#034: Building a Sustainable Future for Rural Health Departments

Local health departments need more resources, narrow funding streams, and outdated electronic health records systems, leading to a fixed scarcity mindset among local health directors. These issues are exacerbated post-pandemic, highlighting the need for regional collaboration, strategic planning, and innovative problem-solving. Through funding from the American Rescue Plan Act (ARP), Tiffany Erichsen's work with local health departments has focused on workforce development and training, improving culture, and building networks of support among health leaders. By learning from other regions across North Carolina, she and her team have provided local leadership training and built communities of practice among rural health educators, emphasizing community building and collaboration.  

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Transcript

091224_Tiffany Erichsen
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[00:00:00] Welcome to the Atrómtios Way podcast. We have meaningful discussions on the challenges in healthcare and the solutions behind them. I am your host, Liz Church. Each episode we dive into the complexities of our health and social system, gaining the experiences and insights of the guests that shape our lives and our communities.

So, we're going to talk about rural health departments today. They play a critical role in ensuring the health and well being of communities that are often geographically isolated and underserved. And these departments face unique challenges, including limited access to medical resources, funding constraints, and the shortage of healthcare professionals.

And despite these obstacles, rural health departments are vital in providing essential services like promoting public health initiatives and responding to emergencies like pandemics and natural disasters. So their work is integral to reducing health disparities and fostering healthier, more resilient, more equitable communities.

Sound familiar? So my guest today is Tiffany Erickson. She's a senior advisor to Odromedas and she's a public health professional with over a decade of experience in health and human [00:01:00] services program management, focusing on fostering health equity. As North Carolina's Region 8 Regional Director for Workforce Development, Tiffany spearheaded the 621 American Rescue Plan Act COVID 19 Public Health Regional Workforce Development Grant Initiative.

Big one, isn't it? And the goal was to enhance the local public health workforce in southeastern North Carolina. We're going to explore the major challenges local health departments face, and how these have fueled a scarcity mindset among directors, the impact of the post pandemic environment, calling for regional collaboration, strategic planning, and innovative solutions.

So, without further ado, here we go. Hi Tiffany! Welcome to the podcast! Hello! So, as we begin, let's discuss your work with rural health departments funded through the American Rescue Plan Act, or ARPA. Is that right, ARPA? Yes. Okay, fantastic. So, for everyone listening, this was a federal law passed in March [00:02:00] of 2021 to provide direct relief to communities, and is the foundation for the Cover Up Act.

So, Tiffany, can you explain how the American Rescue Plan Act has facilitated the workforce development and training in rural health departments, and what was the end goal? Sure, Liz, and thanks so much for having me today. Um, so, as many of us know, the COVID 19 pandemic really stretched the public health workforce.

And so, through the American Rescue Plan Act, the North Carolina Division of Public Health made funds available for each of the 10 regions of the North Carolina Association of Local Health Directors. So the state is broken down into 10 regions and each region received funds through the ARPA grant. And the goal of this funding is really to help the local health departments recover from the pandemic and to help build the capacity of those local public health departments to continue to meet the [00:03:00] needs of their communities.

So the ARPA funding supports regional efforts to strengthen the public health foundational capabilities to address the local public health needs that arose from the pandemic and to help them prepare for the future. In many rural health departments across the state of North Carolina, This funding provided very needed opportunity for local health directors to take a step back and to look at that bigger picture of how to prepare for the future.

Um, so they've been able to plan strategically with a focus on resource sharing across the region and really to focus on innovative problem solving. And collaborative efforts have been made to forecast local workforce needs. And then regions have developed workforce pipelines to help address those needs.

We've identified skill gaps, and then we've provided training to address those gaps. And many regions have built structures like community of practice to improve collaboration between local health [00:04:00] department staff so they can share their innovative solutions and their best practices and learn from each other.

You worked on strategic planning and creating communities of practice among health department leaders. So, can you share some successful examples of how these initiatives have improved local health departments? Yeah, we have worked on strategic planning with our health directors as a big focus of our efforts.

Since 2013, our team at UNCW has facilitated what we call the Southeastern North Carolina Regional Health Collaborative. And over the years, that's evolved to include the leaders of each of the 9 county health departments across the region, which is region 8 in North Carolina. And, um. Really, the goal of this collaborative is to improve public health through collective regional impact.

So we already had this existing structure when our book came along to. To really utilize and leverage to to do this work. Um, so the preexisting collaborative served as a [00:05:00] leadership team that we partnered with to plan strategically for the use of the funds. In the summer of 2022, our team conducted a comprehensive needs assessment.

