Integrating Personal and Public Health Services in Los Angeles

San Gabriel Valley and Metropolitan Service Planning Area Health Office (SPA 3 & 4 )

SPA 3 & 4 VIEWPOINT

INTEGRATING PERSONAL AND PUBLIC HEALTH SERVICES IN LOS ANGELES COUNTY Findings and Recommendations from a SWOT Analysis

SPA 3 & 4 BEST PRACTICE COLLECTION RELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES

M. RICARDO CALDERÓN, SERIES EDITOR

October 2004

Los Angeles County Department of Health Services • Public Health

At a Glance SAN GABRIEL VALLEY SERVICE PLANNING AREA (SPA 3) METROPOLITAN SERVICE PLANNING AREA HEALTH OFFICE (SPA 4)

241 North Figueroa Street, Room 312 Los Angeles, California 90012 (213) 240-8049 The Best Practice Collection is a publication of the San Gabriel Valley (SPA 3) and Metropolitan Service Planning Area (SPA 4). The opinions expressed herein are those of the editor and writer(s) and do not necessarily reflect the official position or views of the Los Angeles County Department of Health Services. Excerpts from this document may be freely reproduced, quoted or translated, in part or in full, acknowledging SPA 3 & 4 as the source.

Internet: http://www.lapublichealth.org/SPA 3 Internet: http://www.lapublichealth.org/SPA 4

LOS ANGELES COUNTY BOARD OF SUPERVISORS Gloria Molina, First District Yvonne Brathwaite Burke, Second District Zev Yaroslavsky, Third District Don Knabe, Fourth District Michael D. Antonovich, Fifth District DEPARTMENT OF HEALTH SERVICES Thomas L. Garthwaite, MD. Director and Chief Medical Officer

Jonathan E. Fielding, MD, MPH, MBA. Director of Public Health and County Health Officer

A. Belinda Towns, MD, MPH. Medical Director, Public Health

AUTHORS Jennifer Belden, MPH. SPA 3 & 4 Epidemiology Analyst

David Caley, RN, PHN.

Program Director, Community Liaising Program

Angela Salazar, MPH.

Program Director, Health Education

BEST PRACTICE COLLECTION TEAM M. Ricardo Calderón, Series Editor

Manuscript Author & SPA 3 & 4 Area Health Officer

The SPA 3 & 4 Best Practice Collection fulfills the Los Angeles County Department of Health Services (DHS) local level goal to restructure and improve health services by “establishing and effectively disseminating to all concerned stakeholders comprehensive data and information on the health status, health risks, and health care utilization of Angelinos and definable subpopulations”.1 It is a program activity of the SPA 3 & 4 Information Dissemination Initiative created with the following goals in mind: To highlight lessons learned regarding the design, implementation, management and evaluation of public health programs To serve as a brief theoretical and practical reference for program planners and managers, community leaders, government officials, community based organizations, health care providers, policy makers and funding agencies regarding health promotion and disease prevention and control To share information and lessons learned in SPA 3 & 4 for community health planning purposes including adaptation or replication in other SPA’s, counties or states To advocate a holistic and multidimensional approach to effectively address gaps and disparities in order to improve the health and well-being of populations The SPA 3 & 4 Information Dissemination Initiative is an adaptation of the Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice Collection concept. Topics will normally include the following: 1. SPA 3 & 4 Viewpoint: An advocacy document aimed primarily at policy and decision-makers that outlines challenges and problems and proposes options and solutions.

2. SPA 3 & 4 Profile: A technical overview of a topic that provides information and data needed by public, private and personal health care providers for program development, implementation and evaluation.

3. SPA 3 & 4 Case Study: A detailed real-life example of policies, strategies or projects that provide important lessons learned in restructuring health care delivery systems and/or improving the health and well being of populations.

4. SPA 3 & 4 Key Materials: A range of materials designed for educational or training purposes with up-to-date authoritative thinking and knowhow on a topic or an example of a best practice.

Carina Lopez, MPH.

Project Manager, Information Dissemination Initiative

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INTEGRATING PERSONAL AND PUBLIC HEALTH SERVICES IN LOS ANGELES COUNTY

Table of Contents i. PREFACE: AN INTEGRATED HEALTH SERVICES APPROACH

4

An Integrated Health Services Approach

Integration Model

ii. EXECUTIVE SUMMARY

6

I. INTRODUCTION II. METHODS

………………………………………………………..........7

……………………………………………………………................ 8

III. FINDINGS AND RECOMMENDATIONS …………………………………..............….. 8

Communication Leadership and Decision Making Morale, Motivation and Attitudes Customer Service Workforce Development Access to Health Care Policies and Procedures Funding and Resource Allocation Preventive Medicine and Services Medical Records System

8 9 9 9 10 10 11 11

IV. WHERE DO WE GO FROM HERE? ………………………………………….............. 12 V. CONCLUSION …………………………………………………………...............

12

VI. REFERENCES ……………………………………………………..............…

12

VII. APPENDICES .……………………………………………………...............…… 13

Appendix A: Survey: Organizational Appraisal Appendix B: Limitations of Survey Appendix C: Survey Responses (SWOT Analysis) Appendix D: 10 Central Themes of Integration Appendix E: Community Liaising Program Concept Paper

