Training Primary Care Physicians for Local Health Authority Duties in Texas

Abstract

Only one fourth of Texas counties have a local health authority (LHA) or health district. Primary care physicians in the remaining counties could be trained in public health basics by providing an online LHA training course and courses at annual meetings of the Texas Medical Association and the Texas Academy of Family Physicians.

The Texas Department of State Health Services should develop a web portal for LHAs. The Texas Association of Local Health Officials should also provide automatic limited membership for LHAs.

These initiatives would provide public health training to primary care physicians and would greatly improve availability of public health services for the citizens of Texas.

The US Department of Health and Human Services recently identified priority drivers of public health quality and outcomes. One of these priority drivers is “workforce and education,” developing and sustaining a competent public health workforce by “ensuring that educational and skills content are appropriately aligned with core and discipline-specific competencies.”^1(p4) As members of the public health workforce, local health authorities (LHAs) have the responsibility to connect the health of individuals to public health services in the communities which they serve. The role of the LHA is essential to assuring a vision of healthy people in healthy communities. This analytic essay describes a collaborative approach to facilitate clinician education and lifelong learning, contributing to the national goal of population health improvement.

LOCAL HEALTH AUTHORITIES IN TEXAS

Under Title 25 of Texas Administrative Code “a health authority is a physician appointed …to administer state and local laws relating to public health within the appointing body’s jurisdiction.”² The law defines a physician as a person licensed to practice medicine by the Texas State Board of Medical Examiners. Counties are not required to have a health department or a health authority. If the county chooses not to appoint a health authority, the director of 1 of the state’s 8 regional health departments acts as the health authority for that county. Only 73 (29%) of 254 Texas counties have an appointed health authority.³ Expanding the number of counties with LHAs may help to make public health services more available in rural areas.

A possible scenario may have occurred when children visited a municipal swimming pool in South Texas. The next day, these children developed vomiting, diarrhea, and fever. Their mothers concluded that the swimming pool was the likely source of the outbreak. The mothers decided to contact the county health department. When they looked in the phone book, there was no listing for the county health department. After an Internet search, they determined that there was no local health department in their county. Public health services are administered by the Regional Health Department in Harlingen, Texas, more than 180 miles to the south. After another period of searching, they located the telephone number for the Regional Health Department and reported the incident. An investigator was assigned to the case and arrived several days later.

DUTIES OF LOCAL HEALTH AUTHORITIES

What makes a health authority different from other public health professionals is their administration of and responsibility for the “police powers” of the health department. In addition to administering public health core functions and essential services⁴ within the jurisdiction, a health authority enforces ordinances, sanitation laws, and quarantine rules.⁵

The public health structure in Texas has 3 levels: the Department of State Health Services (DSHS) in Austin, Texas; 8 Public Health Regions, each administered by a Regional Medical Director who is a physician with a master’s degree in public health; and LHAs.⁶ LHAs are responsible to their county judges for administration of public health in their county. Regional Health Authorities are responsible to the DSHS Commissioner for provision of public health services within their region, including supporting appointed LHAs and acting as the LHA for counties that do not have an appointed LHA. A survey of LHAs conducted by the DSHS in 2001, the most recent data available, revealed that of the 73 Texas LHAs, two thirds are part time, and one third of the part-time health authorities hold volunteer unpaid positions.⁷ Sixty-five percent of LHAs had no job description, and more than half performed additional duties not required of LHAs by state law.

ADVANTAGES AND CHALLENGES

Although the Regional Health Authorities all have advanced public health degrees, the result of counties having no LHA is an inequity in the presence of public health services between counties with appointed LHAs and counties without an appointed LHA. Counties without an LHA do not have a locally based health official who citizens and public officials can consult. For instance, Region Eleven of the Texas DSHS, located in Harlingen, Texas, is responsible for 19 counties with an area of 23 000 square miles. Six counties have an appointed LHA. The other 13 counties rely on the services of the Regional Director. For a single health authority to provide and administer public health services to 13 counties in an area larger than Maryland and Massachusetts combined is a challenging task. An LHA is responsible to 1 county judge for public health activities in the county. The Region Eleven director must deal with 13 county judges while providing guidance and support to the other 6 counties that do have health departments.

