Longitudinal Trends in Insurer Participation in Multisector Population Health Activities.

Healthcare organizations increasingly engage in activities to identify and address social determinants of health (SDOH) among their patients to improve health outcomes and reduce costs. While several studies to date have focused on the evolving role of hospitals and physicians in these types of population health activities, much less is known about the role health insurers may play. We used data from the National Longitudinal Survey of Public Health Systems for the period 2006 to 2018 to examine trends in health insurer participation in population health activities and in the multi-sector collaborative networks that support these activities. We also used a difference-in-differences approach to examine the impact of Medicaid expansion on insurer participation in population health networks. Insurer participation increased in our study period both in the delivery of population health activities and in the integration into collaborative networks that support these activities. Insurers were most likely to participate in activities focusing on community health assessment and policy development. Results from our adjusted difference-in-differences models showed variation in association between insurer participation in population health networks and Medicaid expansion (Table 2). Population health networks in expansion states experienced significant increases insurer participation in assessment (4.48 percentage points, P < .05) and policy and planning (7.66 percentage points, P < .05) activities. Encouraging insurance coverage gains through policy mechanisms like Medicaid expansion may not only improve access to healthcare services but can also act as a driver of insurer integration into population health networks.

US Hospital Service Availability and New 340B Program Participation.

Importance: The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended. Objective: To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership. Design, Setting, and Participants: Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024. Exposures: New enrollment in 340B between 2012 and 2018. Main Outcomes and Measures: Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services. Results: The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05). Conclusions and Relevance: The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.

Examining Characteristics of Local Public Health Systems With Exceptional Tribal Organization Participation.

OBJECTIVE: To learn feasible ways to increase multisector community partnership with tribal organizations, meaning tribal health authorities or American Indian and Alaska Native (AI/AN)-serving organizations, by examining characteristics of local public health systems with exceptional tribal organization participation. DESIGN, SETTING, AND PARTICIPANTS: In total, 728 local public health departments were surveyed in 2018 to generate a nationally representative sample of local public health systems in the United States. A positive deviance approach using logistic regression helped identify local public health systems that had tribal organization participation despite characteristics that make such participation statistically unlikely. Local public health systems with exceptional tribal organization participation were compared with systems with conventional participation, examining measures known to impact the formation of public health partnerships. MAIN OUTCOME MEASURE: This study used an exploratory logistic regression approach to identify unique characteristics of local public health systems with exceptional tribal organization participation. RESULTS: Of 728 health systems surveyed, 21 were identified as having exceptional tribal organization participation. Across varying thresholds to identify exceptional participation, having a higher network density and prioritizing equity in public health activities were found to consistently distinguish exceptional tribal organization participation in both nonrural and rural areas. CONCLUSIONS: Public health partnerships with tribal organizations are possible even in circumstances that make them unlikely. Efforts to build denser networks of collaborating organizations and prioritize equity may help public health systems achieve success with tribal organization partnerships.

Contemporary Public Health Finance: Varied Definitions, Patterns, and Implications.

The financing of public health systems and services relies on a complex and fragmented web of partners and funding priorities. Both underfunding and "dys-funding" contribute to preventable mortality, increases in disease frequency and severity, and hindered social and economic growth. These issues were both illuminated and magnified by the COVID-19 pandemic and associated responses. Further complicating issues is the difficulty in constructing adequate estimates of current public health resources and necessary resources. Each of these challenges inhibits the delivery of necessary services, leads to inequitable access and resourcing, contributes to resource volatility, and presents other deleterious outcomes. However, actions may be taken to defragment complex funding paradigms toward more flexible spending, to modernize and standardize data systems, and to assure equitable and sustainable public health investments.

Association Between Insurer Connectivity in Appalachian Population Health Networks and Preventable Hospitalizations: Evidence from Kentucky.

Introduction: Addressing complex health and social needs requires cross-sector collaboration to deliver medical, social, and population health services at the community level. Capacity in community health and social services networks may be constrained in regions like Appalachia due to the combined effects of rurality and persistently poor health and social outcomes. One way that cross-sector networks serving low-resource communities can expand their capacity is by engaging partners, like health insurers, who can leverage resources from outside the local area. Purpose: This study examines insurer connectivity in cross-sector networks across Kentucky's geographic regions and the association between connectivity and the probability of an individual experiencing a preventable hospitalization. Methods: A cross-sectional design was used that linked data from the National Longitudinal Survey of Public Health Systems (NALSYS) with 2018 patient-level Kentucky hospital discharge data to examine the association between insurer connectivity in community networks and preventable hospitalizations across urban, rural non-Appalachian, and Appalachian regions. Results: Analysis of the data shows substantial geographic variation in the association between insurer connectivity in community networks and preventable hospitalization. Insurer connectivity in rural Appalachian communities was associated with lower likelihood that an individual was admitted for a preventable hospitalization ( p < 0.01). Implications: Findings suggest insurer connectivity in cross-sector community health and social services networks has the potential to strengthen network capacity to address preventable hospitalizations and improve health outcomes and well-being for the people of Appalachia.