Appendix F: SPA 3 & 4 Organizational Chart

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PREFACE

i. PREFACE: AN INTEGRATED HEALTH SERVICE APPROACH The Integration Plan of the Los Angeles County (LAC) Department of Health Services (DHS), drafted by the integration planning team cochaired by Drs. Jonathan E. Fielding, Director of Public Health and County Health Officer, and Jeffrey Guterman, Director of Clinical Resource Management for LAC-DHS, provided focus and initiative to the integration effort. However, in order to provide a more comprehensive approach to integration, the integration planning goals must be expanded to address existing intra-organizational issues. The current plan identifies the integration areas of Immunizations, Tobacco Control, Substance Abuse, and Information Systems as the issues to address initially. While these are important issues, they should be considered as assurance of standards of care and a foundation on which to build further integration efforts. The proposed Integration Plan should include the broader concepts of integration (e.g., policy and procedure, access to health care, medical records system, etc.), inclusive of staff from all levels, and adhere to pre-designated timelines. Our suggestions for this expansion are as follows: • Implement an annual “needs assessment” in order to identify key areas for improvement within DHS between personal and public health.

These assessments should be given to staff at all levels of the organization. The initial needs assessment should be completed no later than May 31, 2005.

• Assign one representative from both personal and public health to act as an Integration Liaison Repre-

sentative for the integration effort.

These liaisons should be senior level managers within the organization. Liaisons will continually report progress (quarterly) to the executive leadership. This liaison should be assigned prior to June 15, 2005.

• Analyze and report survey findings to staff at all levels no later than July 31, 2005.

• Develop “grass-roots” level working groups (Personal and Public Health Integration Groups: PPHIGs) for both personal and public health. Each working group should be comprised of a staff level representative from all programs, units and Service Planning Areas (SPAs). These groups should be identified by July 1, 2005. The first meetings should be held no later than July 31, 2005.

• Create task forces within PPHIGs to address each of the issues identified by the needs assessment at the groups’ first meetings, no later than July 31, 2005.

• Develop key areas and priorities for integration within PPHIGs. Each PPHIG reports to their respective liaison and agency with these findings. This should be accomplished by October 31, 2005.

The end goal of the integration process should not be this needs assessment only, or the development of an integration plan, but rather a continued commitment from both personal and public health to work toward one integrated health care delivery system. This process should seek to identify existing resources which can be coordinated to more effectively communicate about best practices, standards of care, established benchmarks, and evidencebased practices in order to promote wellness and reduce disparities. Buyin and a sense of urgency from the executive leadership are necessary to provide momentum, promote the vision, drive the process and enhance the goals of the organization.

“To reach a state of complete physical, mental and social wellbeing, an individual or group must be able to identify and to realize aspirations, to satisfy needs and to change or cope with the environment. “Health” is, therefore, seen as a resource for everyday life, not the objective of living”.

World Health Organization, 1986

• Integration Liaison Representatives will work with their respective executive leadership to prioritize and identify targeted steps for the integration of personal and public health by no later than December 31, 2005.

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.

World Health Organization, 1948

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INTEGRATION MODEL

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EXECUTIVE SUMMARY

ii. EXECUTIVE SUMMARY The health care delivery system in Los Angeles County and throughout the country is being constantly challenged by problems like obesity, a large uninsured population, growing health disparities, and emerging diseases and threats such as bioterrorism, influenza vaccine shortages and West Nile Virus. Within Los Angeles County, a population of more than 10 million socially, ethnically, and culturally diverse residents, budget constraints, suspended and discontinued services, and the rising costs associated with health care have lead to a system that is fragmented and uneasily accessible to the population most in need of its services.

“Integrated service delivery is the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for the money”.

World Health Organization

The continued polarization of personal and public health services has contributed the system’s inability to keep pace with current demand.

For the system to survive in today’s world of constant crisis, the Department must seek to integrate services in order to preserve scarce resources and provide more comprehensive, “holistic” care. It is in this climate that the Service Planning Area (SPA) 3 & 4 Area Health Office was charged with

developing an approach to integration at the broad level of clinical services.

By surveying the staff and management from both personal and public health, 10 key themes emerged from the data. These themes identify barriers that prevent the successful integration of personal and public health services in Los Angeles County, and when addressed, will demonstrate substantial improvements in the way we do business. In order for the Department to successfully implement an integration of services we must first: • Improve communication • Strengthen leadership and decsion making • Increase morale • Provide excellent customer service • Foster workforce development • Expand access to health care • Review and revise policies and procedures • Identify new funding sources • Incorporate preventive medicine and services, and • Modernize the medical records system.

“Integrative medicine is described as orienting the health care process to create a seamless engagement by patients and caregivers of the full range of physical, psychological, social, preventive and therapeutic factors known to be effective and necessary for the achievement of optimal health”.

As these changes cannot be implemented simultaneously, we must initially focus on items or themes that have the greatest potential for positive impact.

“Integration of primary health services can be seen as a variety of managerial or operational changes to health systems to bring together inputs, organizations, management and delivery of particular service functions. Integration aims to improve the service in relation to efficiency and quality”.

Ranjani K. Murthy

The findings and recommendations outlined here illustrate the areas of action and change that we believe should be integrated by personal and public health, including our community partners and stakeholders.

