Strengthening New York's Public Health System for the 21st Century
REPORT OF THE PUBLIC HEALTH INFRASTRUCTURE WORK GROUP TO THE PUBLIC HEALTH COUNCIL
APPENDIX A - WORKFORCE SUBCOMMITTEE REPORT
The public health work force is an essential element of the public health infrastructure. The public health work force is defined as " …those individuals responsible for providing essential public health services regardless of the organization in which they work and who are competent to perform public health functions and assure the delivery of essential public health services."36 A public health professional is defined as: "… a person educated in public health or a related discipline who is employed to improve health through a population focus."37 Because local health departments are seen as "the primary organizing and mobilizing forces for public health practice in most communities"38 the committee conducted its assessment on the public health work force employed by local health departments in NYS.
- Kristine Gebbie, Dr. Ph., RN, Co-Chair, Director of Center for Health Policy, Columbia University School of Nursing
- Edward Salsberg, MPA, Co-Chair, Executive Director, Center for Health Workforce Studies, University at Albany School of Public Health
- Robert Denz, P. E., Director of Environmental Health, Broome County Health Department
- Claudine Jones-Rafferty, Center for Environmental Health, NYS DOH Bridget Walsh, President, NYS Public Health Association
- Sue Ellen Wagner and Trish McBreen, Healthcare Association of NYS
- Sylvia Pirani, MPH, Director Office of Local Health Services, NYSDOH
- Jean Moore, Deputy Director, Center for Health Workforce Studies, University at Albany School of Public Healt
The objective of the Work Force Subcommittee was to assess the supply, distribution, recruitment, retention, training and competencies of the public health work force in local health departments. The ultimate goal was to understand the most compelling work force issues facing the local public health infrastructure in NYS and make recommendations for ways to overcome barriers and facilitate higher performance. From the broadest perspective, the subcommittee was concerned with work force capacity and capabilities in the context of contemporary public health challenges and emerging expectations. While the subcommittee focused its assessment on the local public health work force, findings and recommendations related to training may apply equally to the state public health work force.
The Subcommittee undertook its assessment by examining statewide data and background on the state and local public health work force including the following:
- CDC National Public Health Performance Standards Program/New York, Versions 5B and 5C referencing data submitted May-November 2001.
- "The Public Health Work Force Enumeration 2000" by HRSA and a NYS specific local health department enumeration conducted by DiManno, P., Pirani, S., Williams, D., Young, C. as part of the National Public Health Leadership Institute sponsored by the University of North Carolina and the Centers for Disease Control. See Attachment I for additional background on the local survey.
- NYS Sanitary Code Part 11, which establishes minimum qualifications of public health personnel. The NYS Sanitary Code also requires continuing education training for public health sanitarians, but not for any other title.
- Nationally developed core competencies for public health nurses, environmental health sanitarians and public health educators.
- The committee also conducted a Telephone Survey of 5 local health departments representing the diverse urban, suburban and rural regions in NYS. The survey included questions about specific job titles including public health nurse, public health educator, sanitarian, epidemiologist and/or disease outbreak managers and public health physician. See Attachment II for survey instrument.
CDC National Public Health Performance Standards Program Results:
- LHDs in NYS participated in a field test of the CDC national public health performance standards from May-November 2001. The local health departments were asked to assess their performance in delivering all 10 public health essential services (see Section VII in the main report for further delineation). Of the participating counties, 49 LHDs completed survey instrument 5b that asked them to assess the performance of their local health department. Another 8 LHDs engaged community partners to assess the performance of their public health system.
- Central to this review was the assessment from the LHDs on how they performed Public Health Essential Service # 8: Assure a Competent Public Health and Personal Health Care Workforce. The LHDs were asked to self evaluate the following aspects of work force development:
- 8.1 Workforce Assessment,
- 8.2 Workforce Standards,
- 8.3 Continuing Education,
- 8.4 Understanding Determinants of Health,
- 8.5 Cultural Competence,
- 8.6 Leadership Development
Figure 1 shows that that the variability among scores was high, with the LHDs rating themselves the highest for developing public health workforce standards (question 8.2) and the lowest for conducting a work force assessment (question 8.1).