A health authority that lives in the county is able to quickly travel to any part of the jurisdiction to respond to an emergency. Also, living in a rural county provides opportunities for the health authority to develop personal relationships with local leaders and elected officials. In times of emergencies, having existing relationships increases the efficiency of the response.⁸

Several challenges are notable. Some LHAs have no staff to assist them. Even counties with health departments have few employees with public health training.⁹ In smaller health departments, the staff has many duties and responsibilities, making it difficult to handle the many requirements of a health department.¹⁰ Because most LHAs outside of large cities do not have a graduate public health degree or specialized training in public health, they may not know public health theory or state procedures well. In times of large-scale emergencies, such as wildfires or hurricanes, the Regional Director must organize responses with multiple counties and county judges. This can require an enormous effort of coordination and administration. Regional Health Directors must carefully plan how best to place themselves to respond to the emergency. This may mean staying at a central headquarters rather than being present at the site of the emergency.

Of the counties with appointed LHAs, many LHAs are rural primary care physicians who serve part time.¹¹ Concerns about time requirements, lack of training, and possible liability may make local physicians reluctant to take on the duties of the LHA. Most of the 24 full-time LHAs are located in larger cities. Even those physicians with advanced public health degrees have little training in the specific police duties of a LHA. Also, many LHAs supervise areas such as code enforcement and animal control, which are additionally appointed responsibilities and not direct duties of LHAs by law.

TARGETING RURAL PRIMARY CARE PHYSICIANS

The effectiveness of public health programs could be enhanced if local primary care physicians were trained in public health¹² and could assume part-time positions as LHAs for their counties and cities. Currently, there is no formal training available to appointed LHAs in Texas.

Rural primary care physicians experience longer work hours and lower incomes compared with their urban colleagues.¹³ These factors have contributed to a shortage of primary care physicians in rural communities. These decrements are made up for by close associations with patients and the community. Some LHAs receive a stipend for their services. This benefit may make the difference between a physician staying in the community or leaving for more lucrative large cities. That small additional income may provide a stable financial resource to supplement income from uncertain medical practice receipts. Rural physicians frequently have difficulty leaving their practices to travel to meetings for continuing medical education (CME). Members of the American Academy of Family Physicians (AAFP) are required to obtain 150 hours of CME every 3 years, of which 75 hours must be AAFP prescribed credit approved by the Academy.¹⁴ The Texas Board of Medical Examiners requires that all licensed physicians in Texas obtain 24 hours of CME each year, including 1 hour of ethics education.¹⁵ Thus, an approach to engage rural primary care physicians by combining CME and public health education would be advantageous.

OUTCOMES OF PRIMARY CARE PHYSICIAN TRAINING

The short-term outcome of primary care physician training would be to increase the number of primary care physicians who have public health training in rural communities.^16,17 If this is successful, the percentage of counties with a LHA would rise. In the long-term, counties would have a local person who could respond to public health concerns and who could implement DSHS programs and policies. Measures of success would include the number and percentage of primary care physicians who received public health instruction. Other outcome measurements would be the number and percentage of counties with 1 or more physicians with public health training and the number and percentage of counties with an appointed LHA. Figure 1 provides a tracking model for primary care physician public health training.

FIGURE 1—

Tracking model for primary care physician training in Texas.

Note. CME = continuing medical education; LHA = local health authority; NP = nurse practitioner; PA = physician's assistant; TAFP = Texas Academy of Family Physicians; TALHO = Texas Association of Local Health Officials; TMA = Texas Medical Association.

Four courses of action are recommended to encourage physicians to become LHAs and to obtain training in LHA duties.

Local Health Authority Training Course

The cornerstone of the LHA initiatives is an evidence-based public health training course to prepare LHAs to discharge their legal duties. The content would be based on a needs assessment of current LHAs. The course would be primarily designed for appointed LHAs and primary care physicians. The course would be developed and administered by a school of public health. Once the model is validated, the courses could be offered statewide to primary care physicians on an ongoing basis. This would extend public health information and skills among the primary care physician community and would potentially provide a trained reserve of physicians who could respond to public health issues in their area and who could possibly become appointed LHAs. The courses could also be offered to primary care residencies and to medical schools to build a public health knowledge base among physicians in training.^18–21 The training could additionally be expanded to nurse practitioners (NPs) and physician’s assistants (PAs). Although by Texas law NPs and PAs cannot perform the duties of a health authority, they can assist Regional Medical Directors and LHAs in the performance of their duties. Possibly, a new class of LHA could be created for NPs and PAs as Deputy Health Authorities to assist LHAs and Regional Medical Directors.

Course structure.

