Public health departments becoming more important on The Road Ahead

March 2020 is when everything changed. Two years later, we are examining how those changes inform us and inspire new direction.

Over the coming weeks, we will be taking a look at the way forward and how change has transformed our communities in every way — schools, health care, politics, policing, entertainment, religion, nonprofits and business.

Stories by a team of local reporters will be published periodically over the next several weeks and online at delcotimes.com/tag/coronavirus/

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As the new Delaware County Health Department readies to launch, it is adopting the next generation philosophy of public health as well as preparing for the next pandemic the county may face.

“Like everyone in this county, many of us at one time or another were touched by the pandemic either through loss or through illness,” Rosemarie Halt, chair of Delaware County’s Board of Health, said at a two-year COVID memorial early in March. “Together, we fought with the limited tools that we had — first with testing, then with vaccines. So much of what we did was based on who we were serving — our fellow neighbors and friends and relatives … The battle is not over and we still need to work hard to ensure that we protect the health and safety of our community.”

A years-long advocate for establishing a county health department, Halt expressed her hope that by now having it in place the goal of protecting the community would be easier.

Creation of the Delaware County Health Department began in early 2020, only a few weeks before COVID presented itself here as Pennsylvania’s first case. With 576,000 residents, Delaware County was the largest county in the United States without its own health department.

The 60-plus employee, $10-million department with multiple locations was given final Act 315 approval from the Pennsylvania Department of Health to begin operations April 2.

“The ultimate goal of the public health department is to … prevent injury, illness, disease and premature death,” Melissa Lyon, director of the Delaware County Health Department, explained, adding that the health care system intervenes when someone has been injured or has gotten sick. “Public health is everything before that.”

And, it’s pervasive, down to seat belts and speed limits, air bags and anti-lock brakes.

“We know that if people drive 55, if you’re in an accident, you’re less likely to die,” Lyon said. “That’s why we have a speed limits”

As Delaware County delves formally into public health, officials have decided to adopt the Public Health 3.0 model attributed to Dr. Karen DeSalvo, former Assistant Secretary for Health in the U.S. Department of Health and Human Services.

Public Health 1.0 focuses on sanitation and hygiene, much of which can be handled by measures like chlorinating water supplies and managing waste removal. Public Health 2.0 includes the treatment, mitigation and prevention of infectious and communicable diseases and the distribution of vaccines.

In Public Health 3.0, the county health department becomes the chief health strategist for the county in addressing priorities by determining issues arising from primary and secondary sources of data and social determinants of health.

Lyon explained that the focus becomes, “How do we help the county be strategic in their approach to creating a healthy, safe, vibrant, thriving community?”

Many issues in this model are the chronic diseases, ones that are multi-level and which the systemic root cause has to be solved by the larger community, creating a critical need for the health department to have partnerships with community and non-traditional partners.

Collecting data and presenting it in a meaningful way is foundational for Public Health 3.0.

Lyon explained that comes from primary data, which is word on the streets, focus deserts, etc. and secondary data, such as infant mortality — data that is recorded by someone who puts it into a system and then is retrieved by health department staff.

“Through that, we look at trends,” she said. “Our job is to watch trending — what’s happening.”

COVID flashed a spotlight on data collection.

“We’ve never been designed to publicly share that data, which is what happened in COVID,” Lyon said. “Everyone wanted to know the data – how are you making your decisions, why are these decisions being made. It’s interesting. Nobody really cares about why I am making decisions about syphilis. Nobody really cares about decisions I’m making about gonorrhea.”

However, each of the viruses are treated with the same approach – watching trends and then figuring out how to prevent the disease and its spread.

“There’s nothing unique about how we collect data, watch for trends, analyze it and take action,” Lyon said. “COVID sort of shook that up because everyone’s like, ‘I don’t believe you.’ ‘What’s the data?’ because it impacted everybody. It really put people in hardships.”

As a result, data dashboards were created for public consumption.

“In public health, we’ve known in order to have communities value what we do, they need to understand how we do our work,” Lyon said. “So (Public Health) 3.0 has been designed  — we’ve been working on this idea long before COVID — how do we collect the data, how do we display it to the consumer in a way that makes sense and is meaningful to the consumer.”

The barrier previously had been the lack of resources to invest in these data systems as Lyon explained that the last time a good investment was made in public health at the national level was in the late 1980s.

Now, the U.S. Centers for Disease Control and Prevention and the Pennsylvania Department of Health are changing their strategies to be more transparent to the public as Delaware County is looking at best practices to determine what will work best here as well.

“I honestly I believe that these are really great leaps forward for public health,” Lyon said. “They are. They are. They might not seem like it to the community but they are to us.”

This data can include incidence rates, such as the number of new cases per 100,000; prevalence, the total number of cases in a period of time; and life years lost.

Lyon gave the example of Black men who have lost their lives due to law enforcement brutality or shootings.

“If you look at the total number, in general, it’s not going to gain a lot of traction,” she said. “If we expected the 20-year-old to live to 65, we have now lost 45 years of this person’s life.”

When multipliers are added, she said, “That now puts you at a place that now this is an issue. We have a premature death problem due to something that is happening in our community.”