For integration to be successful at DHS, change must first be initiated by the administration and progressively be adopted and driven by staff at all levels. DHS must ensure that true integration is the goal, one in which there is a sharing of ideas, philosophies, goals, and values. It is only through shared vision and values that we can successfully move from two divergent departments into one integrated system.

Institute of Medicine 6 Integrating Personal and Public Health Services in Los Angeles County: SPA 3 & 4 Viewpoint

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INTRODUCTION

I. INTRODUCTION The health of individuals, families and communities can no longer be secured simply by personal or public health alone. The growing population combined with the growing number of influences on individual health has made it increasingly difficult for any one agency alone to ensure the health and well being of a population. It is not only through collaboration and the integration of the two systems (personal and public health) but through partnerships with other sectors that overall health is achieved.

Health is shaped by outside laws and policies, employment and income, social norms and influences and, as such, requires an approach that includes agencies from all sectors of society including academia, media, sports industry, entertainment industry, political arena, and faith-based community among others.

“Healthy” means more than just the absence of disease. The human being is a fusion of body, mind, and spirit - one dependent upon the other for optimal quality of life” American Association of Integrative Medicine

In Los Angeles County, with an area of more than 4,000 square miles and a population of over 10 million ethnically and culturally diverse residents, meeting the health care needs of the population has become increasingly arduous. Currently, clients have difficulty accessing care due to the availability of fewer services scattered throughout a large geographic area.

Clients who need both personal and public health services must travel from center to center to access these services. Current trends are shifting away from two separate health care systems towards a more “holistic” approach incorporating internal and external stakeholders that address the health and well-being of individuals, families and communities. This shift has led the department to investigate methods by which services within the county could be integrated.

“The purpose of integrating health services is to enable the overall health system or program to provide appropriate services to more people, closer to where they live and work, at an earlier stage of disease development, and as part of a continuum of care process”.

SPA 3 & 4 Area Health Office LAC/DHS

What is Integration?

Over the past few decades, counties, health departments, and health experts and care providers have used the word “integration” with a variety of meanings and in different situations. For some, integration may mean a new organizational structure merging various disease control programs or regular coordination through information sharing among decision makers and program managers. Other views are that integration means adding tasks to already overburdened staff, sharing resources such as transportation among dif-

ferent programs or providers, and expanding services or co-locating different institutions in the same building.

All of these views fail to appreciate that the aim of integrating services is to enable the overall health program or system to provide appropriate services to more people at an early stage of disease development. How do we accomplish this? This requires more services in one location that are closer to where people live and work, improving communication, revising policy and procedure, and addressing disparities in health care in order to assure that the most vulnerable within our population have access to quality care and services. These services can include health promotion and education, preventive/evidencebased medicine, specialty care, social services, and primary and public health care. Incorporation of all these services would create one integrated, comprehensive health care delivery system. In order for this integration to be successful, DHS must fully understand its “strengths, weaknesses, opportunities and threats” and incorporate this knowledge into all development and planning.

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METHODS

II. METHODS In order to better assess the current needs, a SWOT Analysis was performed to identify internal strengths and weaknesses as well as internal and external opportunities and threats. As a tool, this analysis helps to focus activities into areas where there is existing strength and greatest opportunity, while simultaneously providing awareness of perceived weaknesses and threats that may inhibit progress.

A survey was developed using the SWOT Analysis as a guide. In order to elicit individual responses, open ended questions were created to provide an opportunity for participants to express unique thoughts, not limiting answers to closed-ended or few pre-selected options. The survey comprised a total of four questions and one page in length (see appendix A; also see Appendix B for limitations of the survey). A convenience sample (sampling based on availability, access and readiness) was used due to the limited amount of time in which to gather data. A total of 102 participants completed the survey prior to the deadline of Tuesday, October 26, 2004. Participants included staff and management from multiple programs within public health and a limited sampling of personal health staff and community partners. It is believed that more responses would have been received had there been more time to collect data. (For a list of all responses, see appendix C).

As data were analyzed, trends began to emerge. From the more than 230 comments, suggestions and opinions, 10 central themes (see appendix D) were developed that encompass

all aspects of organizational life including (in no specific order): communication, access to health care, leadership and decision making, policies and procedures, funding and resource allocation, workforce development, morale motivation and attitudes, medical records and preventive medicine and services.

III. FINDINGS AND RECOMMENDATIONS: 1. COMMUNICATION Findings: Communications and collaborations between Personal and Public Health are limited, leading to a duplication of efforts, inefficient use of resources, fragmented services, missed opportunities, decreased morale, and apparent competition between both personal and public health. This point was reinforced through the data with more than 40 different comments dealing with all aspects of communication. Currently within DHS there is a lack of cooperation and collaboration between both personal and public health. Without the encouragement of consistent and open communication DHS will fail to further develop existing relationships and build the necessary links between personal and public health.

Additionally, without building a shared vision or common goals the staff will continue to work in fragmented, compartmentalized units rather than a synergistic, teamwork approach that is necessary for DHS to be effective.

Recommendations: 1.1 Assign e-mail accounts and provide access to internet and intranet for all staff. This strategy would

ensure that all staff would receive important messages without relying on supervisors or managers to disseminate information.