We wanted to identify what training and resources were needed by the staff and region 8. And so we found that staff felt they needed training in a number of areas, like communication skills, leadership development, understanding and interpreting data. They also were really interested in developing relationships with staff members and other health departments within the region to help facilitate that learning from their peers and learning with each other and collaborating.

Um, staff really wanted the public within their communities to know about all the services that they provide across the health departments because they knew that there were people that needed services or didn't know that those services existed. And that was really important to them. And they also expressed the need for some specific resources.

Like improved technology and equipment [00:06:00] and so in collaboration with the health directors, our team designed several initiatives to help address a lot of these needs. 1 of the initiatives that you mentioned already was the health educators, community of practice, and we developed a community of practice to provide a formal sustainable structure.

So that health educators from across the region. Could collaborate with each other. Share their best practices, share their challenges and what kinds of solutions they're coming up to with to address those. What kind of programs were really successful within their county and the best practices that they found and so they have looked at tobacco education programs.

They looked at their community health needs assessments, their community health improvement plans. They're planning a training on facilitation to help build skills that they need to facilitate meetings with community partners. They've really taken ownership and built this sustainable program that they can continue to use across the region [00:07:00] to help each other improve their services.

Another initiative that we pursued involved communication training for all staff members. So first we distributed a communication style assessment to each staff member in the region, and this assessment report, or the report that came from the assessment, provided insights into each individual personal communication style and strengths.

And then we hosted a number of webinars with a faculty expert from our campus at UCW. To teach everyone how to apply these communication strategies and, and their particular communication style to help manage conflict and to, um, improve the dynamics and the culture within their health departments. And so we received feedback that this has really improved some of their team dynamics in the local health departments.

Another initiative that we worked on was contracting a communications firm to build a campaign. For each health department in the region, and then the region as a [00:08:00] whole to really educate community members about the different services that are available to them through their local health department.

And as I said before, this is something that was really important to staff to make sure that their community members understood how many services they could receive from their local health department. So, for that project, 25 staff members from across all 9 counties took part in these in depth interviews to help design this campaign that would raise awareness for their services.

And it also provided public transportation services that would explain how to access the health department from across the counties, or the 1 that's closest to, if it might be in another county, some counties allow that. And so, so these different initiatives that we worked on really were designed to address those very specific needs that we found in that needs assessment.

This is all great stuff. I mean, like, we could write a book about all of this and, and shine a light on, look what we did, the successful outcomes to [00:09:00] all of these things. To kind of pivoting into talking about funding streams. So when you and I were discussing preparing for this conversation, you were talking about how normally funding streams are pretty narrow.

They have narrow definitions on how they can be used and when and so on and so forth. But the American Rescue Plan Act had a lot more flexibility. So How have historical funding limitations affected health departments and what changes have you observed with the flexibility of ARPA? Sure. Well, funding for local public health departments can be really complex.

So they receive funding from multiple sources, federal funds, state funds, Medicaid, county appropriations, sources like grants, fees for service. So it can be a wide range and a lot of different. Funding streams have real significant funding limitations attached to them, and that can significantly impact the services that the local health departments can [00:10:00] provide.

So that can impact their efficiency and the health outcomes of the communities that they serve. So I have a specific example for you. A few years ago, funding was provided for syringe exchange programs, and that can be an important strategy for harm reduction. However, the funding did not cover the purchase of new syringes.

It's awfully challenging to operate a syringe exchange program when you're not able to purchase syringes, right? Another instance that a colleague was sharing with me recently. She was involved in a community transformation grant project that was aimed at increasing access to walking and biking. And even though that was the goal of the project, they were not able to use the funding to develop walking trails, or bike paths, or purchase bicycles for people who need them, or shoes for people who need them, but they could fill their supply closet with pencils if they wanted to.

So there's really this [00:11:00] disconnect. Between the goals of some funding and what it's allowed to be used to purchase. So, the ARPA funding, it was initially a 1 year grant. It has been extended at no additional cost, but it was designed to address workforce needs. But hiring someone with funding that lasts only 1 year is not a sustainable strategy either.

So it's not perfect, right? But ARPA funding provided a lot more flexibility. So, there were restrictions, of course, but the funding allowed the regions. And even counties within the regions to identify their unique, most pressing needs, and then allocate those resources accordingly. So, a lot of the regions identified similar training needs, like leadership data analysis.

