Wrong Pocket

One more lesson learned from several current teams (a couple in Nebraska and one in North Carolina): it is hard to create a sustainable wellness program.

I think a key reason is the "wrong pocket" issue: the dollar saved by preventing disease does not necessarily return to the pocket of the person who spent the dollar on wellness. This makes it a challenge to sell wellness programs to customers.

Three teams are working hard to figure out how to make it work-- what are the wellness services that can be offered, to whom, such that the health department does not go broke, customers are pleased, and the community as a whole winds up healthier in five years?

Would love to hear your comments and suggestions...

--Stephen Orton

Back in Nebraska

Reflections on my latest trip to Nebraska, where five new teams started writing business plans last week.

•  Nebraska public health folks are really well networked in their communities. These five teams include representatives from the YMCA, school systems, a non-profit doing youth development, multiple hospitals, extension service, a board of health, and a rep from the Chamber of Commerce. 
•  Nebraska communities do a good job on their CHA process as a result of their strong networks, and people involved in Community Health Assessment work (especially partners) are ready to get down to action. For the more action-oriented, it is a huge relief to get down to the specifics of *what we're going to do* in response to the data and the priorities. 
• If you have a good CHA, you are ready to write a business plan. These Nebraska teams clearly have the data they need (or they know where to find it). And they have committed partners - even more committed now than they were before!
• If you spend time driving in Nebraska, you may come to believe that your GPS is broken, because it displays a single straight line in the middle of the screen for long stretches of time. It isn't a malfunction, it's just I-80. 
• Nebraska demographical fact: five cows for every person. North Carolina fact: three turkeys for every person.

Next session: next week in Asheville! I'll be watching for turkeys.

-- Stephen Orton

Model Practices

I've written before about a team from the Cumberland Plateau district in Virginia -- they wrote a business plan for mass flu vaccination in schools in Tazewell and Russell Counties. Took a few years, but they finally got the pilot completed, and the pilot worked, and they expanded.

Yadda yadda yadda, things progressed, Flu's Clues is now Flu-a-gator, and the team won a "Model Practice" award from NACCHO for the projectd. I hope you will read about the award and the team's implementation here: http://bit.ly/IRZ3Tm

Congratulations (belatedly) to the whole team, especially Kathy Hypes, who always stays in touch on their doings. You've been a model for many other health departments who are trying to build on your success!

--Stephen Orton

Graduates in the news...

Congrats Pat Townley on your retirement-- so proud to number you among the graduates of the Management Academy!

Pat got a lovely write-up in her local paper in Rome, Georgia:

http://romenews-tribune.com/view/full_story/16938884/article-Townley%E2%80%99s-legacy-as-public-health-advocate--nurse-manager-honored?instance=home_news

Mental Health and Substance Abuse

I'm seeing a trend of interest in integrating mental health and substance abuse services-- and I'm seeing some implications in the way agencies are approaching the idea.

By "a trend" I mean that it has come up three times in the last couple of weeks.

Talking with a potential customer a few weeks ago I asked about their project ideas. I look for ideas that galvanize key partners, meet a key need, and involve revenue generation. One of their key priorities was to figure out a way to integrate mental health and substance abuse services in a way that makes more sense for clients, makes more sense in terms of efficiency, and looks forward to a time beyond block grants, to a reimbursement model.

To me, this sounds like a great fit for a business plan: priority need, committed partners, revenue generation required.

One week later, I got an email from a Management Academy grad from several years back. They had just received HRSA funding for their business plan, doing similar work in rural Nebraska.

Last week, a group from Maryland presented their final business plan on the same topic. The team really impressed us with their commitment to see the change through, because they really believe that they can provide measurably better care and deliver better outcomes, and also create measurable administrative efficiencies, by doing the hard work of integrating. They are committed to this path even though the reimbursement picture is foggy at best. No one is sure how this work will get compensated. The only certainty seems to be that the funding model will be changing often, and perhaps dramatically, at least for the next couple of years.

You can't plan for everything. It certainly puts you way ahead of the curve to have planned for what you can plan for, though. These teams are being proactive. They are moving with purpose toward a better future state. And they are preparing themselves, as part of their plan, for uncertainty on the revenue side of the equation.

--Stephen Orton

On The Road in North Platte

A week or two after launching four new groups in North Platte I'm still thinking about the amazing public health system in Nebraska.

The four teams we are working with from north central Nebraska are all rural. Very rural. In fact they would tell you that they don't have enough population to count as rural: most of their counties are "frontier," a few with densities of less than one person per square mile. The health districts themselves have only been around for ten years. The state used tobacco settlement money to establish public health infrastructure.

The teams are working on great public health prevention issues: restaurant inspections (a role not in the public health portfolio in some areas), dental sealants for kids, healthy workplace products, sustainable plans for distributing vaccinations (flu and whatever comes next).

