likely centralized states are more than twice as as employees at decentralized/ (24.8%) African-American Mountains andlargely decentralized states (10.7%). The of white employeesMidwest have the greatest percentage the South(89.4%; other regions range from 65-75%), (21.2%) and Great Lakes (27.8%) and the Mid-Atlantic have the greatest percentages of black/African-American and the West employees (other regions range from 4-14%), (15.3%;has the greatest percentage of Asian employees does not showother regions range from 2-6%). State size of state healthconsistent patterns with racial categories agency employees. percentages for 2010 and 2012. Decentralized/largelypercentages for 2010 agencies have a greaterdecentralized state health employees (35%) than centralized/ percentage of male (25%). There are no trends in genderlargely centralized states employees by region or state size. of state health agency STATE HEALTH AGENCY EMPLOYEE DEMOGRAPHICS DEMOGRAPHICS EMPLOYEE AGENCY HEALTH STATE STATE HEALTH AGENCY WORKFORCE 42 ASTHO Profile ofStateandTerritorial Public Health,Volume Four VACANCIES ANDRETIREMENTS (mean=62) andlarge(mean=195) states. number ofseparations(mean=282) thansmall On average, medium-sizedstateshadagreater means rangefrom122to168). other regions’ Mid-Atlantic andGreatLakes meanfor2015=242; other regions(Southmeanfor2015=235; separate fromthestatehealthagencythan Mid-Atlantic andGreatLakes hadmoreemployees 2014 (179).Onaverage, statesintheSouthand reflect asteadyincreasefrom2013(155)and (yearly rangefrom263to275),thesenumbers While lowerthantheaveragesfor2009–2011 employees separatedfromstatehealthagencies. In 2015,anaverageof198nontemporary AGENCY VACANT POSITIONS MAP OFSTATE HEALTH FIGURE 2.3 NOTES 10 Thisnumberincludes retirements. 10

0621 0821 2020 2019 2018 2017 2016 ELIGIBLE FORRETIREMENT, 2016-2020(N=38-40) AVERAGE PERCENTAGE OFFULL-TIMECLASSIFIEDEMPLOYEES FIGURE 2.4 PERCENT OF VACANT POSITIONS 6-10% 1-5% 0% NO DATA 20%+ 11-20% 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% STATE HEALTH AGENCY WORKFORCE 43 31- 40% 41%+ NO DATA 0-10% 11-20% 21-30% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and PERCENT OF EMPLOYEES ELIGIBLE PERCENT OF EMPLOYEES FOR RETIREMENT IN 2020 Figure 2.5 shows the projected retirement Figure 2.4. to this item in 2016 than 2010 or 2012. State health agenciesto this item in 2016 than 2010 or 2012. State in the Mountains and Midwest have fewer vacant positions on average than state health agencies in other regions (mean Mountains and Midwest=72; other regions’ means range from 178-552 more states have Larger vacancies). vacancies (587) than small (113 vacancies) and medium number of Despite the large (396 vacancies) states. actively recruiting state health agencies are only vacancies, of vacancies. or 25 percent for an average of 90 positions, 2016 to 2020, the percentage of state health From agency employees that are eligible for retirement is expected to increase from 17 to 25 percent as shown in eligibility percentage for each state in 2020. FIGURE 2.5 MAP OF PROJECTED RETIREMENT ELIGIBILITY IN 2020 The average number of vacant positions at state health agencies in 2016 was 365, and the median number of vacancies was 138. While the average number of vacant positions increased from 282 in 2010 to 304 in 2012 to 365 a function of six more states responding in 2016, this is likely In 2016, 14 percent of state health agency positions wereIn 2016, 14 percent of state health agency This percentage is slightly higher than the percentage vacant. of vacant positions in 2010 (11%) and 2012 (12%). New England states have the highest percentage of vacancies (21%), while states in the Mountains and Midwest have the states have a lowest percentage of vacancies (7%). Larger greater percentage of vacancies (18%) than small (10%) and Figure 2.3 shows the percentage of medium (14%) states. vacant positions by state. STATE HEALTH AGENCY WORKFORCE 44 ASTHO Profile ofStateand Territorial Public Health, Volume Four WORKFORCE DEVELOPMENT a designatedworkforcedevelopmentdirector. and SouthernWestern statesaremostlikely tohave development director. Centralized/largelycentralizedstates health agenciesalsoreporthavingadesignatedworkforce not yetbeenimplemented. Morethanhalf(54%)ofstate have beenpartiallyimplemented, and31percenthave 16 percenthavebeenfullyimplemented, 53percent 76 percentofstateswithaworkforcedevelopmentplan, have createdaworkforcedevelopmentplan. Ofthe increase of17percentfrom2012.AllNewEnglandstates needs andcorecompetencydevelopment. Thisisan workforce developmentplanthataddressesstafftraining of statehealthagencieshavecreatedadepartment development andlearning. Morethanthree-quarters(76%) and helppublichealthprofessionalsmanagetheircareer management,performance andworkforceplanning) workforce developmentefforts(e.g., recruitment, training, asastarting pointtoguideorganizations’ to serve effectively.public healthservices Theyaredesigned health workers thatenablethemtodelivertheessential describe thedesirableskillsandcharacteristicsofpublic The CoreCompetenciesforPublic HealthProfessionals NOTES 12 11 Competencies/index.htm. Competencies/index.htm. informatics_competencies.pdf. For information onNLNleadershipcompetencies, seewww.nln.org/facultyprograms/ Informatics CompetenciesforPublic HealthProfessionals, seewww.nwcphp.org/documents/training/tools-resources/ corecompetencies/Pages/About_the_Core_Competencies_for_Public_Health_Professionals.aspx. For information on For moreinformationontheCoreCompetenciesforPublicHealth Professionals, seewww.phf.org/programs/ Accessed March3,2017. programs/corecompetencies/Pages/About_the_Core_Competencies_for_Public_Health_Professionals.aspx. Public HealthFoundation. “About theCoreCompetenciesforPublicHealthProfessionals.” Available atwww.phf.org/ 11

job descriptions. competencies forpublichealthprofessionalstoprepare of statehealthagenciesalsoreportedusingtheinformatics often fordevelopingtrainingplans. However, 29percent when statesusedanyofthecompetencies, itwasmost (only 37%werefamiliarwiththiscompetency).Ingeneral, National League forNursing(NLN)leadershipcompetencies training plans. Respondents wereleastfamiliarwiththe all publichealthworkers, oranothercompetencytodevelop professionals, emergencypreparednesscompetenciesfor agencies haveusedcorecompetenciesforpublichealth displayed inFigure2.6.Morethanhalfofstatehealth in thecourseofmanagingagencypersonnel. Results are with anduseofvariouspublichealthcorecompetencies Respondents werealsoasked toindicatetheirfamiliarity We Do We In the next section of the report, In thenextsectionofreport, agencies andtheindividualswhoworkinstatepublichealth. discussion hascenteredonthestructureofstatehealth In thischapterandthefirstsectionof Profile Report, state healthagenciesprovidethroughoutthecountry. , focus moves to the myriad services and activities that andactivitiesthat , focusmovestothemyriadservices State Health Agencies: What What Agencies: Health State STATE HEALTH AGENCY WORKFORCE 45 25% 6% 10% 10% 2% 63% 17% 33% 83% 33% 0% 0% 18% 22% 72% 34% 14% 0% 26% 18% 64% 32% 6% 6% 33% 19% 29% 31% 10% 23% 22% 16% 29% 18% 8% 39% 0% 10% OTHER COMPETENCY 20% NLN LEADERSHIP COMPETENCIES ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 30% QUAD COUNCIL PUBLIC HEALTH NURSING COMPETENCIES QUAD COUNCIL PUBLIC HEALTH CORE COMPETENCIES FOR PUBLIC HEALTH PROFESSIONALS FOR PUBLIC HEALTH CORE COMPETENCIES 40% 12 INFORMATICS COMPETENCIES FOR PUBLIC HEALTH PROFESSIONALS COMPETENCIES FOR PUBLIC HEALTH INFORMATICS 50% EMERGENCY PREPAREDNESS COMPETENCIES FOR ALL PUBLIC HEALTH WORKERS HEALTH COMPETENCIES FOR ALL PUBLIC EMERGENCY PREPAREDNESS 60% 70% 80% FAMILIARITY WITH AND USE OF PUBLIC HEALTH CORE COMPETENCIES HEALTH USE OF PUBLIC WITH AND FAMILIARITY 90% FAMILIAR WITH BUT HAVE NOT USED WITH BUT HAVE • FAMILIAR • CONDUCTING PERFORMANCE EVALUATIONS • DEVELOPING TRAINING PLANS JOB DESCRIPTIONS • PREPARING • OTHER USE WITH • NOT FAMILIAR FIGURE 2.6 FIGURE 100% STATE HEALTH AGENCY WORKFORCE 46 ASTHO Profile ofStateand Territorial Public Health, Volume Four and researchers. biostatisticians, andpublichealth scientists vitalstatistics.Includesepidemiologists, report Mayalsocollectdataand appropriate interventions. and diseasepotentialtomake recommendationson analytic studies,andevaluationofdiseaseoccurrence fieldinvestigations, Conducts ongoingsurveillance, Epidemiologist/Statistician sanitarians, andinspectors. occupational healthworkers or technicians, environmental healthspecialists,scientists,engineers, health ofanindividualorgroup.Includesenvironmentalists, water quality, andsolidwaste)consequently, the may affecttheenvironment(e.g.,foodsafety, airand Investigates, monitors,andidentifiesproblemsorrisksthat EnvironmentalHealth Worker network anddatabaseadministrators. legal personnel,computersystemanalysts,and resources specialists,grantandcontractsmanagers, and legalissues.Includesfinancialanalysts,human accounting, humanresources,informationtechnology, specializedworkinareasofbusiness,finance, Performs Staff Business andFinancialOperations abuse counselors. counselors,andmentalhealthsubstance services behavioral counselors,communityorganizers,social public healthsocialworkers, HIV/AIDScounselors, behavioral issues.Includespsychiatrists,psychologists, toclientsregardingmental,social,and health services mental healthstatus.Mayalsoprovidedirectbehavioral Develops andimplementsstrategiestoimprovecommunity Behavioral HealthStaff and divisiondirectors. administrators, deputydirectors,bureauchiefs, such ashealthcommissioners,officers,public agency executivesregardlessofeducationorlicensing, Includesalltop subdivision ofpublichealthservices. Oversees theoperationsofoverallagencyoramajor Agency Leadership OCCUPATIONAL CLASSIFICATIONS OF2016 DESCRIPTIONS ANDEXAMPLES and medicaltechnologists. aidesorassistants, technicians,laboratory laboratory scientists, hazards. Includeslaboratorians,laboratory diagnose, treat,andmonitordiseaseenvironmental analysesthatprovidedatato procedures, andperforms testing Plans, designs,andimplementslaboratory WorkerLaboratory education specialists. educators, healtheducationcoordinators,and Includeshealth use ofhealthprogramsandservices. of individualsandcommunities,promotestheeffective health-relatedbehaviors andmodify strategies tosupport Develops andimplementseducationalprograms Health Educator and dentalassistants. health. Includespublichealthdentists, dentalhygienists, oral healthactivitiessuchasdiet choicesaffectingoral mouth. Mayalsoeducateindividuals orgroupsonproper Diagnoses andtreatsproblemswith teeth,gums,andthe Oral HealthProfessional clerks, maintenancestaff, andoperators. administrative assistants,secretaries,receptionists,office administrativetasksandclericalduties.Includes Performs Office and Administrative Support nutritionists, WIClactationstaff, andWICnutritionstaff. Includesdieticians, effectiveness ofcurrentinterventions. May alsoprovidenutritionalcounselingandevaluatethe the nutritionenvironment,andfoodpolicy. relatedtonutrition,Develops andimplementsinterventions Nutritionist toclients. services treat, orimprovesuchrisks.Mayprovidedirectmedical designedtoprevent, evaluates programsorinterventions of illnessordisabilityanddevelops,implements, Licensed nursewhoidentifiespersonsorgroupsatrisk Practitioner Nurse STATE HEALTH AGENCY WORKFORCE 47 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and Quality Improvement Specialist Quality Improvement collaboratively within public health agency to lead and Works establish appropriate performance management and quality improvement systems. May also play a lead role in systems assessment and preparing the agency for national public health Includes performanceaccreditation. management and quality improvement directors, performance improvement managers, and performance improvement directors. Public Health Nurse health nursing. Includes nurse conducting public Registered school nurses and community health nurses. Public Health Physician or groups at risk of Licensed physician who identifies persons and evaluates illness or disability and develops, implements, programs or interventions treat, or improve designed to prevent, such risks. May provide direct medical services to clients. Includes physicians, but not licensed physicians and preventative medicine psychiatrists and psychologists. Public Information Specialist for the Serves as communications coordinator or spokesperson agency to provide information about public health issues to the media and public. Includes public information officers and public information specialists. Other Assistant Physician who identifies persons or groups at risk of Licensed professional develops, implements, and evaluates illness or disability and programs or interventions designed to prevent, treat, or improve direct medical servicessuch risks. May provide to clients. Staff Preparedness the plans, procedures, and training Manages or develops public health response to all-hazards programs involving the preparedness coordinators, incident events. Includes emergency preparedness managers, and emergency managers, emergency preparedness specialists. Public Health Informatics Specialist principles and Public health professional who applies informatics public health standards to improve population health. Includes informaticists. information systems specialists and public health STATE HEALTH AGENCY ACTIVITIES 48 ASTHO Profile ofStateand Territorial Public Health, Volume Four WHAT WEDO STATE PUBLICHEALTH PART II STATE HEALTH AGENCY ACTIVITIES 49 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and This chapter describes the variety of activitiesThis chapter describes and services provide. that state health agencies health agencies’It explores state involvement health insurance in worksite wellness programs, and health impact assessments, exchanges, their It will also discuss research studies. training responsibility for federal initiatives, and for local health agency personnel, technical assistance. data will be 2016 As in previous chapters, 2007 datacompared with 2012, 2010, and and the section will note when possible, agency workforcedifferences in the state health and state region, by governance structure, However, population size when applicable. agencyrather than note differences by 205 public healthcharacteristic for each of the this activities on which data was collected, section provides an index of each public health index is the sum of the Each activity category. number of activities performed by each state. The percentage of activities performed in a given category is then compared by agency the 2016 Profile example, For characteristic. Survey had 14 items about maternal and child the MCH index was so health (MCH) services, calculated by summing the number of those 14 MCH services performed each state. by Chapter 3 Chapter HEALTH STATE ACTIVITIES AGENCY STATE HEALTH AGENCY ACTIVITIES 50 ASTHO Profile ofStateand Territorial Public Health, Volume Four FINDINGS KEY decreased by23%). in thenumberofstatesproviding treatment(both cancerhadthegreatest decreases breast/cervical activities decreasedinfrequency. BothHIV/AIDSand From treatment 2010to2016,almostallsurveyed 2016 witha20percentdrop. showedthelargestdecreasefrom2010to services in 2010to37percent2016.Sexualassaultvictim whichincreasedfrom31percent prevention services, with theexceptionofsubstanceabuseeducationand themfrom2010to2016, agencies directlyperforming showedadecreaseinstatehealth All clinicalservices in 2010to18percent2016. directly thisservice health agenciesperforming greatest decrease,droppingfrom47percentofstate cancerscreeningsshowedthe Breast andcervical 10 havedecreasedinfrequencyfrom2010to2016. Overall, ofthe15screeningactivitiessurveyed, numbers. 2010 However, thisslightincreaseisstilllowerthan themfrom2012to2016. number ofstatesperforming eight oftheseactivitieshaveseenanincreaseinthe thathavedecreasedduringthistimeperiod, services prevention 2016 (82%).Amongthe16otherprimary thathasseenanincreasefrom2010(78%)to service notificationistheonly STD counselingandpartner preventionactivitiessurveyed, Of the17primary and 2012;59%in2016). engaged inruralhealthinitiatives(73%2010 (31% in2010to16%2016),followedbyagencies Program (SCHIP)showedthegreatestdecrease engaged intheStateChildren’s HealthInsurance decreased.Thenumberofagencies services activitiestoensure accesstohealthcare performing From 2010to2016,thepercentageofstates of 46in2012toanaverage52 in2016. agencies engagedinhasrisen, fromanaverage The meannumberofresearchstudies thatstatehealth exploring integratingOneHealth intotheiractivities. their programming,whileanadditional 18percentare toengagewiththeOneHealthapproachin started Thirty-four percentofstatehealthagencieshave and otherstateagencies. tolocalhealthdepartments transferring theseservices These changesareprobablyduetofundingcutsand vector control(16%decreasefrom2010to2016). poison control(25%decreasefrom2010to2016)and number ofstatehealthagenciesdirectlyperforming Notable decreasesinspecificactivitiesincludethe has decreasedfrom2010(42%)to2016(37%). directly activities thatstatehealthagenciesperformed The averagenumberoftotalenvironmentalhealth themdirectly. inlieuofperforming to thirdparties agencies mayalsobecontractingouttheseactivities bystatehealthagencies; activities directlyperformed In addition, thesenumbersonlyreflectdecreasesin changesovertime. explanation fortheseobserved Medicaid andinsuranceduringthistimeisonepossible the increaseinnumberofindividualscoveredby andactivities; many services in directlyperforming From amarked 2010to2016,statesreported decline but only54percentin2016. directlyin2010 thisservice agencies performing healthcare needs,with79percentofstatehealth forchildrenwithspecial forservices was observed from 2010to2016.Themostnotabledecrease theactivity in thenumberofstatesdirectlyperforming 12haveseendecreases surveyed, 14 MCHservices Ofthe state healthagenciesprovidingMCHservices. There hasalsobeenadeclineinthepercentageof STATE HEALTH AGENCY ACTIVITIES 51 % 82% 88% 88% 90% 92% 96% 96% 96% 98% 98% N 41 44 44 45 46 48 48 48 49 49 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and Participation in these programs has remained veryParticipation

The 10 federal initiatives for which state health agencies most state health agencies initiatives for which The 10 federal in in 2016 are displayed report having responsibility frequently 3.1. Table high since 2012. STATE HEALTH AGENCY RESPONSIBILITY FOR FEDERAL INITIATIVES, 2016 (N=50) FOR FEDERAL INITIATIVES, AGENCY RESPONSIBILITY HEALTH STATE National Comprehensive Cancer Control Program grant (CDC) National Comprehensive Cancer Control Program HIV pharmacies (ADAP) Injury prevention (CDC) Vital statistics (NCHS) Hospital Preparedness Program (HPP) cooperative agreement (ASPR) Hospital Preparedness Program (HPP) cooperative Women, Infants, and Children program (USDA) Infants, and Children Women, Immunization funding, Section 317 program CDC Public Health Emergency Preparedness (PHEP) cooperative agreement CDC Public Health Emergency Preparedness (PHEP) Preventive Health and Health Services Block Grant (CDC) Preventive Health and Health Services Block Grant Maternal and child health/Title V program Maternal and child health/Title FEDERAL INITIATIVE TABLE 3.1 TABLE State health agencies often have programmatic and financial programmatic and agencies often have State health have sole When they do not for federal initiatives. responsibility share responsibility state health agencies typically responsibility, agency local governmental agency, with another state health organization. a local health department), or nonprofit (e.g., RESPONSIBILITY FOR FEDERAL INITIATIVES FEDERAL FOR RESPONSIBILITY STATE HEALTH AGENCY ACTIVITIES 52 ASTHO Profile ofStateand Territorial Public Health, Volume Four TECHNICAL ASSISTANCE ANDTRAINING ACCESS TOHEALTHCARE SERVICES increased—showed the greatest increase from 2010 (39%) increased—showed thegreatestincreasefrom 2010(39%) medical insurance—whichwas onlyoneoftwoactivitiesthat 2010 and2012;59%in2016). Outreachandenrollmentfor by agenciesengagedinrural healthinitiatives(73%in greatest decrease(31%in2010 to16%in2016),followed The numberofagenciesengaged inSCHIPshowedthe almostalloftheseactivitiesdecreased. states performing to ensureaccess. From 2010to2016,thepercentageof bythemoststatehealthagencies activities performed and enrollmentformedicalinsurancewerethethree minority healthinitiatives, ruralhealthinitiatives, andoutreach access tohealthcareservices. In2016,healthdisparities/ of statehealthagenciesthatengageinactivitiestoensure diseases andconditions. Figure3.2showsthepercentage receiving theappropriatecaretopreventillnessandtreat isanessentialfirststepin Access tohealthcareservices TABLE 3.2 most state health agencies provided training to local health most statehealthagenciesprovidedtrainingtolocal personnel. AsshowninFigure3.1,thetopicsforwhich agencies providetrainingtolocalhealthdepartment In additiontoprovidingtechnicalassistance, statehealth both ofthesearejustslightlylowerthanthosereportedin2012. andaccreditation;thefrequencies for (QI)/performance most oftenonthetopicofqualityimprovement provided tohospitalsandlocalpublichealthdepartments, As showninTable 3.2,technicalassistanceismostfrequently training toavarietyofpartnersonnumberdifferenttopics. State healthagenciesprovidetechnicalassistanceand Nonprofits/community-based organizations Local publichealthagencies Laboratories Hospitals Providers Emergency medicalservices STATE HEALTH AGENCYPARTNER TECHNICAL ASSISTANCE PROVIDEDBYSTATE HEALTH AGENCIESTOPARTNERS, 2016(N=48) 553% 81% 45 80% 48 85% 44 76% 48 73% 46 48 N QI/PERFORMANCE/ ACCREDITATION MANAGEMENT (N=9) havealoan repaymentprogramforphysicians. positions). AllstatesintheMountains andMidwestregion centralized/largely centralized states(30%averageforall are morelikely tohaveloanrepayment programsthan largely decentralized states(55% averageforallpositions) Decentralized/ programs increasedforallpositions surveyed. From 2010to2016,thenumberofstateswithloanrepayment than halfhaveprogramstoincreasethesupplyofdentists. programs toincreasethesupplyofphysicians, andmore Table 3.3,aroundtwo-thirds ofstateshaveloanrepayment the supplyofselectpositionsincommunity. Asshownin Many statessponsorloanrepaymentprogramstoincrease careprovidersin2016. support toprimary of statehealthagenciesalsoreportedprovidingfinancial to 2016(41%).Inadditiontheseactivities, 80percent than mediumandlargestates(83%86%,respectively). provided trainingonasmallerpercentageoftopics(52%) topics inSouth;57-76%ofotherregions).Smallstates percentage oftopicscomparedtootherregions(94% states weremorelikely toprovidetrainingonagreater centralized/largely centralizedstates(58%oftopics).Southern on agreaterpercentageoftopics(83%topics)than decentralized/largely decentralizedstatesprovidedtraining also thetoptrainingareasin2010and2012.Onaverage, and control, tobacco, preparedness, andMCH. Thesewere department personnelin2016werediseaseprevention DATA DATA 0 4 2 8 18% 13% 38% 9% 75% 2% 27% 4% 62% 42% 6% 75% 50% 44% 41% 56% 71% 65% 40% 46% 54% 75% 52% 60% 46% 54% 67% 60% 63% 67% HEALTH PUBLIC PUBLIC LAW DEVELOPMENT POLICY POLICY WORKFORCE WORKFORCE ISSUES NONE OF NONE OF TOPICS THESE THESE STATE HEALTH AGENCY ACTIVITIES 53 76% 78% 72% 88% 94% 88% 6% 4% 8% N/A 84% 70% 86% 92% 88% 31% 27% 32% 61% 76% 76% 82% 88% 84% 82% 80% 70% 78% 82% 76% 90% 90% 84% 0% OTHER TOBACCO 10% FOOD SAFETY PREPAREDNESS NONE OF THE ABOVE 20% ENVIRONMENTAL HEALTH ENVIRONMENTAL MATERNAL AND CHILD HEALTH AND MATERNAL ADMINISTRATIVE PROCEDURES ADMINISTRATIVE 30% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and DISEASE PREVENTION AND CONTROL PREVENTION DISEASE 40% CULTURAL COMPETENCIES/HEALTH DISPARITIES COMPETENCIES/HEALTH CULTURAL VITAL RECORDS, STATISTICS, OR SURVEILLANCE RECORDS, STATISTICS, VITAL Food safety did not appear on the 2010 Profile Survey. safety did not appear on the 2010 Profile Note: Food 50% 60% 70% 80% 90% 100% • 2010 • 2012 • 2016 (N=49-50) 2010-2016 PERSONNEL, DEPARTMENT DEPARTMENT PROVIDED TO PROVIDED TO STATE HEALTH HEALTH STATE LOCAL HEALTH LOCAL HEALTH FIGURE 3.1 FIGURE AGENCY TRAINING AGENCY TRAINING STATE HEALTH AGENCY ACTIVITIES 54 ASTHO Profile ofStateand Territorial Public Health, Volume Four FIGURE 3.2 AGENCY ACCESS TO HEALTHCARE STATE HEALTH 2010-2016 (N=47-51) SERVICES, • 2016 • 2012 • 2010 100% Note: Federally qualifiedhealthcentersandcommunity centersappearedonly onthe2016Profile Survey. 90% 80% STATE PROVIDED HEALTH INSURANCE(NOTSUPPORTED BYFEDERALFUNDS) 70% INSTITUTIONAL CERTIFYING AUTHORITY FORFEDERALREIMBURSEMENT FEDERALLY QUALIFIEDHEALTH CENTERSANDCOMMUNITY 60% HEALTH DISPARITIES AND/ORMINORITYHEALTH INITIATIVES STATE CHILDREN’SHEALTH INSURANCEPROGRAM(SCHIP) OUTREACH ANDENROLLMENTFORMEDICALINSURANCE 50% 40% HEALTH INSURANCEREGULATIONS 30% FAITH-BASED HEALTH PROGRAMS EMERGENCY MEDICALSERVICES 20% TRIBAL HEALTH RURAL HEALTH 10% 0% 86% 94% 84% 21% 27% 29% 16% 35% 31% 39% 46% 51% 6% 4% 6% 59% 73% 73% 17% 21% 28% 35% 41% 49% 27% N/A N/A 41% 38% 39% 8% 9% 10% STATE HEALTH AGENCY ACTIVITIES 55 % 25% 35% 35% 54% 63% 2016 N 12 17 17 26 30 % 32% 36% 38% 55% 70% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 2012 N 15 17 18 26 33 other comprehensive state strategies and initiatives indoor air policies and tobacco-free buildings). (e.g., at population-based primaryLooking prevention activities centralized/largely centralized states on average overall, perform more population-based primary prevention services (65%) than decentralized/largely decentralized states (51%). states perform population- the most Western On average, based primary prevention services (68%), while states in perform the fewest (41%). and Great Lakes the Mid-Atlantic of population-based primaryPerformance prevention services does not vary significantly by state population size. Only the number of the prevention services provided was and no information was collected about the measured, quantity or intensity of each service provided. % 22% 52% 44% 70% 85% 2010 6 N 14 12 19 23 STATE-SPONSORED LOAN REPAYMENT PROGRAMS TO INCREASE THE SUPPLY OF PROVIDERS, 2010-2016 (N=27-48) PROGRAMS TO INCREASE THE SUPPLY LOAN REPAYMENT STATE-SPONSORED Other primary care providers Nurses Mid-level providers Dentists PROVIDER TYPE Physicians TABLE 3.3 TABLE State health agencies provide a variety of population-based primary Figure 3.3 displays the prevention services. percentage of state health agencies that directly performed population-based primary prevention services from 2010 to 2016. Of the 17 activities surveyed, STD counseling and partner notification is the only primary prevention service that increased from 2010 (78%) to 2016 (82%). Among the 16 primary prevention services that decreased during this eight of these activities increased in the number time period, of states performing them from 2012 to 2016. However, Asthma this slight increase is still lower than 2010 numbers. prevention has shown a particularly substantial decrease over from 65 percent of states performing this servicetime, directly in 2010 to 44 percent in 2012 to 30 percent in 2016. One possible explanation is that asthma is being absorbed into POPULATION-BASED PREVENTION SERVICES PRIMARY