And we were all allowed to develop and fund the trainings that were tailored to our regions needs. So, in region 8, we implemented a mini grant process, and we distributed funds to individual counties. So that [00:12:00] the staff could access those specific resources that they talked about, like technology and some of their training needs too, because the different counties had some different needs.

But a lot of the counties use these funds to cover training and travel expenses related to training. They also paid some recruitment bonuses and retention bonuses to hire and retain their staff. Some of the counties provided educational stipends, so they were able to take current staff and increase their education that might make them more eligible for other opportunities where there are bigger needs.

And it also, um, kept, would retain those employees because while they're going to school, then it's being paid for, they'll stay working there. One county used ARPA funding to retrofit their nurse meeting room with technology so that they could use it for virtual trainings and so they could access in the future and continuously more training that way.

Another county hired a quality improvement [00:13:00] specialist to help improve patient flow within their clinic and increase staff productivity. So this shows how ARPA funding has been used. And I've really been instrumental in addressing unique needs of each region and even those counties within the region.

That flexibility has given leaders of local public health departments the room to engage in strategic planning and innovative problem solving. So what my team and I have witnessed is that there's a real desire among these leaders and their staff to innovate, to problem solve, to change existing structures and service methods.

Um, of course, there are hurdles to overcome. There's. Political will, governance structures that add additional layers, as we said, funding, um, and always the biggest resource time, but there's a real desire to innovate and to problem solve. And so ARPA really gave some of those, that opportunity to find what will best meet the local needs.

And it [00:14:00] seems like with a lot of the things that you listed off, a lot of it was resource based. Um, like not having that resource readily available, whether it was physical, digital or, um, like a learning capability. Exactly. So, um, I mean, obviously, rural health departments often face these challenges, and especially since, you know, we've come into a realm where not only are we worrying about like a pandemic, now we're learning, we're worried about cyber attacks.

Um, it's crazy, but we've had more cyber attacks by the end of June. They were like, yeah, that's worse than it was in 2023. And I was like, well, it's only been six months. It's. It's scary. So when you think about like rural health departments, rural providers, they don't have the resources to defend themselves as easily.

So I'm not saying like we need to go into cyber security in this moment here, but One of the things pertains to patient data and the securing of those things but You know, how that is collected is through electronic health records. So can [00:15:00] you talk about electronic health records impact the effectiveness of rural health departments?

Yeah, sure. Um, well, the issue with electronic health records has been a major pain point of the rural health departments in region eight. And so a major responsibility of local health departments is assessment and surveillance, right? And so this involves a systemic ongoing collection and then analysis and dissemination of data.

And that data should really inform decision making that impacts public health. How it's been described to me by the health directors in, in my region, in region eight, Is that when North Carolina switched from paper record keeping to electronic health records in the health departments, the company that most of the health departments contracted and and pretty much all of the rural health departments in my region.

Worked with the same company and they came in and said to the health care providers. How do you want us [00:16:00] to build these templates and the provider said, well, we want something that looks just like what we use all day. This paper thing. We don't want to learn a whole new system. And also learn a different way to have to collect data, which we wanted to be as seamless as possible of a transition, which makes sense.

So, the company developed customized templates for each county. They had templates already, but instead. Of using those, they developed customized templates. And those mirrored each county's paper health records. So they already were starting out with different things with for each county. But whenever this company made a customized template, they made the data fields, empty text fields.

So, if you know anything about data analysis, you know how difficult it is to extract. And analyze unstructured data, that's an open text boxes. This is really hindering the ability of our health departments to monitor health trends. [00:17:00] And respond to public health emergencies in a timely manner with the text fields.

The quality of the data can be compromised. There may be inconsistent data entry or spelling errors or other kinds of lacks of standardization that lead to an accuracy inaccuracies. And then this process, this really onerous process of manually extracting the data. Interpreting it and then analyzing it is extremely time consuming.

So this is particularly problematic. If there were another public health emergency and we need timely data, it, it really takes significant resources that can be used for other critical public health activities. So, now reporting might actually be just as difficult for these rural health departments as it was when we had paper records.

But there's just much more reporting that's expected of them because they should be able to access this data [00:18:00] and easily put it into reports. And so it, it has widened this gap between rural and urban health departments who have the resources to. To have proper templates, and so with the ARPA funding, our region made it a priority.

To utilize that funding to try to improve some of these efficiencies, we have seven of our counties use the same companies. System, and so we contracted a quality improvement specialist to assess the pain points of each county and the workflows that were associated with it. And they were able to provide some support to individual counties and improve some of the workflows.

