Strengthening the U.S. Public Health Service Commissioned Corps: A View From The Assistant Secretary for Health

OBJECTIVE

To summarize the results of the major management review of the U.S. Public Health Service Commissioned Corps (2009-2010) and note related outcomes.

METHOD

Narrative from the U.S. Assistant Secretary for Health, who directed and oversaw the management review.

RESULTS

The management review led to 46 recommendations, all of which have since been implemented. The subsequent organizational and operational changes have unified reporting structures, streamlined the administrative Corps organizational structure, and transferred support services to providers with expertise in uniformed services to create a new integrated personnel and payroll system. Related processes have also prompted a systematic billet review as well as establishment of explicit criteria for eligibility to become a Corps officer. Corps leaders report improvements in recruiting talented officers, increased selectivity from the candidate pool, and enhanced matching of incoming officers with agency assignments. Furthermore, Corps activity has grown in both traditional and innovative ways.

CONCLUSION

The Corps has enjoyed heightened activity and outcomes in the era of health reform. The management review and its implementation have strengthened the Corps, helping officers to do their job and achieve their mission.

Toward an integrated public health approach for epilepsy in the 21st century

Epilepsy, a complex spectrum of disorders, merits enhanced public health action. In 2012, the Institute of Medicine (IOM) released a seminal report on the public health dimensions of the epilepsies, recommending actions in 7 domains. The report urged a more integrated and coordinated national approach for care centering on the whole patient, including heightened attention to comorbidities and quality of life; more timely referral and access to treatments; and improved community resources, education, stakeholder collaboration, and public communication. The US Department of Health and Human Services responded to this report by accelerating and integrating ongoing initiatives and beginning new ones. This article summarizes recent federally supported activities promoting an integrated public health approach for epilepsy, highlighting progress in response to the landmark 2012 IOM report and identifying opportunities for continued public health action.

A proposed 'health literate care model' would constitute a systems approach to improving patients' engagement in care

Improving health outcomes relies on patients' full engagement in prevention, decision-making, and self-management activities. Health literacy, or people's ability to obtain, process, communicate, and understand basic health information and services, is essential to those actions. Yet relatively few Americans are proficient in understanding and acting on available health information. We propose a Health Literate Care Model that would weave health literacy strategies into the widely adopted Care Model (formerly known as the Chronic Care Model). Our model calls for first approaching all patients with the assumption that they are at risk of not understanding their health conditions or how to deal with them, and then subsequently confirming and ensuring patients' understanding. For health care organizations adopting our model, health literacy would then become an organizational value infused into all aspects of planning and operations, including self-management support, delivery system design, shared decision-making support, clinical information systems to track and plan patient care, and helping patients access community resources. We also propose a measurement framework to track the impact of the new Health Literate Care Model on patient outcomes and quality of care.

The public health journey: the meaning and the moment

The public health journey is a remarkable one, filled with twists and turns as well as risks and rewards. Because promoting the health of others represents a mission brimming with meaning, our professional work is also profoundly personal. At this extraordinary moment in our nation's public health history, I reflect on the purpose of the journey and comment on the opportunities before us to become a healthier nation in the future.

Defining and measuring chronic conditions: imperatives for research, policy, program, and practice

Current trends in US population growth, age distribution, and disease dynamics foretell rises in the prevalence of chronic diseases and other chronic conditions. These trends include the rapidly growing population of older adults, the increasing life expectancy associated with advances in public health and clinical medicine, the persistently high prevalence of some risk factors, and the emerging high prevalence of multiple chronic conditions. Although preventing and mitigating the effect of chronic conditions requires sufficient measurement capacities, such measurement has been constrained by lack of consistency in definitions and diagnostic classification schemes and by heterogeneity in data systems and methods of data collection. We outline a conceptual model for improving understanding of and standardizing approaches to defining, identifying, and using information about chronic conditions in the United States. We illustrate this model's operation by applying a standard classification scheme for chronic conditions to 5 national-level data systems. Although the literature does not support a single uniform definition for chronic disease, recurrent themes include the non-self-limited nature, the association with persistent and recurring health problems, and a duration measured in months and years, not days and weeks--Thrall. So far, many different approaches have been used to measure the prevalence and consequences of chronic diseases and health conditions in children, resulting in a wide variability of prevalence estimates that cannot be readily compared--van der Lee et al.