STATE HEALTH AGENCY ACTIVITIES 58 ASTHO Profile ofStateand Territorial Public Health, Volume Four from 47 percent of state health agencies performing this this from 47percentofstatehealth agenciesperforming greatest decreaseinfrequency ofperformance, dropping cancerscreenings showedthe period. Breastandcervical 10havedecreasedinfrequencyoverthis time surveyed, 42 percentin2016.Overall, ofthe 15screeningactivities directlyin2010to thisservice health agenciesperforming frequency ofperformance, risingfrom33percentofstate blood leadscreeningsshowedthegreatestincreasein tuberculosis, HIV/AIDS, andotherSTDs. From 2010to2016, agencies directlyscreenforarenewbornscreenings, The fourdiseasesandconditionsthatmoststatehealth screeningsfordiseasesandconditions. that directlyperform Figure 3.6displaysthepercentageofstatehealthagencies ANDCONDITIONS SCREENING FORDISEASES BY STATE HEALTH AGENCIES,2010-2016(N=49-50) VACCINE ORDERMANAGEMENTPERFORMEDDIRECTLY FIGURE 3.4 international travelimmunizationsdirectly(seeFigure3.4). approximately one-quarterconductordermanagementfor for bothchildhoodandadultimmunizations. Incontrast, distribution for vaccineordermanagementandinventory More than90percentofstatehealthagenciesareresponsible IMMUNIZATION SERVICES 100% 90% INTERNATIONAL TRAVEL VACCINES 50%60%70%80% CHILDHOOD IMMUNIZATIONS • 2010 ADULT IMMUNIZATIONS • 2012 0%10%20%30%40% • 2016 96% 92% 98% 24% 27% 24% 90% 82% 92% 100% DIRECTLY BYSTATE HEALTH AGENCIES,2010-2016(N=49-50) VACCINE ADMINISTRATION TOPOPULATION PERFORMED FIGURE 3.5 (percentages ranged from 21-26%). (percentages rangedfrom21-26%). more screeningactivities(52%) thanstatesinotherregions substantially at thelocallevel. Southernstates performed health departmentsmaybeconducting somescreenings largely decentralizedstates(19%),perhapsbecauselocal more ofthe15screeningactivities(44%)thandecentralized/ Overall, centralized/largelycentralizedstatesperformed federally qualifiedhealthcenters. is possiblethatthisdecreaseduetobetterlinkages with may seemcounterintuitiveduetoMedicaidexpansion, it directlyin2010to18percent2016.Althoughthis service international travelvaccinestopopulations(seeFigure3.5). adult vaccines, andlessthanone-quarterdirectlyadminister state healthagenciesdirectlyadministerchildhoodand When itcomestoadministeringvaccines, lessthanhalfof 90% INTERNATIONAL TRAVEL VACCINES 50%60%70%80% CHILDHOOD IMMUNIZATIONS • 2010 ADULT IMMUNIZATIONS • 2012 0%10%20%30%40% • 2016 18% 18% 14% 40% 45% 46% 44% 49% 42% STATE HEALTH AGENCY ACTIVITIES 59 26% 17% 14% 26% 27% 26% 71% 63% 70% 59% 58% 66% 33% 42% 42% 10% 13% 8% N/A 29% 24% 57% 65% 60% 14% 15% 6% 24% 23% 24% 31% 27% 22% N/A 17% 18% 61% 63% 60% 24% 17% 16% 47% 25% 18% 0% OTHER ASTHMA HIV/AIDS DIABETES OTHER STDS BLOOD LEAD 10% PREDIABETES TUBERCULOSIS OTHER CANCERS BODY MASS INDEX 20% HIGH BLOOD PRESSURE NEWBORN SCREENINGS NEWBORN COLON/RECTUM CANCER CARDIOVASCULAR DISEASE CARDIOVASCULAR BREAST AND CERVICAL CANCER BREAST AND CERVICAL 30% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 40% 50% 60% Body mass index and prediabetes did not appear on the 2010 Profile Survey. Note: Body mass index and prediabetes did not appear on the 2010 Profile 70% 80% 90% 100% • 2010 • 2012 • 2016 (N=48-51) SCREENING 2010-2016 PERFORMED PERFORMED FOR DISEASES FOR DISEASES FIGURE 3.6 FIGURE AND CONDITIONS AND CONDITIONS HEALTH AGENCIES, HEALTH DIRECTLY BY STATE BY STATE DIRECTLY

STATE HEALTH AGENCY ACTIVITIES 62 ASTHO Profile ofStateand Territorial Public Health, Volume Four TREATMENT FORDISEASES of 12-17% for other regions). of 12-17%forotherregions). regions (30%fortheSouth;range directlythan statesfromother services greater percentageofdiseasetreatment average, a Southernstatesperformed (14%).On of 13treatmentservices 1.8out decentralized statesperformed for diseases, whiledecentralized/largely 2.8 outof13(21%)treatmentservices centralized statesdirectlyperformed On average, centralized/largely changes overtime.observed this timeisonepossibleexplanationforthese covered byMedicaidandinsuranceduring The increaseinthenumberofindividuals treatment (bothdecreasedby23%). decreases inthenumberofstatesproviding cancerhadthegreatest breast/cervical decreased infrequency. BothHIV/AIDSand treatmentactivities almost allsurveyed HIV/AIDS, andotherSTDs. From 2010to2016, fortuberculosis, provided treatmentservices percentage ofstatehealthagencies 2016. Duringthistimeperiod, thegreatest diseases andconditionsfrom2010to that directlyprovidedtreatmentforselect the percentageofstatehealthagencies of treatmentservices. Figure3.8displays state healthagenciesprovideavariety In additiontoscreeningfordiseases, and 2016Profile Surveys. Note: Obesityonlyappearedonthe2012 DIRECTLY BYSTATE HEALTH AGENCIES,2010-2016(N=46-50) TREATMENT FORDISEASESANDCONDITIONS PERFORMED FIGURE 3.8 100% • 2010 90% 80% • 2012 70% • 2016 60% 50% 40% CORONARY HEART DISEASE BREAST/CERVICAL CANCER 30% COLON/RECTUM CANCER HIGH BLOODPRESSURE 20% OTHER CANCERS TUBERCULOSIS BLOOD LEAD OTHER STDS DIABETES HIV/AIDS OBESITY ASTHMA OTHER 0%10% 8% 18% 31% 32% 33% 55% 10% 10% N/A 22% 10% 18% 8% 14% 8% 10% 8% 6% 54% 51% 57% 2% 0% 8% 12% 16% 8% 14% 12% 22% 60% 56% 59% 2% 2% 14% 6% 8% 8% STATE HEALTH AGENCY ACTIVITIES 63 N/A N/A 90% 94% 94% 92% 96% 96% 92% 94% 94% 92% 24% 18% 14% 70% 51% 66% N/A 45% 58% 78% 71% 67% 34% 39% 45% 82% N/A N/A 0%10% OTHER BIOMONITORING 20% INFLUENZA TYPING NEWBORN SCREENING BLOOD LEAD SCREENING 30% CHOLESTEROL SCREENING FOODBORNE ILLNESS TESTING BIOTERRORISM AGENT TESTING OTHER ENVIRONMENTAL TOXINS OTHER ENVIRONMENTAL 40% VECTOR-BORNE ILLNESS TESTING 50% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 60% 70% 80% 90% 100% FIGURE 3.9 • 2016 • 2012 LABORATORY ACTIVITIES PERFORMED DIRECTLY ACTIVITIES PERFORMED DIRECTLY LABORATORY BY STATE HEALTH AGENCIES, 2010-2016 (N=49-50) AGENCIES, HEALTH BY STATE • 2010 Note: Other environmental toxins only appeared Survey; biomonitoring only on the 2010 Profile Surveys; appeared on the 2012 and 2016 Profile illness testing only appeared vector-borne Survey. on the 2016 Profile The laboratory services that state health agencies performed directly from 2010 to 2016 are displayed in Figure 3.9. The three lab services performed the most are bioterrorism agent testing, and influenzafoodborne illness testing, of state health The percentage typing. agencies performing each of these activities remained stable from 2010 whichto 2016. Blood lead screening, showed a notable decrease from 69 percent in 2010 to 51 percent in 2012, increased in 2016 to 66 percent of state health agencies performing On average, this service directly. medium and large states performed a greater percentage of lab services (72% of lab services for both) than small states (56%). STATE LABORATORY SERVICES STATE STATE HEALTH AGENCY ACTIVITIES 100% BY STATE HEALTH AGENCIES,2010-2016(N=49-51) REGISTRY MAINTENANCEACTIVITIESPERFORMED DIRECTLY FIGURE 3.10 medium orsmallstates(59%and47%,respectively). average, largestatesaremorelikely tomaintainregistries(67%)than registries (64%)thancentralized/largelycentralizedstates(44%).On Decentralized/largely decentralizedstatesaremorelikely tomaintain agencies maintainedincludeHIV/AIDS, tuberculosis, andtraumaregistries. these activitiesduringthistimeperiod. Otherregistriesthatstatehealth some decreaseinthepercentageofstatehealthagenciesperforming were childhoodimmunization, birthdefects, andcancer. Allhave shown maintained bythemoststatehealthagenciesbetween2010and2016 directly from2010to2016isdisplayedinFigure3.10.Thethreeregistries theseactivities The percentageofstatehealthagenciesthatperformed mandates andtopromotethehealthwell-beingoftheirresidents. State healthagenciesmaintainregistriesinresponsetostateandfederal REGISTRY MAINTENANCE • 2010 appeared onthe 2016Profile Survey. Note: Otherdidnotappear onthe2010Profile HepatitisC only Survey; 90% • 2012 80% 70% • 2016 60% 50% 40% CHILDHOOD IMMUNIZATION 30% 20% BIRTH DEFECTS HEPATITIS C DIABETES CANCER OTHER 0%10% 76% 76% 80% 53% 33% N/A 4% 6% 16% 76% 76% 92% 94% 96% 98% 61% N/A N/A STATE HEALTH AGENCY ACTIVITIES 65 22% 23% 14% 29% 31% 30% 24% 27% 21% 6% 4% 10% 37% 38% 20% 49% 43% 39% 78% 60% 54% 57% 55% 44% 10% 13% 6% 24% 13% 10% 29% 25% 26% 40% 29% 32% 47% 40% 36% 49% 42% 28% 0%10% WIC HOME VISITS PRENATAL CARE PRENATAL 20% CHILD NUTRITION FAMILY PLANNING FAMILY OBSTETRICAL CARE EARLY INTERVENTION EARLY WELL CHILD SERVICES 30% SCHOOL HEALTH SERVICES SCHOOL HEALTH SPECIAL HEALTHCARE NEEDS SPECIAL HEALTHCARE 40% NON-WIC NUTRITIONAL ASSESSMENTS 50% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 60% COMPREHENSIVE PRIMARY CARE CLINICS FOR KIDS COMPREHENSIVE PRIMARY COMPREHENSIVE SCHOOL HEALTH CLINICAL SERVICES COMPREHENSIVE SCHOOL HEALTH 70% 80% 90% EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT EARLY 100% • 2016 FIGURE 3.11 • 2012 • 2010 . The three most common MCHFigure 3.11. The three most common MATERNAL AND CHILD HEALTH ACTIVITIES PERFORMED ACTIVITIES AND CHILD HEALTH MATERNAL On average, centralized/largely centralized On average, states performed a greater percentage of MCH services directly (47%) than decentralized/largely decentralized states (12%). Southern states provided more MCH services on average than states in other regions (50% in South; 14-24% in other regions). The MCH services that state health performedagencies are displayed in 2016 in servicesagencies provided that state health were servicesbetween 2010 and 2016 for the healthcare needs, children with special Agriculture’s Women, Department of U.S. and (WIC) program, and Children Infants, in there was a decline Overall, home visits. health agenciesthe percentage of state the 14 MCH Of providing MCH services. services surveyed, decreases 12 have seen in the number of states directly performing them from 2010 to 2016. The most notable decrease was observed for services for children with special healthcare needs, with 78 percent of state health agencies performing this service directly in 2010 but only 54 percent in 2016. MATERNAL AND CHILD HEALTH SERVICES HEALTH CHILD AND MATERNAL DIRECTLY BY STATE HEALTH AGENCIES, 2010-2016 (N=48-51) AGENCIES, HEALTH BY STATE DIRECTLY STATE HEALTH AGENCY ACTIVITIES 66 ASTHO Profile ofStateand Territorial Public Health, Volume Four DATA COLLECTION,EPIDEMIOLOGY, ACTIVITIES ANDSURVEILLANCE or populationsize. governance classification, region, across the numberofactivitiesperformed 2016). Therewerenonotabledifferencesin activities(88%in2010to94% did injury over time(88%in2010to96%2016),as theseactivities of statesdirectlyperforming showed asteadyincreaseinthenumber in 2016.Environmentalhealthactivities and perinataleventsorriskfactorsactivities communicable/infectiousdisease performing percent ofstatehealthagenciesreported foodborne illnessactivitiesin2016,and98 health agenciesreporteddirectlyperforming relatively stablefrom2010to2016.Allstate and anumberoftheseactivitiesremained epidemiology, activities, andsurveillance datacollection, health agenciesperform in activitiesasdisplayed and surveillance front linesfordatacollection, epidemiology, onthe State healthagenciesoftenserve DATA COLLECTION,EPIDEMIOLOGY, ANDSURVEILLANCE were notincludedinthe2016Profile Survey. Note: Reportable diseasesandinsuranceoutreach . The majority of state Figure 3.12.Themajorityofstate ACTIVITIES PERFORMEDDIRECTLY BYSTATE HEALTH AGENCIES, 2010-2016(N=49-51) • 2010 • 2012 FIGURE 3.12 • 2016 100% 90% 80% 70% 60% 50% COMMUNICABLE/INFECTIOUS DISEASES PERINATAL EVENTSORRISKFACTORS 40% SYNDROMIC SURVEILLANCE BEHAVIORAL RISKFACTORS ENVIRONMENTAL HEALTH 30% ADOLESCENT BEHAVIOR INSURANCE OUTREACH REPORTABLE DISEASES FOODBORNE ILLNESS CANCER INCIDENCE CHRONIC DISEASES 20% VITAL STATISTICS MORBIDITY DATA INJURY 0%10% 94% 92% 88% 96% 92% 88% 94% 94% 80% 78% 77% 78% 94% 94% 94% 90% 90% 94% N/A 44% 51% 100% 98% 92% 98% 98% 96% 98% 94% 94% 96% 98% 96% N/A 100% 96% 96% 94% 96% 88% 94% 92% STATE HEALTH AGENCY ACTIVITIES 67 52% 56% 74% 22% 23% 22% 20% 21% 20% 24% 23% 22% 24% 23% 24% 24% 23% 22% 0%10% NURSES DENTISTS PHYSICIANS PHARMACISTS 20% PHYSICIAN ASSISTANTS OTHER PROFESSIONALS 30% 40% 50% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 60% • 2016 70% 80% • 2012 90% • 2010 100% professional licensure activities. States in New England tended to perform States in professional licensure activities. more professional licensure activities than states in other regions (46% in New England; 20-37% in other regions). The category “other professionals” and nurse social workers, included emergency medical technicians, among many others. aides, FIGURE 3.14 ACTIVITIES PERFORMED DIRECTLY PROFESSIONAL LICENSURE AGENCIES, 2010-2016 (N=47-50) HEALTH BY STATE State health agencies are also involved in overseeing professional licensure activities. Figure 3.14 displays the percentage of state health agencies that directly performed professional licensure activities between the percentage of 2010 and 2016. Overall, state health agencies performing the various professional licensure activities remained stable from 2010 to 2016, with about one-quarter of state health agencies directly performing Looking at all of the regulation, inspection, inspection, at all of the regulation, Looking in states and licensing activities together, New England performed a greater percentage of these activities on average than other regions (52% in New England; 38-48% for other regions). Medium and large states on average also performed a greater percentage of regulation, and licensing activities (45% and inspection, 46%, respectively) than small states (38%). State health agencies enforce the laws andState health agencies health and ensureregulations that protect Figure 3.13 shows the 15 most safety. commonly performed inspection, regulation, and licensing activities from 2010 to 2016. The three regulatory performed activities by werethe most state health agencies in 2016 and licensing of labs, inspection, regulation, Out of and trauma systems. food service, 10 have the top 15 most common activities, decreased in frequency from 2010 to 2016. and licensing inspection, Although regulation, of labs is still the most commonly performed largest decrease from it has seen the activity, 2010 (90%) to 2016 (76%). The regulation, of public swimming and licensing inspection, pools is the one activity that consistently increased in frequency from 2010 (63%) to 2016 (74%). REGULATION, AND LICENSING INSPECTION,

STATE HEALTH AGENCY ACTIVITIES 70 ASTHO Profile ofStateand Territorial Public Health, Volume Four ENVIRONMENTAL HEALTH ACTIVITIES TABLE 3.4 poisoncontrol(25%decreasefrom2010to performing activities includethenumberofstatehealthagenciesdirectly and otherstateagencies. Notabledecreasesinspecific tolocalhealthdepartments and transferringtheseservices to 2016(37%).Thesechangesarelikely duetofundingcuts directlydecreasedfrom2010(42%) agencies performed number oftotalenvironmentalhealthactivitiesthatstate health activitiesbetween2010and2016.Overall, theaverage selectenvironmental state healthagenciesthatperformed environmental health. Table 3.4showsthepercentageof we live, sostatehealthagenciesarekey playersinpromoting Human healthisinextricablylinked totheenvironmentsinwhich Environmental epidemiology Food safetytraining/education Radiation control Toxicology Radon control Indoor airquality Private watersupplysafety Public watersupplysafety Vector control Groundwater protection Surface waterprotection Hazmat response Outdoor airquality Hazardous wastedisposal Collecting unusedpharmaceuticals Animal control Land useplanning Poison control Noise pollution Other pollutionprevention Coastal zonemanagement Mosquito control Air pollution ENVIRONMENTAL HEALTH ACTIVITIESPERFORMEDDIRECTLY BYSTATE HEALTH AGENCIES,2010-2016(N=48-51) 2010 ecnaeo tt elhAece ecnaeo tt elhAece PercentageofStateHealthAgencies PercentageofStateHealthAgencies Percentage ofStateHealthAgencies 90% 88% 71% 73% 61% 69% 53% 53% 63% 45% 35% 37% 14% 22% 18% 18% 14% 33% 37% 22% 8% 8% 0% Note: Airpollutionand mosquitocontrolonlyappeared onthe2010Profile Survey. 2012 (40% and38%,respectively). activities (33%)thanmediumandlargestates alowerpercentageofenvironmentalhealth performed England; 32-39%inotherregions).Onaverage, smallstates health activitiesthanstatesinotherregions(46%New agreaterpercentageofenvironmental England performed Looking atenvironmentalhealthactivitiesoverall, statesinNew rising from14percentin2010to242016. it, increase inthenumberofstatehealthagenciesperforming Outdoor airqualitywastheoneactivitythatsawasignificant 2016) andvectorcontrol(16%decreasefrom2010to2016). 94% 84% 69% 69% 63% 65% 47% 49% 56% 47% 29% 35% 27% 16% 12% 16% 12% 12% 10% 8% 2% N/A N/A 2016 90% 80% 70% 60% 60% 56% 52% 50% 47% 42% 37% 24% 24% 20% 18% 12% 10% 8% 8% 7% 6% N/A N/A STATE HEALTH AGENCY ACTIVITIES 71 4% 4% 6% 8% 12% 12% 15% 16% 20% 22% 23% 34% 53% 63% 68% 76% 78% 84% 2016 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 6% 8% 10% 13% 16% 21% 22% 13% 25% 27% 23% 27% 69% 63% 63% 81% 77% 88% over time were seen for health consultations for childcare seen for health over time were 53% in 2016) and forensics (69% in 2012 to environments states 2010 to 15% in 2016). On average, laboratories (31% in region performed a lower and Great Lakes in the Mid-Atlantic public health activities than statespercentage of other 33-39% Lakes; and Great in Mid-Atlantic in other regions (25% in other regions). 2012 Note: Health consultations for childcare environments and support for veterans and military Survey. personnel and their families did not appear on the 2010 Profile N/A N/A 4% 10% 14% 16% 16% 20% 31% 28% 22% 24% 39% 61% 67% 71% 77% 78% Percentage of State Health Agencies Percentage of State Health Agencies Agencies Percentage of State Health 2010 OTHER PUBLIC HEALTH ACTIVITIES PERFORMED DIRECTLY BY STATE HEALTH AGENCIES, 2010-2016 (N=48-51) AGENCIES, HEALTH BY STATE ACTIVITIES PERFORMED DIRECTLY OTHER PUBLIC HEALTH Agriculture regulation State mental health authority without substance abuse State tuberculosis hospitals Substance abuse facilities Eldercare services State mental health authority with substance abuse Forensics laboratory Needle exchange Medical examiner State mental health institutions/ hospitals Support for veterans and military personnel and their families Occupational safety and health services Health consultations for childcare environments Nonclinical services in correctional facilities Institutional Review Board Veterinarian services Veterinarian State health planning and development Trauma system coordination Trauma TABLE 3.5 TABLE Other public health activities that state health agencies health activities that Other public in and 2016 are displayed between 2010 provided directly public health the three other 3.5. During this time period, Table activities directly performed by the most state health agencies health planning state coordination, were trauma system all of and veterinarian services, and development services, The largest decreases relatively stable. which have remained OTHER PUBLIC HEALTH ACTIVITIES HEALTH PUBLIC OTHER STATE HEALTH AGENCY ACTIVITIES 72 ASTHO Profile ofStateand Territorial Public Health, Volume Four in other regions). in otherregions). an HIE(37%inNewEngland;10-25% England aremorelikely toalready have 0-10% inotherregions),while states inNew HIEs thananyotherregion(43%intheWest; states aremorelikely tobeworkingestablish largely decentralizedstates(58%).Western establishing HIEs(71%)thandecentralized/ largely centralizedstatesarelesslikely tobe involved inestablishinganHIE. Centralized/ of statesreportednotcurrentlybeing federally-facilitated exchanges, 66percent 14 percentwereengagedinstate-basedor of agenciesalreadyhadanHIEand As depictedinFigure3.16,while20percent their statewascurrentlyestablishing an HIE. state healthagencieswereasked whether with theAffordableCareAct(ACA).In2016, health insuranceineachstateaccordance setuptofacilitate thepurchaseof services Health insuranceexchanges(HIEs)are HEALTH INSURANCEEXCHANGES medium states(25%and29%,respectively). integrating OneHealth(47%)thansmallor so (50%).Large statesaremorelikely tobe and Midwestregionaremostlikely todo Health (13%),whilestatesintheMountains England areleastlikely tobeintegratingOne largely centralizedstates(14%).StatesinNew integrating OneHealth(39%)thancentralized/ decentralized statesaremorelikely tobe into theiractivities. Decentralized/largely percent areexploringintegratingOneHealth their programming, whileanadditional18 engage withthisOneHealthapproachin state healthagencieshavestartedto As seeninFigure3.15,34percentof the healthofanimalsandenvironment. the connectionbetweenhumanhealthand has paidincreasedattentiontoOneHealth, In recentyears, thefieldofpublichealth ONE HEALTH ACTIVITIES integrating norexploring STATE HEALTH AGENCYENGAGEMENTINONEHEALTH, 2016(N=50) FIGURE 3.15 integrating OneHealth BY STATE HEALTH AGENCIES,2016(N=50) ESTABLISHMENT OFHEALTH INSURANCEEXCHANGES FIGURE 3.16 agency already No HIEestablished Agency isneither I amnotfamiliar with OneHealth health activities State health into itspublic has anHIE 20% 24% 24% 66% federally-facilitated HIE integrating OneHealth Agency isexploring health activities into itspublic 18% One Healthinto health activities 4% Yes, integrating Agency is its public 34% state-based 10% Yes, HIE STATE HEALTH AGENCY ACTIVITIES 73 8% 4% 20% 63% 59% 54% 74% 71% 88% 31% 35% 46% 88% 84% 84% 98% 100% 100% 61% 80% 82% 14% 20% 28% 84% 94% 92% 41% 47% 52% 35% 37% 46% 0%10% OTHER 20% SMOKE-FREE BUILDING 30% FARMER’S MARKET FOR STAFF MARKET FARMER’S HEALTHY MATERNITY POLICIES MATERNITY HEALTHY 40% 50% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and SMOKE-FREE VENUES FOR OFF-SITE MEETINGS HEALTHY VENDING POLICY IN OFFICE BUILDING HEALTHY 60% MENU LABELING IN OFFICE BUILDING CAFETERIA HEALTHY EATING POLICIES FOR CATERED EVENTS POLICIES FOR CATERED EATING HEALTHY 70% INSURANCE COVERAGE FOR TOBACCO CESSATION PROGRAMS INSURANCE COVERAGE FOR TOBACCO CESSATION 80% 90% FOOTAGE REQUIREMENTS OUTSIDE OF BUILDING FOR SMOKE-FREE AREA FOOTAGE WEIGHT LOSS OR PHYSICAL ACTIVITY CHALLENGES OR INCENTIVES FOR STAFF WEIGHT LOSS OR PHYSICAL ACTIVITY CHALLENGES 100% • 2016 FIGURE 3.17 • 2012 • 2010 AGENCIES, 2010-2016 (N=49-50) COMPONENTS OF WORKSITE WELLNESS PROGRAMS IMPLEMENTED AT STATE HEALTH HEALTH STATE PROGRAMS IMPLEMENTED AT Worksite wellness programs can help wellness programs Worksite support thestate health agencies well-beingphysical and emotional of their employees while serving as a model for other agencies and businesses in their communities. Components of state health agencies’ worksite wellness programs between 2010 and 2016 are shown in Figure 3.17. The majority of worksite wellness activities have either increased or remained the same between 2010 and 2016, with the exception of offsite meetings venues for smoke-free and footage requirements outside The areas. of building for smoke-free greatest increase was in insurance coverage for tobacco cessation programs (61% in 2010 to 82% in 2016) and healthy vending policies in office buildings (31% in 2010 to 46% in 2016). states in New England On average, tended to offer more worksite wellness activities than states in other regions (73% in New England; 56-67% in other regions). Small states tended to offer fewer worksite wellness program components (60%) than medium and large states (65% and 64%, respectively). WORKSITE WELLNESS STATE HEALTH AGENCY ACTIVITIES 74 ASTHO Profile ofStateand Territorial Public Health, Volume Four studies with a formal research agreement in 2012 (30%). studies withaformal researchagreementin2012 (30%). on areoccurringbasis, which wasdoublethenumberof the universityorresearchinstitute toconductjointstudies formal researchagreementbetween theagencyand researchers, 61percentofstudies in2016involveda For thosestate health agenciesthatcollaboratedwith an increasefromtheaverageof27studiesin2012. researchers basedatauniversityorresearchinstitute, they conductedanaverageof38studieswith When statesparticipatedinresearchstudies2016, medians=4 – 33). 36; (means=6– median=35) thanmediumandsmallstates research studiesinthepasttwoyears(mean=106; On average, largestateshaveparticipatedinmore to statesinotherregions(means=21– 46; medians=5–20). compared number ofstudies(mean=113;median=27) England stateshaveparticipatedinthelargestaverage New centralized states(mean=18;median=14). thancentralized/largely median=36) (mean=84; decentralized stateshaveparticipatedinmorestudies to 41percentofstudiesin2012.Decentralized/largely agency led54percentofthestudiesin2016,compared mean=46; median=15).Onaverage, thestatehealth number ofstudiesconductedin2012(range=1– 427; 668 (mean=52;median=13),anincreasefromthe ranged fromaminimumofzerotomaximum health agenciesengagedinoverthepasttwoyears In 2016,thenumberofresearchstudiesthatstate (56% and59%,respectively). participants (38%)thanmediumorlargestates to engageinrecruitingstudysitesand/or 75-89% inotherregions).Smallstateswerelesslikely practice thanstatesinotherregions(45%theWest; in identifyingtopics/questionsrelevanttopublichealth states (43%).Western stateswerelesslikely toengage findings topracticethancentralized/largelycentralized in activitiestohelpotherorganizationsapplyresearch largely decentralizedstates(64%)reportedparticipating data andfindings. Significantlymoredecentralized/ key stakeholders; andanalyzinginterpretingstudy data forastudy;disseminatingresearchfindingsto includedcollecting, exchanging,performed orreporting stable. Themostcommonresearchactivitiesthatstates engaging inresearchactivitiesremainedrelatively 2012 and2016,thenumberofstatehealthagencies participated inbetween2012and2016.Between types ofresearchactivitiesthatstatehealthagencies research findingsinvariousways. State healthagenciespromoteresearchanddisseminate RESEARCH ACTIVITIES shows the Figure 3.18showsthe 100% APPLYING RESEARCHFINDINGSTOPRACTICESWITHINORGANIZATION • 2012 BY STATE HEALTH AGENCIES,2012-2016(N=48-49) PARTICIPATION INRESEARCHSTUDIESPAST TWOYEARS FIGURE 3.18 COLLECTING, EXCHANGING,ORREPORTING DATA FORASTUDY DISSEMINATING RESEARCHFINDINGSTOKEYSTAKEHOLDERS ANALYZING ANDINTERPRETINGSTUDYDATA ANDFINDINGS RECRUITING STUDYSITESAND/ORPARTICIPANTS • 2016 AND/OR PROTOCOLSFORPUBLICHEALTH STUDIES DEVELOPING ORREFININGRESEARCHPLANS IDENTIFYING TOPICS/QUESTIONSRELEVANT HELPING OTHERORGANIZATIONS APPLY RESEARCH FINDINGSTOPRACTICE TO PUBLICHEALTH PRACTICE I DON’TKNOW 0%10%20%30%40%50%60%70%80%90% 88% 90% 88% 85% 88% 90% 59% 54% 78% 81% 84% 81% 2% 0% 69% 75% 51% 58% STATE HEALTH AGENCY ACTIVITIES 75 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and , 24% 16% 15% 40% 61% 44% 0%10%20%30%40%50%60%70%80%90% NO YES I DON’T KNOW

State Health Agencies: How We Do It • 2016 This chapter has explored the range of state health agencies’ roles and responsibilities and the services activities that they provide. and The next section of the report, addresses the tools and techniques that state health agencies use health. to provide these servicesthe nation’s that protect • 2012 100% FIGURE 3.19 TWO YEARS IN HIA TRAINING IN PAST PARTICIPATION 2012-2016 (N=46-48) AGENCY, HEALTH BY ANYONE IN STATE