And so, in the future, we want to really focus on advocating for the ability of. Counties to share their templates, especially the larger counties, be able to share them with the rural counties, give them access to these templates that are built to produce the reports [00:19:00] that are required. And so, if larger counties are able to share those resources, it could really help make the rural health departments more efficient and effective.

It would also, it's also important to continue to advocate at the state level for our rural health departments around assessment and surveillance, because that is a big pain point. not just with the EHRs, but for all kinds of reporting and assessment. I had a conversation with one of our senior advisors talking about data quality and you know, the importance of having that right data.

And I feel that, you know, forgetting, I don't want to say forgetting the state's not purposely doing it, but like, North Carolina is mostly rural, you know, This data is very impactful for the functioning of the state, have the circumstances, the current situation of the state. And it's kind of, it is alarming that, um, there's all these different points that, that bother me.

The first point is the analytics part where, you know, you have a text field that's not named appropriately or there it causes more issue. So then you have to [00:20:00] do cross referencing and that takes so much time that it's just, nobody wants to do that. Nobody wants to do it. Exactly. Exactly. You're hurting more than you're helping.

Right. And it takes so much effort from multiple people just to try to pull a report. And so there are efforts across the state to try to improve that. Um, there are some new data reporting, um, opportunities that people are piloting. But there's also, you know, individual counties want the ability to choose.

How to collect their data and also what company to contract with and so there's like this. Given take between having the state tell them how to do it and and then also so empowering local communities to decide what's what's important for them and how to. Address their own needs, but also to provide the support.

Because, you know, when with the shift to electronic health records. [00:21:00] Those providers who answered those questions, they didn't even know what they didn't know. And so there wasn't that support from the state to help with that transition to understand how to do it. So, there was this need that was expressed and you were allowed to do it, figure it out on your own, but there also needs to be support from the state on what makes sense.

And, you know, afterwards, you're going to have to report. So you have to do X, Y, Z, to collect the data, those kinds of things that, um, that really need to be done. To be provided so that local communities can still make their own decisions and they're empowered to do what will address their own needs. But also they have all the information that's necessary to make those decisions that are the best for them.

It's kind of ironic that, you know, we're out of this world. I don't want to say realm, but like we're out of most of the pandemic, the COVID 19 still exists. So we're still in like a post pandemic state and we recognize like we need to have [00:22:00] all these things that has been accomplished through the initiatives, through the ARPA.

Now, Would you say that the need has been like, okay, we need to continue this going forward, or it's been like, okay, we're out of the, mostly out of the pandemic now. We can kind of go back to the way it was. Do you see any of that coming back? No, I think there's a lot of residual. You know, I think a lot of the needs really surfaced at the time, and so they're much more apparent than they were, just, you know, we can see health disparities a lot easier in some communities that arose from the pandemic and have not been addressed in the way that we wish that they, they could be.

It's clear that changes are necessary. Also, the workforce has really been stretched very, very thin. And. The resources have not always been there to help, um, bring on new. People into the workforce, [00:23:00] and in a lot of rural counties, there aren't. People people are moving out of our rural counties, so there aren't those staff members to come in and fill positions just like all of our industries.

The workforce is aging and people are retiring. And so, um, you know, we really need to support that workforce and make sure that they are. They're able to address those needs because the needs are still very apparent. Right. Right. And I know that might have seemed like a like a, well, duh, Liz, kind of like, you know, response.

But, but it was one of those things where it's like, you know, you see so many people trying to say like, okay, we can go back to normal now. And it's like, no, like, A lot of problems came out, like, came to the light, uh, because of the pandemic because we were all able to really pay attention because there was a crisis at hand.

And um, I think one thing that was interesting when you and I were talking about planning for the episode is that when the ARPA grant came in, it was more of like, we can't use it because this is so much money. [00:24:00] This is so much stuff. Stuff that we're getting from this. Like we've never had this much before.

So there's been this need to shift more towards a abundant mindset and then have this innovative problem solving. So can you talk about how health departments can transition from a scarcity mindset to a more strategic and innovative approach? Yeah, for sure. Um, well, innovative problem solving is not something that happens overnight.

And so it really requires a lot of time and capacity and financial support. Sure. And then when you're dealing with regional work, it takes even more time because you really need to. Build those trusting relationships and build consensus and that extra layer of collaboration is necessary before you can even decide on what projects to pursue.

And then once those projects get off the ground, they evolve and that consensus building needs to continue. So, for health departments to transition from this scarcity mindset to a [00:25:00] more strategic and innovative approach. I think it really starts with what I was saying about that workforce, like, developing.