Public Health Work Force Enumeration
Of the 11 million workers employed in the health sector in 2000, a national enumeration of the public health workforce estimated that over 448,000 of them were public health workers, by the broadest definition, i.e. individuals who provide one or more of the essential public health services, regardless of discipline or work setting. Using the same definition, the study found that New York State had approximately 18,700 public health workers or 73 workers per 100,000 population, compared to 158 per 100,000 for the entire country. New York was found to be in the lower third of states in public health workers per capita.39
In 2002, it was estimated that more than 12,700 full time equivalent (FTE) public health workers were employed by the state and local health departments in New York State.40 Of the total, nearly 57% worked in local health departments across the state while the remainder worked for the New York State Department of Health. A survey of local health departments conducted in 2001-02 provided in-depth data on the size and composition of their workforce and is detailed below.41
Geographic Distribution of the Workforce of Local Health Departments (LHDs) in NYS
Survey respondents reported approximately 7,270 FTE public health workers employed at LHDs across the state and nearly 69% of them worked in LHDs in urban counties. However, there were more public health workers per capita in LHDs in rural counties42 than in urban counties.
- There were nearly 5,000 FTE public health workers employed by local health departments in urban areas or 35.643 FTEs per 100,000 population.
- There were over 2,275 FTE public health workers employed by local health departments in rural areas or 76.2 FTEs per 100,000 population.
Composition of the Workforce of Local Health Departments in NYS
Survey respondents reported over 70 occupational titles in the LHD workforce. While there are certain differences between urban and rural counties in the configuration of their workforces, these differences may reflect the scope of services provided. Attachment I provides a list of these titles, grouped into nine occupational categories.
- While nurses represented 22% of the total LHD workforce, they accounted for 42% of FTEs in rural LHDs, but only 14% of FTEs in urban LHDs.
- Scientific/investigative staff comprised 20% of the total LHD work force. This included environmental health staff (i.e., engineers, sanitarians, and environmental technicians) who alone represented 15% of the total public health workforce. However, in the 21 counties where environmental health services is provided by the NYS Department of Health, environmental health staff are not employed by the LHD.
- Epidemiologists, communicable disease staff and disease control investigators represented 5% of the total LHD work force.
- Education/outreach staff comprised 10% of the total LHD workforce, while health educators who were included in this category were only 2% of the total LHD work force.
- Physicians44 comprised 1% of the total LHD work force.
- Support personnel, including program aides, public health assistants and support staff, comprised nearly 28% of the total LHD workforce.
Telephone Survey Findings:
Recruitment and Retention
- The LHDs surveyed identified budget constraints as the most significant barrier to adequate staffing. Lengthy hiring procedures also contributed to the problem.
- Public health nurses, public health sanitarians and public health educators are the titles that pose recruitment difficulties, i.e. finding qualified candidates, particularly in rural areas.
- The LHDs surveyed reported success with career ladders for public health nurses (PHNs) and sanitarians, i.e. recruiting RNs who pursue the required education to become PHNs and recruiting environmental technicians who would qualify to fill vacant sanitarian positions.
- Some LHDs facing hiring difficulties for public health educators reported using staff in other titles to perform health education functions. These LHDs indicated that the minimum qualifications for public health educators in the State Sanitary Code were too narrow to enable them to recruit needed candidates for these positions.
- While the LHDs surveyed reported good retention of their workforce, most are concerned with the aging of their workforce and future loss of staff through retirement.
- The LHDs surveyed reported a variety of strategies to address their need for epidemiology services: the larger LHDs have epidemiologists on staff while the smaller LHDs recruit staff from other professions, such as RNs who receive additional training in epidemiology. The rural LHDs reported successfully using either state DOH regional epidemiology resources or those provided via a regional bioterrorism/epidemiology pilot project.
- The larger LHDs surveyed were more likely to employ physicians for both administrative and clinical positions, while the smaller LHDs were more likely to contract with physicians to serve as clinical consultants.
- Physicians in larger LHDs were more likely to have formal public health training than the physicians working in smaller LHDs.
- Other titles identified as hard to recruit included home health aides.
- The larger LHDs surveyed were more likely to have staff with formal public health training, usually working in program administration.
Competencies and Training
- The LHDs surveyed all reported substantial need for continuing education, particularly in areas related to emerging public health issues.
- Access to available training was constrained by limited resources, poorly designed training, competing priorities, and inaccessible times and locations.
- The LHDs surveyed agreed that the environmental health course required of sanitarians was essential to assisting the staff to meet core competencies. From a broader perspective, the LHDs surveyed were in favor of adding additional training for key staff but concerns about unfunded mandates dampened their support for additional training requirements. They also reported that a national recommendation for PH worker certification of basic competencies requires further study before implementation.