In all four cases they are working hard to find the sustainable revenue stream to support their work over the long haul.

One more thing they all share: great partnerships. Before there were health districts, many of these rural areas had health coalitions of health-conscious partners. As a result, the health leaders in these areas all think very deeply about how to engage and empower their partners. And the partners respond.

To me, the trip it felt like a glimpse at the origins of public health agencies: energy and green shoots and wide-open spaces for the community service mission to express itself.

--Stephen Orton

Wanted to share this email with you from Nancy Cripps, long-time staffer to the Management Academy.

It is with both joy and sadness I send this email. I am retiring on Friday, September 9.

Forty years ago, I embarked on a vocational path looking for a meaningful career. From a telephone operator, to sales representative to administrative assistant. However, I would not know what meaningful was until I joined the public health profession. These last 10 years have been the best time of my life because I was working with the most dedicated of all professions. Certainly, public health workers are dedicated to leaving the world a better place.

I also was able to learn from the best of the best. I will be forever grateful for having the best teachers in the country Janet Porter, Steve Orton and Karl Umble. From them, I learned many skills among them are communication, management and relationship building. Best of all, by observing them in action, I learned leadership skills. With those leadership skills, I was able to do community work and will continue that community work in my retirement.

My greatest joy was helping all you, my students, write your own business plans while fulfilling all your other responsibilities. Whether it was a friendly reminder or a word of encouragement, I felt I was helping your communities through you.

I am excited about this new adventure in my life. I promise you I will take all I learned from you to make my own community happier, safer and most of all healthier.

It was an honor and pleasure working with you.

--Nancy Cripps

On The Road in Raleigh

We launched four new teams in Raleigh this week! Here's a quick look at the projects going forward from that group:

• A phone app/game to help drive school culture change
• A revenue-supported plan for delivering quality improvement training
• On-line weight loss and lifestyle change program... already piloted, and it works
• Diabetes Education at the local level, sustained by revenues

A key theme for me at this session is this: Public Health agencies are ready, willing and motivated to find partners and revenue streams to support their work. Gone are the days when we had to convince some teams that it was OK to think about generating revenue... now revenue-generation is seen as an important part of the public health portfolio. That doesn't mean *every* project or function needs to be revenue-supported, because some can't or shouldn't. It does mean that agencies need to have the tools to create business plans when revenue-generation is appropriate and will make a product or service better, more effective, more integrated, more sustainable.

-- Stephen Orton

Management Academy On The Road

Here's a quick update on our Management Academy On The Road program. We completed a pilot in Florida with five counties; we launched a new group in Maryland this spring; two more groups launch this summer. The program is two on-site days, supported by webinars and technical assistance before and after (details on the MAPH website).

Here's a short list of business plan ideas in development across these groups.

• An ER Diversion project with hospitals, public health and the Federally Qualified Health Center
• An "Academic Health Department" plan to allow the county to participate in clinical trials, bringing in revenue and expanding treatment options
• A dental clinic add-on to an existing Ryan White organization
• A free clinic to create a bridge for the uninsured until 2014
• A health coaching project
• A project to combine substance abuse/behavioral health in an integrated organization

What ideas are sitting in your community's health improvement plan? What ideas are bubbling up from your community health assessment or your MAPP process? Can we help you push them to implementation?

--Steve Orton

Business Planning On The Road

Yes, we are piloting a program that provides business planning development to communities where they live. We're starting by targeting MAPP communities at the "Action Cycle" end of their process. (MAPP = Mobilizing Action through Planning and Partnership-- check it out at naccho.org/mapp)

Here's how the program works.

• We consult with you in advance to identify the best ideas to develop business plans around, and then form teams around those ideas.
• We come to your community for a one or two-day session; you convene as many members of your MAPP team as is necessary to get one or two or four business plans started.
• At the end of that session, your team or teams will have a good outline of a feasibility plan completed.
• We meet via webinar or conference call with each team as they develop a full feasibility plan.
• If the plan is in fact feasible, we coach them through the full business plan.

I should clarify what I mean by "team" in this context: I mean a cross-community team. For instance, you might have team members from the health department, the hospital, the other hospital, the United Way, the YMCA, the school system, the community health center, the county-- or all of the above.

We're in the middle stages with several teams in Florida right now, and some of the feasibility plans look really good. Two stand-out plans: adding dental services to an existing HIV clinic, and doing ER diversion with at least two and probably three different hospitals across a county.

The lesson for me is this: communities can develop business plans very quickly and efficiently if they already have a good, fresh assessment in hand, and a wide range of partners queued up and ready to go. That defines the MAPP communities we're working with: motivated partners, good data, identified priorities.

-- Stephen Orton

Success Story: Highland Health Center

Congratulations to our friends in Gaston County NC on their Highland Health Center Grand Opening and Building Dedication last Tuesday, July 27!

