In 2022, the Joint Commission on Health Care conducted a study on local health department structure and financing. This study followed several recent legislative actions regarding local health departments, including the elimination of the requirement that a local health department director be a licensed physician; authorization for several localities to administer their health departments locally through contracts with the Virginia Department of Health (VDH); and the revision of local match rates based on updating the factors used to calculate local revenue generation capacity (which was phased in over three fiscal years, beginning in FY 2022).
As part of the 2022 study, JCHC staff conducted a survey of county administrators to understand the relationships between counties and their health departments. The report included a series of recommendations, most of which the Commission referred to VDH with a request to establish a workgroup to prioritize the study’s policy options. VACo was invited to participate in this workgroup, which convened its first meeting in mid-August. Jim Taylor, Deputy County Administrator for Hanover County, is representing VACo on the workgroup.
VDH formed an internal steering committee of district and central office staff after receiving the study referral, and this group has recommended prioritizing the following policy options, viewing these recommendations as foundational to achieving other goals:
- Require all health districts to participate in the Community Health Assessment (CHA)/Community Health Improvement Plan (CHIP) process. The Community Health Assessment is a systematic process to identify key health needs, issues, and assets, and the Community Health Improvement Plan is typically a three- to five-year collaborative effort to address public health problems identified by the Community Health Assessment.
- Develop a state performance management process for local health departments, focusing on assessing their capacity, assisting with continuous quality improvement, and providing accountability for meeting public health functions.
- Track cooperative budget funding per capita, comparing it to local health department needs and making necessary adjustments as additional funding is made available.
In addition, the Secretary of Health and Human Resources has encouraged VDH to consider the other policy options from the JCHC report, including exploring ways to improve access and linkages to clinical care. VDH was also encouraged to use the workgroup as an opportunity to reimagine the role and priorities of local health departments. VACo has recommended that VDH focus on stabilizing staffing; the public health workforce is also a priority of the VDH steering committee, but was not included in the committee’s top three priorities as it is being considered as part of the agency’s budget process.
At the workgroup’s August meeting, discussion centered around the three proposed priority options. VDH staff provided background on the CHA/CHIP process, noting that there is variation in participation among local health departments, which some workgroup participants attributed to their differing levels of resources. Nonprofit hospitals and Federally Qualified Health Centers must conduct similar assessments (albeit on different timelines), and there was discussion regarding the potential for cooperation with the local health departments to avoid duplication of efforts.
The workgroup considered several aspects of a potential system for performance measurement, including questions of measuring outcomes versus outputs, as well as discussion about public health metrics that may be beyond local health departments’ control. Workgroup members discussed the use of accountability measures as targets, and as a shared responsibility with the community (as in the Community Health Improvement Plan process), as well as how some metrics might be able to be used to drive additional investment to departments rather than triggering funding cuts or other punitive measures.
As part of the discussion of potential changes to General Fund allocations to local health departments to consider need rather than historical spending patterns, VDH staff provided an overview of actions taken by the 2021 General Assembly to codify the cooperative budget process and to update the data in the formula and phase in the updated allocations over three fiscal years. One option considered by VDH for further improvements to the funding formula is an additional General Fund allocation, without a local matching requirement, for disadvantaged communities. Members also discussed tensions created by the different timelines for adoption of local budgets relative to the determination of local health departments’ state budget allocations.
VACo is soliciting feedback from members on the questions discussed at the workgroup’s first meeting, as well as several additional questions to inform VACo’s participation in this effort. Questions circulated to county administrators include the following:
- Are you aware of the health district’s Community Health Assessment/Community Health Improvement Plan process? How much value does it provide to your community? How should local health departments use community health assessment and improvement plan results? How would you like this information shared with the county? Should this process be connected to the local government cooperative budget agreement?
- Do you currently receive any performance measures from your health district or department? What data indicators would help you understand your local health department’s performance? Which indicators would benefit your entire community in understanding its performance?
- Currently, state General Funds for local health departments are based mainly on historical funding levels. If the distribution were based on needs, what criteria should this model consider?
- What improvements do you wish to see in your local health department’s budget development process?
- To what extent does high turnover in your local health department impact your county’s relationship with the department?
- Do you have recommendations for stabilizing the local health department workforce? Are there successful recruitment and retention strategies used for county staff that could apply to health department staff?
Any feedback from VACo members on these questions would be most appreciated and may be directed to Katie Boyle (kboyle@vaco.org).
VACo Contact: Katie Boyle