The survey states if their state health agency had also asked In both 2012 and 2016, participated in an HIA in the past two years. though had participated, fewer than half of state health agencies slightly during this time (threethe average number of HIAs increased and Great Lakes in 2012 to four in 2016). States in the Mid-Atlantic states while Western region conducted the fewest HIAs (mean=2), conducted fewer HIAsconducted the most (mean=5). Small states (mean=4 for both). Of(mean=2) than medium and large states half in HIA training, those states in which a staff member participated in an HIA advisoryalso reported state health agency participation states participated in an HIA advisorycommittee in 2016. All Western committee (0-57% in other regions). Health impact assessments (HIAs) are the process by which an are the process assessments (HIAs) Health impact a project or policy’s evaluates agency systematically potential Survey state and 2016, the Profile In 2012 asked health effects. HIA in the agency had attended an health agencies if anyone The number of state health agencies years. training in the past two 2012 in HIA training decreased between that reported participation had By 2016, the number of agencies that (61%) and 2016 (44%). agencies was almost equal to the number of participated in training as shown in Figure 3.19. Individuals fromthat had not participated participated in an HIA training to have most likely states were Western from states in the Mountains and Midwest(67%), while individuals to have done so (20%). region were least likely HEALTH IMPACT ASSESSMENTS IMPACT HEALTH PLANNING AND QUALITY IMPROVEMENT 76 ASTHO Profile ofStateand Territorial Public Health, Volume Four HOW WEDOIT STATE PUBLICHEALTH PART III PLANNING AND QUALITY IMPROVEMENT 77 State health 1 HRSA. “Quality Improvement.” Available HRSA. “Quality Improvement.” Available at www.hrsa.gov/sites/default/files/quality/ toolbox/508pdfs/qualityimprovement.pdf. Accessed June 23, 2017. ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 1 NOTES agencies are also increasingly involved inagencies are also increasingly developing a public health accreditation, measuring set of public health standards, health agency performance against those recognizing and rewarding or standards, This them. health departments that meet agencies’chapter describes state health completion of accreditation prerequisites and intentions to apply for accreditation, state health agencies’ performance efforts, management systems and QI and use of the U.S. staff involvement in QI, Force’s ServicesCommunity Preventive Task ServicesGuide to Community Preventive (“The Community Guide”). When available, we compare 2016 data with 2012, 2010, and describe differences and 2007 data, in state health agency planning and QI region, efforts by governance structure, and state population size. State health agencies play an integralState health agencies (QI), whichrole in quality improvement HRSA defines as “systematic and continuous improvementactions that lead to measurable in health care services and the health status of targeted patient groups.” Chapter 4 Chapter PLANNING AND QUALITY IMPROVEMENT PLANNING AND QUALITY IMPROVEMENT 78 ASTHO Profile ofStateand Territorial Public Health, Volume Four FINDINGS NOTES KEY 2 Accessed October 3,2017. www.phaboard.org/news-room/accreditation-activity/. Activity asofSeptember19,2017. Available at Public HealthAccreditationBoard. Accreditation development (50%). planning (78%),grantwriting(68%),andpolicy Community Guideinthepasttwoyearsforprogram State healthagenciesmostcommonlyusedthe descriptions thatincludeQI-relatedresponsibilities(64%). (64%),andjob committee tocoordinateQIefforts is throughstafftrainingonQImethods(84%),a orencouragestaffinvolvementinQIefforts support The mostcommonwaysthatstatehealthagencies Six Sigma(32%). or Plan-Do-Study-Act (76%),Lean (58%),and in statehealthagenciesarePlan-Do-Check-Act The threemostcommonQIframeworksorapproaches in 2016). over time(67%in2010,75%2012,and90% managementplansteadilyincreased performance The percentageofstatehealthagencieswithaformal inothersectors(70%). partners relationshipwithkey strengthening theiragency’s andaddresshealthpriorities(73%), to identify capacity agency (76%),increaseintheiragency’s within theiragency(82%),strongercultureofQIin orunits greater collaborationacrossdepartments withintheiragency(85%), improvement opportunities the followingbenefits:Greaterqualityandperformance were mostlikely havingalreadyexperienced toreport Accredited statesandthosepursuingaccreditation intend todosowithinthenexttwoyears. have notyetregisteredine-PHAB,69percent 13 states thatplantoapplyforaccreditationbut agencies haveachievedaccreditation. September 2017, eightadditional statehealth nationalaccreditationprogram.Asof voluntary through thePublicHealthAccreditationBoard’s(PHAB) of statehealthagencieshadachievedaccreditation wascompleted,40percent At thetimesurvey the lastthreeyears. percent ofstatehealthagencieshavedonesowithin developed anagency-wide strategicplan, and71 As of2016,96percentstatehealthagencieshave to 64percentin2016. has steadilyincreasedfrom23percentin2007 health improvementplanwithinthelastthreeyears indevelopingastate developing orparticipating The percentageofstatehealthagenciesthatreported of thosehavingdonesowithinthelastthreeyears. completing astatehealthassessment,with54percent In 2016,94percentofstatehealthagenciesreported 2 f the Of PLANNING AND QUALITY IMPROVEMENT 79 8% 6% 34% 10% 27% 4% 47% 59% 54% 10% 4% 6% 25% 4% 2% 0% NO 10% 20% 30% YES, FIVE OR MORE YEARS AGO NO, BUT PLAN TO IN THE NEXT YEAR 40% YES, WITHIN THE LAST THREE YEARS 50% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 60% YES, MORE THAN THREE BUT LESS THAN FIVE YEARS AGO YES, MORE THAN THREE BUT LESS THAN FIVE YEARS 70% • 2016 (2) create a state health improvement plan, and plan, a state health improvement (2) create The three strategic plan. (3) develop an agency-wide the state health prerequisites are interconnected; the state health improvement plan, assessment informs be eligible To strategic plan. which informs the agency must have these three prerequisites for accreditation, the past five years. been completed within 80% • 2012 90% • 2010 100% FIGURE 4.1 AGENCIES, 2010-2016 (N=49-50) HEALTH ASSESSMENT BY STATE HEALTH DEVELOPMENT OF STATE ). All Western states Figure 4.1). All Western have completed a state health assessment in the last five years. From 2010 to 2016, the percentage of From state health agencies that developed a state health assessment in the last five years increased from 55 percent in 2010 to 65 percent in 2012 to 84 from percent in 2016. Additionally, 2012 to 2016, the percentage of state health agencies that plan to develop a health assessment in the next year decreased from 27 to 4 percent, reflecting the increase in state health agencies that have already developed a state health assessment (see State health assessments provide information to state health agencies about the health of the population they serve and identify areas for contributing health improvement, factors to higher health risks or poorer health outcomes among targeted and community populations, resources to improve health status. As of 2016, 94 percent of state health agencies have developed a state and 54 percent health assessment, of those have done so within the last three years. PHAB established a voluntaryPHAB established national accreditation agencies in and tribal health local, program for state, with the accreditation provides agencies PHAB 2011. their performanceopportunity to measure and demonstrate for submitting an There are three prerequisites accountability. relate to planning all of which application for accreditation, (1) conduct a state health assessment, and QI: STATE HEALTH ASSESSMENTS HEALTH STATE ACCREDITATION PREREQUISITES PREREQUISITES ACCREDITATION PLANNING AND QUALITY IMPROVEMENT 80 ASTHO Profile ofStateand Territorial Public Health, Volume Four STATE HEALTH IMPROVEMENTPLANS developed using a state health assessment’s results. developed using astatehealthassessment’s a healthimprovementplanhave onethatwas Eighty-nine percentofstatehealth agencieswith to updatetheplanwithin next threeyears. improvement planin2016, 41 (87%) intend Of the47statesreportingastate health improvement planinthelastthreeyears. or participatedindevelopingastatehealth likely thanlargestates(77%),tohavedeveloped than mediumstates(65%),whichinturnareless with size, suchthatsmallstates(50%)arelesslikely the lastthreeyearsshowsapositiverelationship developing astatehealthimprovementplanwithin centralized). Developmentoforparticipationin vs. 57decentralized centralized/largely percent the lastthreeyears(69%ofdecentralized/largely in developingastatehealthimprovementplan centralized statestohavedevelopedorparticipated somewhat morelikely thancentralized/largely Decentralized/largely decentralizedstatesare already developedone(seeFigure4.2). the increaseinnumberofstatesthathave substantially from2012(35%)to2016(4%),reflecting health improvementplaninthenextyeardecreased to developorparticipateindevelopingastate the percentageofstatehealthagenciesthatplan 64 percentin2016.Aswithstatehealthassessments, continually increased, from23percentin2007to state healthimprovementplaninthelastthreeyears that developedorparticipatedindevelopinga to 2016,thepercentageofstatehealthagencies having donesowithinthelastfiveyears. From 2007 state healthimprovementplan, with88percent had developedorparticipatedindevelopinga As of2016,97percentstatehealthagencies and implementprojects, programs, andpolicies. priorities, directtheuseofresources, anddevelop can usethestatehealthimprovementplantoset health. Thecommunity, stakeholders, andpartners willworktogethertoimprovethestate’s they serve how statehealthagenciesandthecommunities health improvementplan’spurposeistodescribe that thestatehealthassessmentidentified. Thestate systematic planstoaddresstheprioritiesandissues State healthimprovementplansarelong-term, 100% OF ASTATE HEALTH IMPROVEMENTPLAN,2007-2016(N=49-51) DEVELOPMENT ORPARTICIPATION INDEVELOPMENT FIGURE 4.2 • 2007 more thanthreeyearsagobutless thanfiveyearsago”inthisfigure. three yearsago”responsesfrom 2007 werecategorizedunder“Yes, years,” “Yes, morethanthreeyearsago,” and“No.” “Yes, morethan Note: In2007,theresponseoptionswere “Yes, withinthe last three 90% • 2010 80% YES, MORETHANTHREEBUTLESSFIVEYEARSAGO 70% • 2012 YES, WITHINTHELASTTHREEYEARS NO, BUTPLANTOINTHENEXTYEAR • 2016 YES, FIVEORMOREYEARSAGO NO 0%10%20%30%40%50%60% 2% 8% 25% 20% 6% 8% 16% N/A 64% 43% 37% 23% 4% 35% 14% N/A 24% 6% 8% 57% PLANNING AND QUALITY IMPROVEMENT 81 30% 52% 21% 32% 20% 21% 44% 16% 20% 10% 15% 26% 30% 17% 21% 26% 0%10%20%30%40%50%60% NO YES NOT APPLICABLE LINKED TO SOME PLANS • 2016 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and • 2012 70% 80% • 2010 90% As of 2016, 96 percent of state health agencies had and 71 percent of strategic plan, developed an agency-wide state health agencies had done so within the last three years. A greater percentage of centralized/largely centralized states (86%) had developed a strategic plan in the last three years than decentralized/largely decentralized states (64%). • 2007 FIGURE 4.3 FIGURE PLANS TO LOCAL IMPROVEMENT HEALTH STATE LINKING OF (N=39-50) IMPROVEMENT PLANS, 2007-2016 HEALTH 100% Strategic planning is a process for defining and determining and direction over three to fivean agency’s priorities, roles, plans to A strategic plan sets forth what an agency years. and how it will know if it has how it will achieve it, achieve, The strategic plan provides a guide for making achieved it. decisions on allocating resources and taking action to pursue strategies and priorities. AGENCY-WIDE STRATEGIC PLANS STRATEGIC AGENCY-WIDE State health agencies were also asked whether were also asked State health agencies plan was linked their state health improvement In 2016, plans. to local health improvement health agencies with state69 percent of state health improvement plans had plans that improvement plans. to local health were linked Figure 4.3 displays the percentage of state health agencies with state health improvement health improvement plans to local plans linked statefrom 2007 to 2016. The percentage of all health agencies with state health improvement health improvement plans to local plans linked percentdecreased from 30 percent in 2007 to 17 and in 2010, but then increased in 2012 (21%) with2016 (26%). The percentage of agencies to some state health improvement plans linked plans increased from 2007 to 2010, decreased 2012,from 52 percent in 2010 to 21 percent in Statesbut then increased to 32 percent in 2016. than states in other in New England are more likely plansregions to have state health improvement improvement plans (50% of to local health linked 22-33% of states in other New England states vs. regions). Medium and large states are more likely to have state health improvement plans linked to some plans (44% and 47%, respectively) than small states (11%). Decentralized/largely decentralized states are decentralized Decentralized/largely their state health to have developed more likely health assessment plan using state improvement centralized states centralized/largely results than decentralized states (96% of decentralized/largely centralized states). centralized/largely 75% of vs. likely the more the larger the state, Additionally, their state healththey are to have developed state health assessmentimprovement plan using 88% of medium states, states, results (79% of small have done so). and 100% of large states PLANNING AND QUALITY IMPROVEMENT 82 ASTHO Profile ofStateand Territorial Public Health, Volume Four from 18-29%fortheotherfourregions). states inotherregions(percentagesrange implemented plansinthepastyearthan percentage ofSouthernstates(58%) largely decentralizedstates(16%).Agreater plan withinthepastyearthandecentralized/ centralized states(50%)implementedastrategic A greaterpercentageofcentralized/largely decreased from 17 percent to8percent. yet implementedanagency-wide strategicplan percentage ofstatehealthagenciesthathadnot is displayedinFigure4.5.From 2012to2016,the status forstatehealthagenciesfrom2010to2016 had notyetbeenconducted. Implementation though anannualwrittenevaluationonprogress implemented theplanmorethanoneyearago, in thepastyear, andanother24percenthad implemented theiragency-wide strategicplan completed astrategicplanin2016had Thirty percentofstatehealthagenciesthat developed anagency-wide strategicplan. increase inthenumberofstatesthathavealready year decreasedfrom2012to2016,reflectingthe develop anagency-wide strategicplaninthenext the percentageofstatehealthagenciesthatplanto assessments andstatehealthimprovementplans, level at71percentin2016.Aswithstatehealth strategic planinthelastthreeyears, remaining with 71percenthavingdevelopedanagency-wide this numberincreasedtonear2007levelsin2012, decreased from76percentto57percent. However, agency-wide strategicplaninthelastthreeyears of statehealthagenciesthathaddevelopedan Figure 4.4.From 2007to2010,thepercentage strategic plansfrom2007to2016isdisplayedin The percentageofstatehealthagencieswith in thisfigure. categorized under“Yes, withinthe lastthreeyears” were “Yes” and“No.” “Yes” responsesfrom2007were Note: In 2007, the response options for this question In 2007,theresponseoptionsforthisquestion 100% 100% • 2010 FIGURE 4.5 OF AGENCY-WIDE STRATEGIC PLAN,2010-2016(N=46-50) • 2007 FIGURE 4.4 STRATEGIC PLAN,2007-2016(N=44-49) ANNUAL WRITTENEVALUATION ONPROGRESSNOTYETCONDUCTED 90% 90% • 2012 • 2010 80% 80% YES, MORETHANTHREEBUTLESSFIVEYEARSAGO STATE HEALTH AGENCYIMPLEMENTATION STATE HEALTH AGENCYDEVELOPMENTOFAGENCY-WIDE 70% 70% ONE ORMOREWRITTENEVALUATIONS CONDUCTED • 2016 • 2012 IMPLEMENTED MORETHANONEYEARAGO; IMPLEMENTED MORETHANONEYEARAGO; YES, WITHINTHELASTTHREEYEARS NO, BUTPLANTOINTHENEXTYEAR • 2016 IMPLEMENTED INTHEPAST YEAR YES, FIVEORMOREYEARSAGO NOT YETIMPLEMENTED NOT APPLICABLE NO 0%10%20%30%40%50%60% 0%10%20%30%40%50%60% 30% 31% 7% 4% 25% 16% 8% 17% 13% 34% 10% 29% 24% 17% 36% N/A N/A 9% 24% 2% 4% 15% N/A 71% 71% 57% 76% 4% 25% 6% N/A 22% N/A 13% N/A PLANNING AND QUALITY IMPROVEMENT 83 8% 22% 4% 4% 0% 40% 16% 4% 18% 4% 53% 26% 0%10%20%30%40%50%60% 2016 15% 2017 54% TO APPLY FOR ACCREDITATION TO APPLY APPLICATION FOR ACCREDITATION APPLICATION STATE HEALTH AGENCY HAS REGISTERED HEALTH STATE WHETHER TO APPLY FOR ACCREDITATION WHETHER TO APPLY STATE HEALTH AGENCY HAS NOT DECIDED HEALTH STATE AGENCY HAS DECIDED NOT HEALTH STATE STATE HEALTH AGENCY HAS SUBMITTED AN HEALTH STATE STATE HEALTH AGENCY PLANS TO APPLY FOR AGENCY PLANS TO APPLY HEALTH STATE ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and IN E-PHAB IN ORDER TO PURSUE ACCREDITATION 70% STATE HEALTH AGENCY HAS ACHIEVED ACCREDITATION HEALTH STATE ACCREDITATION BUT HAS NOT YET REGISTERED IN e-PHAB BUT HAS NOT ACCREDITATION ANTICIPATED YEAR OF LETTER OF INTENT SUBMISSION ANTICIPATED STATE HEALTH AGENCY PARTICIPATION IN PHAB ACCREDITATION IN PHAB ACCREDITATION AGENCY PARTICIPATION HEALTH STATE 80% • 2016 90% 8% on a 2018 23% decided Have not • 2012 target year 100% FOR ACCREDITATION, 2016 (N=13) FOR ACCREDITATION, PROGRAM, 2012-2016 (N=49-50) PROGRAM, 2012-2016 FIGURE 4.7 FIGURE 4.6 Public Health Accreditation Activity as Board. “Accreditation of September 19, 2017.” Available at www.phaboard.org/news-room/ accreditation-activity/. Accessed October 3, 2017. Figure 4.6 shows the progression 3 3 Thirteen states plan to apply for accreditation, Thirteen states plan to apply for accreditation, Sixty-nine but have not yet registered in e-PHAB. two years percent intend to do so within the next (see Figure 4.7). Only two state health agencies indicated that they do not intend to apply for with one saying that the fees are accreditation, too high and one indicating that the standards Both states are not appropriate for their agency. also reported that the time and effort to pursue accreditation exceeds the benefits to their agencies. of states through the accreditation process fromof states through the accreditation process in2012 to 2016. There are no notable differences accreditation status by governance classification, or state size. region, State health agencies that choose to pursue process. accreditation are at different stages in the have already percent of state health agencies Forty and another 26 percentachieved accreditation, not yetplan to apply for accreditation but have As of September 2017, eight registered in e-PHAB. additional state health agencies have achieved accreditation. INTENTION TO APPLY APPLY INTENTION TO FOR ACCREDITATION NOTES PLANNING AND QUALITY IMPROVEMENT 84 ASTHO Profile ofStateand Territorial Public Health, Volume Four BENEFITS OFACCREDITATION TABLE 4.1 quality and performance improvement opportunities within improvementopportunitieswithin quality andperformance experienced thefollowingbenefits:Accreditationstimulated in or registeredine-PHABtopursueaccreditationaredisplayed accreditation, submittedanapplicationforaccreditation, experienced. Results forstatesthathadalreadyachieved benefits ofaccreditation, eitheranticipatedoralready accreditation torespondaseriesofitemsonthepotential agencies hadachievedaccreditationorwerepursuing asked respondentswhosestatehealth In 2016,ASTHO and responsibilities entity’s knowledgeofour agency’s roles Improve ourboardofhealthorgoverning our agency’s rolesandresponsibilities Increase thepublic’s working knowledgeof partners inothersectors Strengthen ouragency’s relationshipwithkey departments orunitswithinouragency Stimulate greatercollaborationacross training andworkforcedevelopment identified andaddressedgapsinemployee Increase theextenttowhichagencyhas opportunities, etc.) or increasingcompetitivenessforfunding (e.g., bymakingagencymoreefficient Improve ouragency’s financialstatus programs and/orbusinesspractices evidence-based practicesforpublichealth Increase theextenttowhichouragencyuses to ourcustomers provide high-qualityprogramsandservices Improve ouragency’s overallcapacityto address healthpriorities. Increase ouragency’s capacitytoidentifyand informs decisions performance managementsystem Increase theextenttowhichinformationfrom of QIinouragency Strengthen theculture our agency improvement opportunitieswithin Stimulate qualityandperformance Accreditation Benefit Table 4.1.Statesweremostlikely toreporthavingalready ACCREDITED/IN-PROCESSSTATE HEALTH AGENCIES’PERCEIVEDBENEFITSOFACCREDITATION, 2016(N=33) accreditation benefit experienced Agency hasalready Frequency 03%1 33% 11 39% 30% 13 33% 70% 10 11 82% 23 61% 27 30% 20 10 39% 52% 13 52% 17 52% 17 73% 17 48% 24 76% 16 85% 25 28 3 %1 39% 13 9% % benefit experience accreditation Anticipate agencywill Frequency 8 2 6 5 8 5 management systeminfluencesdecisions. increase theextenttowhichinformationfromperformance benefits, morethanhalf(52%)anticipatedthatitwould their agencieswouldexperienceanarrayofaccreditation partners inothersectors(70%).Whilestatesanticipatedthat relationshipwithkey (73%), andstrengthenedtheiragency’s capacity toidentifyandaddresshealthpriorities agency’s the cultureofQIintheiragency(76%),increased departments orunitswithintheiragency(82%),strengthened their agency(85%),stimulatedgreatercollaborationacross 24% 18% 15% 24% 15% 6% % anticipate thatitwill and doesnot accreditation benefit experienced Agency hasnot Frequency 5 3 1 1 2 1 0 2 0 0 0 0 5 236% 12 15% 9% 3% 3% 6% 3% 0% %1 30% 10 6% 0% 0% 0% 0% % Don't know Frequency 9 7 1 4 2 0 0 4 0 0 27% 21% 12% 12% 3% 6% 0% 0% 0% 0% % PLANNING AND QUALITY IMPROVEMENT 85 % 8% 8% 8% 25% 17% 17% 17% 33% 17% 33% 42% 27% 2 4 5 3 1 1 3 2 2 2 4 1 Frequency Don't know % 8% 8% 9% 0% 0% 8% 8% 8% 17% 17% 17% 17% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 2 1 1 1 0 0 1 2 1 2 2 1 Frequency Agency has not experienced accreditation benefit and does not anticipate that it will % 67% 58% 50% 64% 67% 67% 75% 67% 50% performance opportunities within their improvement the culture of QI in their agency (92%), strengthening to which the agency (92%), and increasing the extent gaps in employee agency has identified and addressed training and workforce development (83%). 8 7 6 7 8 8 9 8 6 1111 92% 92% 10 83% Frequency Anticipate agency will experience accreditation benefit PERCEIVED BENEFITS OF ACCREDITATION AMONG STATE HEALTH AGENCIES WITH PLANS TO APPLY FOR ACCREDITATION, 2016 (N=12) FOR ACCREDITATION, AGENCIES WITH PLANS TO APPLY HEALTH AMONG STATE PERCEIVED BENEFITS OF ACCREDITATION Improve our board of health or governing entity’s knowledge Improve our board of health or governing entity’s roles and responsibilities of our agency’s Strengthen our agency’s relationship with Strengthen our agency’s key partners in other sectors working knowledge of our Increase the public’s roles and responsibilities agency’s Stimulate greater collaboration across departments or units within our agency Increase the extent to which the agency has identified and addressed gaps in employee training and workforce development Increase the extent to which our agency uses evidence-based practices for public health programs and/or business practices financial status (e.g., by making Improve our agency’s agency more efficient or increasing competitiveness for funding opportunities, etc.) Improve our agency’s overall capacity to provide high-quality Improve our agency’s programs and services to our customers Increase the extent to which information from performance management system informs decisions capacity to identify Increase our agency’s and address health priorities Strengthen the culture of QI in our agency Accreditation Benefit Stimulate quality and performance improvement opportunities within our agency TABLE 4.2 TABLE State health agencies that plan to apply for accreditation, that plan to apply for accreditation, State health agencies a similar in e-PHAB were asked but have not yet registered benefits. series of questions about anticipated potential 4.2. State health agencies in Table are displayed Responses that they anticipated experiencing to report were most likely quality and the following accreditation benefits: Stimulating PLANNING AND QUALITY IMPROVEMENT 86 ASTHO Profile ofStateand Territorial Public Health, Volume Four largely decentralizedstateswere nearlytwiceaslikely 2016 thantheywerein2012(29%vs. 12%).Decentralized/ managementplandepartment-wideperformance in (39% vs. 22%),andtohavefullyimplementeda plan department-wide in2016thantheywere2012 management have partiallyimplementedaperformance (see Figure4.8).Statehealthagenciesweremorelikely to percent in2010to752012902016 managementplanincreasedfrom67 performance The percentageofstatehealthagencieswithaformal PERFORMANCE MANAGEMENTSYSTEMS from the PHAB Acronyms and Glossary ofTerms: from thePHABAcronymsandGlossary consensus. Thefollowingdefinitionsareadapted components havebeenrefinedtobetterreflect Over thelastfewyears, thedefinitionsofthesefour measures,performance progressreporting, andQI. up offourcomponents:Performance standards, managementsystemismade A performance services inordertoachievemeasurableimprovements. services the processesunderlyingpublichealthprogramsand appliedto approach (suchasPlan-Do-Check-Act) Quality improvementreferstoaformal,systematic and sharingofsuchinformationthroughfeedback. ofprogressinmeetingstandardsandtargets reporting ofprogressmeansdocumentationand Reporting of immunizedchildren). as“good”or“excellent,”percentage agency services investigations, percentageofclientswhoratehealth of epidemiologistsonstaffcapableconducting goalorobjective(e.g.,thenumber performance outcomes relevanttotheassessmentofanestablished measures orindicatorsofcapacities,processes, measuresareanyquantitative Performance or basedonnational,state,scientificguidelines. be setbybenchmarkingagainstsimilarorganizations, 100% immunizationrateforallchildren).Standardsmay as“good”or“excellent,” rate healthagencyservices 80%ofallclientswho 100,000 populationserved, (e.g.,oneepidemiologistonstaffper performance guidelines thatareusedtoassessanorganization’s standards Performance NOTES 4 Available atwww.phaboard.org/wp-content/uploads/PHAB-Acronyms-and-Glossary-of-Terms-Version-1.0.pdf. PHAB. “Acronyms ofTerms, andGlossary Version 1.0.”AccessedMay16,2017. are objective standards or are objectivestandardsor 4

100% IN PLACEAT STATE HEALTH AGENCIES,2010-2016(N=49) FORMAL PERFORMANCEMANAGEMENTPROGRAM FIGURE 4.8 • 2010 medium (24%)andlarge(19%) states. management planimplementeddepartment-wide than (44%) weremorelikely tohaveaformalperformance and GreatLakes vs. 0%-10%forotherregions).Smallstates other regions(25%donothaveaplanintheMid-Atlantic managementplanthanstatesin a formalperformance of statesintheMid-Atlantic andGreatLakes donothave department-wide (56%vs. 29%).Agreaterpercentage managementplan implemented aformalperformance as centralized/largelycentralizedstatestohavepartially 90% • 2012 80% YES, PARTIALLY IMPLEMENTEDFORSPECIFICPROGRAMS YES, FULLY IMPLEMENTEDFORSPECIFICPROGRAMS 70% YES, PARTIALLY IMPLEMENTEDDEPARTMENT-WIDE • 2016 YES, FULLY IMPLEMENTEDDEPARTMENT-WIDE NO 0%10%20%30%40%50%60% 16% 22% 25% 10% 25% 33% 6% 18% 16% 39% 22% 18% 29% 12% 8% PLANNING AND QUALITY IMPROVEMENT 87 54% 88% 76% 8% 10% 12% 29% 4% 4% 19% 20% 16% 25% 14% 10% 29% 43% 58% 8% 20% 32% 0%10%20%30%40%50%60%70%80%90% LEAN SIX SIGMA BALANCED SCORECARD • 2016 OTHER FRAMEWORK OR APPROACH NO SPECIFIC FRAMEWORK OR APPROACH ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and PLAN-DO-CHECK-ACT OR PLAN-DO-STUDY-ACT PLAN-DO-CHECK-ACT OR • 2012 BALDRIDGE PERFORMANCE EXCELLENCE CRITERIA BALDRIDGE PERFORMANCE EXCELLENCE CRITERIA • 2010 100% FIGURE 4.9 FIGURE FRAMEWORKS OR APPROACHES USED QUALITY IMPROVEMENT (N=48-50) AGENCIES, 2010-2016 HEALTH STATE AT State health agencies indicated that they used a number of The most frequently techniques in their QI efforts in the past year. used techniques were obtaining baseline data (96%), setting measurable objectives (96%), and mapping a process (90%). The percentage of state health agencies using these techniques in 2010, 2012, and 2016 is displayed in Figure 4.10. There was an increase in the use of all techniques from 2010 to 2012 to 2016, with the exception of obtaining baseline data (slight decrease from 2012 to 2016) and setting measurable objectives (remained level from 2012 to 2016). percent of all state health agencies report Forty-seven while 41 percent implementing formal QI programs agency-wide, report implementing formal QI activities in specific programmatic (see Figure 4.11). or functional areas but not agency-wide While the percentage of state health agencies implementing 82% 100% 96% 88% 96% 96% 63% 80% 88% 10% 0% 2% 67% 88% 90% 49% 57% 72% 51% 63% 78% 0%10%20%30%40%50%60%70%80%90% NONE OF THE ABOVE MAPPING A PROCESS OBTAINING BASELINE DATA OBTAINING IDENTIFYING ROOT CAUSES ANALYZING RESULTS OF A TEST RESULTS ANALYZING • 2016 SETTING MEASURABLE OBJECTIVES TESTING EFFECTS OF AN INTERVENTION • 2012 • 2010 100% ELEMENTS OF STATE HEALTH AGENCY QUALITY IMPROVEMENT EFFORTS, AGENCY QUALITY IMPROVEMENT EFFORTS, HEALTH ELEMENTS OF STATE 2010-2016 (N=49-50) FIGURE 4.10 State health agencies engage in a variety of QI frameworks or in a variety of QI frameworks agencies engage State health frameworks commonly used 2016, the three most In approaches. Plan-Do-Check-Act/Plan-Do-Study-Act or approaches were Six Sigma (32%). Figure 4.9 shows the (58%), and (76%), Lean that state health agencies usedQI frameworks or approaches and Six Sigma While use of Lean in 2010, 2012, and 2016. use of to increase over time, frameworks have continued increased from 2010 to Plan-Do-Check-Act/Plan-Do-Study-Act the from 2012 to 2016, though it is still 2012, but then decreased Use of Balanced Scorecard has shown most commonly used. the percentage In addition, over time. a consistent decrease reporting no specific framework orof state health agencies 2010 to 4 percentapproach decreased from 28 percent in in 2016. in 2012, and remained level at 4 percent STATE HEALTH AGENCY QUALITY IMPROVEMENT EFFORTS IMPROVEMENT QUALITY AGENCY HEALTH STATE PLANNING AND QUALITY IMPROVEMENT 88 ASTHO Profile ofStateand Territorial Public Health, Volume Four efforts, andhavearecognition awardforstaffQI excellence. staff onQImethods, have aQIcommitteetocoordinate QI more likely thancentralized/largely centralizedstatestotrain QI (64%).Decentralized/largely decentralizedstateswere coordinate QIefforts(64%),and jobdescriptionsthatinclude through trainingstaffonQImethods (84%),aQIcommitteeto supported orencouragedstaffinvolvementinQIeffortswas In 2016,themostcommonwaysthatstatehealthagencies STAFF INVOLVEMENT INQUALITYIMPROVEMENT regions (17%forWest; 38%-50%forotherregions). specific programmaticorfunctionalareasthanstatesinother Western stateswere lesslikely toreportformalQIactivitiesfor programmatic orfunctionalareasdecreasedfrom2012to2016. the percentageimplementingformalQIactivitiesinspecific formal QIprogramsagency-wide increasedfrom2012to2016, IN PLACEAT STATE HEALTH AGENCIES,2012-2016(N=48-50) ELEMENTS OFFORMAL,AGENCY-WIDE QUALITYIMPROVEMENTPROGRAMS FIGURE 4.12 DESCRIPTION TOMONITORQIWORKTHROUGHOUTTHEAGENCY QI ISINCORPORATED INEMPLOYEEPERFORMANCEAPPRAISALS 100% STAFF MEMBERWITHDEDICATED TIMEASPART OFTHEIRJOB • 2012 QI ISINCORPORATED INEMPLOYEEJOBDESCRIPTIONS QI RESOURCESANDTRAININGOPPORTUNITIES ARE ONGOING BASISTODRIVEIMPROVEMENTEFFORTS • 2016 AGENCY PERFORMANCEDATA ISUSEDONAN AGENCY QICOUNCILOROTHERCOMMITTEE LEADERSHIP DEDICATES RESOURCESTOQI OFFERED TOSTAFF ONANONGOINGBASIS THAT COORDINATES QIEFFORTS AGENCY-WIDE QIPLAN NONE OFTHEABOVE 0%10%20%30%40%50%60%70%80%90% 80% 88% 58% 40% 76% 69% 82% 83% 64% 23% 30% 29% 32% 25% 0% 2% 66% 50% 47% oflargestates). and largestates(75%ofsmallvs. 53%ofmediumand an ongoingbasistodriveimprovementeffortsthanmedium data on (50%). Smallstatesaremorelikely touseperformance coordinates QIeffortsthancentralized/largelycentralizedstates states (77%)haveanagencyQIcouncilorothercommitteethat A greaterpercentageofdecentralized/largelydecentralized QI-monitoring time, whichbothdecreasedovertime. dedicates resourcestoQIandastaffmemberwithdedicated wide QIprogramsincreased, withtheexceptionofleadershipthat basis (76%).From 2012to2016,allelementsofformal, agency- and trainingopportunitiesthatareofferedtostaffonanongoing monitor QIworkthroughouttheagency(80%),andresources member withdedicatedtimeaspartoftheirjobdescriptionto that dedicatesresources(e.g., time, funding)toQI(82%),astaff Figure 4.12,themostcommonelementsinplaceareleadership formal agency-wide QIprogramtheyhaveinplace. Asshownin State healthagenciesrangeintermsofwhichelementsa agencies from2010to2016areshowninFigure4.13 Changes instaffinvolvementQIeffortsatstatehealth incentives, and othermethodsdecreased from 2012to2016. to 2016.Incontrast, trainingstaffonQImethods, monetary goalsallincreased from2012 of employeeperformance excellence, andparticipation inQIeffortsincludedaspart descriptions includingQI, recognition awardsforstaffQI Having aQIcommitteetocoordinate QIefforts, job 100% IMPROVEMENT ACTIVITIES,2012-2016(N=49) NATURE OFSTATE HEALTH AGENCY’SCURRENTQUALITY FIGURE 4.11 • 2012 IMPLEMENTED INSPECIFICPROGRAMMATIC/FUNCTIONAL QUALITY IMPROVEMENTPROGRAMAGENCY-WIDE • 2016 AGENCY’S QUALITYIMPROVEMENTACTIVITIES FORMAL QUALITYIMPROVEMENTACTIVITIES AGENCY ISNOTCURRENTLY INVOLVED IN ARE INFORMALORAD-HOCBYNATURE AGENCY HASIMPLEMENTEDAFORMAL QUALITY IMPROVEMENTACTIVITIES AREAS BUTNOTAGENCY-WIDE .