A Gaston County team developed the business plan through the Management Academy to plan out how to co-locate health department and health center services. You can read more about the Grand Opening here.

This is a classic example of a public health business plan:

• Starts from health needs
• Identifies a key target market (in this case a specific section of the city)
• Maps out a mutually beneficial alliance (in this case, the health department and the FQHC in the city)
• Shows how the money will flow

Hats off to the whole team, and thanks to Health Director Colleen Bridger for sending them!

--Steve Orton

Recovery Act funds for Public Health

It seems that some public health agencies have access to Recovery Act funds to do specific new things.

The challenge is to figure out how to spend that money in a way that makes a difference during the two years you have it, without losing those gains at the end of the time. One way to approach such an opportunity is to think in terms of start-up funding. Spend the money (time, effort) building something that can then go by itself.

Perhaps in two years you can build something that creates more community health and generates sufficient revenue on its own to support itself through user fees. Perhaps you can build something that generates sufficiently impressive results after two years that you can interest some other funder-- one that values the outcomes you are creating. Perhaps at the end of two years, you operationalize your exit plan: your agency steps back and the program is taken over by an external partner who cares about it and can run it sustainably, with the thanks and blessing of your busy staff!

From the Management Academy Director

Recently I read an interesting blog written by Dr. Louis Rowitz. Dr. Rowitz, has built a unique career in academia via public health practice issues and initiatives. He currently serves as the director of the University of Illinois Center for Public Health Practice. He has published two public health leadership books entitled Public Health Leadership: Putting Principles into Practice and Public Health for the 21st Century: The Prepared Leader.
The most recent blog focused on the Need to Learn.
Here is a short segment of the article:
Every time we read a book, take a course, attend a conference, work collaboratively with others, use our creativity skills, solve a problem, resolve a conflict, improve the quality of our organizations, or communicate with others, we increase the return on investment in our personal growth and on the organizations for which we work. Knowledge management is cost effective and increases cost efficiency.

The blog is thought provoking and he goes on to cover other subjects related to leadership. He offers a segment of Leadership Is An Art by Max DePree and lists the ideals of helping a leader to define reality. Here are just a few:

• No matter how good a job you do, you can still lose your job.
• Not all team members do the work.
• It is your good managers that make you like your job.
• Most leaders don’t change. The weaknesses remain. Play to the person’s strengths.
• Don’t expect politicians to value what you do. Their priorities are not your priorities.
• Resilience is the secret weapon of leadership.
• People don’t want change and they use budget considerations to justify their resistance.

For more on Rowitz, see
http://rowitzonleadership.wordpress.com/

Dr. Frieden on the implementation gap

The new director of CDC Tom Frieden spoke in Chapel Hill recently and said something I thought was interesting and provocative about managing in public health. (You can hear part of the talk on YouTube). Here's what he said:

We have an implementation gap. The gap between what we know and what we wish to know is huge. But the gap between what we know and what we do is even larger.

In other words, we need to pay more attention to execution. We know what's important, and for the most part we know what things would need to happen to make a difference in those important areas. So what would it take to change the "what we do" side of the equation? Effective plans that are doable.

--Steve Orton

From the Management Academy Director

NACCHO (the National Association of County and City Health Officials) offers a Model Practices Program that "recognizes initiatives that demonstrate exemplary and replicable qualities in response to identified public health needs."
This year, there were 23 local health departments that received Model Practices Awards. Their projects focused on a a variety of topics, including the following that may be of interest to you:

• Vaccination on Wheels - Take It To The Streets
• Accreditation Preparedness
• Ensuring a Competent Public Health Workforce
• A Communicable Disease Prevention and Response Tool for Schools

And, in the past, a couple of North Carolina teams have also had winning entries:

• Henderson County Health Department - Influenza Vaccination Program
• Cabarrus County Health Alliance - Transitioning from a Public Health Department to a Public Health Authority

Have you and your staff submitted any Model Practices? Have you visited the website and searched for Model Practices within the Database? Would you be interested in contributing to a Model Practices Database reserved just for your state and their public health initiatives?

Civic Entrepreneurship: Union Independent School

Wanted to share a "civic entrepreneurship" news story -- Jim Johnson is the founding co-director of the Management Academy for Public Health and has taught in the program every year since 1999.

http://gazette.unc.edu/archives/09aug26/file.4.html

From the Management Academy Director

This year, the Management Academy for Public Health begins its 11th year. The 54 participants represent North Carolina, Nebraska and Virginia. Upon graduation, this group will join over 1050 public health professionals who have completed the Academy, gained valuable management skills and in some cases, went on to fully implement their business plans.

This year's cohort is focused on a variety of important health issues for their communities. Through their Community Health Assessments and the MAPP process (Mobilizing Action through Planning and Partnerships), they are aware of the problems in their communities. Even though most teams are in the preliminary stages of determining their specific business plans, they have already started preparing their general ideas to develop a sustainable business plan.