Reducing racial and ethnic disparities: the action plan from the department of health and human services

The Department of Health and Human Services (HHS) recently unveiled the most comprehensive federal commitment yet to reducing racial and ethnic health disparities. The 2011 HHS Action Plan to Reduce Racial and Ethnic Health Disparities not only responds to advice previously offered by stakeholders around the nation, but it also capitalizes on new and unprecedented opportunities in the Affordable Care Act of 2010 to benefit diverse communities. The Action Plan advances five major goals: transforming health care; strengthening the infrastructure and workforce of the nation's health and human services; advancing Americans' health and well-being; promoting scientific knowledge and innovation; and upholding the accountability of HHS for making demonstrable progress. By mobilizing HHS around these goals, the Action Plan moves the country closer to realizing the vision of a nation free of disparities in health and health care.

Healthy people: a 2020 vision for the social determinants approach

For the past three decades, the Healthy People initiative has represented an ambitious yet achievable health promotion and disease prevention agenda for the nation. The recently released fourth version-Healthy People 2020-builds on the foundations of prior iterations while newly embracing and elevating a comprehensive "social determinants" perspective. By clearly articulating a new overarching goal to "create social and physical environments that promote good health for all" and a new topic area dedicated to defining the social determinants of health approach, it breaks new ground. Specifically, the 2020 plan emphasizes the need to consider factors such as poverty, education, and numerous aspects of the social structure that not only influence the health of populations but also limit the ability of many to achieve health equity. Improving health is too multifaceted to be left to those working in the health sector alone. Using a social determinants approach can reframe the way the public, policy makers, and the private sector think about achieving and sustaining health. This article describes why such a social determinants approach can enhance our collective efforts to improve population health. This is achieved by defining the context for this new perspective, the process by which the Healthy People 2020 goals and objectives were developed, and the challenges and opportunities ahead. Adding this broad, social determinants perspective and vision for shared societal responsibility for change leaves Healthy People 2020 poised to promote a stronger legacy for a healthier nation and reaffirm a unity of purpose for the future.

New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly 'crisis care'

Health literacy is the capacity to understand basic health information and make appropriate health decisions. Tens of millions of Americans have limited health literacy--a fact that poses major challenges for the delivery of high-quality care. Despite its importance, health literacy has until recently been relegated to the sidelines of health care improvement efforts aimed at increasing access, improving quality, and better managing costs. Recent federal policy initiatives, including the Affordable Care Act of 2010, the Department of Health and Human Services' National Action Plan to Improve Health Literacy, and the Plain Writing Act of 2010, have brought health literacy to a tipping point-that is, poised to make the transition from the margins to the mainstream. If public and private organizations make it a priority to become health literate, the nation's health literacy can be advanced to the point at which it will play a major role in improving health care and health for all Americans.

Creating a framework for getting quality into the public health system

The US health care system has undertaken concerted efforts to improve the quality of care that Americans receive, using well-documented strategies and new incentives found in the Affordable Care Act of 2010. Applying quality concepts to public health has lagged these efforts, however. This article describes two reports from the Department of Health and Human Services: Consensus Statement on Quality in the Public Health System and Priority Areas for Improvement of Quality in Public Health. These reports define what is meant by public health quality, establish quality aims, and highlight priority areas needing improvement. We describe how these developments relate to the Affordable Care Act and serve as a call to action for ensuring a better future for population health. We present real-world examples of how a framework of quality concepts can be applied in the National Vaccine Safety Program and in a state office of minority health.

Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life

The escalating problem of multiple chronic conditions (MCC) among Americans is now a major public health and medical challenge, associated with suboptimal health outcomes and rising health-care expenses. Despite this problem's growth, the delivery of health services has continued to employ outmoded "siloed" approaches that focus on individual chronic diseases. We describe an action-oriented framework--developed by the U.S. Department of Health and Human Services with additional input provided by stakeholder organizations--that outlines national strategies for maximizing care coordination and for improving health and quality of life for individuals with MCC. We note how the framework's potential can be optimized through some of the provisions of the new Patient Protection and Affordable Care Act, and through public-private partnerships.

A 2020 vision for educating the next generation of public health leaders

To meet the dynamic and evolving challenges of public health in the 21st century, our society should foster the next generation of public health leaders. We offer a vision for doing so, by introducing prevention literacy and education from the earliest possible starting point and then broadening these concepts throughout the educational ladder. Making this societal commitment now to nurture such future leaders should make the country healthier by 2020 and beyond.

Understanding worldwide youth attitudes towards smoke-free policies: an analysis of the Global Youth Tobacco Survey

BACKGROUND

Smoke-free policies (SFPs) in public places are increasing globally, but developing countries are lagging behind. Understanding youth attitudes towards SFPs can inform SFP initiatives.

METHODS

A multilevel logistic regression analysis of data collected from youth aged 13-15 years (2000-2006) who completed the Global Youth Tobacco Survey (GYTS) in 115 countries, primarily in the developing world, was conducted. The analysis examined relationships between support for SFPs and individual-level measures related to smoking status, and exposure to secondhand smoke (SHS), controlling for demographic and environmental factors of interest and country-level policy factors.

RESULTS

In all, 77.3% of 356,395 youth in 115 countries favoured SFPs, including majorities of non-smokers (78.7%) and smokers (63.6%). In the multivariable analysis knowledge of smoke harm was the strongest predictor of favouring SFPs (OR 2.42, 95% CI 2.27 to 2.67). Exposure to countermarketing (OR 1.40, 95% CI 1.25 to 1.57) and school anti-smoking education (OR 1.22, 95% CI 1.13 to 1.31) were also positively associated. Current smoking (OR 0.48, 95% CI 0.41 to 0.53), susceptibility to smoking (OR 0.46, 95% CI 0.40 to 0.52) and exposure to tobacco promotion were negatively associated. Significant country-level variation was observed. The presence of any national smoke-free legislation in a country was positively associated with youth favouring such policies.

CONCLUSIONS

The majority of youth worldwide support, yet lack, smoke-free policies in public places, while being regularly exposed to SHS. Youth support of SFPs is most positively associated with knowledge of the harmful effects of tobacco smoke. Redoubling education efforts represents an opportunity to establish smoke-free environments and improve health of children in developing countries.

The Boston Health Care for the Homeless Program: a public health framework

During the past 25 years, the Boston Health Care for the Homeless Program has evolved into a service model embodying the core functions and essential services of public health. Each year the program provides integrated medical, behavioral, and oral health care, as well as preventive services, to more than 11 000 homeless people. Services are delivered in clinics located in 2 teaching hospitals, 80 shelters and soup kitchens, and an innovative 104-bed medical respite unit. We explain the program's principles of care, describe the public health framework that undergirds the program, and offer lessons for the elimination of health disparities suffered by this vulnerable population.

Translating research evidence into practice to reduce health disparities: a social determinants approach

Translating research evidence to reduce health disparities has emerged as a global priority. The 2008 World Health Organization Commission on Social Determinants of Health recently urged that gaps in health attributable to political, social, and economic factors should be closed in a generation. Achieving this goal requires a social determinants approach to create public health systems that translate efficacy documented by research into effectiveness in the community. We review the scope, definitions, and framing of health disparities and explore local, national, and global programs that address specific health disparities. Such efforts translate research evidence into real-world settings and harness collaborative social action for broad-scale, sustainable change.

Chronic Obstructive Pulmonary Disease hospitalization rates in Massachusetts: a trend analysis

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) causes a huge economic burden and >80% of COPD cases are attributable to smoking. Massachusetts introduced a comprehensive Tobacco Control Program (MTCP) in January 1993. A trend analysis of COPD hospitalization rates might indirectly reflect the potential impact of such comprehensive tobacco control programs.