0%10%20%30%40%50%60%70%80%90% 0% 2% 47% 27% 12% 2% 41% 69% PLANNING AND QUALITY IMPROVEMENT 89 4% 2% 0% 12% 21% 8% 37% 27% 44% 65% 44% 64% 57% 85% 84% 10% 0% 0% 25% 48% 64% 27% 44% 44% 31% 27% 32% 0%10%20%30%40%50%60%70%80%90% OTHER . Use of Figure 4.14 MONETARY INCENTIVES MONETARY JOB DESCRIPTIONS INCLUDE QI JOB DESCRIPTIONS INCLUDE FUNDING TO SUPPORT QI EFFORTS FUNDING TO SUPPORT • 2016 TRAINING TO STAFF ON QI METHODS ON QI STAFF TRAINING TO PART OF EMPLOYEE PERFORMANCE GOALS PART QI COMMITTEE TO COORDINATE QI EFFORTS QI COMMITTEE TO COORDINATE PARTICIPATION IN QI EFFORTS INCLUDED AS IN QI EFFORTS PARTICIPATION ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and • 2012 RECOGNITION AWARD FOR STAFF QI EXCELLENCE FOR STAFF RECOGNITION AWARD DO NOT ACTIVELY ENCOURAGE STAFF INVOLVEMENT ENCOURAGE STAFF DO NOT ACTIVELY • 2010 FIGURE 4.13 FIGURE EFFORTS QUALITY IMPROVEMENT IN INVOLVEMENT STAFF (N=49-50) AGENCIES, 2010-2016 HEALTH STATE AT 100% This chapter has described state health agencies’ accreditation readiness and engagement in QI efforts. The next chapter will focus on the increased use of health information systems and technology in state public health agencies. the guide for priority setting decreased from 61 percent in 2012 to 48 percent in 2016. Changes in state health agencies’ use of The Community Guide from 2010 to 2016 are displayed in 48% 61% 48% 2% 8% 14% 73% 49% 50% 83% 67% 68% 85% 86% 78% 10% 10% 8% 0%10%20%30%40%50%60%70%80%90% OTHER GRANT WRITING PRIORITY SETTING

5 NONE OF THE ABOVE PROGRAM PLANNING POLICY DEVELOPMENT HHS. “The Community Guide: What is that Task Force?” Available at www.thecommunityguide.org/ Available Force?” HHS. “The Community Guide: What is that Task task-force/what-task-force. Accessed June 23, 2017. • 2016 5 • 2012 NOTES • 2010 Established in 1996 by HHS, the Community Preventive Services Community Preventive the in 1996 by HHS, Established interventions population health seeks to identify that areTaskforce and improve increase lifespans, to save lives, scientifically proven force produces recommendations and The task quality of life. ofgaps to help inform the decisionmaking identifies evidence other government and local health departments, state, federal, employers, healthcare providers, communities, agencies, organizations. and research schools, In 2016, state health agencies had most commonly used TheIn 2016, state health the past two years for program planningCommunity Guide in and policy development (50%).(78%), grant writing (68%), decentralized states were more likely Decentralized/largely to use the guide forthan centralized/largely centralized states A greater and priority setting. writing, grant program planning, Midwest (90%)percentage of states in the Mountains and in other regionsused the guide for grant writing than states (percentages ranged from 57% to 68%). USE OF THE COMMUNITY GUIDE COMMUNITY OF THE USE USE OF THE COMMUNITY GUIDE AT STATE HEALTH AGENCIES, HEALTH STATE USE OF THE COMMUNITY GUIDE AT 2010-2016 (N=48-50) FIGURE 4.14 100% HEALTH INFORMATION MANAGEMENT 90 ASTHO Profile ofStateand Territorial Public Health, Volume Four HEALTH INFORMATION MANAGEMENT 91 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and Health information exchange (HIE) Health information exchange 1 HHS. “AboutHealthIT.gov.” Available at www.healthit.gov. at www.healthit.gov. Available HHS. “AboutHealthIT.gov.” Accessed June 8, 2017. HIMSS. “The National Alliance for Health Information Technology Coordinator for Health to the Office of the National Report Information Key Health on Defining Information Technology at: www.himss.org/national-alliance- Available Terms.” Technology health-information-technology-report-office-national-coordinator- health. Accessed June 6, 2017. 1 2 2 As more healthcare providers adopt HIT, public adopt HIT, As more healthcare providers NOTES health agencies will be more likely to exchange data directly to exchange data likely health agencies will be more in forming This increase in data exchange will assist with them. Direct data between the two. and maintaining partnerships parties access to real-time exchange will also grant both which will aid in streamlining the deliveryhealth information, and publicand effectiveness of both healthcare health programs. information on state healthThis chapter includes detailed agencies’ public health information systems and how use of the healthcare system andthey interact electronically with health agency include state Topics other public health entities. leaders who have responsibility for HIE/HIT issues; entities with which state health agencies exchange data and how that data is exchanged; and how state health agencies use HIE There is also a discussion of informatics for specific programs. as well as the program areas for which state office locations, health agencies collect data electronically and their systems to address the Meaningful Use public health objectives. HEALTH INFORMATION INFORMATION HEALTH MANAGEMENT the electronic technology (HIT) supports Health information providers of health information between use and exchange pharmacies, as insurers, as well system, across the healthcare electronic it also includes the use of and public health; health records (EHRs). Chapter 5 Chapter is the electronic movement of health-related informationis the electronic movement of to nationally recognizedamong organizations according standards. HEALTH INFORMATION MANAGEMENT 92 ASTHO Profile ofStateand Territorial Public Health, Volume Four FINDINGS KEY data through an HIE. data throughan HIE. within astatesystem (90%),and20percentcollected collected On average,electronicdatawas mostoften diseases, vitalrecords,andnewborn screeningin2016. All agenciescollecteddataonlab results,reportable data electronicallyhasincreased from2012to2016. The numberofstatehealthagencies thatcollect nosuchofficewithintheiragency.of statesreported centralized atthestatelevel(both12%).Ten percent in separateprogramteamsandofficesthatare There areequalnumbersofinformaticsofficeslocated informatics officesarelocatedwithintheagencyitself. More thanhalf(57%)ofstatehealthagencies’ health agencies. information managementsystems(55%)atstate overall decisionmakingauthorityforpublichealth responsibility fordecisionsregardingHIE(29%)and (or equivalent)mostfrequentlyhaveprimary widely disbursedinstates.Chiefinformationofficers responsibilityfordecisionsregardingHIEis Primary conditions, whichdecreasedby 21percent. ofreportable exception iselectroniccasereporting theone stable forfourofthefiveregistries surveyed; health agencieswithestablished systemsremained objectives. From 2012to2016,thenumberofstate systems tomeetmanyMeaningfulUsepublichealth The majorityofstatehealthagencieshaveestablished with otherstates. clinical providers,and32percentshareddata with otheragencies,49percentshareddata 53percentshareddata local healthdepartments, Sixty-five percentofagenciesshared data with State healthagenciesarealsosharingdata. a careerseriesforinformatics. health agencies(49%)neitherhave,norplanto informatics careerseries,whilearoundhalfofallstate Only 16percentofstatehealthagencieshavean HEALTH INFORMATION MANAGEMENT 22% 33% 22% N/A N/A N/A 2% 35% 41% 29% N/A N/A N/A 14% 10% 4% 0% N/A N/A N/A 2% 20% 16% 4% 8% 2% 10% 4% 4% 16% 0%10%20%30%40%50%60%70%80%90% OTHER INFORMATICS DIRECTOR INFORMATICS CHIEF INFORMATION OFFICER CHIEF INFORMATION FOR STATE OR HEALTH AGENCY OR HEALTH FOR STATE • 2016 WITHIN THE STATE OR GOVERNMENT WITHIN THE STATE (OR EQUIVALENT) FOR MULTIPLE AGENCIES FOR MULTIPLE (OR EQUIVALENT) HIT COORDINATOR OFFICER (OR EQUIVALENT) OFFICER (OR EQUIVALENT) HIT COORDINATOR • 2012 BOARD OR COMMITTEE FOR MULTIPLE AGENCIES BOARD OR COMMITTEE FOR MULTIPLE HIT COORDINATOR OFFICER (OR EQUIVALENT) FOR OFFICER (OR EQUIVALENT) HIT COORDINATOR MULTIPLE AGENCIES WITHIN STATE OR GOVERNMENT AGENCIES WITHIN STATE MULTIPLE CHIEF PUBLIC HEALTH INFORMATICS OFFICER OR CHIEF INFORMATICS CHIEF PUBLIC HEALTH OFFICER (OR EQUIVALENT) FOR STATE OR HEALTH AGENCY OR HEALTH FOR STATE OFFICER (OR EQUIVALENT) BOARD OR COMMITTEE FOR THE STATE OR HEALTH AGENCY OR HEALTH FOR THE STATE BOARD OR COMMITTEE • 2010 100% CHIEF INFORMATION OFFICER OR CHIEF MEDICAL INFORMATION INFORMATION OR CHIEF MEDICAL OFFICER CHIEF INFORMATION MEDICAL INFORMATION OFFICER FOR STATE OR HEALTH AGENCY OR HEALTH STATE OFFICER FOR MEDICAL INFORMATION FIGURE 5.1 FIGURE INFORMATION AUTHORITY FOR HEALTH DECISIONMAKING PRIMARY STATE ISSUES AT TECHNOLOGY INFORMATION HEALTH EXCHANGE OR (N=49) AGENCIES, 2010-2016 HEALTH Note: HIT coordinator officer for state/multiple agencies and chief public health informatics officer only available Survey. in 2016 Profile Centralized/largely centralized states are nearly twice Centralized/largely centralized states are decentralized states as decentralized/largely as likely 24%) have a chief information officer (or (43% vs. equivalent) exercise primary responsibility for HIE/HIT to have a board states are more likely Western issues. or committee exercise primary responsibility for other regions). 0-23% for vs. HIE/HIT issues (43% for West than large A greater percentage of small states (40%) officer states (24%) report that the chief information exercises (or equivalent) for the state health agency Medium states are equally likely primary responsibility. to have either a chief information officer or a board or committee (both 24%). In 2016, 29 percent of state health agencies reported In 2016, 29 percent officer (or equivalent) for that the chief information held primarythe state health agency responsibility In another HIE or HIT issues. for decisions regarding a board or health agencies, 16 percent of state 2010 From committee had primary responsibility. of state health agencies to 2016, the percentage officer (or equivalent) in which a chief information held primary while the responsibility decreased, or committees with primarypercentage of boards As shown in responsibility increased four-fold. SurveyFigure 5.1, the 2016 Profile added three which may explain additional answer options, the the overall decrease in percentages for as responses were spread majority of answers, across more options in 2016. PRIMARY RESPONSIBILITY FOR FOR RESPONSIBILITY PRIMARY EXCHANGE INFORMATION HEALTH HEALTH INFORMATION MANAGEMENT 94 ASTHO Profile ofStateand Territorial Public Health, Volume Four MANAGEMENT SYSTEMS PUBLIC HEALTH INFORMATION DECISIONMAKING AUTHORITYFOR or mediumstates(both47%). decisionmaking authority(71%) compared tosmall chief informationofficer(or equivalent) hasoverall most commonlyreportthatthe statehealthagency’s (23% inSouthvs. 0-17% inotherregions).Large states informatics directorhasdecisionmakingauthority Southern statesaremorelikely toreportthatthe (37% inNewEnglandvs. 0-11% inotherregions). state agenciesexercisesdecisionmakingauthority report thatthechiefinformationofficerformultiple regions, NewEnglandstatesarealsomorelikely to the mostcommondecisionmakingauthorityinall chiefinformationofficer(orequivalent)is agency’s states (71% vs. 48%). Althoughthestatehealth authority thandecentralized/largelydecentralized officer (orequivalent)hasoveralldecisionmaking centralized statesreportthatthechiefinformation A greaterpercentageofcentralized/largely and percentagesin2016(seeFigure5.2). 2016, likely affectingthespreadofresponses additional answeroptionswerealsoaddedin increased from47percentto55percent. Three equivalent) hadoveralldecisionmakingauthority reporting thatthechiefinformationofficer(or 2016, thepercentageofstatehealthagencies information managementsystems. From 2010to decisionmaking authorityforstatepublichealth chief informationofficer(orequivalent)hasoverall In morethanhalfofstatehealthagencies, the INFORMATION MANAGEMENTSYSTEMS,2010-2016(N=49) OVERALL DECISIONMAKINGAUTHORITYFORSTATE PUBLICHEALTH FIGURE 5.2 MEDICAL INFORMATION OFFICERFORSTATE ORHEALTH AGENCY CHIEF INFORMATION OFFICERORCHIEFMEDICALINFORMATION 100% in 2016Profile Survey. chief publichealthinformaticsofficer onlyavailable Note: • 2010 BOARD ORCOMMITTEEFORTHESTATE ORHEALTH AGENCY OFFICER (OREQUIVALENT) FORSTATE ORHEALTH AGENCY Board or committee for state/multiple agencies and Board orcommitteeforstate/multiple agenciesand CHIEF PUBLICHEALTH INFORMATICS OFFICERORCHIEF CHIEF INFORMATION OFFICER(OREQUIVALENT) • 2012 AGENCIES WITHINSTATE ORGOVERNMENT BOARD ORCOMMITTEEFORMULTIPLE • 2016 FOR MULTIPLE AGENCIES INFORMATICS DIRECTOR OTHER 0%10%20%30%40%50%60%70%80%90% 6% N/A N/A 12% 8% 14% 12% 8% 10% 0% N/A N/A 55% 55% 47% 12% 29% 29% 2% N/A N/A HEALTH INFORMATION MANAGEMENT 95 4% 12% 14% 8% N/A 10% 22% 12% 59% 57% 0%10%20%30%40%50%60%70%80%90% OTHER 16% 27% currently has career series an informatics Yes, my agency Yes, No, but my No, career series for an informatics agency is planning AGENCY DOES NOT HAVE CENTRALIZED AT THE STATE LEVEL THE STATE CENTRALIZED AT WITHIN THE STATE HEALTH AGENCY HEALTH STATE WITHIN THE SEPARATE TEAM FOR EACH PROGRAM AREA SEPARATE ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and • 2016 • 2012 100% 8% 49% Other FIGURE 5.3 FIGURE AGENCIES, HEALTH STATE OFFICES AT OF INFORMATICS LOCATION (N=49) 2012-2016 FIGURE 5.4 CAREER SERIES, AGENCIES WITH INFORMATICS HEALTH STATE 2016 (N=49) No, no plan No, career series for an informatics “Agency does not have” only available Note: “Agency Survey. in 2016 Profile In 2016, states were asked whether their public In 2016, states were asked health agencies had a career series specifically agencies Almost half of state health for informatics. nor planned to indicated that they neither had, while only an informatics career series, have, 16 percent of state health agencies indicated that they had an informatics career series (see Figure 5.4). Decentralized/largely decentralized states are more to be in the process of planning for an informatics likely career series than centralized/largely centralized states having an 7%). No New England states report (40% vs. states are and New England informatics career series, a career nor plan to have, to neither have, most likely 29-56% for others). series (75% for New England vs. to have an informatics Southern states are most likely 0-17% for others). vs. for South career series (31% to have an are least likely states (12%) Large informatics career series compared to small (20%) and medium states (18%). An informatics office’s location varies depending on varies depending office’s location An informatics of state In more than half the state health agency. informatics office was located the health agencies, number that has remainedwithin the agency—a 2012 to 2016. During this samelargely constant from located the number of offices however, time period, housed within each programas a separate team that were while the number of offices area decreased, Additionally, level increased. centralized at the state health agencies reported that10 percent of state informatics office in 2016 (seethey did not have an that the it is equally likely states, Figure 5.3). In Western officestate health agency will house the informatics office at allor that they will not have an informatics states (71%)(both 43%). A greater percentage of large the state healthhave informatics offices located within states (53%). agency than small (47%) and medium INFORMATICS CAREER SERIES CAREER INFORMATICS LOCATION OF LOCATION OFFICES INFORMATICS HEALTH INFORMATION MANAGEMENT 96 ASTHO Profile ofStateand Territorial Public Health, Volume Four ELECTRONIC DATA COLLECTIONANDEXCHANGE small vs. 53-88%for mediumandlarge). for mediumandlarge)Medicaid billing(38%for geocoded dataformapping (56%forsmallvs. 94-100% other regions).Smallstatesare muchlesslikely tocollect data onMedicaidbilling(29% forWest vs. 50-85% for for otherregions).Western statesare leastlikely to collect in otherregions(40%forMountains/Midwestvs. 86-100% likely tocollectgeocodeddataformappingthanstates states. StatesintheMountainsandMidwestregionareless (69% vs. 36%)thandecentralized/largelydecentralized EHRs (77%vs. 46%)andonsitewastewatertreatmentdata largely centralizedstatesaremuchmorelikely tocollect centralized states(96% vs. 79%). Incontrast, centralized/ collect environmentalhealthdatathancentralized/largely Decentralized/largely decentralizedstatesaremorelikely to treatment systems(18%increaseforboth). inspections andonsitewastewater data onfoodservice include thepercentageofstatescollectingelectronic Notableincreases increased acrossallareassurveyed. 2016, thenumberofstatescollectingdataelectronically collection in2012.AsshownFigure5.5,from2012to were alsothemostcommonareasforelectronicdata screening. Lab results, reportable disease, andvitalrecords lab results, reportablediseases, vitalrecords, andnewborn health agenciesreportedelectronicdatacollectionfor program-specific informationelectronically. In2016,allstate State healthagenciescollect, receive, andexchange and withother states (80%). often sharedwithotheragencies withinthestate(91%) from federalagencies(96%). Vitalrecordsdatawasmost disease datawasmostcommonly senttoandreceived local healthdepartmentswithin thestate(87%).Reportable was alsomostoftensharedwith clinicalproviders(94%)and reporting andexchangecapacity(76%).Immunizationdata an HIEentity(65%),andithadthemostbidirectional Immunization datawasmostcommonlyreceivedthrough shared datawithotherstates. shared datawithclinicalproviders, and32percent data withotheragencieswithinthestate, 49percent health departmentswithinthestate, 53percentshared average of65percentagenciesshareddatawithlocal from them(56%).Intermsofsharingelectronicdata, an agencies senddatatofederalandreceive data reportingandexchange(35%),abouthalfof agencies havethecapacitytoconductbidirectional and healthsystems. Aroundone-third ofstatehealth health-related informationsecurelybetweenproviders through anHIEentity—asystemdesignedtoshare 20 percentofstatehealthagenciesreceiveddata most oftencollectedwithinastatesystem(90%),and shared (Table 5.1).Onaverage, electronicdatawas further informationonhowthedatawascollectedand gathered on aspecificprogramin2016,the Profile Survey For statehealthagenciesthatdidcollectelectronicdata HEALTH INFORMATION MANAGEMENT 97 % 31% 30% 32% 25% 5 8 8 6 N Agency Sends/ Receives Data to/ from Federal Agencies % 7% 4% 27% 15 48% 20% 20% 16 55% 18% 20 51% 27% 18 55% 24% 22% 22 61% 8 3 2 6 7 9 6 1 8 N Data Shared with Other States % 47% 17% 7 4 N Data Shared with Other Agencies within State % 53% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 8 N Data Shared with Local Health Departments within State % 6% 20% 22 73% 16 53% 21% 26 61% 20 47% 14 33% 34 79% 24% 15 60% 13 52% 6 1 9 6 N Data Shared with Clinical Providers % 9% 18 39% 31 71% 42 91% 36 80% 39 85% 2% 25 56% 38 84% 22 49% 23 51% 43 96% 2% 20 46% 36 84% 24 56% 23 54% 35 81% 7% 31 78% 18 47% 19 48% 4% 37 79% 15 33% 16 34% 10 21% 20 44% 6% 19 56% 21 62% 26 77% 7% 30 68% 34 77% 18 41% 21 48% 33 75% 9% 43 94% 39 87% 33 72% 25 54% 28 62% 9% 15 42% 22 61% 24 67% 11 31% 12 34% 8% 8% 19 53% 24 67% 13 36% 10% 19% 11% 12 44% 13 48% 14 52% 17% 19 63% 19 66% 15 52% 18% 11% 13 34% 31 82% 26 70% 14 39% 26 72% 21% 14 58% 11 46% 4 3 1 1 3 3 5 3 2 2 3 4 3 8 4 2 5 3 N Data Collected Primarily with Local System % N Data Collected Primarily with State System % 19% 28 90% 35% 13 81% 17% 25 83% 20% 32 91% 32% 22 92% 6 6 5 7 8 N Bidirectional Data Reporting and Exchange Capacity % 7% 0% 7% 11 41% 24 89% 7% 5% 4% 11% 19 41% 42 91% 18% 14 32% 42 98% 23% 10 25% 37 93% 13% 15 32% 45 96% 12% 12 36% 31 94% 14% 11 25% 36 82% 11% 10 27% 33 89% 22% 10 28% 33 92% 5 2 8 0 2 2 9 6 4 2 6 4 1 8 N Data Received Through HIE Entity 46 31 46 19 41% 16 36% 44 98% 44 17 27 30 40 47 34 44 23 52% 22 50% 41 93% 37 44 37 25 24 11 46% 13 57% 19 79% 36 Total N PROGRAM AREAS FOR WHICH STATE HEALTH AGENCIES COLLECT DATA ELECTRONICALLY, 2016 ELECTRONICALLY, COLLECT DATA AGENCIES HEALTH STATE FOR WHICH AREAS PROGRAM Water wells Water (licensing and/or testing) Vital records Food service inspections Reportable diseases Outbreak management Onsite wastewater treatment systems Medicaid billing Reproductive health Early hearing detection Newborn screening Healthcare systems data (e.g., bed availability) Laboratory results Immunization 46 30 65% 35 76% 42 91% Geographic-coded data for mapping analysis WIC Environmental health Electronic health record Case management TABLE 5.1 TABLE