Medicaid Payment For Postpartum Long-Acting Reversible Contraception Prompts More Equitable Use.

To increase access to highly effective contraception and improve reproductive autonomy, a growing number of state Medicaid programs pay for the provision of immediate postpartum long-acting reversible contraception (LARC) in addition to providing a global payment for maternity care. Using Pregnancy Risk Assessment Monitoring System data, we examined postpartum LARC use both overall and by race and ethnicity among respondents with Medicaid-paid births during the period 2012-18 in eight states that implemented immediate postpartum LARC payment and eight states without it. Using a quasi-experimental difference-in-differences design, we found that the policy resulted in an overall 2.1-percentage-point increase in postpartum LARC use. Our triple-differences analysis found no significant change among White mothers and a 3.7-percentage-point increase in use among Black mothers compared with White mothers. Additional research is needed to determine whether this increase was aligned with patients' preferences and whether hospitals' immediate postpartum LARC policies and practices take a patient-centered approach that supports reproductive autonomy and equity.

Impact of state Medicaid expansion on cross-sector health and social service networks: Evidence from a longitudinal cohort study.

OBJECTIVE: To examine the impact of state Medicaid expansion on the delivery of population health activities in cross-sector health and social services networks. Community networks are multisector, interorganizational networks that provide services ranging from the direct provision of individual social services to the implementation of population-level initiatives addressing community outcomes. DATA SOURCES: We used data measuring the composition of cross-sector population health networks 2006-2018 National Longitudinal Survey of Public Health Systems (NALSYS) linked with the Area Health Resource File. STUDY DESIGN: A difference-in-differences approach was used to examine the impact of expansion on organization engagement in population health activities and network structure. DATA COLLECTION/EXTRACTION METHODS: Stratified random sampling of local public health jurisdictions in the United States. We restricted our data to jurisdictions serving populations of 100,000 or more and states that had NALSYS observations across all time periods, resulting in a final sample size of 667. PRINCIPAL FINDINGS: Results from our adjusted difference-in-differences estimates indicated that Medicaid expansion was associated with a 2.3 percentage point increase in the density of population health networks (p < 0.10). Communities in states that expanded Medicaid experienced significant increases in the participation of local public health, local government, hospital, nonprofit, insurer, and K-12 schools. Of the organizations with significant increases in expansion communities, nonprofits (7.7 percentage points, p < 0.01), local public health agencies (6.5 percentage points, p < 0.01), hospitals (5.8 percentage points, p < 0.01), and local government agencies (6.0 percentage points, p < 0.05) had the largest gains. CONCLUSIONS: Our study found increases in cross-sector participation in population health networks in states that expanded Medicaid compared with nonexpansion states, suggesting that additional coverage gains are associated with positive changes in population health network structure.

Who Delivers Maternal and Child Health Services? The Contributions of Public Health and Other Community Partners.

Policy Points Local health departments with direct maternal and child health service provisions exhibit greater social service collaboration, thereby enhancing community capacity to improve health care access and social determinant support. These findings may prioritize collaboration as a community-based effort to reduce disparities in maternal and child health and chronic disease. CONTEXT: Improving maternal and child health (MCH) care in the United States requires solutions to address care access and the social determinants that contribute to health disparities. Direct service provision of MCH services by local health departments (LHDs) may substitute or complement public health services provided by other community organizations, impacting local service delivery capacity. We measured MCH service provision among LHDs and examined its association with patterns of social service collaboration among community partners. METHODS: We analyzed the 2018 National Longitudinal Survey of Public Health Systems and 2016 National Association of County and City Health Officials Profile data to measure the LHD provision of MCH services and the types of social services involved in the implementation of essential public health activities. We compared the extensive and intensive margins of social service collaboration among LHDs with any versus no MCH service provision. We then used latent class analysis (LCA) to classify collaboration and logistic regression to estimate community correlates of collaboration. FINDINGS: Of 620 LHDs, 527 (85%) provided at least one of seven observed MCH services. The most common service was Special Supplemental Nutrition Program for Women, Infants, and Children (71%), and the least common was obstetric care (15%). LHDs with MCH service provision were significantly more likely to collaborate with all types of social service organizations. LCA identified two classes of LHDs: high (n = 257; 49%) and low (n = 270; 51%) collaborators. Between 74% and 96% of high collaborators were engaged with social service organizations that provided basic needs services, compared with 31%-60% of low collaborators. Rurality and very high maternal vulnerability were significantly correlated with low collaboration among MCH service-providing LHDs. CONCLUSIONS: LHDs with direct MCH service provision exhibited greater social service collaboration. Collaboration was lowest in rural communities and communities with very high maternal vulnerability. Over half of MCH service-providing LHDs were classified as low collaborators, suggesting unrealized opportunities for social service engagement in these communities.

Best of ARM: Evaluating engagement in multisector community health networks: The case of tribal organizations.