In the Public Health 3.0 model, community partners also play a vital role.

In one capacity, hospitals complete community health needs assessments and there is a regional one as well, Lyon said.

By using that data, a community health improvement plan is created.

“It’s a road map and we build on them basically year after year,” the health director said. “It’s like a strategic plan.”

While Delaware County is unique in building a county health department around this model, Lyon explained other health departments are very aware of it.

“They’re retrofitting it,” she said. “They’re adopting the Public Health 3.0 strategies, models, framework. The beauty of what’s happening here in Delaware County is that we can build it within that lens and not have to retrofit our strategy.”

For example, even though Berks County does not have its own county health department, the commissioners there have approved a study to identify gaps in the health care system by gathering information such as socioeconomic factors to health indicators to emergency preparedness, identifying where the needs are and creating recommendations to address those.

They specifically struck language that would allow the data to be used to determine if a county health department is needed from the requests for proposal for the study.

An additional component of Public Health 3.0 is the national accreditation.

“Another thing about Public Health 3.0 that we will absolutely be using here in Delaware County as not only our framework, but it will become our philosophy, it will be our culture – we will be doing the accreditation work,” Lyon said. “It’s really transformative in how a public health department functions because it builds in what we call performance management.”

She explained that the department measures its performance and if that is not up to the level they expect, then they look at the reasons behind that and adjust in a process called continuous quality improvement.

“For a long time, public health — this is no fault of anyone — we did a lot of measuring of outputs: how many clinics did we hold, how many people did we serve, but we weren’t necessarily measuring as intentionally as we should the outcomes,” Lyon said.

In addition to the foundational parts such as the community health needs assessment and the community health improvement plan, the department picks outcomes, such as a 2 percent decrease in low birth weights in babies, to measure and report in the accreditation process.

“It really does philosophically change the way public health department’s function,” Lyon said. “We have said that we are going to ultimately be responsible for this outcome so that means that everything we do drive us to that outcome.”

A focus on social determinants of health is also an element of this health model to determine on which populations are suffering more from a particular illness and why and where the disparities are.

Lyon gave the example of how single moms of lower incomes tend to be more likely to smoke.

“You take single moms of a higher income and you compare them, just income alone, they’re less likely to smoke,” she said. “We want to dig down. What’s causing this? Sometimes from community to community, it’s the same reasons, but not always, not always. It depends.”

Another example she gave was birth outcomes for Black women.

“Black women have poorer birth outcomes, regardless of their education and their income and it’s clearly racism,” Lyon said. “It’s clearly the color of their skin. If we have populations that have poor health outcomes for no other reason than the color of their skin, then we have a problem …. The health equity lens is to say, ‘OK, where are we seeing disproportionate outcomes and why and then, how do we equitably address it?’ We’ll be setting up our health department to be thinking in that strategic way.”

Lyon said the newly formed health department is also preparing for the next pandemic.

“We are really putting together a department that should be able to be better prepared or at the ready for the next pandemic,” she said. “Now, that doesn’t just happen internally. That requires community commitment.”

In a public health event of magnitude, after-action reports are compiled.

“You basically write out what worked, what didn’t work, what you don’t ever want to do again, what you want to replicate,” Lyon said, adding that the after-action report builds out your improvement plan that explores different angles such as operational effectiveness and populations served and underserved.

“We really take a hard look – did we leave any population behind?” Lyon said. “If so, why and we shall never do that again. That’s how we’re going to be wired and planning and moving forward.”

Different communities approach when to complete after-action reports differently.

Lyon was the county health department director in Erie, Pa., prior to coming to Delaware County. There, they had started an after-action report.

“We realized this thing was going to go on and we’re like, ‘You know what? We need a snapshot right now,’” she said, adding that others will be completed in later COVID phases.

In Delaware County, there has already been some work done around an after-action report as all the documentation has been captured, it just needs to be pulled together, according to the health director.

After the after-action report is crafted, drills are performed based on what is identified in the improvement plan.

“Even after those drills, when it’s done, you circle back – did it drill out the way you thought? Did you accomplish your goals?” Lyon said.

As a part of protocol, Lyon said she’ll call every health department staff member unannounced to see how quickly they answer their phone to see how long it would take them to respond to an emergency if it were happening that day.

At the Delaware County COVID-19 Memorial earlier this month, state Sen. Amanda Cappelletti, D-17 of Delaware and Montgomery counties, spoke of the need to be forward thinking with public health.

“We’re here … because too many members of our community were impacted by the pandemic beyond just a simple adjustment of their daily habits,” she said. “There are empty seats at dinner tables, clothes collecting dust in closets and an emptiness within loved ones’ hearts.”

As Delaware County has lost more than 1,800 community members due to the pandemic, the senator said the path to healing isn’t linear.

“We pause and pay tribute to those that we have lost over the past two years to remember we are not alone in our grief and to remember that your loss is not just a  statistic,” Cappelletti said. “While we are far from the other side of the pandemic, we must remain vigilant in protecting our family, friends and neighbors so that we can avoid just one more unimaginable loss.”