HEALTH INFORMATION MANAGEMENT 100 ASTHO Profile ofStateand Territorial Public Health, Volume Four MEANINGFUL USE perform bidirectionaldatareporting andexchange perform on average);however, far lesshadsystemsthatcurrently Meaningful Use-compliantmessages fromEHRs(81% of statehealthagencieshad systemsthatreceived and exchange(seeTable 5.2).In2016,alargemajority collected additionalinformation ondatareceipt, reporting, States withMeaningfulUseobjectives systemsalso 71-82% forothers). (93%forsmallvs.electronic syndromicsurveillance for others).Smallstatesaremostlikely tohavesystemsfor 77-86% reporting ofreportableconditions(59%forlargevs. states areleastlikely tohavesystemsforelectroniccase had immunizationandpublichealthregistries, butlarge 17-33% forotherregions).Additionally, alllargestates data registries(46%forMid-Atlantic/Great Lakes vs. and GreatLakes aremostlikely tohavesystemsforclinical 57-86% forotherregions),whilestatesintheMid-Atlantic of reportableconditions(90%forMountains/Midwestvs. most likely tohavesystemsfortheelectroniccasereporting regions). StatesintheMountainsandMidwestregionare (57%forWestsyndromic surveillance vs. 80-92%forother Western statesareleastlikely tohavesystemsforelectronic (85% vs. 62%),andclinicaldataregistries(33%vs. 24%). vs. 73%),electroniccasereportingofreportableconditions (92% have systemsforelectronicsyndromicsurveillance Centralized/largely centralizedstatesaremorelikely to (100% vs. 77%)thancentralized/largelycentralizedstates. registries (100%vs. 85%)andpublichealthregistries to haveMeaningfulUsesystemsrelatedimmunization Decentralized/largely decentralizedstatesaremorelikely decreased by21percent. electronic casereportingofreportableconditions, which theoneexceptionisfor of thefiveregistriessurveyed; agencies withestablishedsystemsremainedstableforfour registries. From 2012to2016,thenumberofstatehealth while only30percentofstateshadsystemsforclinicaldata results, had systemsforelectronicreportablelaboratory public healthobjectives. In2016,allstatehealthagencies agencies havesystemsinplacetoaddressMeaningfulUse As showninFigure5.6,themajorityofstatehealth receipt andexchangeofdatawiththeprovidercommunity. requires apublichealthinfrastructurethatcansupportthe health. ImplementingMeaningfulUseofEHRsbyproviders coordination amongproviders, andimprovepopulation to advancehigh-qualitycare, reducecosts, facilitatecare Clinical Health(HITECH)ActpromotesusingEHRsandHIEs The HealthInformationTechnology forEconomicand and exchange (81%). bidirectionaldatareporting were mostlikely toperform messages fromEHRs. Additionally, immunization registries systems mostlikely toreceiveMeaningful Use-compliant systems(97%)were the electronic syndromicsurveillance (45% onaverage).Immunization registries(98%)and 100% 2012-2016 (N=46-49) EXISTENCE OFSYSTEMSFORMEANINGFULUSEOBJECTIVES, FIGURE 5.6 laboratory communicable disease reports” in 2012. in2012. communicablediseasereports” laboratory resultswaslabeled“electronic electronic reportablelaboratory in2012; waslabeled“cancerregistry” public healthregistry “electronic communicablediseasereportingsystem”in2012; electronic casereportingofreportableconditionswaslabeled Note: • 2012 ELECTRONIC CASEREPORTING OFREPORTABLE CONDITIONS PUBLIC HEALTH REGISTRY (INCLUDINGCANCERREGISTRY) Clinical data registry only available in 2016 Profile Survey; onlyavailablein2016Profile Survey; Clinical dataregistry ELECTRONIC SYNDROMICSURVEILLANCE SYSTEM ELECTRONIC REPORTABLE LABORATORY RESULTS • 2016 CLINICAL DATA REGISTRY IMMUNIZATION REGISTRY OTHER REGISTRY 0%10%20%30%40%50%60%70%80%90% 96% 98% 82% 81% 100% 96% 30% N/A 73% 94% 94% 96% 56% 57% HEALTH INFORMATION MANAGEMENT 101 % 33% 67% 4 2 N System Currently Performs Bidirectional Data Reporting and Exchange % 69% 67% 9 2 N ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and Meaningful Use-Compliant Messages from EHRs % 56% N 9 5 4949 4949 47 100%49 46 42 96%48 40 94% 88% 4546 35 82% 34 17 98% 14 73% 37 76% 38% 35 30% 24 97% 12 81% 69% 13 27% 12 35% 36% Total NTotal Agency has System System Receives MEANINGFUL USE OBJECTIVES, 2016 This chapter focused on the electronic use and exchange of health information between providers across multiple systems. This chapter focused on the electronic use and exchange of health information between receive and attention will turn to state health agency finance and how agencies In the next and final chapter of this section, distribute funds to improve public health. Electronic reportable laboratory results Immunization registry Public health registry (including cancer registry) Electronic syndromic surveillance system Electronic case reporting of reportable conditions Clinical data registry Other registry TABLE 5.2 TABLE STATE HEALTH AGENCY FINANCE 102 ASTHO Profile ofStateand Territorial Public Health, Volume Four STATE HEALTH AGENCY FINANCE 103 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and STATE HEALTH HEALTH STATE FINANCE AGENCY health agencies chapters describe how state Previous the public health servicesare organized, activities and responsible for and the workforce they provide, improving the nation’s public safeguarding and This chapter describes how public health health. Individual state health agencies use this is funded. and inform information to conduct comparisons including stakeholders, a broad array of partners and policymakers, federal grantmakers, and foundations. In 2016, ASTHO state health agencies to report asked and dollars distributed to expenditures, on revenues, and nonprofit local and regional health agencies This chapter fiscal years. organizations for the prior two funding sources, describes state health agency and the dollars distributed to health expenditures, organizations agencies and community-based examines primarily for 2014 and 2015, and Information years. differences between these two purposes from prior years is used for comparison as some definitions have changed when applicable, ASTHObetween survey states also asked iterations. to provide more detailed information on sources of federal funding they received in 2014 and 2015. Not expenditure, all states provided values for all revenue, each table Therefore, or organization categories. and figure below includes a note with the number of states that responded to the question. Chapter 6 Chapter STATE HEALTH AGENCY FINANCE 104 ASTHO Profile ofStateand Territorial Public Health, Volume Four FINDINGS KEY categories, and contract partners. categories, andcontractpartners. sources offunding,expenditure intermsoffundingpatterns, States vary organizations (40%). health agencies(42%)andnonprofit distributed toindependentlocal contracts, grants,andawardswere one-third ofstatehealthagency governmental entities.Morethan nonprofit organizations,andother health agencies,tribal and awardstolocalregional/district budgets) throughcontracts,grants, $6 billion(about20%oftheirtotal agencies distributedapproximately In both2014and2015,statehealth careandWIC. services/consumer largest spendingcategorieswereclinical vital statistics,andhealthdata.Thetwo health laboratory, prevention, injury chronicdisease, of healthservices, care,quality clinical services/consumer increases intotalexpendituresfor Between 2014and2015,therewere and 2015was$84. for thestatesand D.C. in both2014 The medianpercapitaexpenditure from CDC(16%). 2015 andthenexthighestpercentage nearly half(45%)comingfromUSDA for originates fromavarietyofsources,with exceeded $14.3billion. Federal funding health agencyfederalrevenuefor2015 2014 wasjustover$14billion, whilestate State healthagencyfederalrevenuefor from statefunds. was federal funds,whileone-quarter health agencyrevenuein2015wasfrom respectively. Nearlyhalf(48%)ofstate of $307millionand$280million, and 2015,withmeanstaterevenues state healthagencyrevenuefor2014 Federal fundswerethelargestsourceof state funds. funds, feesandfines,other decreases intotalrevenueforfederal Between 2014and2015,therewere 2014 ($30.8billion)to2015($28.6billion). decreased by$2.2billion(7.7%)from State healthagencytotalrevenue STATE HEALTH AGENCY FINANCE 105 $15,055 $13,704 $1,863 $1,848 $2,718 $2,788 $6,684 $7,047 $4,459 $3,205 $0 FEES AND FINES FEDERAL FUNDS OTHER SOURCES OTHER STATE FUNDS OTHER STATE $2,000 STATE GENERAL FUNDS STATE Includes tobacco settlement funds, payment Includes tobacco settlement funds, for direct clinical services (except Medicare and foundation and other and Medicaid), private donations. Includes revenues received from the state that are not from the state general fund. Includes revenues received from state general Includes revenues received operations. revenue funds to fund state funds. Excludes federal pass-through contracts, Includes all federal grants, and cooperative agreements. Includes fines, regulatory fees, and laboratory fees. Data not available for 2012 and 2013. $4,000 ASTHO Profile of State and Territorial Public Health, Volume Four Public Health, Volume ASTHO Profile of State and Territorial Note: $6,000 Other sources Other state funds State general funds funds Federal and fines Fees Funding Source Descriptions Funding TABLE 6.1 TABLE DESCRIPTIONS FUNDING SOURCE 2015 $28.6 $8,000 2014 $30.8 $10,000 2013 2012 $12,000 2011 $28.1 2010 $26.7 TOTAL STATE HEALTH AGENCY REVENUE FOR 2014 AND 2015 BY SOURCE OF FUNDING, IN MILLIONS (N=49) HEALTH STATE TOTAL $14,000 • 2015 Not all states provided values for $30.1 2009 Note: 43-49). all revenue sources (range: • 2014 2008 $29.1 TOTAL STATE HEALTH AGENCY REVENUE, IN BILLIONS, 2008-2015 (N=46-49) IN BILLIONS, 2008-2015 AGENCY REVENUE, HEALTH STATE TOTAL FIGURE 6.1 State health agencies were asked to report revenue to report were asked State health agencies 6.1 by funding source (see Table for 2014 and 2015 displayed in are sources). Results for definitions of funding 7.7 percent decline in funding, Figure 6.2. Despite the overall and in total revenue for state general funds there were increases in 2014 and 2015 (funding not included other sources between settlement funds, tobacco e.g., the federal or state categories; payment for direct clinical services other than Medicare and and other private donations). foundation Medicaid, State health agency total revenue has fluctuated over has fluctuated agency total revenue State health 2015 (see to $28.6 billion in $29.1 billion in 2008 from time, seen between 2009 and 2010, Figure 6.1). The largest dip was revenue decreased by $3.4 billion. when state health agency FIGURE 6.2 STATE HEALTH AGENCY REVENUE AGENCY HEALTH STATE $16,000 STATE HEALTH AGENCY FINANCE 106 ASTHO Profile ofStateandTerritorial Public Health,Volume Four funding bygovernanceclassification, region, orsize. noteworthy differencesinpercent ofstateorfederal to statefundsbyagencycharacteristic, thereareno revenue. Whencomparingreliance onfederalfunds funding accountsfor40percent ormoreoftheirtotal within thisrange. Inamajorityofstates(80%),federal as ahistogram, whichshowshowstatesaredistributed distribution offederalfundingispresentedinFigure6.6 agencies receivefromfederalandstatesources. The and maximumpercentageoffundsthatstatehealth between states. Table 6.2presentsthemedian, minimum, approaches 50percentacrossstates, thisproportionvaries Although thefederalproportionofhealthagencyrevenue significantly from2014($307million)to2015($280million). received bystatehealthagencies, whichhasdecreased depicts theaveragedollaramountoffederalfunding federal fundingsourcesfrom2008to2015.Figure6.5 to 2015.Figure6.4depictsthepercentageofrevenuefrom federal funding, whichhasalsofluctuatedfrom2008 from SHAs receivebetween44-54percent oftheirtotalrevenue BY FUNDINGSOURCEFOR2015(N=44-49) PERCENTAGE OFSTATE HEALTH AGENCYREVENUE FIGURE 6.3 was fromothersources(seeFigure6.3). one-quarter wasfromstategeneralfunds, and10percent health agencyrevenuein2015wasfromfederalfunds, not fromthestategeneralfund).Nearlyhalf(48%)of state funds(i.e., revenuesreceivedfromthestatethatare total revenueforfederalfunds, feesandfines, andother Conversely, from2014to2015,thereweredecreasesin Other statefunds State generalfunds sources (range: 44-49). Note: Fees andfines 11% 6% 25% Not all states provided values for all revenue Not allstatesprovidedvaluesforrevenue Other sources 10% Federal funds 48%

FIGURE 6.5 2008-2015 (N=46-49) PERCENTAGE OFSTATE HEALTH AGENCYREVENUEFROMFEDERALFUNDS, FIGURE 6.4 PERCENTAGE OFFEDERALVERSUSSTATE FUNDING,2015(N=49) TABLE 6.2 IN MILLIONS,2008-2015(N=46-49) AVERAGE FEDERALFUNDINGREVENUEFORSTATE HEALTH AGENCIES, $282 2008 2008 MEDIAN MAX MIN 44% $295 2009 2009 47% $298 2010 2010 54% 84.62% 24.30% 52.23% Federal Note: Note: 53% $306 2011 2011 Data notavailablefor2012and2013. Data notavailablefor2012and2013. 2012 2012 2013 2013 74.87% 13.29% 34.93% State $307 49% 2014 2014 $280 2015 2015 48% STATE HEALTH AGENCY FINANCE 107 100% 80% 60% ASTHO Profile of State and Territorial Public Health, Volume Four Public Health, Volume ASTHO Profile of State and Territorial 40% 2015 Federal Funding Proportion of SHA Budget Proportion Funding Federal 20% DISTRIBUTION OF FEDERAL FUNDING, 2015 (N=49)

8 6 4 0 2

10 Number of States of Number FIGURE 6.6 $63 $20 $0 $810 $63 $25 $0 $896 $41 $13 $0 $786 $40 $14 $0 $749 $99 $16 $0 $2,066 $71 $14 $0 $1,263 $307 $197 $25 $1,816 $280 $180 $26 $1,822 $136 $53 $4 $1,443 $144 $58 $4 $1,506 MEAN MEDIAN MIN MAX MEAN MEDIAN MIN MAX 2014 AVERAGE STATE HEALTH AGENCY REVENUE BY SOURCE OF FUNDING FOR 2014 AND 2015, IN MILLIONS (N=49) AGENCY REVENUE BY SOURCE OF FUNDING HEALTH STATE AVERAGE Not all states provided values for all Other sources Fees and fines Federal funds Other state funds State general funds revenue sources (range: 43-49). revenue sources (range: Note: TABLE 6.3 TABLE presents the mean, median, median, 6.3 presents the mean, Table revenue for and maximum minimum, For 2014 and 2015 by source of funding. all sources of funding for both fiscal years, in some the mean exceeds the median, indicating cases by a substantial amount, that several state health agencies with particularly high revenues from specific the mean. (increased) sources skewed STATE HEALTH AGENCY FINANCE 108 ASTHO Profile ofStateand Territorial Public Health, Volume Four FIGURE 6.7 FEDERAL REVENUE federal revenuefor2015exceeded$14.3billion. Asshown for 2014wasjustover$14billion, whilestatehealthagency from HRSAandEPA. Statehealthagencyfederalrevenue decreases intotalfederalrevenuebetween2014and2015 Housing andUrbanDevelopment).However, therewere of Energy, DepartmentofTransportation, Departmentof Security (DHS),andotherfederalsources(e.g., Department Medicaid, HHS, Medicare, theDepartmentofHomeland were increasesintotalfederalrevenuefromUSDA, CDC, the largestsinglesource. Between2014and2015,there variety ofsources, withfundingfromUSDAstandingoutas As showninFigure6.7,federalfundingoriginatesfroma $7,000 revenue sources(range: 48-50). Note: • 2014 Not all states provided values for all federal Not allstatesprovidedvaluesforfederal STATE HEALTH AGENCYFEDERALREVENUEBYSOURCEFOR2014AND2015,INMILLIONS (N=48-50) • 2015 $6,000 $5,000 $4,000 skewed (increased)themean. particularly highfederalrevenuesfromspecificsources amounts, indicatingthatseveralstatehealthagencieswith or exceededthemedians, insomecasesbysubstantial funding. Aswithallsourcesoffunding, themeansequaled maximum federalrevenuefor2014and2015bysourceof Table 6.4presentsthemean, median, minimum, and highest percentagecamefromCDC(16%). total federalrevenuein2015wasfromUSDA; thenext in Figure6.8,nearlyhalf(45%)ofstatehealthagencies’ $3,000 $2,000 OTHER FEDERALSOURCES $1,000 MEDICARE MEDICAID USDA HRSA CDC DHS HHS EPA $0 $96 $228 $1,504 $1,529 $6,484 $6,406 $104 $4 $1,133 $1,121 $2,299 $2,142 $2,003 $1,888 $127 $116 $628 $576 STATE HEALTH AGENCY FINANCE 109 HRSA USDA CDC Medicaid HHS Medicare DHS EPA Other federal funding sources ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 2015 45% 16% 14% 1O% 8% 1% 1% 1% 4% Not all states provided values for all federal revenue sources (range: 48-50). Not all states provided values for all federal revenue sources (range: Note: $6 $1 $0 $112 $2 $1 $0 $19 $0 $0 $0 $1 $4 $0 $0 $94 $4 $2 $0 $16 $4 $2 $0 $22 $14 $5 $0 $176 $15 $5 $0 $184 $51 $2 $0 $1,132 $57 $3 $0 $940 $32 $19 $0 $153 $31 $17 $0 $156 $27 $7 $0 $286 $26 $6 $0 $269 $45 $34 $0 $173 $48 $40 $0 $261 $139 $85 $0 $1,096 $141 $94 $0 $1,075 MEAN MEDIAN MIN MAX MEAN MEDIAN MIN MAX 2014 AVERAGE STATE HEALTH AGENCY FEDERAL REVENUE BY SOURCE OF FUNDING FOR 2014 AND 2015, IN MILLIONS (N=50) AGENCY FEDERAL REVENUE BY SOURCE OF FUNDING FOR 2014 AND 2015, IN MILLIONS HEALTH STATE AVERAGE Other federal funding sources EPA DHS USDA Medicare Medicaid HRSA HHS CDC TABLE 6.4 TABLE FIGURE 6.8 FIGURE FOR 2015 (N=50) BY FUNDING SOURCE AGENCY FEDERAL REVENUE HEALTH OF STATE PERCENTAGE STATE HEALTH AGENCY FINANCE 110 ASTHO Profile ofStateand Territorial Public Health, Volume Four STATE HEALTH AGENCY EXPENDITURES TABLE 6.5 in 2015.For allrespondents, meanpercapitaexpenditures were approximately$30.8billionin2014and$28.6 expenditure categories).Statehealthagencytotalexpenditures (seeTable 6.5fordefinitionsof 2015 byexpensecategory state healthagenciestoreportexpendituresfor2014and asked In additiontocataloguingsourcesoffunding, ASTHO Other Administration Vital statistics Health laboratory Health data Quality ofhealthservices and response All-hazards preparedness care services/consumer Clinical Environmental health WIC preventionInjury Infectious disease Chronic disease EXPENDITURE CATEGORY DESCRIPTIONS Includes forensicexaminationandinfrastructure fundstolocalpublichealthagencies. payment reformandbenefitreform. such asparticipationinstatehealthplan reformandfederaleffortssuchashealthadvisorycommittees, well as management. Alsoincludesexpensesrelated tohealthreformandpolicy(onlyiftheyarenotalreadyembeddedinprogram areas), communications, legalaffairs,contracting,accounting,purchasing,procurement, generalsecurity, parking,repairs,andfacility and finance,inadditiontoindirectcostssuchasbuilding-related(e.g.,rent, supplies,maintenance,andutilities),budget, technology, information Includes allcostsrelatedtodepartmentmanagement,executiveoffice(statehealth official),humanresources, reports, andcustomerserviceatthestatelevel. Includes allcostsrelatedtovitalstatisticsadministration,includingrecordsmaintenance, reproduction,generatingstatistical administration, building-relatedcosts,andsupplies. Includes costsrelatedtoadministrationofthestatehealthlaboratory, includingchemistrylab,microbiologylaboratory statistics analysis),monitoringofdiseaseandregistries,childhealth accidentsandinjuries,deathreporting. Includes surveillanceactivities,datareportsandcollectionscosts,reportproduction, analysisofhealthdata(includingvital the healthagency, providerandfacilityqualityreporting,institution complianceaudits.Alsoincludesfinancingactivities. administered bythehealthagency, physicianandproviderloanprogram, icensingboardsandoversightadministeredby mammogram), regulationofemergencymedicalsystemsuchastraumadesignation,health-relatedboardsorcommissions Includes qualityregulatoryprogramssuchashealthfacilitylicensureandcertification,equipment(e.g.,x-ray, clinics andpointsofdistribution/PODs). with responsesuchasshelters,emergencyhospitalsandclinics,distributionofmedicalcountermeasures(vaccination Includes disasterpreparednessprograms,bioterrorism,andpreparationresponse,includingcostsassociated family planningdirectservices),refugeepreventivehealthprograms,studentservices,andearlychildhoodprograms. emergency healthservices,geneticstateassistancetolocalclinics(e.g.,prenatal,childhealth,primarycare, family planningeducationandabstinenceprograms,chronicrenaldisease,breastcervicalcancertreatment,TB Alzheimer’s disease,adultdaycare,medicallyhandicappedchildren,AIDStreatment,pregnancyoutreachandcounseling, Includes allclinicalprogramssuchasfundsforIndianhealthcare,accesstocare,pharmaceuticalassistanceprograms, service inspectionsandlodginginspections. swimming) waterandwastedisposalsystems,pesticideregulationdisposal,nuclearpowersafety. Alsoincludesfood hazardous materialstraining,radon,waterqualityandpollutioncontrol(includingsafedrinkingwater, fishingadvisories, Includes leadpoisoningprograms,non-pointsourcepollutioncontrol,airquality, solidandhazardouswastemanagement, Includes allexpendituresrelatedtotheWICprogram,includingnutritioneducationandvoucherdollars. child abuseprevention,occupationalhealth,safeschools,andboatingrecreationalsafety. defensive driving,highwaysafety, mineandcavesafety, onsitesafetyandhealthconsultation,workplaceviolenceprevention, Includes childhoodsafetyandhealthprograms,consumerproductsafety, firearmsafety, fireinjuryprevention, veterinary diseasesaffectinghumanhealth,andhealtheducationcommunicationsrelatedtoinfectiousdisease. Includes immunizationprograms(includingthecostofvaccineandadministration),infectiousdiseasecontrol, includes safeanddrug-freeschools,healtheducationrelatedtochronicdisease,nutrition(excludingWIC). abuse prevention.Includesprogramssuchasdiseaseinvestigation,screening,andoutreachhealtheducation.Also Includes chronicdiseasepreventionsuchasheartdisease,cancer, tobaccopreventionandcontrolprograms,substance Expenditure Category Descriptions Expenditure Category responding statesandD.C. on spendingrange, aredisplayedinFigure6.9forall 2015. Per capitaexpendituresfor2015,categorizedbased expenditures weresomewhatlowerat$84forboth2014and were $105for2014and$1002015.Medianpercapita STATE HEALTH AGENCY FINANCE 111 $151-$200 $201+ NO DATA ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 2015 $1-$50 $51-$100 $101-$150 FIGURE 6.9 EXPENDITURES FOR 2015 (N=49) MAP OF PER CAPITA in centralized/largely centralized states, whereas only the in centralized/largely centralized states, health departmentstate health agency contribution to local decentralizedexpenditures is included in decentralized/largely higher freestanding health agencies have Similarly, states. thataverage per capita expenditures than agencies are under a larger agency. $97 $77 $42 $234 $87 $78 $36 $189 $88 $72 $33 $250 $84 $68 $28 $209 $110 $93 $33 $405 $109 $93 $28 $361 $143 $118 $59 $405 $133 $115 $65 $361 $105 $84 $33 $405 $100 $84 $28 $361 MEAN MEDIAN MIN MAX MEAN MEDIAN MIN MAX 2014 PER CAPITA EXPENDITURES BY GOVERNANCE CLASSIFICATION AND STRUCTURE FOR 2014 AND 2015 (N=49) EXPENDITURES BY GOVERNANCE CLASSIFICATION PER CAPITA by structure and governance classification. 6.6 by structure and governance classification. Table Under larger agency Freestanding Decentralized/largely decentralized Centralized/largely centralized States and D.C. The mean, median, minimum and maximum per median, The mean, displayed are capita expenditures for all states and D.C. in Centralized/largely structure and governance classification. capita expenditurescentralized states have higher average per This is due than decentralized/largely decentralized states. to local health department expenditures that are included TABLE 6.6 TABLE STATE HEALTH AGENCY FINANCE 112 ASTHO Profile ofStateand Territorial Public Health, Volume Four FIGURE 6.10 statistics, injury prevention, statistics, andhealthdataaccountedforthe injury care(24%)andWIC(19%).Vital from clinicalservices/consumer other. In2015, thegreatestpercentageofexpenditurescame diseases, environmentalhealth, all-hazardspreparedness, and between 2014and2015forWIC, administration, infectious data. Conversely, thereweredecreasesintotalexpenditures prevention,health laboratory, vitalstatistics, injury andhealth consumer care, qualityofhealthservices, chronicdisease, there wereincreasesintotalexpendituresforclinicalservices/ 2014 and2015byexpensecategory. Between2014and2015, Figure 6.10showstotalstatehealthagencyexpendituresfor $8,000 expenditure categories(range: 36-49). Note: • 2014 Not all states reported values for all Not allstatesreportedvaluesfor $7,000 STATE HEALTH AGENCYEXPENDITURESBYEXPENSECATEGORY FOR2014AND2015,IN MILLIONS (N=49) • 2015 $6,000 $5,000 $4,000 categories skewed (increased)themean. agencies withparticularlyhighexpendituresfromspecific substantial amounts, indicatingthatseveralstatehealth categories exceededthemedians, insomecases by category. Onceagain, themeansforallexpenditure maximum expendituresfor2014and2015byexpense Table 6.7presentsthemean, median, minimum, and spent oneachofthethreecategories(seeFigure6.11). lowest expenditures, withonly1percentoftotalexpenditures $3,000 $2,000 CLINICAL SERVICES/CONSUMER CARE QUALITY OFHEALTH SERVICES ALL-HAZARDS PREPAREDNESS ENVIRONMENTAL HEALTH $1,000 HEALTH LABORATORY INFECTIOUS DISEASE INJURY PREVENTION CHRONIC DISEASE ADMINISTRATION VITAL STATISTICS HEALTH DATA OTHER WIC $0 $5,440 $6,980 $3,311 $4,272 $1,893 $1,688 $2,033 $2,189 $210 $197 $708 $684 $181 $170 $224 $221 $2,587 $2,584 $1,059 $1,173 $3,147 $3,226 $6,872 $6,428 $927 $966 STATE HEALTH AGENCY FINANCE 113 Other All-hazards preparedness Health laboratory Injury prevention Vital statistics Health data 3% 2% 1% 1% 1% 12% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 2015 Clinical services/consumer care WIC Administration Quality of health services Infectious disease Chronic disease Environmental health

24% 19% 11% 9% 7% 7% 4% Not all states provided values for all expenditure categories (range: 36-49). Not all states provided values for all expenditure categories (range: Note: $4 $2 $0 $18 $4 $2 $0 $19 $4 $3 $0 $23 $4 $3 $0 $24 $5 $2 $0 $44 $5 $1 $0 $46 $14 $10 $0 $112 $15 $10 $0 $109 $20 $13 $0 $84 $19 $11 $0 $81 $24 $10 $0 $305 $22 $10 $0 $165 $34 $17 $1 $224 $39 $17 $2 $225 $45 $28 $2 $250 $41 $25 $3 $253 $57 $17 $0 $978 $57 $17 $0 $972 $67 $19 $0 $2,172 $66 $20 $0 $2,055 $115 $17 $0 $1,931 $92 $14 $0 $1,157 $142 $87 $0 $1,333 $113 $83 $0 $812 $143 $56 $0 $1,317 $153 $68 $0 $1,717 MEAN MEDIAN MIN MAX MEAN MEDIAN MIN MAX 2014 Not all states reported values for all expenditure categories (range: 36-49). categories (range: Note: Not all states reported values for all expenditure AVERAGE STATE HEALTH AGENCY EXPENDITURES BY EXPENSE CATEGORY FOR 2014 AND 2015, IN MILLIONS (N=49) AGENCY EXPENDITURES BY EXPENSE CATEGORY HEALTH STATE AVERAGE Other Health data Vital statistics Injury prevention Health laboratory All-hazards preparedness Environmental health Chronic disease Infectious disease Quality of health services Administration WIC Clinical services/consumer care PERCENTAGE OF STATE HEALTH AGENCY EXPENDITURES BY EXPENSE CATEGORY FOR 2015 (N=49) BY EXPENSE CATEGORY AGENCY EXPENDITURES HEALTH OF STATE PERCENTAGE FIGURE 6.11 FIGURE TABLE 6.7 TABLE STATE HEALTH AGENCY FINANCE 114 ASTHO Profile ofStateand Territorial Public Health, Volume Four local healthagencies, independentregionalordistrict were slightdecreasesindollarsdistributedtoindependent agencies, andnonprofitorganizations. Conversely, there state-run regionalordistricthealthoffices, tribalhealth in dollarsdistributedtostate-runlocalhealthagencies, awards. Between2014and2015,therewereslightincreases approximately $6.1billionthroughcontracts, grants, and both 2014and2015,statehealthagenciesdistributed departments andcommunity-based organizations. In distributed viacontracts, grants, andawardstolocalhealth asked statehealthagenciestoreportdollars ASTHO AND COMMUNITY-BASED ORGANIZATIONS FOR2014AND2015,INMILLIONS(N=33) FIGURE 6.12 DEPARTMENTS ANDCOMMUNITY-BASED ORGANIZATIONS STATE AGENCY CONTRACTS,GRANTS,ANDAWARDS TOLOCAL HEALTH $3,000 • 2014 all organizations(range: 20-33). Note: Not all states provided values for Not allstatesprovidedvaluesfor STATE HEALTH AGENCYCONTRACTS,GRANTS,ANDAWARDS DISTRIBUTEDTOLOCALHEALTH DEPARTMENTS • 2015 $2,500 $2,000 $1,500 (See (58%) ofstatehealthagencycontracts, grants, andawards. local healthdepartments, receivedthegreatestproportion both state-runlocalhealthdepartmentsandindependent oflocalhealthdepartments, including combined category nonprofit organizations(42%and40%,respectively).The distributed toindependentlocalhealthagenciesand of statehealthagencycontracts, grants, andawardswere Figure 6.12 health offices, andothergovernmententities(see Table 6.8 INDEPENDENT REGIONALORDISTRICTHEALTH OFFICES STATE-RUN REGIONALORDISTRICTHEALTH OFFICES $1,000 ). Asshownin fordefinitionsoforganizationtypes.) INDEPENDENT LOCALHEALTH AGENCIES STATE-RUN LOCALHEALTH AGENCIES OTHER GOVERNMENTAL ENTITIES Figure 6.13 NONPROFIT ORGANIZATIONS $500 TRIBAL HEALTH AGENCIES , morethanone-third $0 $2,407 $2,300 $337 $377 $14 $19 $2,523 $2,642 $134 $143 $993 $979 $432 $401 STATE HEALTH AGENCY FINANCE 115 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and Tribal health agencies Tribal State-run local health agencies Nonprofit organizations Independent local health agencies State-run regional or district health offices Independent regional or district health offices Other government entities 16% 42% 7% 2% 0.24% 40% 6% Not all states provided values for all organizations (range: 20-33). Note: Not all states provided values for all organizations (range: PERCENTAGE OF STATE HEALTH AGENCY CONTRACTS, GRANTS, AND AWARDS DISTRIBUTED TO LOCAL HEALTH DEPARTMENTS DEPARTMENTS DISTRIBUTED TO LOCAL HEALTH AGENCY CONTRACTS, GRANTS, AND AWARDS HEALTH OF STATE PERCENTAGE FOR 2015, IN MILLIONS (N=33) ORGANIZATIONS AND COMMUNITY-BASED FIGURE 6.13 STATE HEALTH AGENCY FINANCE 116 ASTHO Profile ofStateand Territorial Public Health, Volume Four TABLE 6.8 2014 and2015. Onceagain, themeansforall organizations departments andcommunity-based organizationsfor through contracts, grants, andawards tolocalhealth maximum dollarsthatstatehealth agenciesdistributed Table 6.9 Other governmental entities Nonprofit organizations Tribal health agencies healthoffices Independent regional ordistrict healthoffices regional ordistrict State-run Independent localhealthagencies localhealthagencies State-run Contracts, Grants,andAwardsRecipient Type Descriptions presentsthemean, median, minimum, and CONTRACTS, GRANTS,ANDAWARDS RECIPIENTTYPEDESCRIPTIONS health officesthatareledbynon-stateemployees. Includes expenditurespassedthroughthestatehealthagencytoregionalordistrictpublic health officesthatareledbystateemployees. Includes expenditurespassedthroughthestatehealthagencytoregionalordistrictpublic that areledbystaffemployedlocalgovernment. Includes expenditurespassedthroughthestatehealthagencytolocalpublicagencies that areledbystaffemployedstategovernment. Includes expenditurespassedthroughthestatehealthagencytolocalpublicagencies such aspublicschools,parksandrecreation,safety. Includes expenditurespassedthroughthestatehealthagencytoother governmentalentities as community-basedorganizations. Includes expenditurespassedthroughthestatehealthagencytononprofit organizationssuch Includes expenditurespassedthroughthestatehealthagencytotribal publichealthagencies. from 2014to2015. (increased) themean. Spending wasfairlyconstant with particularlyhighexpenditures tovariousentitiesskewed amounts, indicatingthatseveral statehealthagencies exceeded themedians, insome casesbysubstantial STATE HEALTH AGENCY FINANCE , Insular Areas 2015 Not all states provided values for all organizations (range: 20-33). (range: Not all states provided values for all organizations Note: $7 $0 $0 $59 $7 $0 $0 $61 $12 $6 $0 $66 $11 $8 $0 $63 $74 $39 $0 $714 $80 $45 $0 $743 $20 $0 $0 $222 $23 $0 $0 $223 $80 $39 $0 $1,241 $79 $44 $0 $1,149 $41 $0 $0 $378 $43 $0 $0 $376 $.80 $.01 $0 $5 $.70 $.01 $0 $4 MEAN MEDIAN MIN MAX MEAN MEDIAN MIN MAX 2014 AVERAGE DOLLARS DISTRIBUTED BY STATE HEALTH AGENCIES THROUGH CONTRACTS, GRANTS, AND AWARDS DISTRIBUTED TO LOCAL HEALTH HEALTH TO LOCAL DISTRIBUTED AND AWARDS GRANTS, CONTRACTS, THROUGH AGENCIES HEALTH BY STATE DISTRIBUTED DOLLARS AVERAGE will provide an overview freely associated states. of the activities, structure, and workforce of the U.S. territories and The first three sections of the ASTHO Profile of State and Territorial Public Health have focused on the structure of state health agencies, Profile of State and The first three sections of the ASTHO agencies, the activities and servicesthe professionals who comprise state health health agencies perform, that state and the tools, utilize to performprocesses, and resources that state health agencies these functions. The fourth section of the report, Other governmental entities Nonprofit organizations Tribal health agencies Tribal Independent regional or district health offices State-run regional or district health offices Independent local health agencies State-run local health agencies TABLE 6.9 TABLE DEPARTMENTS AND COMMUNITY-BASED ORGANIZATIONS FOR 2014 AND 2015, IN MILLIONS (N=33) FOR 2014 AND ORGANIZATIONS COMMUNITY-BASED AND DEPARTMENTS INSULAR AREAS 118 ASTHO Profile ofStateand Territorial Public Health, Volume Four AREAS INSULAR PART IV INSULAR AREAS 119 The occupational classification with the most FTEs was public health nurses due (mean=216, median=32), most likely to the provision of more clinical services in the insular areas. Insular area health agencies perform the most primary prevention activities (92%) and surveillance and data, epidemiology, activities (86%). Insular area health agencies are involved in a number of planning and quality improvement (QI) activities. About half of insular area agencies plan to apply for have while the remainder accreditation, not yet decided whether to apply (43%). The most common program areas for which agencies collect electronic information include: immunization (100%), laboratory results (86%), reportable diseases (86%), and vital records (86%). ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and In 2016, the governmental structure of the insular area public health agencies was roughly split between freestanding/ independent agencies (57%) and those under an umbrella agency (43%). The average budget for 2014 was $59.5 million (median=$27.8 million) and the average budget for 2015 was $61.5 million (median=$32.3 million). In 2015, the average per capita expenditure on public health in the insular areas was $389 and the median was $197. On average, insular area public health agencies have 375 full-time equivalent employees (FTEs) per 100,000 people. The average number of vacant positions within insular area health agencies is 689 (median=32). KEY FINDINGS This chapter provides an overview of the structure, functions, and resources of and resources functions, an overviewThis chapter provides of the structure, also associated states, territories and freely agencies of the U.S. the public health three island jurisdictions in territories include The U.S. insular areas. referred to as the of the Northern and the Commonwealth Guam, Samoa, the Pacific—American Virgin Rico and the U.S. of Puerto the two Caribbean territories Mariana Islands—and nation states holding insular areas include three sovereign The remaining Islands. also known as compact nations: association with the United States, compacts of free of the and the Republic States of Micronesia, Federated the of Palau, the Republic collectively constitute the jurisdictions Pacific the Together, Marshall Islands. Pacific Islands (USAPI). U.S.-affiliated The uniqueness jurisdictions on many measures. There is wide variability across these and systemic differences) socioeconomic, geographic, of each insular area (e.g., the insular despite their individual diversity, Yet can explain much of this variation. health departments described the state and D.C. areas are collectively distinct from close relatively Primary their remoteness, differences include in previous chapters. and challenges associated with high systems, integration with their healthcare In 2016, and non-communicable diseases. incidences of both communicable health agencies responded to the survey, seven of the eight insular area rate to date. resulting in the highest response Chapter 7 Chapter INSULAR AREAS INSULAR AREAS 120 ASTHO Profile ofStateand Territorial Public Health, Volume Four OVERVIEW OF THE INSULAR AREAS OVERVIEW OFTHEINSULAR primary focusfortheseagencies, asareclimatechange primary diseases (e.g., dengue, chikungunya, andZika) area and oversight.health services Communicableandtropical providerofbothclinicalandpublic astheprimary serve the healthcaresystemineachjurisdictionandfrequently area healthagenciesareoftencloselyintegratedwith from healthdepartmentsinthestatesandD.C. Insular of structuresandpriorities, butarecollectivelydistinct Health agenciesintheinsularareasrepresentavariety medications mayrequiretravelbyboat. careandbasic island communities, accesstoevenprimary communication, andaccesstoservices. For someremote Hawaii), whichcancausedifficultieswithtransportation, geographically remote(2,500-4,600milesfromHonolulu, available intheU.S. statesandD.C. USAPIsareespecially to healthcareandpublichealthresourcesthanthose associated statesoftenfaceadifferentlevelofaccess population andgeography(seeTable 7.1),andthefreely The islandjurisdictionsarerelativelysmallintermsofboth TABLE 7.1 Republic oftheMarshallIslands Republic ofPalau Federated StatesofMicronesia Freely AssociatedStates U.S. VirginIslands Puerto Rico Guam Commonwealth oftheNorthernMarianaIslands American Samoa U.S. Territories NOTES POPULATION ANDGEOGRAPHICSIZEOFTHEINSULARAREAS,2016 1 United NationsStatisticsDivision. “UNData”.Available at data.un.org. AccessedMay2017. 1 also representtheseagenciesandprovidesomesupport. other federalgrants. However, internationalorganizations these jurisdictionsaresometimesunabletoparticipatein for federalentitlementprograms, andhealthagenciesin associated statesandtheirresidentsaregenerallyineligible as Medicaid, butoftenatareducedrate. Thefreely territories participateinfederalentitlementprogramssuch entitlement programsdiffersbyjurisdictiontype. U.S. continental UnitedStates, eligibilityforfederal residents’ public healthfundingstreamssimilartothoseinthe funding andprogramming. Althoughtheyreceivemajor intheireligibilityforfederal These jurisdictionsalsovary presidential reportingstructure. states arenationalbodiesledbyministerswitha to agovernor, whereasagenciesinthefreelyassociated recovery. Healthofficialsintheterritoriesgenerallyreport also dedicatesignificantresourcestopreparednessand increased vulnerabilitytonaturaldisasters, insularareas and chronicdiseasepreventiontreatment. With