An agile and multidisciplinary workforce that can adapt to the changing needs of the local community. So making sure that we, um, we have. Well, trained people who are passionate about what they do. We found so much passion for. public health and for local community. When we did our needs assessment, it was just the overwhelming reason why people go into public health is to support their community.

And so we need to make sure that we're supporting that workforce and making sure that they're resilient and agile to adapt. I think we also need to foster partnerships. So that is public health can't do it all on their own and they don't try. They really focus on working with community based organizations within their community and also.

Partnerships with academic institutions, both for building pipelines for the workforce. And to share best [00:26:00] practices and do research on best practices, and those kinds of opportunities that exist with those academic partnerships, and those can really. Help with resource sharing, but they also require that emphasis on collaboration and so it's.

It's takes that extra time and capacity, but I think as we focus on those kinds of collaborations and resource sharing across the regions. That health departments can move away from that scarcity mindset and take a more strategic and innovative approach. And then they'll be better equipped for future health challenges.

What are your hopes for the future of the Rural Health Departments and, you know, what kind of key challenges do you believe are necessary to enhance their effectiveness and, um, efficiency? When I think about Rural Health Departments, I think, um, about the fact that they are the backbone to their rural communities.

Um, really, they're the ones that are making sure that everyone has access to quality health care [00:27:00] within their community. And so they are really the ones helping to bridge those health disparity gaps. And boost the overall health of their populations. So I think. For the future, it's all about stability and flexibility.

So, imagine if these health departments had a steady flow of funds that they could use as they saw fit to really address their unique. Needs, um, rather than juggling funds from different sources with their own sets of rules and reporting requirements. Like, we already talked about so we can streamline this process.

That could really be a game changer in terms of efficiency and effectiveness, especially for the rural health departments. I think we need to explore innovative funding models, new ideas about how to. Fund rural local health departments so that they can use that funding in a tailored way to address their unique needs.

But it's not just [00:28:00] about money, right? It's also about data, as we've talked about, and the future of local public health in North Carolina and everywhere is tied to how we use data, how we collect it, how we share it, how we communicate it. And so that data will drive improvements in how we deliver services.

And the outcomes that we achieve, and so we have to make sure that we're able to capture it. In an efficient way and report on it in an efficient way so that we can also share it with each other. So that's a big goal of our counties is to just be able to share the data with each other and see how we.

We compare as a region to other region and then, of course, the workforce, we can't forget about those people that are behind the scenes with their boots on the ground doing that work. And so it's. Absolutely crucial that we build and retain a strong public health workforce. And those are the people that are out there in their communities, making a difference every day.

We need to make sure that they are supported. And then finally, I [00:29:00] think it's really essential as we've already touched on. To respect that local decision making, make sure that every community is empowered to meet their own needs and to evaluate their own circumstances and decide how to meet those needs.

So we know that our Rural Health Departments work extremely hard to improve the health of our communities. And when all of the stakeholders, all of those, uh, members of the communities are invested, when they can help put together the resources and collaborate with each other, then they'll be able to really enhance the effectiveness and efficiency of our Rural Health Departments.

And our rural communities deserve it. Yes, they do. Yes, they do. We're closing on that. That's it. Yes, they do. Absolutely. Well, I, I really appreciate you coming and talking to me about this. I mean, I learn something new every single time I do these interviews with folks and I'm like, Oh, what are we learning today, ladies and gentlemen?

We're all health departments. End of the [00:30:00] day, it is important stuff that we're learning about. And because we're learning about the good work that you're doing to better the community. So people have better access to healthcare, better knowledge to things with their community needs. It's all good stuff.

So yeah, at the end of the day. Thank you, Tiffany. Thank you, Liz. Thanks for having me. The Atrómtios Way is produced by me, Liz Church. Editorial assistance for this episode was by my fantastic team at Atrómtios. I would like to express our heartfelt appreciation to our guests who've shared their expertise, stories, and insights with us on the podcast.

And finally, a big thank you to our listeners. Your support and engagement have meant the world to us at Atrómtios. We're a boutique consulting firm with the imperative mission of creating healthier, more resilient, more equitable communities. I encourage you to connect with us. Let's continue these conversations and work together towards positive change.

You can listen to all of our previous episodes on our website, atromitosconsulting.com/atromitos-way. That's A R T O M I T O S. We can also be found on Apple Podcasts, Spotify, Amazon Music, or wherever you get your podcasts. We'll see you next time!