Common themes have emerged from the Center’s work with the Shared Services Learning Community (SSLC).
Several SSLC team leads voiced a need to learn how to better manage the effects of change. For example, a new cross-jurisdictional sharing (CJS) arrangement can impact staff responsibilities, and an election can bring new policymakers into the mix who need to understand the concepts.
The Center identified the topic of change management for the 2013 third quarter webinar, Managing Change, and team leads enthusiastically voiced their support for assistance in this area.
Assessing Current Capacity
Many of the teams have completed assessments of their participating jurisdictions’ services. The assessments have helped them understand their collective capacity and will be used as the basis to identify areas of collaboration. The Public Health Accreditation Board (PHAB) standards most frequently serve as the basis for these assessments.
Many of the sites are addressing financial issues associated with CJS. The first issue is simply calculating and presenting the cost of the shared service in terms that are readily understood by the participating jurisdictions and their public administrators. In some cases this also means developing a uniform fee structure shared by the jurisdictions. For some this also means developing and presenting the cost for each jurisdiction to provide the service by itself compared to the cost of providing it jointly to assist in determining the cost benefit potential of CJS. Developing a plan or formula for the distribution of the shared service costs across the participating jurisdictions is a very challenging issue that needs to be addressed by most teams. Due to the wide variety of sharing arrangements being considered, differences in state and local law and practice, etc., it appears that most of these solutions will be fairly unique. And finally, while not exclusively a financing issue, teams are also seeking guidance on how to describe or quantify the value of public health services.
All that stated, the Center is working to identify common threads and will develop technical assistance to meet these needs — both as a group wherever possible, and individually as appropriate.
The Center’s January 2014 meeting in San Diego will feature plenary and breakout sessions dedicated to financial issues with CJS arrangements.
“Active engagement” during the CJS process seems to have a different meaning for public health practitioners and for policymakers. Public health officials and/or their designees often actively engage in CJS work on a day-to-day basis as they hammer out the details required for exploring, planning and implementing CJS arrangements. They also are working to find the most effective way to actively engage policymakers in these efforts, i.e., to find the “sweet spot” that keeps policymakers informed at all times and draws them into more detailed discussions during key times.
It seems to be more effective to engage policymakers at their existing regional meetings as opposed to initiating new regional meetings or forums focused solely on CJS arrangements for public health. Using venues where policymakers already convene to work on issues of regional interest also has the potential effect of raising their awareness of public health issues to the same level as other issues they already discuss, like transportation, regional planning, etc. In addition, it means that public health officials spend less time and effort coordinating meetings with policymakers.
While all of the teams have policymakers who are dedicated to serving as team members, the extent of engagement varies widely. Some teams have one or more policymakers who are responsive and active participants, while others report that it is difficult to have the type of engagement they would like. Still other sites are working to establish relationships with newly elected policymakers. Team leads reported that the Center’s 2013 second quarter webinar on effectively communicating about public health was very valuable to their efforts and expressed the importance of continuing to work on communication with policymakers.
Existing Regional Identity
The existence of a regional identity, when it pre-exists a CJS activity, appears to be a facilitator for sharing public health services. People who have worked together before can probably identify shared goals and visions more easily than new coalitions that have to learn how to work together. Trust also is an important factor: a sense of regional identity often helps assure a higher level of trust among partners.
Emerging Regional Identity
Where a singular regional identity doesn’t exist, or is more loosely knit, some team leads are deliberately shedding the individual health department “hat” and donning the “regional” hat while working on CJS arrangements. This requires approaching population health from a much broader geographic perspective, and consciously working to better the broader area while understanding that that each individual area stands to benefit in the process.
The creation and/or nurturing of a regional identity is likely to go a long way in sustaining CJS efforts after the project funding ends. In that sense, “the whole is greater than the sum of its parts” when thinking about CJS arrangements.
There are issues to be resolved when jurisdictions that vary in the size of their population work together. Typically, health departments serving all population sizes have specific concerns related to sharing resources. For example, how should the cost of the sharing arrangement be allocated? Should it be split per capita or should it be split per jurisdiction? Splitting per capita could impact the resources of the larger jurisdictions, but splitting per jurisdiction could impact the resources of the smaller jurisdictions. Once that is decided, should the governance of a shared arrangement be distributed in the same way? Many learning community sites are working through issues related to large variations in population size.
Several of the sites expressed surprise at the length of time it takes for those at the table to reach decisions about various matters. For some, this was largely reflective of key stakeholders not sharing an understanding of the value of a robust public health system and/or the reason to engage in the proposed CJS efforts, and these sites modified their strategies accordingly. For others, the reason seems to be that the team members did not already have established relationships, and therefore more time was needed to get through the predictable stages of team development before CJS work could be accomplished.
Trust is an essential element in all successful CJS arrangements. It is important to consider the existing trust between parties when determining the feasibility of sharing services. The Center is developing a tool to assist in measuring the level of trust among partners from different organizations and jurisdictions.