1.2 Create opportunities for program directors and department heads to be more visible and accessible to staff. Without direct communication from leadership, staff feel disconnected and uninformed.

1.3 Develop a liaising program to link personal and public health services together and to community organizations and agencies. Model this program after the SPA 3 & 4 Area Health Office’s Community Liaising Program (see Appendix E).

1.4 Convene joint planning meetings between personal and public health staff at all levels. These meetings, in order to be effective, should include strategic goals, objectives and action planning.

2. LEADERSHIP AND DECISIONMAKING Findings: The department’s hierarchy is built upon the idea that only those at the upper most levels of the system are involved in decision making, policy making and resource allocation with limited input and feedback from line level staff. At the same time, these decisions are often taken out of the hands of department heads and controlled by political agendas, further enforcing a bureaucratic infrastructure and status quo. This infrastructure is based on hierarchical chains of command, organization by function, impersonal relationships, and coordination from above. This leads to a system that is unable to address the complexities, need for cross-functional communication, and necessary in-depth relationships and

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FINDINGS AND RECOMMENDATIONS

information sharing that is mandated in health care today.

Recommendations: 2.1 Foster opportunities to develop leaders at every level (see appendix F).

2.2 Inspire an atmosphere of genuine teamwork throughout DHS. Successes are dependent on the participation of all players (employees).

2.3 Expand current efforts to provide comprehensive leadership training to staff at all levels and provide opportunities to exercise newly learned skills.

2.4 Establish succession planning strategies that work to ensure stability and maintain momentum within the organization.

3. MORALE, MOTIVATION AND ATTITUDES: Findings: The separation of personal and public health has created a sense of dissatisfaction, resistance, and decreased motivation among staff and management. In DHS today, staff and programs alike feel “undervalued”, that they are not important, and not critical to the service delivery system.

The department is seen as impersonal, uncaring, lacking concern and respect not only for programs and staff but for clients and customers.

Additionally, low morale and motivation continues to hinder the ability of DHS to function effectively and efficiently in the community. Without a shared sense of cooperation and buy-in there will be a great deal of resistance at all levels to any proposed change.

Recommendations:

Recommendations:

3.1 Develop strategies including possible incentives, rewards and other methods to acknowledge talented and gifted staff.

4.1 Monitor and continually evaluate customer satisfaction using customer suggestion boxes, surveys and mystery patients.

3.2 Empower and educate staff about how to navigate through the organization with expanded career paths and promotional opportunities.

4.2 Continue efforts to provide customer service training to staff at all levels.

3.3 Encourage and demonstrate an atmosphere of mutual value and respect throughout the department.

3.4 Foster relationship building and a sense of community within DHS to improve employee attitudes and morale aimed to enhance a shared sense of vision and buy-in.

4. CUSTOMER SERVICE Findings: Customer service is not only affected by direct interactions and communications with clients but, in large part, based on the ability of staff to function effectively in their individual roles. As the system exists today, staff lacks the support necessary to provide excellent service due in part to low staffing levels and the inefficiency of the system. This inefficiency often requires an exorbitant amount of labor to accomplish the simplest of tasks. When not addressed, these problems ultimately lead to frustration and resentment among staff. The system has created barriers to service delivery ultimately making it difficult for staff to demonstrate their concern for the client’s well being.

4.3 Strengthen existing cultural sensitivity training in order to improve cultural competence throughout DHS. Encourage workforce to share stories within programs and departments to correct cultural misconceptions.

4.4 Revise employee job descriptions and performance evaluations to include customer service as a responsibility. Ensure that all documentation reflects the DHS focus on customer service excellence.

5. WORKFORCE DEVELOPMENT: Findings: Severe staffing shortages have left DHS anemic and unable to carry out necessary day-to-day functions. These shortages have lead to increased work loads while depriving staff of the opportunities for education and development. Lack of opportunities for development and education creates stagnation in both the individual employee as well as the organization as a whole.

This leads to resentment, decreased efficiency and overall performance in addition to difficulty recruiting and retaining talented, enthusiastic staff.

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FINDINGS AND RECOMMENDATIONS

Recommendations:

receive fragmented services.

5.1 Increase staffing to appropriate levels.

Recommendations:

5.2 Review and revise recruitment and retention strategies throughout DHS. Include in these strategies options for flexible schedules, incentives and other enticements.

5.3 Increase opportunities for continuing education to fulfill license renewal requirements with contingency plans to accommodate attendance of such classes.

5.4 Create an environment where staff from all levels are encouraged and given the opportunity to attend professional meetings and conferences.

5.5 Expand the core functions of public health class to include roles and responsibilities of both personal and public health.

6. ACCESS TO HEALTH CARE: Findings: The personal and public health systems are straining to meet the needs of an increasingly larger, more diverse and aged population with a higher incidence of chronic diseases. Limited hours, extensive delays in scheduling and subsequent service delivery, and lack of referral follow-up all create barriers to access for patients. Without a uniform referral system, patients are often forced to seek other avenues from which to access care. The extensive delay in service delivery and lack of referral follow-up often leads to broken appointments and subsequent undiagnosed or untreated illnesses. In addition, as the system exists today, patients spend countless hours traveling from center to center in order to

6.1 Increase the hours of operation for clinics and health centers to include evenings and some weekends to more effectively provide care to our client population.