METHODS

Age-adjusted COPD hospitalization rates/100,000 was abstracted from the Massachusetts Community Health Information Profile Database between 1989 and 2005. Joinpoint Regression Analyses program was employed to estimate annual percent changes (APC) in COPD rates by age, sex and race.

RESULTS

In 1989, 265/100,000 age-adjusted COPD hospitalization rates were reported that increased to 423/100,000 in 1993, and then declined to 329/100,000 in 2005. A significant annual decline of 5.6 percentage points was observed in overall COPD rates from 1993 onwards. A similar temporal pattern, with an age-gradient and a slower annual decline in female COPD rates relative to male COPD rates, was observed. COPD rates in both Blacks and Whites were similar to the general overall pattern. Such consistent annual declines in COPD hospitalization rates from 1993 onwards in Massachusetts also closely correspond to the introduction of the MTCP in January 1993.

CONCLUSION

The findings indirectly suggest that smoking cessation should remain the cornerstone strategy for the prevention and control of COPD burden. However, additional studies across different population settings are essential for a definitive conclusion with regard to the immediate impact of a comprehensive tobacco control program on COPD hospitalization rates showing possible gender susceptibility.

"Operation Helping Hands": Massachusetts health and medical response to Hurricane Katrina

INTRODUCTION

As Hurricane Katrina bore down on New Orleans in August 2005, the city's mandatory evacuation prompted the exodus of an estimated 80% of its 485,000 residents. According to estimates from the US Centers for Disease Control and Prevention (CDC), at least 18 states subsequently hosted more than 200,000 evacuees.

HYPOTHESIS/PROBLEM

In this case study, "Operation Helping Hands" (OHH), the Massachusetts health and medical response in assisting Hurricane Katrina evacuees is described. Operation Helping Hands represents the largest medical response to evacuees in recent Massachusetts history.

METHODS

The data describing OHH were derived from a series of structured interviews conducted with two leading public health officials directing planning efforts, and a sample of first responders with oversight of operations at the evacuation site. Also, a literature review was conducted to identify similar experiences, common challenges, and lessons learned.

RESULTS

Activities and services were provided in the following areas: (1) administration and management; (2) medical and mental health; (3) public health; and (4) social support. This study adds to the knowledge base for future evacuation and shelter planning, and presents a conceptual framework that could be used by other researchers and practitioners to describe the process and outcomes of similar operations.

CONCLUSIONS

This study provides a description of the planning and implementation efforts of the largest medical evacuee experience in recent Massachusetts history, an effort that involved multiple agencies and partners. The conceptual framework can inform future evacuation and shelter initiatives at the state and national levels, and promotes the overarching public health goal of the highest attainable standard of health for all.

Secular trends in adult male smoking from 1992 to 2006 in South Korea: age-specific changes with evolving tobacco-control policies

OBJECTIVES

For years, South Korea has had one of the highest levels of tobacco use among males in the world, but a steady decline has been observed recently. This study examined how the smoking behaviour of male adults changed with age after the implementation of national tobacco control policies in 1995.

STUDY DESIGN

Repeated cross-sectional study using a national survey.

METHODS

Data were obtained from the 1992, 1995, 1999, 2003 and 2006 results of a repeated cross-sectional survey, the Social Statistics Survey. The smoking status of adult men was compared before (1992 and 1995 surveys) and after (1999, 2003 and 2006 surveys) the implementation of government-directed tobacco control policies using graphical methods and logistic regression analysis.

RESULTS

After the implementation of tobacco control policies, the percentage of current male smokers decreased while the percentage of former smokers increased markedly. Smoking prevalence among older men (aged 50 years or more) reduced initially, and this decline was more pronounced after the tobacco control policies were implemented. Smoking prevalence in younger men (aged 30-49 years) declined in 2003 when more comprehensive tobacco control policies were implemented.

CONCLUSIONS

This study suggests that comprehensive tobacco control policies in South Korea reduced smoking prevalence among males, initially among older men and later among both older men and younger men.