The current list of topics include: Increasing vaccination rates, establishing a community health center and developing plans to address mental health services, health data analysis, occupational health, diabetes, teen pregnancy, access to primary care, substance abuse and the need for more school health nurses.

In order to develop a viable business, participants learn valuable business skills. During the on-site retreat August 3-6, the faculty spent a lot of time imparting tips related to businesses outside of public health. Frequently, Management Academy participants say "We are not a business; we are public health".

What do you think are some of the best and worst characteristics of a business organization and why do you think some participants are unwilling to accept attributes of businesses outside of public health?

A little off-topic

Over the past month, I’ve had a few experiences that don’t have much to do with public health business planning, but something to do with public health. I traveled to Greece for two weeks, spending time in the Cyclades islands of Folegandros and Santorini, and in the capital, Athens. Greece is an interesting mixture when it comes to public health:

1. They have a very good health care safety net system, paid for by the state. A couple of cab drivers told us how proud they were of their public health program. One was less enthusiastic because, although he himself, who has significant health issues, has never had a problem getting care, he “had heard that some people have some bureaucratic hassles.” He doesn’t realize the “bureaucratic hassles” we have in the states – even if you have health insurance, but especially if you do not!

2. Everyone smokes. Greece is Europe’s biggest-smoking nation: more than 40% of adults smoke. I don’t think we realize what a job we’ve done in this country to curb smoking, until you go to a nation where everywhere you turn – restaurants, stores, taxi-cabs – people are smoking. Greece is attempting to impose anti-smoking laws now – as of July 1, new laws banning smoking from hospitals, schools, and public places are going into effect. But restaurants can avoid the ban if they create smoking sections and they will also be allowed to ban non-smokers if they don’t want to have a smoking section! This is the third attempt in 10 years to curb smoking in Greece: it will be a hard habit to break.

3. Greek highways and roads are not for the timid. Greece ranks among the highest European countries in terms of road traffic accidents per kilometer traveled. Athens has done a great job of making itself more pedestrian friendly in recent years, although the narrow streets, lack of attention to speed limits, and lack of attention to parking regulations makes it difficult in places to get around on foot and it would be impossible in a wheel chair.

4. On the other hand, compared to my suburban American home I was able to walk much, much more in Greece than I am at home. Exercise came naturally and easily, built in to every day just getting from here to there. In one place we went, cars weren’t even allowed within the town limits. There’s something to the idea that “car culture” destroys the chance to live an active life.

5. When they tell you not to drink the water, don’t drink the water. They know what they’re talking about!

And, finally, the first thing I did when I got back to the states was get the flu! "Welcome Home!"

They say traveling is a great way to see your own home in a new light. It helps me to appreciate what we do well in the states, and what we could do better.

From the Management Academy Director

Recently, I attended the UNC-Chapel Hill Minority Health Videoconference. The title for this year's event was Breaking the Cycle: Investigating the Intersection of Education Inequities and Health Disparities. The speakers were

1. Reginald Weaver, Past President, National Education Association;
2. Dina Castro, Scientist, UNC FPG Child Development Institute;
3. Nicholas Freudenberg, Distinquished Professor and DPH Program Director in Urban Health Hunter College of Health Sciences/City University of New York; and
4. Lillian Sparks, Executive Director, National Indian Education Association

Each presenter spoke of the connection between education and the public's health and they made recommendations for each field.

They spoke of the need for more training and the need for programs focused on school-based health clinics, mental health programs and services aimed at teens on sexuality and HIV transmission. What are you doing within your community to provide a stable lifestyle to produce successful and healthy students? Please share with us.

Life Planning... get real!

One of the great benefits of a management development program is that it helps you manage your life. Our Management Academy students regularly report that they see improvements first in their performance as a parent or as a spouse as a result of trying to develop themselves as managers. Planning skills, negotiation skills, dialog skills, measurement skills, teamwork skills-- they all transfer.

For some of us, work performance begins at home. Are you taking care of yourself? Are you asking for what you need? Are you having the good, real discussions with your life partner that insure you are fulfilled and whole, working on the priority issues and both pulling in the same direction? In other words, are you doing life planning?

Life plans put work plans into perspective. Karl Umble likes to say that the goal is less about balance and more about "harmony." And the skills are essentially the same for both: the ability to plan well and then push through to execution, to work the plan into existence.

As the skin horse says to the velveteen rabbit, it takes a lot of love and attention to go from a stuffed toy to being real. In this respect, the velveteen rabbit is in line with a long stretch of work on authentic leadership, the notion that leaders have to let their personality come through the role to be maximally effective. They have to be present and real.

Last word is this: congratulations Anne on your wedding-- great team!

-- Steve Orton