3,681,000 Population 105,000 106,000 172,000 53,000 22,000 55,000 56,000 Geography (milesland) 3,425 271 134 210 177 179 70 77 INSULAR AREAS 121

Yes 14% $4 $389 $197 $1,496 2015 (N=6) $4 $386 $196 $1,479 2014 (N=6) ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 932 359 50 4,894 6,523 MEAN MEDIAN MIN MAX TOTAL 1,088 402.5 83 4,919 6,527 No 72% Other 14% MEDIAN MIN MAX MEAN Number of: Staff members FTEs TABLE 7.2 TABLE EXPENDITURES, 2014 AND 2015 PER CAPITA FIGURE 7.1 (N=7) AGENCIES, 2016 INSULAR AREA HEALTH FOR BOARD OF HEALTH NUMBER OF STAFF MEMBERS AND FTEs, 2016 (N=6-7) NUMBER OF STAFF TABLE 7.3 TABLE In 2016, the average size of the insular area health agency workforce was 1,088 staff members and 932 , there was a large range 7.3 As depicted in Table FTEs. in both the number of staff and FTEs. INSULAR AREA HEALTH WORKFORCE AGENCY The insular areas reported on their total budgets for 2014 and 2015. The average budget for 2014 was $59.5 million (median=$27.8 million), and the average budget for 2015 was $61.5 million (median=$32.3 million). In 2015, the average per capita expenditure on public health in the insular 7.2). areas was $389 (Table In 2016, the governmental structure of the insular In 2016, the governmental structure of split area public health agencies was roughly (57%) between freestanding/independent agencies Of and those under an umbrella agency (43%). that the four insular area public health agencies the larger agency’s are under an umbrella agency, public most common areas of responsibility were (50%), assistance (75%), environmental protection abuse and mental health authority with substance percent of insular area health (50%). Twenty-eight ) agencies have a board of health (Figure 7.1 versus 54 percent of state health agencies. INSULAR AREA HEALTH BUDGETS AGENCY INSULAR AREA HEALTH AGENCY INSULAR AGENCY AREA HEALTH AND GOVERNANCE STRUCTURE INSULAR AREAS 122 ASTHO Profile ofStateand Territorial Public Health, Volume Four governor. health officialswereappointedbythe As of2016,71percentallinsulararea Insular AreaHealthOfficials 30 yearsoldin2015. 34 yearsoldin2013and2014, age ofnewhiresintheinsularareaswas predominantly female(67%).Theaverage Insular areahealthagencypersonnelare Agency Demographics Insular AreaHealth development directorwithintheagency. A majority(86%)donothaveaworkforce department workforcedevelopmentplan. health agencieshavecreateda Less thanhalf(43%)ofinsulararea an averageof38positionsin2016. health agencieswereactivelyrecruitingfor was large(Table 7.5).Ofthosevacancies, range inthenumberofvacantpositions like theaveragesizeofworkforce, the agencies in2016(median=32);however, positions withintheinsularareashealth On average, therewere689vacant Vacancies andRecruitments Insular AreaHealthAgency intheinsularareas.clinical services most likely duetotheprovisionofmore health nurses(mean=216,median=32), classification withthemostFTEswaspublic insular areas. Onaverage, theoccupational occupational classificationwithinthe of theaveragenumberFTEsby Table 7.4providesabreakdown prior tobecomingthehealth official. had executivemanagement experience a specificterm. Allsevenhealthofficials officials (57%)werealsoappointedfor NOTES 2 Morethanhalfofallhealth 2 who appointinsular areahealthofficials. As independent countries, freelyassociatedstates havepresidentsasheadsof state, TABLE 7.4 NUMBER OFVACANT POSITIONSANDACTIVERECRUITMENTS,2016(N=6) TABLE 7.5 Number ofpositionsbeingactively recruited Number ofvacantpositions Public healthphysician Public healthinformaticsspecialist Epidemiologist/statistician Health educator Preparedness staff Physician assistant Laboratory worker Nutritionist Environmental healthworker Agency leadership operations staff Business andfinancial Behavioral healthstaff Office andadministrativesupport Public healthnurse Public informationspecialist Nurse practitioner QI specialist Oral healthprofessional NUMBEROFFTEsBYOCCUPATIONAL CLASSIFICATION, 2016 N 2 6 9 7 6 7 6 6 6 6 7 7 6 7 6 7 7 6 0 0 1 0 1 1 2 1 4 7 5 5 7 8 6 5 ENMDA I MAX MIN MEDIAN MEAN 8 32 689 MEAN 823 38 5 17 150 19 164 32 216 14 14 19 20 20 21 11 34 38 42 15 43 MEDIAN 0 0 5 3 2 4 8 0 7 1 1 0 6 7 2 7 I MAX MIN 2 0 0 3 0 2 0 3,815 1345 218 168 835 980 111 105 190 221 128 38 82 65 90 27 23 26 15 INSULAR AREAS 123 ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and About half of all insular area health agencies About half of all insular area health agencies report providing some form of technical assistance. Agencies most often provide technical assistance for QI, performance, and accreditation to healthcare providers (71%). Insular areas report high rates of collaboration. They most often collaborate with hospitals and most commonly collaborate by exchanging information. Insular area health agencies report participating in an average of six research studies (median = 2) over the past two years. The most common research activity that agencies engaged in was collecting, exchanging, or reporting (71%). data for a study All insular area health agencies report responsibility for the following federal initiatives: CDC Public cooperative Health Emergency Preparedness agreement; Section 317 Immunization Grant Title V Maternal and Child Health Services Program; and CDC’sBlock Grant Program; Comprehensive territorial, for state, Cancer Control Programs and tribal organizations. All insular area health agencies report administering immunizations to children and adults. Insular area health agencies report performing the most primary prevention activities (92%) and data, and surveillance activities (86%). epidemiology, A majority of insular areas perform screenings for diseases or conditions. The least common screenings performed by insular area health agencies are for asthma (50%) and blood lead (33%). All insular areas perform inspection, regulation, or licensing activities for food services. No insular area health agencies report performing regulation or inspection for beaches or solid waste haulers. In at least one insular area, this activity has been ceded to the states rather than being performed directly by the insular area’s health agency. Overall, the number of insular area health agencies performing environmental health activities was low (35% of all environmental health activities surveyed all agencies perform on average). However, activities for food safety training/education and vector control. AGENCY INCLUDE NOTABLE NOTABLE ACTIVITIES ACTIVITIES Despite the many differences between insular areas and states, insular area health agencies between insular areas and states, Despite the many differences 7.6 provides Table perform as state health agencies. many of the same core activities a summary of the aggregate number of activities each agency performs by activity type. INSULAR AREA HEALTH AGENCY ACTIVITIES INSULAR AGENCY AREA HEALTH INSULAR AREAS 124 ASTHO Profile ofStateand Territorial Public Health, Volume Four TABLE 7.6 Mariana Islands of theNorthern Commonwealth U.S. VirginIslands Republic oftheMarshallIslands Republic ofPalau Puerto Rico Guam Federated StatesofMicronesia U.S. VirginIslands Marshall Islands Republic ofthe Republic ofPalau Puerto Rico Guam of Micronesia Federated States Jurisdiction Mariana Islands Commonwealth oftheNorthern TOTAL INSULARAREAHEALTH AGENCYACTIVITIESPERFORMEDBYACTIVITYTYPE,2016 (N=10) Services Healthcare Access to N 5 4 1 2 7 4 6 50% 83% 65% 10 13 40% 100% 12 10% 20% 70% 100% 12 40% 100% 12 60% % (N=5) Licensure Professional N 4 3 0 4 5 5 5 (N=12) Surveillance and Epidemiology, Data, N 8 9 9 0%2 63% 20 31% 100% 11 100% 66% 21 100% 0 959% 19 80% 60% 50% 17 80% %1 53% 17 0% % 67% 75% 75% % (N=34) and Licensing Inspection, Regulation, N 3 (N=20) Health Environmental N 4 4 6 5 8 9 9% % 20% 20% 30% 25% 40% 45% % (N=5) Maintenance Registry N 5 2 2 2 4 5 3 (N=8) Services Laboratory N 6 3 6 4 2 5 3 0%1 7 192% 11 87% 13 100% 0%1 100% 15 100% 0 38%1 92% 11 87% 40% 100% 13 12 40% 93% 14 40% 0 510 2100% 12 100% 15 80% 60% % 5 17%1 0%1 5 7100% 17 94% 65% 15 75% 11 71% 100% 10 16 38% 79% 11 75% 71% 50% 69% 10 11 25% 71% 10 75% 63% 12 71% 10 38% % (N=15) Screening N 9 8 (N=14) Health and Child Maternal N 9 4 60% 53% % 64% 29% % (N=12) Treatment (N=16) Services Clinical Other N 6 3 9 N 8 9 9 50% 25% 75% 50% 56% 56% % % Vaccine (N=3) Administration N (N=17) Activities Health Other Public 2 2 3 2 3 2 3 N 5 6 3 8 6 6 100% 100% 100% 67% 67% 67% 67% % 9 588% 15 29% 82% 14 35% 88% 15 18% 7 694% 16 47% 94% 16 35% 94% 16 35% % (N=3) Ordering Vaccine N (N=17) Prevention Primary 2 2 2 3 2 3 3 N 100% 100% 100% 67% 67% 67% 67% % % INSULAR AREAS 125 % 0% 0% 14% 71% 14% 57% in e-PHAB registered to apply for agency plans accreditation, accreditation, but has not yet My public health 0 0 1 5 1 N Strategic Plan % 0% 0% 0% 57% 43% ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 0 0 4 3 0 N Health Improvement Plan 43% health apply for My public whether to % agency has not decided 0% accreditation 14% 14% 57% 14% FIGURE 7.2 AGENCY PARTICIPATION INSULAR AREA HEALTH 2016 (N=7) PROGRAM, IN PHAB ACCREDITATION 0 1 1 4 1 N Health Assessment No No, but plan to in the next year Yes, five or more years ago Yes, Yes, more than three but less than five years ago Yes, Yes, within the last three years Yes, As depicted in Figure 7.2, about half of insular area agencies plan to apply for accreditation but have not yet registered in e-PHAB (57%), while the remainder have not yet decided whether to apply for accreditation (43%). Accreditation All agencies have either developed or plan to develop All insular area health agencies a health assessment. have either developed a health improvement plan within the last three years (43%), or plan to develop a health improvement plan in the next year (57%). In addition, a majority of insular areas have developed an agency-wide strategic plan within the last three years (71%). Insular area health agencies are involved in a number Insular area health agencies are involved 7.7 shows the Table of planning and QI activities. agencies’development status of insular area health health improvement plans, health assessments, and strategic plans. Health Assessments, Health Assessments, Health Improvement Plans, and Strategic Plans DEVELOPMENT OF HEALTH ASSESSMENTS, HEALTH IMPROVEMENT PLANS, AND STRATEGIC PLANS BY INSULAR AREA HEALTH AGENCIES, 2016 (N=7) AGENCIES, 2016 BY INSULAR AREA HEALTH PLANS PLANS, AND STRATEGIC IMPROVEMENT ASSESSMENTS, HEALTH DEVELOPMENT OF HEALTH TABLE 7.7 TABLE INSULAR AREA HEALTH AGENCY PLANNING INSULAR AGENCY HEALTH AREA IMPROVEMENT AND QUALITY INSULAR AREAS unfamiliar (57%and43%,respectively). competencies withwhichagenciesweremost Competencies forPublic HealthNurseswerethetwo for NursingLeadership CompetenciesandQuadCouncil developing trainingplans(57%).TheNationalLeague Health Workers, whichwasmostfrequentlyusedfor Emergency Preparedness CompetenciesforAllPublic public healthprofessionals. Theoneexceptionwas health workers; andtheinformaticscompetenciesfor emergency preparednesscompetenciesforallpublic competencies forpublichealthprofessionals;the including:thecore health competenciessurveyed, familiar with, buthavenotused, thevariouspublic About halfofinsularareahealthagenciesare management programforspecificprograms. has partiallyimplementedaformalperformance implemented oneforspecificprograms. Oneagency program department-wide, whileoneagencyhasfully management implemented aformalperformance management programinplace. Oneagencyhasfully indicated thattheydonothaveaformalperformance More thanhalfofinsularareahealthagencies(57%) and Competencies Performance Management or approach(Figure7.3). of agenciesreportednotusingaspecificframework Scorecard framework(14%).Forty-three percent for QIactivities(57%),followedbytheBalanced Plan-Do-Check-Act orPlan-Do-Study-Act framework Insular areasmostfrequentlyreportusingthe activities inspecificprogrammaticorfunctionalareas. agency-wide, whiletwohaveimplementedformalQI activities, half(N=3)haveimplementedformalQIprograms involvement inQIactivities. OftheagenciesreportingQI All butoneinsularareahealthagencyindicated Quality Improvement BY INSULARAREAS,2016(N=7) QUALITY IMPROVEMENTFRAMEWORKSUSEDINTHELASTYEAR FIGURE 7.3 100% BALDRIDGE PERFORMANCEEXCELLENCECRITERIA(ORSTATE) PLAN-DO-CHECK-ACT ORPLAN-DO-STUDY-ACT NO SPECIFICFRAMEWORKORAPPROACH OTHER FRAMEWORKORAPPROACH BALANCED SCORECARD SIX SIGMA LEAN 0%10%20%30%40%50%60%70%80%90% 0% 0% 0% 14% 0% 43% 57% INSULAR AREAS 127 29% 86% 57% 67% 57% 71% 43% 71% 57% 57% 86% 100% 29% 86% 43% 0%10%20%30%40%50%60%70%80%90% WIC LAB RESULTS IMMUNIZATION VITAL RECORDS VITAL MEDICAID BILLING CASE MANAGEMENT NEWBORN SCREENING REPORTABLE DISEASES REPORTABLE REPRODUCTIVE HEALTH ENVIRONMENTAL HEALTH HEALTH ENVIRONMENTAL OUTBREAK MANAGEMENT EARLY HEARING DETECTION EARLY HEALTHCARE SYSTEMS DATA HEALTHCARE FOOD SERVICE INSPECTIONS FOOD SERVICE ELECTRONIC HEALTH RECORDS ELECTRONIC HEALTH ASTHO Profile of State and Territorial Public Health, Volume Four Territorial Public Health, ASTHO Profile of State and 100% FIGURE 7.4 FIGURE ELECTRONIC AGENCY HEALTH FOR INSULAR AREA PROGRAM AREAS COLLECTION, 2016 (N=6-7) DATA Individual Agency , provides an overview of key information from , provides an overview of key each state and insular area health agency that completed the survey. The preceding chapters of the ASTHO Profile of State The preceding chapters of the ASTHO Profile Public Health have described the structure, and Territorial functions, and activities of state and insular area health agencies. The final section of the report, Profiles Forty-three percent of health agencies reported that percent Forty-three officer had overall decisionmaking the chief information their agency’sauthority regarding public health while 57 percent information management systems, someone other reported that the authority was held by Other authorities than those listed as response options. director. included an IT director and a public health Insular area health agencies differ in terms of who Insular area health agencies has primary health decisionmaking responsibility for Insular area policy and standards. information exchange split in terms of who holds overall health agencies were regarding the agencies’decisionmaking authority public systems. health information management Insular area health agencies also reported on their Insular area health agencies also reported health activities surrounding Meaningful Use public having the Of those agencies that reported objectives. agencies received electronic health record technology, Meaningful Use-compliant messages from only the following registries: electronic reportable laboratory results (67%), immunization registries (57%), and public health registries (17%). Insular area health agencies reported having capacity for bidirectional data reporting and exchange only for immunization registries (57%) and public health registries (17%). displays the program areas in which insular Figure 7.4 displays the program areas in which insular The information. area health agencies collect electronic agencies collect most common program areas for which immunization (100%), electronic information include: laboratory diseases (86%), and results (86%), reportable agencies vital records (86%). No insular area health on geographic reported collecting electronic information onsite wastewater coded data for mapping analysis, and water wells (licensing or testing). treatment systems, Electronic Data Collection and Exchange Electronic Data Collection and Exchange INSULAR AREA HEALTH AGENCY INSULAR AGENCY HEALTH AREA MANAGEMENT INFORMATION HEALTH 128 ASTHO Profile of State and Territorial Public Health, Volume Four INDIVIDUAL AGENCY PROFILES

ALPHABETICAL INDEX

ALABAMA ______130 MONTANA ______159

ALASKA ______131 NEBRASKA ______160

ARIZONA ______132 NEW HAMPSHIRE ______161

ARKANSAS ______133 NEW JERSEY ______162

CALIFORNIA ______134 NEW MEXICO ______163

COLORADO ______135 NEW YORK ______164

COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS ______136 NORTH CAROLINA ______165

CONNECTICUT ______137 NORTH DAKOTA ______166

DELAWARE ______138 OHIO ______167

DISTRICT OF COLUMBIA ______139 OKLAHOMA ______168

FEDERATED STATES OF MICRONESIA ______140 OREGON ______169

FLORIDA ______141 PALAU ______170

GEORGIA ______142 PENNSYLVANIA ______171

GUAM ______143 PUERTO RICO ______172

HAWAII ______144 REPUBLIC OF THE MARSHALL ISLANDS ______173

IDAHO ______145 RHODE ISLAND ______174

ILLINOIS ______146 SOUTH CAROLINA ______175

INDIANA ______147 SOUTH DAKOTA ______176

IOWA ______148 TENNESSEE ______177

KANSAS ______149 TEXAS ______178

KENTUCKY ______150 U.S. VIRGIN ISLANDS ______179

LOUISIANA ______151 UTAH ______180

MAINE ______152 VERMONT ______181

MARYLAND ______153 VIRGINIA ______182

MASSACHUSETTS ______154 WASHINGTON ______183

MICHIGAN ______155 WEST VIRGINIA ______184

MINNESOTA ______156 WISCONSIN ______185

MISSISSIPPI ______157 WYOMING ______186

MISSOURI ______158

ASTHO Profile of State and Territorial Public Health, Volume Four 129 ALABAMA DEPARTMENT OF PUBLIC HEALTH ALABAMA

Agency Mission Top Five Priorities

To serve the people of Alabama by ensuring 1 Funding to maintain public health services conditions in which they can be healthy. 2 Substance abuse (e.g., tobacco, prescription drugs, illicit drugs) 3 Infant mortality 4 Obesity 5 Chronic disease prevention

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/ Source of Funding independent agency and has a largely centralized relationship with local health departments.

Independent local health agencies 2 (led by staff employed by local government) State General Funds 6.7% Other State Funds 1.8% State-run local health agencies Federal Funds 42.1% 65 (led by staff employed by state government) Fees and Fines 5.0% Independent regional or district offices Other Sources 44.5% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state has a board of health. CDC 14.8% HHS 3.8% Planning and Accreditation HRSA 9.7% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 61.9% Health Improvement Plan DHS 0.6% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.2% Other 8.9% The state/territorial agency has submitted an application for accreditation.

Agency Workforce Total Revenue FY15: $472,893,914 The state/territorial health agency has 2,576 FTEs, including Total Federal Revenue FY15: $198,922,578 1,962 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

130 ASTHO Profile of State and Territorial Public Health, Volume Four ALASKA DEPARTMENT OF HEALTH AND SOCIAL SERVICES, DIVISION OF PUBLIC HEALTH ALASKA

Agency Mission Top Five Priorities

To protect and promote the health of Alaskans. 1 Tobacco and nicotine use 2 Colorectal and cervical cancer 3 Poisoning and overdose 4 Infectious disease 5 Child and adolescent health

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 2 (led by staff employed by local government) State General Funds 69.4% Other State Funds 2.0% State-run local health agencies Federal Funds 24.3% 0 (led by staff employed by state government) Fees and Fines 3.5% Independent regional or district offices Other Sources 0.8% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 71.4% HHS 2.8% Planning and Accreditation HRSA 2.9% The state/territorial health agency has developed Medicaid 0.5% the following within the past five years: Medicare 0.3% Health Assessment USDA 0.0% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.0% Other 22.1% The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce Total Revenue FY15: $108,784,200 The state/territorial health agency has 469 FTEs. There are no state/ Total Federal Revenue FY15: $25,244,900 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 131 ARIZONA DEPARTMENT OF HEALTH SERVICES ARIZONA

Agency Mission Top Four Priorities

To promote, protect, and improve the health and wellness 1 Aligning agency resources to achieve targeted health outcomes of individuals and communities in Arizona. 2 Promoting and supporting public health and safety 3 Making focused improvements in public health infrastructure 4 Maximizing agency effectiveness

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/ Source of Funding independent agency and has a decentralized relationship with local health departments.

Independent local health agencies 15 (led by staff employed by local government) State General Funds 6.6% Other State Funds 9.2% State-run local health agencies Federal Funds 76.5% 0 (led by staff employed by state government) Fees and Fines 6.5% Independent regional or district offices Other Sources 1.3% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official reports directly to the governor. The state does not have a board of health. CDC 11.6% HHS 3.2% Planning and Accreditation HRSA 6.4% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 2.3% Health Assessment USDA 76.1% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.0% Other 0.3% The state/territorial agency has submitted an application for accreditation.

Agency Workforce Total Revenue FY15: $277,435,900 The state/territorial health agency has 1,376 FTEs. There are no state/ Total Federal Revenue FY15: $211,828,200 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

132 ASTHO Profile of State and Territorial Public Health, Volume Four ARKANSAS DEPARTMENT OF HEALTH ARKANSAS

Agency Mission Top Five Priorities

To protect and improve the health and 1 Immunizations well-being of all Arkansans. 2 Childhood obesity 3 Hypertension 4 Tobacco 5 Teen pregnancy

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/ Source of Funding independent agency and has a centralized relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 22.9% Other State Funds 0.0% State-run local health agencies Federal Funds 39.7% 94 (led by staff employed by state government) Fees and Fines 4.5% Independent regional or district offices Other Sources 32.9% 0 (led by non-state employees) State-run regional or district offices 5 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official reports directly to the governor. The state has a board of health. CDC N/A% HHS N/A% Planning and Accreditation HRSA N/A% The state/territorial health agency has developed Medicaid N/A% the following within the past five years: Data not available Medicare N/A% Health Assessment USDA N/A% Health Improvement Plan DHS N/A% Strategic Plan EPA N/A% Other N/A% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 2,275 FTEs, including 1,420 Total Revenue FY15: $372,463,274 Total Federal Revenue FY15: Data not available state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 133 CALIFORNIA DEPARTMENT OF PUBLIC HEALTH CALIFORNIA

Agency Mission Top Five Priorities

To optimize the health and well-being 1 Leveraging opportunities to build foundational public health of the people in California. 2 Public Health 2035 initiative 3 Strengthening internal operations 4 Supporting “Let’s Get Healthy California” initiative 5 Workforce development/succession planning

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a decentralized relationship with local health departments.

Independent local health agencies 61 (led by staff employed by local government) State General Funds 8.5% Other State Funds 54.3% State-run local health agencies Federal Funds 37.2% 0 (led by staff employed by state government) Fees and Fines 0.0% Independent regional or district offices Other Sources 0.0% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 15.7% HHS 0.0% Planning and Accreditation HRSA 9.4% The state/territorial health agency has developed Medicaid 9.5% the following within the past five years: Medicare 0.0% Health Assessment USDA 64.6% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.1% Other 0.8% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 3,441 FTEs, including Total Revenue FY15: $1,418,726,042 Total Federal Revenue FY15: $1,663,021,499 1,467 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

134 ASTHO Profile of State and Territorial Public Health, Volume Four COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (CDPHE) COLORADO

Agency Mission Top Five Priorities

To protect and improve the health of Colorado’s people 1 Implementing plans supporting the health and environment and the quality of the state’s environment. priorities (e.g., substance use, mental health, obesity, immunizations, air, and water)

2 Increasing CDPHE’s efficiency, effectiveness, and elegance 3 Improving CDPHE’s employee engagement 4 Promoting health equity and environmental justice 5 Preparing for and responding to all emerging issues

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a decentralized relationship with local health departments.