- While all LHDs surveyed reported linkages for training and recruitment with colleges and universities in their communities, not all reported a relationship with a School of Public Health.
Work Force Training: A statewide public health training task force should be convened in New York State including representatives from all schools of public health, the state and local health departments and other academic partners. This Task Force will consider issues of access, competency based training, leadership skills and public health career curricula at schools and colleges. It will develop specific initiatives that will:
- Support the development of accessible, competency-based training and continuing education programs that meet the needs of the state and local public health work force;
- Ensure that all state and local public health workers have an orientation to the key concepts of public health so that they have a basic understanding of the public health enterprise: its history, its focus on population health, its basis in legal authority, and the many disciplines involved;
- Address the need for focused training for public health leaders on leadership, community partnerships and coalition building, and risk communication and communication approaches to an increasingly culturally diverse community;
- Explore a public health leadership training scholarship program to facilitate participation by state and local leaders in the North East Public Health Leadership Institute or the National Public Health Leadership Institute;
- Develop partnerships with academic, public health and medical institutions that keep the focus on training professionals for employment in state and local health departments and support core curriculum that trains graduates for governmental public health careers;
- Promote attention to public health careers with public school systems and colleges/universities.
Work Force Recruitment: The Public Health Council should review the NYS Sanitary Code to ensure that job titles and minimum qualifications are appropriate to today's public health needs and examine how the sanitary code qualifications and training requirements can be revised to support career ladders. Specifically, the Public Health Council should:
- Ensure that minimum qualifications are appropriate to today's public health needs and reflect current public health core functions and competencies;
- Examine how the state sanitary code qualifications for specific job titles (e.g. sanitarians, public health nurses, public health educators) can be revised to support career ladders and career mobility within local health departments while at the same time maintaining the standards needed for specific positions;
- Examine how changes to the state sanitary code could facilitate training while not posing additional resource burdens on local health departments.
Long Term Recommendations
- The Public Health Council (PHC) should monitor the national discussion about certification of the public health work force. This assessment of the possible role of certification should clarify the standard set of core competencies that should be used as a framework for hiring, for performance evaluation and for training by state and local health departments.
- The PHC should call on all members of the public health system to develop scholarship programs to increase the number of students graduating from schools of public health, nursing, health education and other fields who work in governmental public health agencies in NYS. The State should consider a scholarship program modeled on the National Health Service Corps to retire loans in return for service in the state or local health departments in NYS. Graduates could then be placed in parts of the state where staff shortages have been noted.
- The PHC, the NYS DOH and local health departments should consider how to address long-term shortages in the public health work force based on projected future retirements of state and local staff.
- The NYS DOH and local health departments should engage in a regular assessment and reporting of public health work force needs, supply, and projected vacancies based on normal levels of turnover, including those occasioned by retirement.
Dir. Weights & Measures
Environmental Program Mgr.
Medical Service Analyst
Migrant Program Coordinator
Public Health Representative
|Epi/Disease Control||Comm. Disease Staff
Dis. Control Investigator
|Support Personnel||Program Aide
Public Health Assistant
Home Health Aide
Social Worker (MSW)
Social Worker Assistant
Public Health Chemist
Poison Information Specialist
Evidence Property Control
I. LHD Programs
1. The attachment list shows the current programs that your agency provides, based on the NYSACHO survey and/or Municipal PH Service Plan. Please indicate on the Attachment which of the programs you provide directly or under contract or both.
II. Supply of Workers
2. The second attached list is the data on your workforce from a recent survey conducted by Peggy DiManno as part of a National Public Health Leadership Institute project. Does this accurately reflect the current staffing pattern at your agency? If not, please correct.
III. Specific Job Titles
3. We would like to know more about six specific job titles or occupations: public health nurse, all other registered nurse, public health physician, health educator, epidemiologist and disease control staff, and environmental sanitarian. Attachment III is a brief list of core functions and core competencies as defined by national professional organizations as well as NYS Sanitary Code requirements for these titles.
|Public Health Nurses||All Other Registered Nurses||Public Health Educators||Sanitarians||Epidemiologist/
Dx Outbreak Mgmt
|1. a. Do you have a sufficient number of workers in this title to fulfill you MPHSP?|
|1. b. If no, why not?45
(Select all that apply from the list below)
|2. What is your current vacancy rate46 in this title?|
|3. What is average time to fill a vacancy in this title?|
|4. What is your annual turnover rate47 for this title?|
|5. Do you expect many retirements or departures from this title?