6.2 Convert all county clinics and comprehensive care centers to “Centers for Health”. These centers should provide care using a “holistic” approach and include services such as primary care including preventive medicine, public health, select specialty care and diagnostic services, and social services.

6.3 Review and revise appointment scheduling procedures and programs (i.e., software) so that an appointment can be scheduled from any health center or clinic for any service.

6.4 Ensure that patients receive referrals and subsequent care in a time sensitive manner. Follow-up to patient referrals should be included within the standard of care.

6.5 Facilitate partnerships with the private sector (both for profit and non-profit) in order to assure the provision of services.

7. POLICIES AND PROCEDURES: Findings: The integration of DHS can not occur using existing county policies and procedures that do not reflect a collaborative approach to health care delivery. These policies are outdated and inconsistent often leading to confusion and a lack of coordination within DHS. The current process for developing and/or changing policies and procedures requires multiple labor intensive steps that ul-

timately serve to create unnecessary obstacles. These obstacles, combined with the bureaucratic infrastructure and status quo mentality, leads to a system that is fragmented and inefficient.

Recommendations: 7.1 Strengthen policy making and development capabilities by creating a Policy Development Task Force or Unit. This task force or unit should be comprised of participants from all levels of staff.

7.2 Update existing policies and procedures to reflect a focus on integration.

7.3 Streamline policy writing and review processes to remove needless barriers to change.

8. FUNDING AND RESOURCE ALLOCATION: Findings: Financial resources are becoming increasingly scarce due to economic conditions and the rising cost of health care, particularly for chronic conditions. Unfortunately, agenda-driven politics and decisionmaking control existing funding and resources. As two separate entities, personal and public health services find it necessary to cut services, layoff workers and reduce the already diminished capacity of the DHS to serve its client population. Without the integration of personal and public health both personal and public health cannot share resources and provide opportunities to allocate resources in a more cost-effective manner.

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FINDINGS AND RECOMMENDATIONS

Recommendations: 8.1. Convene a task force comprised of DHS staff and various community partners to examine resource allocation aimed to optimize comprehensive services.

8.2 Encourage ongoing research to develop methods for evidencebased, cost-effective distribution of resources.

8.3 Develop new public/private partnerships in order to seek additional funding resources. By expanding the existing Community Liaising Program, DHS can further nurture strategic alliances and partnerships with public, private and community organizations.

8.4 Prioritize building renovation and repair to accommodate the best utilization of county facilities. (i.e., ensure patient confidentiality and HIPAA compliance through screening/interview rooms, improve patient waiting areas, etc.)

9. PREVENTIVE MEDICINE AND SERVICES: It is increasingly difficult for clinicians to incorporate preventive care into routine health care due to management complexities of risk factors and chronic disease. In addition, hospitals have traditionally focused on treating acute illnesses rather than acting as a center for preventive health. This focus on disease treatment, combined with the disparities that currently exist in patient care, creates a system that is disease oriented and more costly since patients receive treat-

ment at the secondary and tertiary stages of disease development. The lack of integration of preventive services into standard practice creates a climate in which DHS finds itself constantly struggling to meet the needs of a rapidly growing, increasingly aged population with multiple chronic conditions.

Recommendations: 9.1 Launch an evidence-based practice awareness campaign targeting staff (and providers) to increase knowledge of prevention strategies and best practices.

9.2 Intensify efforts to promote Preventive Medicine strategies among the community at large. Efforts should utilize best practice solutions and existing evidence-based strategies.

9.3 Influence policy decision makers regarding on-campus food consumption and physical activities/education at local schools.

9.4 Advocate for expanded insurance coverage for preventive care and services to create a culture of responsibility and accountability within the insurance industry.

10. MEDICAL RECORDS SYSTEM: Findings: The polarization of personal and public health services can be attributed in large part to the current lack of a uniform medical records system. As it exists today, patients who enter the system in public health and then seek care in personal health are assigned different medical record

numbers in each agency. This leads to missing, lost, and multiple copies of medical records, unnecessary duplication of services, and lack of continuity of care resulting in decreased customer satisfaction. The lack of an integrated medical records system that provides access to both personal and public health further inhibits the current service delivery system by decreasing workforce efficiency and morale. Without an integrated system, providers are subject to both personal and public health’s interpretation of HIPAA regulations and standards which thereby impede access to patient records.

Recommendations: 10.1 Upgrade technology (i.e., hardware and software) in order to ensure that systems are standardized throughout DHS. Ensure that computers are updated on a routine basis and programs are compatible between systems.

10.2 Develop an integrated medical records system in which personal and public health access and use the same system. Ideally, this system would have one unique identifier/ medical record number per individual for more efficient filing and retrieval.

10.3 Ensure that all medical records are electronic records and facilitate all necessary maintenance and support of this system.

10.4 Delineate concise guidelines that address HIPAA regulations to instruct staff regarding the specifics of sharing patient information.

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CONCLUSION & REFERENCES

IV. WHERE DO WE GO FROM HERE? The numerous recommendations identified above demonstrate the complexity of the integration of personal and public health. While all of these recommendations are critical to the success of integration efforts, change of this magnitude cannot be accomplished all at once.