The structure of training is important to the success of the endeavor. Training for public health would have to be synchronized with the physicians’ practices. It must not be so time-consuming that it interferes with the physician’s regular work and other commitments. The training should be divided into 1-hour blocks to allow busy physicians to complete a module in 1 session. Possible venues for training include online courses and state meetings of the Texas Medical Association (TMA) or the Texas Academy of Family Physicians (TAFP). The courses should be free or paid for by the appointing county for LHAs and inexpensive for other physicians. The availability of free CME would be an inducement for physicians to become appointed LHAs. Provision of inexpensive CME hours and ethics hours might be an inducement for other physicians to participate. The training should focus on practical, actionable information based on required competencies and responsibilities of LHAs. Elective courses and supportive training could be offered to provide increased skills in other areas of need and interest.

Continuing medical education credit.

The developers of the LHA training course should seek approval from the AAFP for prescribed credit hours. American Medical Association Category 1 credit would be awarded to physicians who are not members of the AAFP. The training course should also provide physicians with their required 1 hour of ethics instruction. The LHA basic training curriculum could be from 6 to 18 CME hours. Table 1 shows a possible 12-hour curriculum. Table 2 shows elective courses that would provide additional opportunities for learning and would be directed to other LHA competencies and responsibilities.

TABLE 1—

Core Subjects for Local Health Authority Training Course, Training Primary Care Physicians in Texas

Class	Subject	Hours CME
I	Leading as a local health authority	0.5
	Legal basis for health authorities	0.5
	Managerial duties of the health authority	1.0
II	Sanitation and food safety I	1.0
	Sanitation and food safety II	1.0
III	Epidemiology and disease outbreaks I	1.0
	Epidemiology and disease outbreaks II	1.0
IV	DSHS and regional health authorities	0.5
	Health departments	0.5
	County and local government	1.0
V	Health preparedness (emergency planning) I	1.0
	Health preparedness (emergency planning) II	1.0
VI	Immunizations	1.0
	Rabies	0.5
	Quarantine	0.5
	Total	12.0

Note. CME = continuing medical education; DSHS = Department of State Health Services.

TABLE 2—

Elective Subjects for Local Health Authority Training Course, Training Primary Care Physicians in Texas

	Subject	Hours CME
1	Grant writing	1.0
	State and federal funding	0.5
	The budgeting process	0.5
2	Alphabet soup: CDC, ATSDR, EPA, TCEQ, etc.	0.5
	ImmTrac (Texas Immunization Registry)	0.5
	WIC and Headstart	0.5
3	Public health communication, collaboration, and advocacy	0.5
	Public information	0.5
4	Animal control	1.0
	Code enforcement	0.5
	Tuberculosis	0.5
5	Outbreak investigations	0.5
	Schools and pools—inspecting other establishments	0.5
6	Public health research	0.5
	Health surveys	0.5
7	Recovery operations	1.0
	Shelter management	1.0
8	Chemical accidents and releases	0.5
	Nuclear accidents and releases	1.0
	Biological incidents	0.5

Note. ATSDR = Agency for Toxic Substances and Disease Registry; CDC = Centers for Disease Control and Prevention; CME = continuing medical education; EPA = Environmental Protection Agency; TCEQ = Texas Commission on Environmental Quality; WIC = Women, Infants, Children.

Certification of training.

Issuing Certification of Training could inform county and city governments of the competencies of their LHA. This recognition of training would not take the place of current public health certification examinations, such as the Certified in Public Health Examination presented by the National Board of Public Health Examiners. It would be recognition that training in public health has been successfully completed. The certification should last for 3 years. To maintain certification after the 3-year period, a physician could either retake and successfully complete the LHA base course or successfully complete 6 hours of elective courses during the 3-year certification period. Ideally, the LHA training should improve the physician’s clinical skills, provide required CME, and develop core competencies in the area of LHA responsibilities.

Coordination with the DSHS and with the State Health Commissioner is critical to the success of the project. The DSHS must insure that all training is consistent with current public health guidelines and with state law.

Web Portal for Local Health Authorities

The DSHS should develop a Web portal and mobile device application dedicated to LHAs, who could access the DSHS database and have opportunities to consult with other LHAs. The Web portal and mobile application should provide links to DSHS agencies, information, and services. A Web portal for LHAs could provide links to information and regulations in a way that is intuitive and does not require extensive searching or computer skills training. One of the main goals of this portal would be to tie the LHA with support services from the region and state.