(many, some, or few)
|6. Do the workers in this title meet the minimal qualifications in the state sanitary code?48|
|7. What are the top 5 training or continuing education needs for this title?
Please indicate in rank order beginning with your most pressing need.
|8. Are there sufficient training opportunities for this title?|
|9. What resources are available to pay for training for this title?|
|10. What kind of agency/organization is best able to meet training needs for this title?|
4a. Do you have a sufficient number of PH physicians to fulfill your MPHSP? If no, why not?45 (Select all that apply from the list below).
4b. Do you employ or contract for PH physician services?
4c. What are the specialties of your PH physicians?
4d. What is the current vacancy rate46 for PH physicians?
4e. What is your annual turnover rate47 for PH physicians?
4f. Do you expect many retirements or departures of PH physicians?
4g. What are the continuing education needs for PH physicians?
4h. Are there sufficient training opportunities for PH physicians?
4i. What resources are available to pay for training for PH physicians?
4j. What kind of agency/organization is best able to meet training needs of PH physicians
IV. Other Public Health Titles
5. What are the other occupations that pose a significant recruitment and/or retention problem? Please indicate the occupation or job title, the vacancy rate, average time for fill the position, and the reason( s) it is difficult to recruit or retain individuals in these occupations. Use Attachment II to complete this question.
V. General Training Issues
6. In general, are their sufficient, accessible training opportunities available for your staff?
7a. Is your county familiar with the training or continuing education resources available from
- SUNY Albany SPH?
- Columbia University SPH?
- SUNY Buffalo SPH?
- New York Medical College SPH?
7b. Are there other schools or programs your county has used? If yes, please identify.
8. Would state training requirements help to ensure staff was adequately trained? Please explain.
9. Is it important to your county to recruit graduates from MPH programs or encourage your staff to obtain MPHs?
10. Would a credentialing program for specific Public Health titles be helpful? Which titles?
11. What are the barriers to obtaining adequate training/continuing education for your staff?
- No budget supporting training
- Geographic inaccessibility
- Staff disinterest
- Supervisor disinterest
- Not valued
- Available training does not inprove job performance
- Other _____________________________________
12a. Is there a need to provide upgrading or promotional opportunities for staff in certain public health titles or occupations? If yes, which ones?
12b. Is the county engaging in succession planning? If yes, for which titles and occupations?
VI. General Issues related to workforce
13. What can schools of public health and/or other academic institutions do to assist you to address your workforce issues?
14. What can the SDOH do?
15. What can the Public Health Council do?
36 All definitions are from "Concepts and Definitions" provided by Kristine Gebbie, Dr. PH, RN, Member of Public Health Infrastructure Work Group. Adapted from US Department of Health and Human Services. 2000. Healthy People 2010.
37 IOM, Future of the Public's Health, 2003
38 APHA, 2000
39 U. S. Department of Health and Human Services, Health Resources and Services Administration. (2000a). The Public Health Work Force: Enumeration 2000. Washington, DC.
40 Based on data provided by the New York State Department of Health and a survey of local health departments in New York State conducted by Peggy DiManno, Sylvia Pirani, Dwight Williams and Carol Young as part of a Public Health Leadership Institute Project
41 Surveys were received from 54 of 58 LHDs, for a response rate of over 93%. Staff working exclusively for Early Intervention Programs or in Certified Home Health Agencies were not included in the enumeration.
42 Using the definition in NYS Public Health Law (a county with a total population of less than 200, 000 is considered rural), there are 19 urban counties and 43 rural counties in New York State.
43 Total FTEs and per capita calculations reflect only those counties that responded to the survey. No adjustment was made for non-respondents.
44 Includes physicians in clinical titles only.
45 Reasons for insufficient number: (a) No/not enough budgeted lines (b) Cannot hire due to budgetary freeze; (c) Lack of qualified candidates; (d) Difficult to attract qualified candidates to this geographic area; (e) Pay and/or benefits not competitive; (f) Services or programs offered have recently expanded; (g) Sanitary code requirements limitations; (h) Other.
46 Vacancy Rate = No. of vacancies / (100 x No. of filled positions + No. of vacancies)
47 Turnover Rate = Total number of jobs / (100 x Total Number of exits from an employer)
48 See Attachment III for state sanitary code qualifications.