Independent local health agencies 54 (led by staff employed by local government) State General Funds 7.1% Other State Funds 25.5% State-run local health agencies Federal Funds 39.9% 0 (led by staff employed by state government) Fees and Fines 15.0% Independent regional or district offices Other Sources 12.6% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official reports directly to the governor. The state has a board of health. CDC 45.4% HHS 1.9% Planning and Accreditation HRSA 8.5% The state/territorial health agency has developed Medicaid 1.5% the following within the past five years: Medicare 1.9% Health Assessment USDA 40.5% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.3% Other 0.1% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 1,328 FTEs, including 25 state/ Total Revenue FY15: $220,302,319 Total Federal Revenue FY15: $215,417,900 territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 135 COMMONWEALTH HEALTHCARE CORPORATION COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS

Agency Mission Top Five Priorities

To improve the health and well-being of the Commonwealth 1 Reorganizational plan with clear reporting and authority lines of the Northern Mariana Islands (CNMI) through excellence 2 Recruitment and retention plan and innovation in service. 3 A service plan code of ethics 4 Facility plan 5 Full implementation of electronic health records

Structure and Relationship with Local Health Departments The state/territorial health agency is under a larger agency— sometimes referred to as a “superagency” or “umbrella agency.”

Organizational Structure The health official reports directly to the governor. The state/territory has the Commonwealth Healthcare Corporation Advisory Board.

Planning and Accreditation The state/territorial health agency has developed the following within the past five years:

Health Assessment Health Improvement Plan Strategic Plan

The state/territorial health agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce The state/territorial health agency has 50 FTEs. INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL

136 ASTHO Profile of State and Territorial Public Health, Volume Four CONNECTICUT DEPARTMENT OF PUBLIC HEALTH CONNECTICUT

Agency Mission Top Five Priorities

To protect and improve the health and safety of the people 1 Disease prevention, management, and surveillance of Connecticut by: Assuring the conditions in which people 2 Public health preparedness and emergency response can be healthy; preventing disease, injury, and disability; and 3 Healthcare industry regulation promoting the equal enjoyment of the highest attainable standard 4 Public health code enforcement of health, which is a human right and a priority of the state. 5 Health data management and registry

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a free-standing/independent agency Source of Funding and has a decentralized relationship with local health departments.

Independent local health agencies 53 (led by staff employed by local government) State General Funds 36.3% Other State Funds 16.9% State-run local health agencies Federal Funds 38.3% 0 (led by staff employed by state government) Fees and Fines 0.0% Independent regional or district offices Other Sources 8.5% 20 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official reports directly to the governor. The state does not have a board of health. CDC 29.7% HHS 0.0% Planning and Accreditation HRSA 13.1% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 44.3% Health Improvement Plan DHS 5.0% Strategic Plan EPA 7.9% Other 0.0% The state/territorial agency has submitted an application for accreditation.

Agency Workforce Total Revenue FY15: $305,555,567 The state/territorial health agency has 702 FTEs, including four Total Federal Revenue FY15: $116,884,996 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014-6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 137 DELAWARE DEPARTMENT OF HEALTH AND SOCIAL SERVICES, DIVISION OF PUBLIC HEALTH DELAWARE

Agency Mission Top Five Priorities

To protect and promote the health of all people in Delaware. 1 Active living and healthy eating 2 Health equity 3 Opioid and heroin addiction 4 Health reform 5 Performance improvement

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 39.3% Other State Funds 16.5% State-run local health agencies Federal Funds 33.7% 0 (led by staff employed by state government) Fees and Fines 0.0% Independent regional or district offices Other Sources 10.5% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 37.8% HHS 0.3% Planning and Accreditation HRSA 23.0% The state/territorial health agency has developed Medicaid 0.7% the following within the past five years: Medicare 0.0% Health Assessment USDA 28.9% Health Improvement Plan DHS 1.2% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 5.7% Other 2.5% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 713 FTEs. There are no state/ Total Revenue FY15: $130,587,377 Total Federal Revenue FY15: $43,957,604 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

138 ASTHO Profile of State and Territorial Public Health, Volume Four DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH DISTRICT OF COLUMBIA

Agency Mission Top Five Priorities

To promote and protect the health, safety, and quality of life 1 Promoting communitywide culture of health and wellness of residents, visitors, and those doing business in the District 2 Strengthening public-private partnerships of Columbia, including: identifying health risks; educating the 3 Closing the chasm between clinical medicine and public public; preventing and controlling diseases, injuries, and health exposure to environmental hazards; promoting effective 4 Promoting data-driven and outcome-oriented approaches community collaborations; and optimizing equitable 5 Applying health equity and social determinants of health to access to community resources. all that the agency does

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a centralized relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 28.6% Other State Funds 20.0% State-run local health agencies Federal Funds 46.8% 1 (led by staff employed by state government) Fees and Fines 4.6% Independent regional or district offices Other Sources 0.0% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 15.6% HHS 8.0% Planning and Accreditation HRSA 46.4% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 12.0% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.2% Other 17.8% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 548 FTEs. There are no state/ Total Revenue FY15: $245,915,548 Total Federal Revenue FY15: $115,118,218 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 139 FEDERATED STATES OF MICRONESIA DEPARTMENT OF HEALTH AND SOCIAL AFFAIRS FEDERATED STATES OF MICRONESIA

Agency Mission Top Five Priorities

To promote and protect health and well-being 1 Decreasing funding in Compact of Free Association of island communities in the Federated States 2 Chronic diseases of Micronesia (FSM). 3 Aging health workforce 4 Putting qualified students in health/medical fields 5 Upgrading quality of medical care in the country

Structure and Relationship with Local Health Departments The state/territorial health agency is a freestanding/ independent agency.

Organizational Structure The health official reports directly to the president of the Federated States of Micronesia. The state/territory does not have a board of health.

Planning and Accreditation The state/territorial health agency has developed the following within the past five years:

Health Assessment Health Improvement Plan Strategic Plan

The state/territorial health agency has not decided whether to apply for accreditation.

Agency Workforce The state/territorial health agency has 83 FTEs. INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL

140 ASTHO Profile of State and Territorial Public Health, Volume Four FLORIDA DEPARTMENT OF HEALTH FLORIDA

Agency Mission Top Five Priorities

To protect, promote, and improve the health of all 1 Eliminating infant mortality people in Florida through integrated state, county, 2 Increasing healthy life expectancy and community efforts. 3 Demonstrating readiness for emerging health threats 4 Establishing a sustainable infrastructure, which includes a competent workforce, standardized business practices, and effective use of technology 5 Establishing a regulatory structure that supports the state’s strategic priorities related to global competitiveness and economic growth

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a shared relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 18.1% Other State Funds 0.6% State-run local health agencies Federal Funds 43.5% 67 (led by staff employed by state government) Fees and Fines 4.3% Independent regional or district offices Other Sources 33.4% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 5.5% HHS 0.2% Planning and Accreditation HRSA 10.4% The state/territorial health agency has developed Medicaid 31.7% the following within the past five years: Medicare 0.0% Health Assessment USDA 37.8% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.0% Other 14.3% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 13,768 FTEs, including 10,213 Total Revenue FY15: $2,683,295,879 Total Federal Revenue FY15: $1,286,193,482 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 141 GEORGIA DEPARTMENT OF PUBLIC HEALTH GEORGIA

Agency Mission Top Five Priorities

To prevent disease, injury, and disability; promote health 1 Childhood obesity and well-being; and prepare for and respond to disasters. 2 Early brain development and language acquisition 3 Infant mortality 4 Access to healthcare/primary care 5 Technological infrastructure

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a shared relationship with local health departments.

Independent local health agencies 159 (led by staff employed by local government) State General Funds 33.0% Other State Funds 0.2% State-run local health agencies Federal Funds 60.4% 0 (led by staff employed by state government) Fees and Fines 0.1% Independent regional or district offices Other Sources 6.3% 0 (led by non-state employees) State-run regional or district offices 18 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 19.4% HHS 4.0% Planning and Accreditation HRSA 18.6% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 53.8% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.0% Other 4.3% The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce Total Revenue FY15: $603,744,049 The state/territorial health agency has 974 FTEs, including Total Federal Revenue FY15: $363,753,469 180 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

142 ASTHO Profile of State and Territorial Public Health, Volume Four GUAM DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES GUAM

Agency Mission Top Five Priorities

To assist the people of Guam in achieving and maintaining their 1 Prevention and control of Zika and communicable diseases highest levels of independence and self-sufficiency in health and 2 Promote elimination of non-communicable diseases social services. 3 Outreach to uninsured, underinsured, indigent, and high-risk groups for nursing services 4 Continue education programs for family planning, childhoodmental health, and abstinence 5 Continue to search and apply for funding sources to assist nurses and prevention programs

Structure and Relationship with Local Health Departments The state/territorial health agency is a freestanding/independent agency.

Organizational Structure The health official reports directly to the governor. The state/territory does not have a board of health.

Planning and Accreditation The state/territorial health agency has developed the following within the past five years:

Health Assessment Health Improvement Plan Strategic Plan INDIVIDUAL AGENCY PROFILES The state/territorial health agency has not decided whether to apply for accreditation.

Agency Workforce The state/territorial health agency has 422 FTEs.

ASTHO Profile of State and Territorial Public Health, Volume Four 143 HAWAII STATE DEPARTMENT OF HEALTH HAWAII

Agency Mission Top Three Priorities

To protect and improve the health and environment 1 Maternal and child health for all people in Hawaii. 2 Mental health 3 Telehealth

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a centralized relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 13.5% Other State Funds 11.9% State-run local health agencies Federal Funds 32.5% 0 (led by staff employed by state government) Fees and Fines 22.4% Independent regional or district offices Other Sources 19.8% 0 (led by non-state employees) State-run regional or district offices 3 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 25.1% HHS 3.1% Planning and Accreditation HRSA 8.2% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 63.7% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.0% Other 0.0% The state/territorial agency has decided not to apply for accreditation.

Agency Workforce Total Revenue FY15: $278,956,338 The state/territorial health agency has 2,631 FTEs. There are no state/ Total Federal Revenue FY15: $46,720,791 territorial agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

144 ASTHO Profile of State and Territorial Public Health, Volume Four IDAHO DEPARTMENT OF HEALTH AND WELFARE, DIVISION OF PUBLIC HEALTH IDAHO

Agency Mission Top Five Priorities

To promote and protect the health and safety of Idahoans. 1 Public health accreditation 2 Development of an Office of Suicide Prevention 3 Population health as part of healthcare reform 4 Workforce development 5 Quality improvement/data analytics

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 4.4% Other State Funds 25.3% State-run local health agencies Federal Funds 63.6% 0 (led by staff employed by state government) Fees and Fines 6.6% Independent regional or district offices Other Sources 0.0% 7 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 18.7% HHS 5.5% Planning and Accreditation HRSA 10.8% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 65.1% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.0% Other 0.0% The state/territorial agency has submitted an application for accreditation.

Agency Workforce Total Revenue FY15: $85,224,196 The state/territorial health agency has 228 FTEs. There are no state/ Total Federal Revenue FY15: $51,247,019 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 145 ILLINOIS DEPARTMENT OF PUBLIC HEALTH ILLINOIS

Agency Mission Top Five Priorities

To promote the health of the people of Illinois through 1 Enhance stakeholder engagement (partnerships) the prevention and control of disease and injury. 2 Improve data quality and dissemination 3 Broaden understanding of agency role and function 4 Improve regulatory compliance 5 Reduce health disparities

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/ Source of Funding independent agency and has a decentralized relationship with local health departments.

Independent local health agencies 96 (led by staff employed by local government) State General Funds 27.4% Other State Funds 28.7% State-run local health agencies Federal Funds 44.0% 0 (led by staff employed by state government) Fees and Fines 0.0% Independent regional or district offices Other Sources 0.0% 0 (led by non-state employees) State-run regional or district offices 7 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 34.5% HHS 28.0% Planning and Accreditation HRSA 26.0% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 10.6% Health Assessment USDA 0.0% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.9% Other 0.0% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 1,124 FTEs, including Total Revenue FY15: $354,074,236 Total Federal Revenue FY15: $146,947,400 550 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

146 ASTHO Profile of State and Territorial Public Health, Volume Four INDIANA STATE DEPARTMENT OF HEALTH INDIANA

Agency Mission Top Five Priorities

To promote and provide essential public health services. 1 Decrease disease incidence and burden 2 Improve response and preparedness networks and capabilities 3 Reduce administrative costs by improving efficiencies 4 Recruit, evaluate, and retain public health workforce 5 Use information and electronic data to develop outcome driven programs

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/ Source of Funding independent agency and has a decentralized relationship with local health departments.

Independent local health agencies 93 (led by staff employed by local government) State General Funds 8.5% Other State Funds 3.4% State-run local health agencies Federal Funds 72.8% 0 (led by staff employed by state government) Fees and Fines 1.4% Independent regional or district offices Other Sources 13.9% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 17.9% HHS 1.8% Planning and Accreditation HRSA 15.5% The state/territorial health agency has developed Medicaid 2.2% the following within the past five years: Medicare 2.7% Health Assessment USDA 58.0% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.3% Other 1.7% The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce Total Revenue FY15: $341,242,237 The state/territorial health agency has 741 FTEs, including Total Federal Revenue FY15: $248,767,286 200 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 147 IOWA DEPARTMENT OF PUBLIC HEALTH IOWA

Agency Mission Top Five Priorities

To promote and protect the health of Iowans. 1 Public health quality improvement 2 State Innovation Model and Healthiest State population health objectives, specifically focusing on tobacco prevention, obesity reduction, and diabetes 3 Funding flexibility for state and local public health agencies 4 Infectious disease control, including healthcare associated infections 5 Improved data and informatics capabilities

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/ Source of Funding independent agency and has a decentralized relationship with local health departments.

Independent local health agencies 101 (led by staff employed by local government) State General Funds 27.9% Other State Funds 0.0% State-run local health agencies Federal Funds 54.7% 0 (led by staff employed by state government) Fees and Fines 0.1% Independent regional or district offices Other Sources 17.3% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 22.6% HHS 0.7% Planning and Accreditation HRSA 17.4% The state/territorial health agency has developed Medicaid 4.2% the following within the past five years: Medicare 0.0% Health Assessment USDA 34.2% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.4% Other 20.6% The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce Total Revenue FY15: $448,303,334 The state/territorial health agency has 469 FTEs. There are no state/ Total Federal Revenue FY15: $126,222,998 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

148 ASTHO Profile of State and Territorial Public Health, Volume Four KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT KANSAS

Agency Mission Top Five Priorities To protect and improve the health and environment of all Kansans. *Information not available

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 100 (led by staff employed by local government) State General Funds13.2% Other State Funds 4.1% State-run local health agencies Federal Funds 68.2% 0 (led by staff employed by state government) Fees and Fines 7.7% Independent regional or district offices Other Sources 6.8% 0 (led by non-state employees) State-run regional or district offices 6 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 33.3% HHS 2.8% Planning and Accreditation HRSA 7.2% The state/territorial health agency has developed Medicaid 0.4% the following within the past five years: Medicare 0.5% Health Assessment USDA 27.1% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.3% Other 28.3% The state/territorial agency has submitted an application for accreditation.

Agency Workforce Total Revenue FY15: $174,349,114 No data available on the number of workers for the Total Federal Revenue FY15: $223,849,113 state/territorial health agency. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 149 KENTUCKY DEPARTMENT FOR PUBLIC HEALTH KENTUCKY

Agency Mission Top Five Priorities

To improve the health and safety of people in Kentucky 1 Opioid dependencies and related issues (e.g., neonatal abstinence through prevention, promotion, and protection. syndrome, harm reduction syringe exchange programs, naloxone rescue) 2 Obesity/diabetes prevention 3 Cancer prevention and detection 4 Tobacco-Free Kentucky 5 Preparing for emerging diseases (e.g., Ebola, Zika virus)

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 61 (led by staff employed by local government) State General Funds 19.8% Other State Funds 0.0% State-run local health agencies Federal Funds 52.3% 0 (led by staff employed by state government) Fees and Fines 24.1% Independent regional or district offices Other Sources 3.9% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 14.3% HHS 7.8% Planning and Accreditation HRSA 9.6% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 64.3% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.3% Other 3.6% The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce Total Revenue FY15: $344,341,595 The state/territorial health agency has 510 FTEs. There are no state/ Total Federal Revenue FY15: $180,007,145 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

150 ASTHO Profile of State and Territorial Public Health, Volume Four LOUISIANA DEPARTMENT OF HEALTH, OFFICE OF PUBLIC HEALTH LOUISIANA

Agency Mission Top Five Priorities

To protect and promote the health and wellness of 1 Increase financial stability all individuals and communities in Louisiana. 2 Foster meaningful internal and external collaborations 3 Improve workforce development 4 Health information technology exchange and infrastructure, utilization, and integration 5 Reduce health disparities

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 2 (led by staff employed by local government) State General Funds 17.6% Other State Funds 1.9% State-run local health agencies Federal Funds 69.0% 63 (led by staff employed by state government) Fees and Fines 8.1% Independent regional or district offices Other Sources 3.4% 5 (led by non-state employees) State-run regional or district offices 9 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 31.7% HHS 0.0% Planning and Accreditation HRSA 11.4% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 56.9% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.0% Other 0.0% The state/territorial agency has registered in e-PHAB in order to pursue accreditation.

Agency Workforce Total Revenue FY15: $329,424,464 The state/territorial health agency has 1,218 FTEs, including 574 Total Federal Revenue FY15: $214,460,785 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 151 MAINE DEPARTMENT OF HEALTH AND HUMAN SERVICES, CENTER FOR DISEASE CONTROL AND PREVENTION MAINE

Agency Mission Top Five Priorities

*Information not available *Information not available

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 2 (led by staff employed by local government) State General Funds 13.8% Other State Funds 21.1% State-run local health agencies Federal Funds 53.7% 0 (led by staff employed by state government) Fees and Fines 0.0% Independent regional or district offices Other Sources 11.4% 0 (led by non-state employees) State-run regional or district offices 9 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 44.4% HHS 2.9% Planning and Accreditation HRSA 20.7% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 28.2% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 3.9% Other 0.0% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 492 FTEs. There are no state/ Total Revenue FY15: $112,045,316 Total Federal Revenue FY15: $60,152,901 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

152 ASTHO Profile of State and Territorial Public Health, Volume Four MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE MARYLAND

Agency Mission Top Five Priorities

To promote and improve the health and safety of all Marylanders 1 Overdose/opioids through disease prevention, access to care, quality management, 2 Zika and community engagement. 3 Healthcare reform 4 Workforce development 5 Budget

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 1 (led by staff employed by local government) State General Funds 33.1% Other State Funds 0.7% State-run local health agencies Federal Funds 46.0% 23 (led by staff employed by state government) Fees and Fines 0.1% Independent regional or district offices Other Sources 20.1% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 25.4% HHS 3.8% Planning and Accreditation HRSA 16.4% The state/territorial health agency has developed Medicaid 0.6% the following within the past five years: Medicare 2.5% Health Assessment USDA 49.7% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.0% Other 1.6% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 9,069 FTEs, including Total Revenue FY15: $466,395,328 Total Federal Revenue FY15: $214,349,087 6,904 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 153 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH MASSACHUSETTS

Agency Mission Top Five Priorities

To prevent illness, injury, and premature death; to ensure 1 Reduce health disparities and achieve health equity for all access to high-quality public health and healthcare services; 2 Utilize and link data in innovative ways to advance precision and to promote wellness and health equity for all people public health and improve population health in the commonwealth. 3 Identify, prevent, and reduce the risk factors associated with opioid overuse, misuse, and overdose 4 Strengthen core public health infrastructure 5 Strive to exceed our customers’ expectations

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/ Source of Funding independent agency and has a decentralized relationship with local health departments.

Independent local health agencies 351 (led by staff employed by local government) State General Funds 56.6% Other State Funds 0.0% State-run local health agencies Federal Funds 29.0% 0 (led by staff employed by state government) Fees and Fines 4.7% Independent regional or district offices Other Sources 9.7% 16 (led by non-state employees) State-run regional or district offices 4 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state has a public health council, which is similar CDC 23.4% to a board of health. HHS 2.4% HRSA 13.8% Planning and Accreditation Medicaid 0.0% The state/territorial health agency has developed Medicare 3.3% the following within the past five years: USDA 33.2% Health Assessment DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Health Improvement Plan EPA 0.0% Strategic Plan Other 24.1%

The state/territorial agency has submitted an application for accreditation. Total Revenue FY15: $961,945,215 Agency Workforce Total Federal Revenue FY15: $247,884,174 The state/territorial health agency has 2,864 FTEs. There are no state/ *FY15 was defined as 7/1/2014 – 6/30/2015. territorial health agency workers assigned to local/regional offices.

154 ASTHO Profile of State and Territorial Public Health, Volume Four MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES, POPULATION HEALTH ADMINISTRATION MICHIGAN

Agency Mission Top Five Priorities

To promote a healthy, safe, and stable environment 1 Emergency response and recovery for Flint water crisis for residents to be self-sufficient. 2 Increasing environmental and policy support for healthy behavior, including the areas of physical activity, nutrition, etc. 3 Ensuring public health capacity to address emerging threats 4 Promoting practices and policies that support all people in attaining their optimal level of health 5 Promoting the development and use of interoperable information systems for public health functions

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a decentralized relationship with local health departments.

Independent local health agencies 45 (led by staff employed by local government) State General Funds 36.2% Other State Funds 9.8% State-run local health agencies Federal Funds 47.8% 0 (led by staff employed by state government) Fees and Fines 6.2% Independent regional or district offices Other Sources 0.0% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 14.4% HHS 4.9% Planning and Accreditation HRSA 10.3% The state/territorial health agency has developed Medicaid 30.3% the following within the past five years: Medicare 0.0% Health Assessment USDA 38.8% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.2% Other 1.1% The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce Total Revenue FY15: $556,486,400 The state/territorial health agency has 474 FTEs. There are no state/ Total Federal Revenue FY15: $462,978,503 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 155 MINNESOTA DEPARTMENT OF HEALTH MINNESOTA

Agency Mission Top Five Priorities

To protect, maintain, and improve the health of all Minnesotans. 1 Health equity 2 Data 3 Mental well-being 4 Public health capacity 5 Informatics and communications

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent Source of Funding agency and has a decentralized relationship with local health departments.

Independent local health agencies 49 (led by staff employed by local government) State General Funds 15.3% Other State Funds 30.8% State-run local health agencies Federal Funds 43.7% 0 (led by staff employed by state government) Fees and Fines 9.0% Independent regional or district offices Other Sources 1.1% 0 (led by non-state employees) State-run regional or district offices 8 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 23.6% HHS 0.0% Planning and Accreditation HRSA 6.6% The state/territorial health agency has developed Medicaid 6.8% the following within the past five years: Medicare 9.1% Health Assessment USDA 51.6% Health Improvement Plan DHS 0.3% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 1.8% Other 0.3% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 1,445 FTEs, including Total Revenue FY15: $533,182,812 Total Federal Revenue FY15: $238,088,535 163 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

156 ASTHO Profile of State and Territorial Public Health, Volume Four MISSISSIPPI STATE DEPARTMENT OF HEALTH MISSISSIPPI

Agency Mission Top Five Priorities

To promote and protect the health of the citizens of Mississippi. 1 Ensure effective implementation of state health improvement plan priorities 2 Cultivate community-based health initiatives 3 Align partners statewide to support health improvement 4 Align funding in support of health improvement priorities 5 Strengthen organizational effectiveness and adaptability

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/ Source of Funding independent agency and has a centralized relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 10.8% Other State Funds 2.9% State-run local health agencies Federal Funds 46.5% 80 (led by staff employed by state government) Fees and Fines 33.6% Independent regional or district offices Other Sources 6.2% 0 (led by non-state employees) State-run regional or district offices 9 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 18.9% HHS 6.5% Planning and Accreditation HRSA 15.8% The state/territorial health agency has developed Medicaid 1.6% the following within the past five years: Medicare 1.3% Health Assessment USDA 51.5% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.7% Other 3.6% The state/territorial agency has submitted an application for accreditation.

Agency Workforce Total Revenue: $318,806,862 The state/territorial health agency has 2,015 FTEs, including Total Federal Revenue: $148,254,404 1,092 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 157 MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES MISSOURI

Agency Mission Top Five Priorities

To be the leader in promoting, protecting, and partnering for health. 1 Reduce infant mortality and prematurity 2 Reduce prescription drug abuse 3 Reduce childhood obesity 4 Increase chronic disease prevention and management activi- ties among seniors 5 Increase access to care in underserved populations

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/ Source of Funding independent agency and has a decentralized relationship with local health departments.

Independent local health agencies 115 (led by staff employed by local government) State General Funds 10.6% Other State Funds 2.3% State-run local health agencies Federal Funds 84.6% 0 (led by staff employed by state government) Fees and Fines 2.5% Independent regional or district offices Other Sources 0.0% 0 (led by non-state employees) State-run regional or district offices 9 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 12.7% HHS 6.2% Planning and Accreditation HRSA 16.9% The state/territorial health agency has developed Medicaid 1.6% the following within the past five years: Medicare 2.6% Health Assessment USDA 56.1% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.2% Other 3.6% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 1,879 FTEs, including Total Revenue FY15: $407,506,438 Total Federal Revenue FY15: $344,837,731 840 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

158 ASTHO Profile of State and Territorial Public Health, Volume Four MONTANA DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES MONTANA

Agency Mission Top Five Priorities

To improve and protect the health of Montanans 1 Tobacco prevention and cessation by creating conditions for healthy living. 2 Childhood and adolescent immunizations 3 Colorectal cancer screening 4 Injury prevention 5 Access to chronic disease prevention programs

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a decentralized relationship with local health departments.

Independent local health agencies 58 (led by staff employed by local government) State General Funds 5.8% Other State Funds 18.5% State-run local health agencies Federal Funds 67.8% 0 (led by staff employed by state government) Fees and Fines 7.2% Independent regional or district offices Other Sources 0.6% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 38.9% HHS 0.0% Planning and Accreditation HRSA 20.4% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 32.2% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.0% Other 8.5% The state/territorial agency has submitted an application for accreditation.

Agency Workforce Total Revenue FY15: $118,304,962 The state/territorial health agency has 195 FTEs. There are no state/ Total Federal Revenue FY15: $45,558,168 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 159 NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, DIVISION OF PUBLIC HEALTH NEBRASKA

Agency Mission Top Five Priorities

To help people live better lives. 1 Prescription Drug Monitoring Program 2 Health disparities and health equity 3 Process improvement 4 Accreditation 5 System of care

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 2 (led by staff employed by local government) State General Funds N/A% Other State Funds N/A% State-run local health agencies Data not available 0 (led by staff employed by state government) Federal Funds N/A% Fees and Fines N/A% Independent regional or district offices Other Sources N/A% 19 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC N/A% HHS N/A% Planning and Accreditation HRSA N/A% The state/territorial health agency has developed Medicaid N/A% the following within the past five years: Data not available Medicare N/A% Health Assessment USDA N/A% Health Improvement Plan DHS N/A% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA N/A% Other N/A% The state/territorial agency has achieved accreditation..

Agency Workforce The state/territorial health agency has 454 FTEs. There are no state/ Total Revenue FY15: Data not available Total Federal Revenue FY15: Data not available territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

160 ASTHO Profile of State and Territorial Public Health, Volume Four NEW HAMPSHIRE DEPARTMENT OF HEALTH AND HUMAN SERVICES, DIVISION OF PUBLIC HEALTH SERVICES NEW HAMPSHIRE

Agency Mission Top Five Priorities

To assure the health and well-being of people in New Hampshire 1 Misuse of alcohol and drugs by protecting and promoting physical, mental, and environmental 2 Healthy mothers and babies health and preventing disease, injury, and disability. 3 Injury prevention 4 Infectious disease prevention 5 Heart disease and stroke

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 2 (led by staff employed by local government) State General Funds 24.4% Other State Funds 0.0% State-run local health agencies Federal Funds 43.6% 0 (led by staff employed by state government) Fees and Fines 1.0% Independent regional or district offices Other Sources 31.0% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state has a public health services improvement council, CDC 86.9% which is similar to a board of health. HHS 2.1% HRSA 9.6% Planning and Accreditation Medicaid 0.0% The state/territorial health agency has developed Medicare 0.0% the following within the past five years: USDA 0.0% Health Assessment DHS 0.0% Health Improvement Plan EPA 0.7% Strategic Plan Other 0.7%

The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB. Total Revenue FY15: $86,940,665 Agency Workforce Total Federal Revenue FY15: $33,603,990 The state/territorial health agency has 227 FTEs. There are no state/ *FY15 was defined as 7/1/2014 – 6/30/2015. territorial health agency workers assigned to local/regional offices.

ASTHO Profile of State and Territorial Public Health, Volume Four 161 NEW JERSEY DEPARTMENT OF HEALTH NEW JERSEY

Agency Mission Top Five Priorities

To improve health through leadership and innovation. 1 Population health 2 Chronic disease 3 Birth outcomes 4 Workplace wellness 5 Performance management

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 90 (led by staff employed by local government) State General Funds 19.3% Other State Funds 1.2% State-run local health agencies Federal Funds 36.1% 0 (led by staff employed by state government) Fees and Fines 43.4% Independent regional or district offices Other Sources 0.0% 1 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state has a public health council, which is similar to CDC 10.0% a board of health. HHS 43.5% HRSA 14.3% Planning and Accreditation Medicaid 8.6% The state/territorial health agency has developed Medicare 0.0% the following within the past five years: USDA 22.1% Health Assessment DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Health Improvement Plan EPA 0.1% Strategic Plan Other 1.3%

The state/territorial agency has submitted an application for accreditation. Total Revenue FY15: $1,726,993,809 Agency Workforce Total Federal Revenue FY15: $618,683,033 The state/territorial health agency has 1,067 FTEs, including 31 state/ *FY15 was defined as 7/1/2014 – 6/30/2015. territorial workers assigned to local/regional offices.