The DSHS should also partner with the TMA and TAFP to provide training experiences to primary care physicians at their state meetings. As part of these initiatives, the DSHS should develop an information campaign to inform primary care physicians and county judges of the opportunities for training and possible appointment as a LHA.

Texas Association of Local Health Officials

The Texas Association of Local Health Officials (TALHO) is a nonprofit organization created to further members’ common goals, including preventing disease and protecting the environment.²² The TALHO could grant LHAs membership in TALHO. This would be a limited category of membership for LHAs at no cost. This LHA membership would provide access to TALHO services, including the Health Alert Network and some video and teleconferencing classes. Providing an automatic free membership for LHAs would be a perk that might make the LHA position more attractive to physicians. Most TALHO members are full-time public health department employees. By contrast, many LHAs are part-time primary care physicians who cannot cancel patient appointments to participate in meetings during regular working hours. TALHO should consider developing programs that would meet the needs and time constraints of primary care physicians. TALHO could partner with the TMA and TAFP to provide TALHO information and training experiences at TMA and TAFP medical meetings. TALHO could offer full membership to LHAs at an attractive rate because in most cases it is paid for by the physicians themselves, not by the county or city that the physician serves.

Currently, the TALHO has only 1 award, the Janet Emerson Public Health Servant Award. A series of certificates and awards should be considered for LHAs and others. Possibilities could include recognition of LHAs who have completed LHA training; tenure recognition for 5, 10, 15, 20, and 25 years of service; and an award for extraordinary contributions to the local or public health community.

ADVANTAGES AND CHALLENGES OF TRAINING

There are a number of advantages of LHA training. Making training and support available to rural physicians could provide a cadre of trained physicians in remote locations who can react to public health situations with improved competency, speed, and agility.²³ Making the training courses attractive to non-LHAs could provide reserve capability and could enhance public health knowledge of the physician community. This program could extend the eyes, ears, and hands of the DSHS into small and remote communities where they currently have no presence. Grants could be used to pay for development costs, and CME fees could pay for upkeep and update once the course is online. This training is intended to be inexpensive for the students and should provide many benefits to DSHS and the citizens of Texas. LHA training could provide tools for the DSHS to track not only LHAs but also physicians who have LHA training and might be recruited either in emergencies or as LHAs in venues without a LHA.

Enhanced LHA training would be a significant undertaking that would require commitment from all stakeholders. Maintaining accurate data on trained LHAs and their locations would be a significant challenge because many physicians move frequently. A tracking tool developed concurrently with the offer of free annual CME-specific content for LHAs could assist in maintaining an accurate count of active and reserve public health clinicians. The current proposals for LHA training would need champions who would push forward to increase the training of the public health physician workforce. Funding will always be challenging, especially during current budget shortfalls. Once the course is available, it must be updated regularly to comply with changes in state law and evidence-based public health practices.

WHAT ACTUALLY HAPPENED

On June 9, 2011, a group of children visited the municipal swimming pool in a small Texas town. The next day, the children developed vomiting, diarrhea, and fever. Their mothers concluded that the swimming pool was the likely source of the outbreak. The mothers decided to contact the county health department. The LHA, a family physician practicing in the community, immediately initiated a contact investigation and sent an inspector to check the pool. Testing showed that there was no chlorine in the pool, and so the pool was closed. The LHA also notified the Regional Medical Director. Over the next 24 hours, state, county, and local officials worked with the municipal pool personnel to correct the problem. The pool reopened the next day. A public health warning was issued concerning diarrheal disease and recommending control measures. As a result of this outbreak, other municipal pools in the county were inspected, and 1 was temporarily closed because of inadequate chlorination. The outbreak of diarrheal illness subsided after 72 hours. This second incident occurred from June 13 to June 16, 2011 in San Patricio County, Texas.

CONCLUSIONS

Public health inequities may occur in Texas counties where there are no appointed LHAs. Making an evidence-based, competency-driven training course with CME credit available to rural primary care physicians may increase the availability of trained LHAs. The Texas DSHS can support this initiative by developing online tools to allow LHAs to access DSHS support. The TALHO could create an automatic limited membership for sworn LHAs. Primary care physicians should be encouraged to pursue training and public health practice opportunities; it is a way to honor the roots of public health practice and to assure a rewarding role for a traditional but vanishing member of the public health workforce. Perhaps the 1988 Institute of Medicine report said it best:

No citizen from any community, no matter how small or remote, should be without identifiable and realistic access to the benefits of public health protection, which is possible only through a local component of the public health delivery system.^24(p144)