Public Health 3.0: Supporting Local Public Health in Addressing Behavioral Health

For the first time in generations, life expectancy in the United States is declining.¹ It is driven in large part by behavioral health challenges manifesting in the opioid epidemic and troubling rises in suicide.^2,3 Communities across the country struggle to absorb the heavy tolls of behavioral and mental health on their well-being and economy. The lack of resources to counter these challenges is particularly jarring in many underserved communities, further widening health disparities by race/ethnicity, sexual and gender identity, rurality, and socioeconomic status.

A SIGNIFICANT THREAT TO THE NATION’S HEALTH

The thrust of the current efforts to stem and then reverse the tide of our behavioral health challenges has largely focused on the health care system. For example, in addressing the opioid and substance use disorder epidemics, policy strategies have been actively leveraged to change prescriber behavior, make addiction treatment more available, and develop less-addictive pain medications. The Affordable Care Act not only expanded access to affordable health insurance but also made covering behavioral health services mandatory for health plans, making treatment possible for millions.

Though these medical approaches to behavioral health are a part of the solution, we cannot treat our way out of this epidemic. Addressing this complex challenge and its fundamental causes⁴ will require cross-sectoral collaboration, integration of data streams, leveraging advanced analytic tools, and establishing accountability measures that drive continuous improvement. These elements are building blocks of modern public health. As such, a vibrant public health infrastructure is needed now more than ever to lead the charge at the local and national levels to effectuate the very definition of public health: what we do as a society to assure the conditions in which everyone can be healthy.

MODERNIZING PUBLIC HEALTH

Across the nation, local health departments have risen to meet complex challenges such as the opioid epidemic by pioneering, innovating, and transforming on the front lines to address the full range of factors that influence a person’s health—from good schools to safe environments, stable housing to transportation, economic development to access to healthy foods. In these pioneering communities, sectors are coming together to address upstream determinants and reinvent their local public health system in a strategic and evidence-based fashion. In many ways, this is driven by the understanding that the greatest challenges of our day to our health and well-being go beyond merely infectious or chronic diseases, such as diabetes, but rather to socioeconomic conditions, such as loneliness and despair, lack of economic opportunity, and adverse childhood experiences.

In a 2016 report, Public Health 3.0: A Call to Action for Public Health to Meet the Challenges of the 21st Century, the US Department of Health and Human Services, Office of the Assistant Secretary for Health, recommended five essential qualities for every community to achieve health for all:

1. Ensure leadership to serve as the chief health strategist for their communities;

2. Establish structured, cross-sector partnerships;

3. Acquire actionable data and clear metrics;

4. Enhance funding flexibility and reduce siloes; and

5. Seek accreditation with the goal of everyone in the United States being supported by an accredited health department.⁵

Through the lens of the Public Health 3.0 framework, in this issue of AJPH, Bommersbach et al. (p. 1334) call for public health to play a major role in addressing our country’s behavioral health challenges. The authors provide concrete examples of how this vision is playing out in local communities across the country, where local agencies actively engage in addressing behavioral health through cross-sectoral partnerships, accreditation, and new accountability and payment models. In these Public Health 3.0 communities, the governmental public health leaders and agencies bring to bear the skills, approaches, and values foundational to the field and essential in reducing the burden of behavioral health for individuals and populations.

For governmental public health to effectively address behavioral health, the authors specifically call to attention a direct linkage to Public Health Accreditation Board (PHAB) accreditation standards. As of June 2018, 223 local, state, and tribal health departments had been accredited or were in progress for accreditation, covering roughly two thirds of the US population.⁶ The opportunity that PHAB accreditation brings is a more transparent and accountable public health infrastructure. It also brings assurance that local and state health departments have the foundational capabilities to deliver essential public health services to the people they serve—identifying community health problems and pursuing evidence-based actions driven by a competent workforce.

Early evidence on the impact of accreditation on the public’s health shows promise. The impact seems largely in the opportunity gained during the process of accreditation itself that seems to drive quality improvement of health departments and strengthen infrastructure and external relationships. However, early versions of PHAB accreditation largely reflected a more traditional model of public health practice. The Public Health 3.0 report specifically called for PHAB criteria and processes for department accreditation to be enhanced and supported to best foster Public Health 3.0 principles and focuses on social determinants of health, equity, and cross-sectorial actions. As PHAB works to modernize its accreditation process, Bommersbach et al. provide timely and informative recommendations for this critical work of integrating behavioral health into the essential functions of local health departments and their role in safeguarding the public’s health.

READYING PUBLIC HEALTH

The evolution to a modern Public Health 3.0 model will not happen overnight. In addition to accreditation, other elements foundational to a Public Health 3.0 health system will need to evolve. Governmental public health is currently struggling to maintain even its foundational, statutory responsibilities, much less support the emerging needs of addressing broader public health issues such as behavioral health. Efforts to develop more flexible and durable funding for the foundational work of Public Health 3.0 are underway and need to be coupled with advances in accreditation. Furthermore, access to timely, actionable data is a necessary element of successful public health interventions to address complex health challenges. This is particularly true for behavioral health and mental health issues given the enduring disconnect between behavioral health services and the rest of the health care system. Data confidentiality and privacy concerns remain a major challenge for communities taking broad public health approaches to address behavioral health.

MEET PUBLIC HEALTH 3.0 VISION

We are facing a historic and intractable epidemic in behavioral health that will require more than what the medical system can bring. It will require us to strategically, thoughtfully, and collaboratively work together to create the conditions in which everyone can be healthy, stay healthy, or return to health. This work will be best served by a transformed public health system that meets the vision of Public Health 3.0. The article by Bommersbach et al. makes clear how essential this work is, and how institutions such as PHAB that define and support public health need to modernize alongside local public health. When we do, we will have a public health system better equipped to respond to complex and important public health challenges we face today and in the future.