To begin, we must develop an approach to improving integration at the level of clinical services that is initially focused on items or themes that have the potential for greatest positive impact. The successful integration of these specific areas has the potential to generate changes within all other identified themes and lay a foundation for innovation and culture change within the organization.

V. CONCLUSION The health care system in Los Angeles County is fragmented and complex often requiring patients to travel from center to center in search of services.

Existing gaps in services are frequently addressed with “silver bullets”, quick, band-aid solutions that do not serve to resolve the deeper and larger issues within the system.

It is essential that DHS understands that integration is not a co-location of two agencies or entities existing together in one facility without collaboration. Integration is the merging of ideas, philosophies, values and goals to provide a more “holistic” approach to health promotion, healthcare, and disease prevention and control.

The Department of Health Services can enhance its performance and effectiveness through comprehensive planning and successful integration of personal and public health services.

Failure to do so will result in status quo, duplication of efforts, depletion of resources, missed opportunities, poor customer service and a continued and corroding fragmentation of the health system. An integrated system will, on the contrary, contribute to create a relevant and responsive system to the priorities and needs of the population, as well as to enhance the ability of DHS to protect, maintain and improve the health status and wellbeing of individuals, families and communities of Los Angeles County.

VI. REFERENCES: Institute of Medicine. The future of the public’s health in the 21st Century.

Washington: National Academies Press, 2003.

Estabrooks, PA, Glasgow, RE, Dzewaltowski, DA. Physical activity promotion through primary care. Journal of the American Medical Association 2003; 289:2913-2916.

Coffield, AB et al. Priorities among recommended clinical preventive services. American Journal of Preventive Medicine 2001; 21:1-9.

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APPENDIX A: Survey A & B: Limitations to Survey

Appendix A: Survey Organization Appraisal Instructions: 1.

Please describe the strengths (attributes or assets) that can facilitate or aid in the integration of Personal and Public Health Services within DHS.

2.

Please describe the weaknesses (deficiencies or areas that need improvement) in the programs, services, policies or procedures of DHS that can interfere with the integration of Personal and Public Health Services.

3.

Please describe the opportunities (strategies for expansion or development) that are needed for the successful integration of Personal and Public Health Services within DHS.

4.

Please describe the threats (risks and challenges) that may prevent the effective integration of Personal and Public Health Services within DHS.

Appendix B: Limitations to the Survey •

As responses were being collected it was realized that question #1 was leading participants to identify opportunities rather than strengths.

•

Inability to survey personal health staff due to time limitations.

•

Qualitative data more difficult to analyze due to the large range of answers.

•

Capturing personal experiences and specific examples was difficult as responses to questions ‘ were sometimes lengthy.

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APPENDIX C: Survey Responses (SWOT Analysis)

Appendix C: Survey Responses STRENGTHS • Both systems service the same population (10) • Willingness to collaborate – optimistic (9) • Staff familiar with the integrated system (7) • Diverse / multicultural workforce (6) • Staff want to provide professional care (5) • Well educated staff (5) • Competent workforce (4) • Existing relationships between Public Health and Personal Health services (3) • Existing resources (lab, x-ray, etc) (3) • Existing range of services (2) • Open communication (2) • Good Public Health referral system (2) • Proven ability to work with difficult situations (2) • Existing facilities in place (2) • Existing leadership with vision (all benefits/all people) (2) • Extensive services in Personal Health to meet healthcare needs (1) • Good inter-departmental communication system (e-mail, MyPHD) (1) • Willingness to share experiences (1) • Increased staff moral with integration of Public Health and Personal Health (1) • Good assurance co-ordination (1) • Proven success of in house referral at HWHC (1) • Open to change (1) • Mutual respect of staff (1) • Proven past integration successes (1)

• Staff familiarity with electronic Medical Record keeping (1) • Case Management (1) • Strong and visible leadership (1) • Staff concern for each other and clients (1) • Creative/Innovative staff (1) • SPA structure and functions (1) Weaknesses • Lack of communication between Personal Health and Public Health (40) • Cannot see patients in a timesensitive manner (leads to broken appointments) (27) • Public Health cannot access medical records from Personal Health (17) • Lack of understanding of Personal Health Services (16) • Lack of understanding of Public Health Services (16) • Staffing levels too low (10) • Different software systems do not communicate with each other (10) • Lack of standardization of Policy and Procedure (10) • Client must go to various centers for various services (requires numerous days, travel arrangements, time) (9) • Lack of uniform referral process (9) • Lack of collaboration between Public Health and Personal Health (9) • Paperwork/forms not consistent from facility to facility (7) • Fragmentation within and between programs and units (6) • Numerous medical record #s assigned to same patient leads to difficulty in retrieval of medical records and confusion (6) • Unsuccessful Private Partnership (Pomona) (5) • Lack of Customer Service (5) • Lack of resources (5) • System is too compartmentalized(4) • Since ’95 split, clients going to private sector (4) • Suspended or discontinued resources (4)