162 ASTHO Profile of State and Territorial Public Health, Volume Four NEW MEXICO DEPARTMENT OF HEALTH NEW MEXICO

Agency Mission Top Five Priorities

To promote health and sound health policy, prevent disease 1 Obesity reduction and disability, improve health services systems, and assure 2 Smoking cessation that essential public health functions and safety net services 3 Control of vaccine-preventable diseases are available to New Mexicans. 4 Teen pregnancy reduction 5 Prevention and control of diabetes

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a centralized relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds N/A% Other State Funds N/A% State-run local health agencies Data not available 0 (led by staff employed by state government) Federal Funds N/A% Fees and Fines N/A% Independent regional or district offices Other Sources N/A% 0 (led by non-state employees) State-run regional or district offices 4 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC N/A% HHS N/A% Planning and Accreditation HRSA N/A% The state/territorial health agency has developed Medicaid N/A% the following within the past five years: Data not available Medicare N/A% Health Assessment USDA N/A% Health Improvement Plan DHS N/A% Strategic Plan EPA N/A% Other N/A% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 3,775 FTEs, including 800 Total Revenue FY15: Data not available Total Federal Revenue FY15: Data not available state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 163 NEW YORK STATE DEPARTMENT OF HEALTH NEW YORK

Agency Mission Top Five Priorities

To protect, improve, and promote the health, productivity, 1 Prevent chronic disease and wellbeing of all New Yorkers by promoting public health 2 Promote healthy women, infants, and children and patient safety; by reducing health disparities; and by assuring 3 Promote healthy and safe environments access to affordable, high-quality health services. 4 Prevent HIV, sexually transmitted diseases, vaccine-preventable diseases, and healthcare-associated infections 5 Promote mental health and prevent substance abuse

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a decentralized relationship with local health departments.

Independent local health agencies 58 (led by staff employed by local government) State General Funds 25.3% Other State Funds 30.6% State-run local health agencies Federal Funds 44.1% 0 (led by staff employed by state government) Fees and Fines 0.0% Independent regional or district offices Other Sources 0.0% 0 (led by non-state employees) State-run regional or district offices 12 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state has a public health and health planning council, CDC 1.0% which is similar to a board of health. HHS 13.1% HRSA 1.6% Planning and Accreditation Medicaid 51.6% The state/territorial health agency has developed Medicare 0.0% the following within the past five years: USDA 23.1% Health Assessment DHS 5.2% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Health Improvement Plan EPA 0.4% Strategic Plan Other 4.1%

The state/territorial agency has achieved accreditation.

Agency Workforce Total Revenue FY15: $4,128,673,660 Total Federal Revenue FY15: $1,822,273,610 The state/territorial health agency has 3,151 FTEs, including 722 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

164 ASTHO Profile of State and Territorial Public Health, Volume Four NORTH CAROLINA DIVISION OF PUBLIC HEALTH NORTH CAROLINA

Agency Mission Top Five Priorities

To promote and contribute to the highest level 1 Improve internal business functions of health possible for the people of North Carolina. 2 Prevent hepatitis C infections 3 Reduce infant mortality rate 4 Reduce prescription opioid misuse, abuse, morbidity, and mortality 5 Improve the medical examiner system

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 85 (led by staff employed by local government) State General Funds 11.7% Other State Funds 0.0% State-run local health agencies Federal Funds 82.1% 0 (led by staff employed by state government) Fees and Fines 6.3% Independent regional or district offices Other Sources 0.0% 6 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 28.3% HHS 0.0% Planning and Accreditation HRSA 1.9% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 69.8% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.0% Other 0.0% The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce Total Revenue FY15: $454,773,148 The state/territorial health agency has 1,924 FTEs, including 714 Total Federal Revenue FY15: $364,118,743 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 165 NORTH DAKOTA DEPARTMENT OF HEALTH NORTH DAKOTA

Agency Mission Top Five Priorities

To protect and enhance the health and safety of all 1 Environmental oil/energy impact North Dakotans and the environment in which we live. 2 Information technology security and health data 3 Integration of public health and private sector/primary care 4 Cardiovascular disease and associated risk factors 5 Accreditation and quality improvement

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a decentralized relationship with local health departments.

Independent local health agencies 28 (led by staff employed by local government) State General Funds 29.7% Other State Funds 1.1% State-run local health agencies Federal Funds 59.3% 0 (led by staff employed by state government) Fees and Fines 5.9% Independent regional or district offices Other Sources 4.1% 8 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state has a state health council, which is similar CDC 28.3% to a board of health. HHS 5.8% HRSA 6.7% Planning and Accreditation Medicaid 1.8% The state/territorial health agency has developed Medicare 3.2% the following within the past five years: USDA 26.3% Health Assessment DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Health Improvement Plan EPA 22.3% Strategic Plan Other 5.6%

The state/territorial agency has submitted an application for accreditation. Total Revenue FY15: $82,371,244 Agency Workforce Total Federal Revenue FY15: $48,823,828 This state/territorial health agency has 355 FTEs. There are no state/terri- *FY15 was defined as 7/1/2014 – 6/30/2015. torial health agency workers assigned to local/regional offices.

166 ASTHO Profile of State and Territorial Public Health, Volume Four OHIO DEPARTMENT OF HEALTH OHIO

Agency Mission Top Five Priorities

To protect and improve the health of all Ohioans 1 One mission, one voice by preventing disease, promoting good health, 2 System alignment and assuring access to quality care. 3 Data-driven performance 4 Workforce development 5 Access to core public health services

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 120 (led by staff employed by local government) State General Funds 14.8% Other State Funds 12.8% State-run local health agencies Federal Funds 67.2% 0 (led by staff employed by state government) Fees and Fines 5.3% Independent regional or district offices Other Sources 0.0% 0 (led by non-state employees) State-run regional or district offices 2 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state has an advisory board that fulfills an advisory role, CDC 16.5% but does not have authority. HHS 2.5% HRSA 11.6% Planning and Accreditation Medicaid 2.7% The state/territorial health agency has developed Medicare 3.9% the following within the past five years: USDA 58.1% Health Assessment DHS 0.0% Health Improvement Plan EPA 0.3% Strategic Plan Other 4.5%

The state/territorial agency has achieved accreditation.

Agency Workforce Total Revenue FY15: $581,819,877 Total Federal Revenue FY15: $390,693,300 The state/territorial health agency has 1,075 FTEs, including 106 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 167 OKLAHOMA STATE DEPARTMENT OF HEALTH OKLAHOMA

Agency Mission Top Five Priorities

To protect and promote health, to prevent disease 1 Infectious disease control, regulatory functions, and injury, and to cultivate conditions by which Oklahomans preparedness, and response services can be healthy. 2 Tobacco use prevention 3 Obesity 4 Children’s health 5 Behavioral health

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a mixed relationship with local health departments.

Independent local health agencies 2 (led by staff employed by local government) State General Funds 16.3% Other State Funds 7.4% State-run local health agencies Federal Funds 56.7% 1 (led by staff employed by state government) Fees and Fines 1.3% Independent regional or district offices Other Sources 18.2% 0 (led by non-state employees) State-run regional or district offices 68 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 14.2% HHS 2.2% Planning and Accreditation HRSA 11.4% The state/territorial health agency has developed Medicaid 17.7% the following within the past five years: Medicare 0.6% Health Assessment USDA 43.9% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.0% Other 10.0% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 2,206 FTEs, including 1,406 Total Revenue FY15: $349,740,633 Total Federal Revenue FY15: $198,395,992 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

168 ASTHO Profile of State and Territorial Public Health, Volume Four OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION OREGON

Agency Mission Top Five Priorities

To promote health and prevent the leading causes of death, 1 Prevent tobacco use, harms of substance abuse, disease, and injury in Oregon. and deaths by suicide 2 Slow the increase of obesity 3 Improve oral health and immunization rates 4 Protect from communicable diseases 5 Implement public health modernization

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 34 (led by staff employed by local government) State General Funds 8.5% Other State Funds 0.0% State-run local health agencies Federal Funds 63.1% 0 (led by staff employed by state government) Fees and Fines 12.3% Independent regional or district offices Other Sources 16.2% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state has a public health advisory board, which is similar CDC 24.0% to a board of health. HHS 2.6% HRSA 8.1% Planning and Accreditation Medicaid 8.7% The state/territorial health agency has developed Medicare 0.8% the following within the past five years: USDA 48.7% Health Assessment DHS 0.0% Health Improvement Plan EPA 6.0% Strategic Plan Other 1.4%

The state/territorial agency has achieved accreditation.

Agency Workforce Total Revenue FY15: $234,501,887 Total Federal Revenue FY15: $147,904,287 The state/territorial health agency has 674 FTEs, including 61 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 169 PALAU BUREAU OF PUBLIC HEALTH PALAU

Agency Mission Top Five Priorities

To ensure that all members of the community have access 1 Strategic planning to the resources, education, knowledge, and services needed 2 Workforce development to achieve the highest possible level of health. 3 Health promotion 4 Surveillance and data capacity building 5 Research and policy development

Structure and Relationship with Local Health Departments The state/territorial health agency is under a larger agency— sometimes referred to as a “superagency” or “umbrella agency.”

Organizational Structure The health official reports directly to the U.S. Secretary of Health and Human Services. The state/territory does not have a board of health.

Planning and Accreditation The state/territorial health agency has developed the following within the past five years:

Health Assessment Health Improvement Plan Strategic Plan

The state/territorial health agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce The state/territorial health agency has 145 FTEs. INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL

170 ASTHO Profile of State and Territorial Public Health, Volume Four PENNSYLVANIA DEPARTMENT OF HEALTH PENNSYLVANIA

Agency Mission Top Five Priorities

To promote healthy lifestyles, prevent injury and disease, 1 Develop a culture of data-driven quality improvement and to assure the safe delivery of quality health care for 2 Continue to work toward public health accreditation all Commonwealth citizens. 3 Publish four-year Health Innovation in Pennsylvania Implementation Plan 4 Implement Prescription Drug Monitoring Program 5 Publish four-year strategic plan

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a mixed relationship with local health departments.

Independent local health agencies 10 (led by staff employed by local government) State General Funds 22.2% Other State Funds 6.5% State-run local health agencies Federal Funds 69.5% 0 (led by staff employed by state government) Fees and Fines 0.2% Independent regional or district offices Other Sources 1.6% 0 (led by non-state employees) State-run regional or district offices 6 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state has a health policy board, which is similar to a board of health. CDC 18.1% HHS 3.0% HRSA 15.6% Planning and Accreditation Medicaid 11.2% The state/territorial health agency has developed Medicare 2.0% the following within the past five years: USDA 49.0% Health Assessment DHS 0.0% Health Improvement Plan EPA 0.1% Strategic Plan Other 1.1%

The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Total Revenue FY15: $1,774,568,000 Agency Workforce Total Federal Revenue FY15: $616,500,000

The state/territorial health agency has 1,105 FTEs, including *FY15 was defined as 7/1/2014 – 6/30/2015. 472 state/territorial workers assigned to local/regional offices.

ASTHO Profile of State and Territorial Public Health, Volume Four 171 PUERTO RICO DEPARTMENT OF HEALTH/ DEPARTAMENTO DE SALUD DE PUERTO RICO PUERTO RICO

Agency Mission Top Five Priorities

To prevent diseases, promote and maintain health so that each 1 Institutionalize the use of health information technology human being reaches physical, emotional, and social well-being that 2 Improve resource acquisition and management to optimize allows for the full enjoyment of life and contribution to the productive health impact efforts of human society. 3 Strengthen the department of health using accreditation 4 Strengthen the infrastructure to support sustainable collaboration 5 Medicare and Medicare parity of funds

Structure and Relationship with Local Health Departments The state/territorial health agency is a freestanding/ independent agency.

Organizational Structure The health official reports directly to the governor. The state/territory does not have a board of health.

Planning and Accreditation The state/territorial health agency has developed the following within the past five years:

Health Assessment Health Improvement Plan Strategic Plan

The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce The state/territorial health agency has 4,894 FTEs. INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL

172 ASTHO Profile of State and Territorial Public Health, Volume Four REPUBLIC OF THE MARSHALL ISLANDS MINISTRY OF HEALTH REPUBLIC OF THE MARSHALL ISLANDS

Agency Mission Top Five Priorities

To strengthen the commitment to the Healthy Islands concept by 1 Address tuberculosis (TB), including multi-drug implementing health promotion to protect and promote healthy resistant TB lifestyles; to improve the lives of the people through primary health; 2 Eradicate leprosy and to build the capacity of the Ministry of Health, communities, 3 Reduce non-communicable diseases and their major families, and partners to actively participate in and coordinate risk factors preventive services programs and activities as the core resources 4 Protect against vaccine-preventable diseases in primary health care services. 5 Fight childhood malnutrition

Structure and Relationship with Local Health Departments The state/territorial health agency is under a larger agency— sometimes referred to as a “superagency” or “umbrella agency.”

Organizational Structure The health official does not report directly to the president of the Republic of the Marshall Islands. The state/territory has a board of health.

Planning and Accreditation The state/territorial health agency has developed the following within the past five years:

Health Assessment Health Improvement Plan Strategic Plan INDIVIDUAL AGENCY PROFILES The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce The state/territorial health agency has 570 FTEs.

ASTHO Profile of State and Territorial Public Health, Volume Four 173 RHODE ISLAND DEPARTMENT OF HEALTH RHODE ISLAND

Agency Mission Top Five Priorities

To positively demonstrate for Rhode Islanders the purpose 1 Promote healthy living for all through all stages of life and importance of public health. 2 Ensure access to safe food, water, and healthy environments in all communities 3 Promote a comprehensive health system that a person can navigate, access, and afford 4 Prevent, investigate, control, and eliminate health hazards and emerging threats 5 Analyze and communicate data to improve the public’s health

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 15.7% Other State Funds 6.8% State-run local health agencies Federal Funds 58.4% 0 (led by staff employed by state government) Fees and Fines 0.0% Independent regional or district offices Other Sources 19.1% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 36.5% HHS 3.2% Planning and Accreditation HRSA 15.0% The state/territorial health agency has developed Medicaid 5.2% the following within the past five years: Medicare 0.0% Health Assessment USDA 31.2% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 1.8% Other 7.1% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 444 FTEs. There are no Total Revenue FY15: $124,790,005 Total Federal Revenue FY15: $72,886,752 state/territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

174 ASTHO Profile of State and Territorial Public Health, Volume Four SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL SOUTH CAROLINA

Agency Mission Top Five Priorities

To improve the quality of life for all South Carolinians 1 Securing and aligning financial resources with strategic by protecting and promoting the health of the public initiatives and the environment. 2 Reducing obesity rates 3 Achieving national public health accreditation 4 Promoting health equity and environmental justice 5 Recruiting and retaining the public health workforce

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a centralized relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 17.7% Other State Funds 0.0% State-run local health agencies Federal Funds 54.1% 63 (led by staff employed by state government) Fees and Fines 0.0% Independent regional or district offices Other Sources 28.3% 0 (led by non-state employees) State-run regional or district offices 4 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 0.0% HHS 48.0% Planning and Accreditation HRSA 0.0% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 51.0% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.0% Other 1.1% The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce Total Revenue FY15: $376,996,654 The state/territorial health agency has 2,991 FTEs, including 1,538 Total Federal Revenue FY15: $196,163,626 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 175 SOUTH DAKOTA DEPARTMENT OF HEALTH SOUTH DAKOTA

Agency Mission Top Five Priorities

To promote, protect, and improve the health of every South Dakotan. 1 Improve the quality, accessibility, and effective use of healthcare 2 Support lifelong health for South Dakotans 3 Prepare for, respond to, and prevent public health threats 4 Develop and strengthen strategic partnerships to improve public health 5 Maximize the effectiveness and strengthen infrastructure of the department of health

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a largely centralized relationship with local health departments.

Independent local health agencies 1 (led by staff employed by local government) State General Funds 8.3% Other State Funds 0.0% State-run local health agencies Federal Funds 53.2% 0 (led by staff employed by state government) Fees and Fines 10.1% Independent regional or district offices Other Sources 28.5% 0 (led by non-state employees) State-run regional or district offices 7 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 48.7% HHS 0.0% Planning and Accreditation HRSA 6.9% The state/territorial health agency has developed Medicaid 5.4% the following within the past five years: Medicare 0.0% Health Assessment USDA 37.0% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.0% Other 2.1% The state/territorial agency has not decided whether to apply for accreditation.

Agency Workforce Total Revenue FY15: $99,623,583 The state/territorial health agency has 430 FTEs. There are no state/ Total Federal Revenue FY15: $95,846,372 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

176 ASTHO Profile of State and Territorial Public Health, Volume Four TENNESSEE DEPARTMENT OF HEALTH TENNESSEE

Agency Mission Top Five Priorities

To protect, promote, and improve the health 1 Reduce tobacco use and prosperity of people in Tennessee. 2 Reduce obesity 3 Increase physical activity 4 Decrease substance abuse, especially opioids 5 Improve organizational functioning using the Baldrige Model

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a mixed relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 35.7% Other State Funds 0.0% State-run local health agencies Federal Funds 40.3% 89 (led by staff employed by state government) Fees and Fines 6.2% Independent regional or district offices Other Sources 17.8% 6 (led by non-state employees) State-run regional or district offices 7 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 25.3% HHS 0.0% Planning and Accreditation HRSA 18.2% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 56.6% Health Improvement Plan DHS 0.0% Strategic Plan EPA 0.0% Other 0.0% The state/territorial agency has not decided whether to apply for accreditation.

Agency Workforce Total Revenue FY15: $527,722,832 The state/territorial health agency has 2,913 FTEs, including 1,799 Total Federal Revenue FY15: $209,648,883 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 177 TEXAS DEPARTMENT OF STATE HEALTH SERVICES TEXAS

Agency Mission Top Five Priorities

To improve health and well-being in Texas. 1 Improve health through prevention 2 Improve health through safety net services 3 Enhance public health response to disasters and disease outbreaks 4 Address emerging changes in the health delivery system 5 Protect consumers through regulation

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 59 (led by staff employed by local government) State General Funds 47.1% Other State Funds 2.5% State-run local health agencies Federal Funds 35.9% 0 (led by staff employed by state government) Fees and Fines 1.3% Independent regional or district offices Other Sources 13.3% 0 (led by non-state employees) State-run regional or district offices 8 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 10.7% HHS 20.1% Planning and Accreditation HRSA 10.1% The state/territorial health agency has developed Medicaid 8.7% the following within the past five years: Medicare 0.4% Health Assessment USDA 49.3% Health Improvement Plan DHS 0.1% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.1% Other 0.5% The state/territorial agency has decided not to apply for accreditation.

Agency Workforce The state/territorial health agency has 11,181 FTEs, including 9,397 Total Revenue FY15: $3,198,763,971 Total Federal Revenue FY15: $1,147,960,636 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

178 ASTHO Profile of State and Territorial Public Health, Volume Four U.S. VIRGIN ISLANDS DEPARTMENT OF HEALTH U.S. VIRGIN ISLANDS

Agency Mission Top Five Priorities

To achieve health equity through public health transformation. 1 Staff recruitment for current vacancies 2 Staff training and development 3 Agency reorganization and stabilization 4 Implementing activities to address health equity 5 Zika response

Structure and Relationship with Local Health Departments The state/territorial health agency is a freestanding/ independent agency.

Organizational Structure The health official reports directly to the governor. The state/territory does not have a board of health.

Planning and Accreditation The state/territorial health agency has developed the following within the past five years:

Health Assessment Health Improvement Plan

Strategic Plan INDIVIDUAL AGENCY PROFILES

The state/territorial agency has not decided whether to apply for accreditation.

Agency Workforce The state/territorial health agency has 359 FTEs.

ASTHO Profile of State and Territorial Public Health, Volume Four 179 UTAH DEPARTMENT OF HEALTH UTAH

Agency Mission Top Five Priorities

To protect the public’s health through preventing avoidable 1 Utahans will be the healthiest people illness, injury, disability, and premature death; assuring access 2 Medicaid expansion under the Affordable Care Act to affordable, quality healthcare; and promoting healthy lifestyles. 3 Opioid overdose prevention 4 Medical examiner caseload 5 Early intervention caseload growth

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a decentralized relationship with local health departments.

Independent local health agencies 13 (led by staff employed by local government) State General Funds 18.5% Other State Funds 5.4% State-run local health agencies Federal Funds 59.9% 0 (led by staff employed by state government) Fees and Fines 12.7% Independent regional or district offices Other Sources 3.6% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 43.2% HHS 1.8% Planning and Accreditation HRSA 12.5% The state/territorial health agency has developed Medicaid 2.2% the following within the past five years: Medicare 2.2% Health Assessment USDA 34.0% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.0% Other 4.2% The state/territorial agency has submitted an application for accreditation.

Agency Workforce Total Revenue FY15: $227,951,260 The state/territorial health agency has 1,012 FTEs. There are no state/ Total Federal Revenue FY15: $136,442,615 territorial health agency workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

180 ASTHO Profile of State and Territorial Public Health, Volume Four VERMONT DEPARTMENT OF HEALTH VERMONT

Agency Mission Top Five Priorities

To protect and promote the best health for all Vermonters. 1 Improve childhood immunization rates 2 Reduce prevalence of mental illness 3 Reduce prevalence of substance abuse 4 Reduce tobacco use 5 Increase good nutrition and physical activity

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 22.3% Other State Funds 0.6% State-run local health agencies Federal Funds 62.4% 0 (led by staff employed by state government) Fees and Fines 2.3% Independent regional or district offices Other Sources 12.5% 0 (led by non-state employees) State-run regional or district offices 12 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 21.8% HHS 20.4% Planning and Accreditation HRSA 7.9% The state/territorial health agency has developed Medicaid 27.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 21.0% Health Improvement Plan DHS 0.2% Strategic Plan EPA 0.6% Other 1.2% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 532 FTEs, including 147 Total Revenue FY15: $118,226,771 Total Federal Revenue FY15: $73,698,737 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 181 VIRGINIA DEPARTMENT OF HEALTH VIRGINIA

Agency Mission Top Five Priorities

To promote and protect the health of all Virginians. 1 Improve the health of Virginians and decrease healthcare costs by controlling communicable disease 2 Improve the health and well-being of families by improving family planning and decreasing unintended pregnancies 3 Improve food security and nutrition for at-risk Virginians 4 Prevent foodborne disease outbreaks in both public and private settings 5 Assure the provision of clean, safe drinking water to all Virginians.

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a largely centralized relationship with local health departments.

Independent local health agencies 2 (led by staff employed by local government) State General Funds 25.9% Other State Funds 0.5% State-run local health agencies Federal Funds 48.9% 128 (led by staff employed by state government) Fees and Fines 14.6% Independent regional or district offices Other Sources 10.2% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state has a board of health. CDC 16.6% HHS 2.3% Planning and Accreditation HRSA 22.1% The state/territorial health agency has developed Medicaid 0.8% the following within the past five years: Medicare 1.7% Health Assessment USDA 50.0% Health Improvement Plan DHS 0.1% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 6.1% Other 0.4% The state/territorial agency has registered in e-PHAB in order to pursue accreditation.

Agency Workforce Total Revenue FY15: $633,778,537 The state/territorial health agency has 3,682 FTEs, including 2,591 Total Federal Revenue FY15: $309,239,289 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

182 ASTHO Profile of State and Territorial Public Health, Volume Four WASHINGTON STATE DEPARTMENT OF HEALTH WASHINGTON

Agency Mission Top Five Priorities

To protect and improve the health of all people in Washington state. 1 Implement plans to achieve End AIDS Washington goals 2 Describe, plan for, track, and begin mitigating and adapting for the public health impacts of climate change 3 Secure sustainable funding for Foundational Public Health Services 4 Reduce the use of tobacco, e-cigarettes/vaping devices, and mari- juana in persons under 21 years old 5 Ensure health equity and improve population health

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is a freestanding/independent agency Source of Funding and has a decentralized relationship with local health departments.

Independent local health agencies 35 (led by staff employed by local government) State General Funds 11.8% Other State Funds 14.3% State-run local health agencies Federal Funds 50.1% 0 (led by staff employed by state government) Fees and Fines 16.7% Independent regional or district offices Other Sources 7.1% 0 (led by non-state employees) State-run regional or district offices 4 (led by state employees)

Organizational Structure

Federal Funding Sources INDIVIDUAL AGENCY PROFILES The health official does not report directly to the governor. The state does not have a board of health. CDC 17.5% HHS 9.9% Planning and Accreditation HRSA 4.5% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.7% Health Assessment USDA 56.2% Health Improvement Plan DHS 0.0% Strategic Plan EPA 4.7% Other 6.5% The state/territorial agency has achieved accreditation.

Agency Workforce The state/territorial health agency has 1,576 FTEs, including 273 Total Revenue FY15: $510,767,432 Total Federal Revenue FY15: $255,963,855 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 183 WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES, BUREAU FOR PUBLIC HEALTH WEST VIRGINIA

Agency Mission Top Five Priorities

To have healthy people and communities and to help 1 Decrease prevalence of obesity and associated factors shape the environments within which people and 2 Reduce tobacco use and associated conditions communities can be safe and healthy. 3 Focus on improving mental health and reducing substance abuse 4 Focus on preventable care and avoidable costs 5 Strengthen evidence-based healthcare, data, and outcomes

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 49 (led by staff employed by local government) State General Funds 30.5% Other State Funds 13.0% State-run local health agencies Federal Funds 55.3% 0 (led by staff employed by state government) Fees and Fines 0.9% Independent regional or district offices Other Sources 0.3% 2 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 14.1% HHS 9.9% Planning and Accreditation HRSA 6.5% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 61.9% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 3.7% Other 3.9% The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce Total Revenue FY15: $225,264,361 The state/territorial health agency has 684 FTEs, including 76 Total Federal Revenue FY15: $124,161,700 state/territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

184 ASTHO Profile of State and Territorial Public Health, Volume Four WISCONSIN DIVISION OF PUBLIC HEALTH WISCONSIN

Agency Mission Top Three Priorities

To protect and promote the health and safety of people of Wisconsin. 1 State public health accreditation 2 Timely completion of the Wisconsin Health Improvement Plan 3 Develop emergency preparedness, response, and recovery procedures that promote a continuum of care in regulated health and residential care facilities

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 0 (led by staff employed by local government) State General Funds 16.1% Other State Funds 2.3% State-run local health agencies Federal Funds 73.2% 0 (led by staff employed by state government) Fees and Fines 5.7% Independent regional or district offices Other Sources 2.6% 0 (led by non-state employees) State-run regional or district offices 5 (led by state employees)

Organizational Structure

The health official does not report directly to the governor. Federal Funding Sources INDIVIDUAL AGENCY PROFILES The state has a public health council, which is similar to a board of health. CDC 32.1% HHS 0.7% HRSA 7.2% Planning and Accreditation Medicaid 0.3% The state/territorial health agency has developed Medicare 0.0% the following within the past five years: USDA 58.8% Health Assessment DHS 0.0% Health Improvement Plan EPA 0.9% Strategic Plan Other 0.0%

The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Total Revenue FY15: $236,803,750 Agency Workforce Total Federal Revenue FY15: $173,403,175

The state/territorial health agency has 470 FTEs, including 46 *FY15 was defined as 7/1/2014 – 6/30/2015. state/territorial workers assigned to local/regional offices.

ASTHO Profile of State and Territorial Public Health, Volume Four 185 WYOMING DEPARTMENT OF HEALTH, PUBLIC HEALTH DIVISION WYOMING

Agency Mission Top Five Priorities

To promote, protect, and improve health and prevent 1 Fostering programmatic excellence disease and injury in Wyoming. 2 Developing efficiencies in program operations 3 Focusing on population-based services versus direct care services 4 Providing cost-effective professional development for staff 5 Promoting value/relevance of public health

Structure and Relationship with Local Health Departments Agency Finance (FY15*) The state/territorial health agency is under a larger agency— Source of Funding sometimes referred to as a “superagency” or “umbrella agency”— and has a mixed relationship with local health departments.

Independent local health agencies 5 (led by staff employed by local government) State General Funds 33.4% Other State Funds 22.6% State-run local health agencies Federal Funds 44.1% 18 (led by staff employed by state government) Fees and Fines 0.0% Independent regional or district offices Other Sources 0.0% 0 (led by non-state employees) State-run regional or district offices 0 (led by state employees)

Organizational Structure Federal Funding Sources The health official does not report directly to the governor. The state does not have a board of health. CDC 43.0% HHS 17.2% Planning and Accreditation HRSA 6.7% The state/territorial health agency has developed Medicaid 0.0% the following within the past five years: Medicare 0.0% Health Assessment USDA 28.3% Health Improvement Plan DHS 0.0% INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL INDIVIDUAL AGENCY PROFILES AGENCY INDIVIDUAL Strategic Plan EPA 0.4% Other 4.4% The state/territorial agency plans to apply for accreditation, but has not yet registered in e-PHAB.

Agency Workforce Total Revenue FY15: $64,144,454 The state/territorial health agency has 1,457 FTEs, including 91 state/ Total Federal Revenue FY15: $28,265,957 territorial workers assigned to local/regional offices. *FY15 was defined as 7/1/2014 – 6/30/2015.

ASTHO Profile of State and Territorial Public Health, Volume Four 186 186 ASTHO Profile of State and Territorial Public Health, Volume Four ASTHO Profile of State and Territorial Public Health, Volume Four 187 The ASTHO Profile of State and Territorial Public Health, Volume Four is a publication of the Association of State and Territorial Health Officials. It describes the structure, functions, and resources of state and territorial health agencies and highlights their contributions to public health.

To view this publication online, visit ASTHO’s website at www.astho.org/profile. 2231 Crystal Drive, Suite 450 Arlington, VA 22202 Phone: (202) 371-9090 www.astho.org

ASTHO Profile of State and Territorial Public Health Volume Four

Copyright© 2017 Association of State and Territorial Health Officials. All rights reserved.