• Public Health and Personal Health Informatics (4) • Cannot access lab results (4) • Sharing of information based on personal relationships “who you know” (3) • Poor attitudes of staff (3) • Problems with staff performance (3) • Human Resources (hiring procedures, promotion, discipline, etc) (3) • Different licensing agencies (JACHO) (3) • Fragmentation of services received (3) • Duplication of services (3) • Management is comfortable with the status quo (3) • Lack of referrals (3) • Lack of communication within management (2) • Blaming each other for failures – lack of accountability (2) • Lack of adequate culturally sensitive translation services (2) • Lack of funding to implement change (2) • Lack of co-ordination between SPAs (2) • Poor understanding of Policy and Procedure in Public Health (2) • Lack of a contact person @ referral site (only one person can fulfill request) (2) • Lack of Quality Assurance (2) • Inability to remind clients about appointments (2) • Management decision making without staff input (2) • Lack of similar terminology, vocabulary, acronyms (1) • Limited access to disease specific services (1) • Lack of continuing education (1) • More leaders than workers (1) • Lack of communication with CBOs (1) • Personal Health sometimes

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APPENDIX C: Survey Responses (SWOT Analysis)

• • • • • • • • • • • • • • • • • •

responds faster to client giving appt. than Public Health staff when calling for same (1) Different billing system (1) Nor priority appoint given to clients with Chronic Disease conditions (1) Adults refused Immunizations (1) Lack of Management engagement in improvement process (1) Too many staff (1) Decreased morale (1) Lack of prescription services (1) Lack of equipment (1) Lack of parking at Health Centers (1) Missing or lost Medical Records (1) Lack of educational materials (1) Lack of patient engagement in their own personal health (1) Staff’s lack of integration experience (1) Greed – opportunistic management (item manipulation, etc) (1) Lack of internet access/e-mail/ GroupWise (1) Multiple steps needed to obtain approval of ideas/actions (1) Treatment for chronic diseases are not reimbursed at the full level of expenses (1) Organizational outcomes negatively impacting staff (1)

OPPORTUNITIES • Educate all staff with how each department/program functions/ works (24) • Integration of Medical Records/ disease reporting systems – less duplication of MR (23) • Cross train staff – multidisciplinary training (23) • Common goals/cooperation (21) • More comprehensive care – holistic approach (19) • Quicker referrals, improved referral process, referrals with follow-up (18) • Improve communication

throughout system (18) • Opportunity for collaboration between programs/departments (17) • Joint planning meetings between public and personal health (supervisors, managers etc.) – must include staff in all processes (16) • Integration – more cost-effective (15) • Facilities would be better utilized one stop shopping (15) • Expansion of services based on needs – community driven (12) • Centralized appointment center (10) • Better continuity of care through sharing of information/resources (9) • Liaison(s) to link personal health and public health (9) • Increase customer service – increased satisfaction (8) • Opportunities to revise employee job descriptions (8) • Better PR Image (7) • Multi-disciplinary approach to care (6) • Standardization of forms (6) • Joint health fairs (5) • Increase staff (5) • Integration of all services/all departments (5) • Decrease duplication of efforts (5) • Leadership training to be better utilized (5) • Access to specialty care (5) • Staff mentoring – expansion of knowledge base (4) • Increase services in one facility – personal and public health (4) • Expand clinic hours – improved client access (4) • Easier access to Medical Records/lab results etc. (4) • Sharing of common resources (4) • Change driven/initiated by administration (4) • Develop better, more comprehensive policies and procedures (3) • Assess current status – prepare for

future (3) • Increase focus on preventive health care/services (3) • DHS-wide internet and email for improved communication (3) • Revamp HR and employee evaluation process (2) • Increase accountability (2) • Instructional/educational videos in waiting areas (2) • More customer service training (2) • Greater promotional opportunities (2) • Better staff utilization (2) • PHN triage (for chronic diseases, infectious disease, other health conditions) (2) • Decrease duplication of services (2) • Veterans on Steering Committees (i.e., those who have been through this before) (2) • Personal Health with opportunity to increase health promotion (2) • Remove terminology barriers (1) • Expand disease specific services to be available everyday (1) • Software with multi-lingual capabilities (1) • Utilization of medical residents – expand services (1) • Networking (1) • Grass roots committees – change (1) • Develop volunteer professional medical staff • Improve phone systems to include educational messages, directions, hours etc. – cultural/linguistic sensitivity (1) • Improve availability of culturally linguistically appropriate education materials – low literacy, multiple languages (1) • Develop resource lists to include legal services, housing, food banks, environmental services (1) • Improve public health objectives/ goals (1) • Keep important services open –

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APPENDIX C: Survey Responses (SWOT Analysis)

• • • • • • • • • • • • • •

• • • •

MLK (1) Increase number of personal health centers (1) Increase federal/state/immigration funding (1) Improve morale (1) Opportunity to demonstrate concern for staff and clients (1) Respect (1) Specialty services referrals (1) Partner with the private sector (1) Health Education and disease prevention (1) Definition of program missions (1) Support mid-level management to authorize cross-training (1) Transparency in the system (1) Develop firm/strong infrastructure to manage logistics (1) Staff participation to implement change (1) Begin with care for infants, toddlers and children as pediatricians are more aware of the power of integrated services (1) Databases that permit info sharing and configuration (1) Share best practices (1) Expand journal groups (1) Expand use of intranet for posting of DHS info (1)

THREATS • Funding – budget crisis, lack of funding, scarce funding sources, funding restrictions, competition for funding etc. (25) • Resistance to change – staff (20) • Lack of shared vision and buy-in (19) • Lack of staffing (17) • Agenda driven (13) • Resistance to change management (11) • Power struggles – between managers, departments, programs, units etc. (11)

• Band-Aid solutions (quick solutions that are temporary and do not solve major issues/problems) versus Comprehensive planning (9) • Separation (’95) – Integration (present) – Separation (7) • Low morale/motivation (7) • Miscommunication throughout/ between systems (7) • Politics/Bureaucracy (7) • Change (6) • Pessimistic attitude (6) • Turf wars between personal and public health and between programs, units (6) • Silo mentality (6) • Integration – decrease in middle management/staff needs – cascade (5) • Staff who are retired on the job (ROJ) (5) • Space issues (5) • Job instability (perceived or actual) (5) • Egos (4) • Lack of communication within management (4) • Large numbers of undocumented, uninsured, immigrant population (4) • HIPAA regulations (4) • Lack of thinking “outside the box” (4) • Fear of unknown/insecurity (3) • SPA boundaries versus clusters versus regions etc. (3) • Lack of open/honest communication (3) • System too complex to change (3) • 1115 Waiver (3) • Too many tasks (2) • Resistance to overtime authorization (2) • Unsuccessful integration – decrease in customer service (2) • Unproven that integration will lead to improved efficiency (2) • Competition between Personal and Public Health staff (2) • Top heavy organization (too many

chiefs, directors etc.) (2) • Some programs feeling “undervalued” (2) • “Not my job” mentality (1) • Language/Cultural competency (1) • Board of Supervisors (1) • Potential inappropriate use of staff (1) • Informatics of both organizations (1) • Lack of public awareness of integration of services (1) • Lack of support (1) • Safety – neighborhood (expansion of hours) (1) • Unsuccessful integration leads to resistance and resentment among staff (1) • Closing of MLK (1) • Managers that are unavailable (1) • Lack of personal health centers (1) • Hours of operation not good for clients (1) • Masterminds of ’95 split still employed by DHS (1) • Perceived/actual lack of resources (1) • Lack of internet access/email (1) • GREED (1) • Fear (1) • Coordination thru coercion (1) • Building maintenance/poor repair (1) • Competition of services with private sector (1) • Cut backs at the state and federal level (1) • Larger economy (1) • Decreased foundation and endowment funding (1) • Lack of trust (public view) (1) • Parochial staff and organizations (1) • News media sensationalizing stories (1)

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APPENDIX D: 10 Central Themes of Integration

Appendix D: 10 Central Themes of Integration 1. Communication

2. Leadership and Decision Making 3. Morale, Motivation and Attitudes 4. Customer Service 5. Workforce Development 6. Access to Health Care 7. Policies and Procedures 8. Funding and Resource Allocation 9. Preventive Medicine and Services 10. Medical Records System

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APPENDIX E: Community Liaising Program Concept Paper

Appendix E: Community Liaising Program Concept Paper COMMUNITY LIAISING PROGRAM (CLP)* Community Health Services, Los Angeles County Department of Public Health The Community Liaising Program is a strategic approach aimed to lead, organize and support a concerted public, private and non-profit sector effort to strengthen, expand and diversify prevention programs and public health services. It was created by M. Ricardo Calderón in the fall of 1999 when he assumed the position of Area Health Officer for the Metropolitan Service Planning Area (SPA 4) at the Los Angeles County Department of Health Services. The CLP is based on Calderón’s work as Regional Director for Latin America and the Caribbean of the United States Agency for International Development AIDS Control and Prevention Project implemented by Family Health International. It draws from the lessons learned and best practice solutions described in his “HIV/AIDS SYNOPSIS Publication Series” along with the realization that: (1) health promotion, wellness, and disease prevention and control are affected by individual, social, economic and environmental factors within and beyond communities that must be addressed comprehensively, and (2) protecting and improving the health and wellbeing of a population is a shared responsibility among residents, public institutions, private for-profit and non-profit organizations, key stakeholders, opinion leaders and policymakers (See http://www.fhi.org/en/hivaids/pub/ archive/handbooks/multidimensionalmodel.htm).

The Community Liaising Program comprises six strategic domains reflecting areas of competence, skills and activity that Area Health Offices must master in order to mobilize, coordinate, and direct broad collaborative actions within complex public health systems. It is a systematic framework of strategies to involve key stakeholders from different industries and sectors of society in health promotion, wellness and disease prevention and control. As Area Health Offices identify and prioritize health issues, establish goals and objectives, apply evidence-based practices, and develop population and program indicators, the CLP approach can be utilized for successful implementation of institutional vision and overall strategy ultimately resulting in increased awareness and resources for health, enhanced Area Health Offices performance, better health outcomes, and improved health status and wellbeing of individuals, families and communities.

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APPENDIX F: SPA 3 & 4 Organizational Chart

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Metropolitan Service Planning area (SPA 4) 241 North Figueroa Street, Room 312 Los Angeles, California 90012 Tel: (213) 240-8049 Fax: (213) 202-6096 www.lapublichealth.org Š 2004 SPA 3 & 4

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