OBJECTIVE: To quantify variation in public health system engagement with tribal organizations across a national sample of communities and to identify predictors of engagement. DATA SOURCES: We used 2018 National Longitudinal Survey of Public Health Systems data, a nationally representative cohort of the US public health systems. STUDY DESIGN: Social network analysis measures were computed to indicate the extent of tribal organization participation in public health networks and to understand the sectors and social services that engage with tribal organizations in public health activities. Two-part regression models estimated predictors of tribal engagement. DATA COLLECTION: A stratified random sample of local public health agencies was surveyed, yielding 574 respondents. An additional cohort of oversampled respondents was also surveyed to include jurisdictions from the entire state upon the request of their respective state health departments (n = 154). Analyses were restricted to jurisdictions with a nearby American Indian and Alaska Native (AI/AN) serving health facility, yielding a final sample size of 258 local public health systems. PRINCIPAL FINDINGS: When an AI/AN serving health facility was present in the region, tribal organizations participated in 28% of public health networks and 9% of implemented public health activities. Networks with tribal engagement were more comprehensive in terms of the breadth of sectors and social services participating in the network and the scope of public health activities implemented relative to networks without tribal engagement. The likelihood of tribal engagement increased significantly with the size of the AI/AN population, the presence of a tribal facility with Indian Health Service funding in the region, and geographic proximity to reservation land (p < 0.10). CONCLUSIONS: The vast majority of public health networks do not report engagement with tribal organizations. Even when AI/AN serving health facilities are present, reported engagement of tribal organizations remains low.

Local Public Health System Capabilities and COVID-19 Death Rates.

OBJECTIVES: Efforts to contain the health effects of the COVID-19 pandemic have achieved less success in the United States than in many comparable countries. Previous research documented wide variability in the capabilities of local public health systems to carry out core disease prevention and control activities, but it is unclear how this variability relates to COVID-19 control. Our study explored this relationship by using a nationally representative sample of 725 US communities. METHODS: We used data collected from the National Longitudinal Survey of Public Health Systems to classify each community into 1 of 3 ordinal categories indicating limited, intermediate, or comprehensive public health system capabilities. We used 2-part generalized linear models to estimate the relationship between public health system capabilities and COVID-19 death rates while controlling population and community characteristics associated with COVID-19 risk. RESULTS: Across 3 waves of the pandemic in 2020, we found a significant negative association between COVID-19 mortality and public health system capabilities. Compared with comprehensive public health systems, intermediate public health systems had an average of 4.97 to 19.02 more COVID-19 deaths per 100 000 residents, while limited public health systems had an average of 5.95 to 18.10 more COVID-19 deaths per 100 000 residents. CONCLUSION: Overall, communities with stronger public health capabilities had significantly fewer deaths. Future initiatives to strengthen pandemic preparedness and reduce health disparities in the United States should focus on local public health system capabilities.

Information exchange among providers and patient-centeredness in transitional care: A five-year retrospective analysis.

BACKGROUND: Responding to the shift toward value-based care, hospitals engaged in widespread experimentation of implementing transitional care (TC) strategies to improve patient experience and reduce unnecessary readmissions. However, which groups of these strategies are most strongly associated with better outcomes remains unknown. METHODS: Using a retrospective longitudinal design, we collected hospitals' TC strategy implementation data for 370 U S. hospitals and obtained claims data for 2.4 million Medicare fee-for-service beneficiaries hospitalized at them from 2009 to 2014. We applied estimated mixed-effects regression models controlling for patient, hospital, and community covariates to assess relationships between TC strategy groups and trends in hospitals' 30-day hospital readmissions, with observation stay and mortality rates as secondary outcomes. RESULTS: Hospitals' adoption of TC groups was associated with higher readmission rates at baseline and larger readmission rate reductions compared to not adopting any of 5 TC groups. The TC group including timely information exchange across care settings, engaging patients and caregivers in education, and/or identifying and addressing patients' transition needs was associated with the largest reductions. Hospitals not implementing any of the 5 TC groups had higher mortality rates and lower observation stay rates throughout the study period. CONCLUSIONS: Our findings suggest that timely information sharing among providers across the care continuum and engaging patients in discharge planning and education may correspond with reduced readmissions. IMPLICATIONS: Our research suggests that hospitals responded to shifts in policy by implementing a diversity of TC strategy combinations; it also provides guidance regarding which combinations of TC strategies corresponded with larger readmission reductions.

Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension.

Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, it remained stable through 2013-2014 and declined to 43.7% in 2017-2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community-clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control.

Identifying Value-Added Population Health Capabilities to Strengthen Public Health Infrastructure.

Policy Points While the coronavirus pandemic has underscored the important role of public health systems in protecting community health, it has also exposed weaknesses in the public health infrastructure that stem from chronic underfunding and fragmentation in delivery systems. The results of our study suggest that the public health system structure can be strengthened through the targeted implementation of high-value population health capabilities. Prioritizing the delivery of value-added population health capabilities can help communities efficiently use limited time and resources and identify the most effective pathways for building a stronger public health system and improving health outcomes over time. CONTEXT: While the novel coronavirus pandemic has underscored the important role of public health systems in protecting community health, it has also exposed weaknesses in the public health infrastructure that stem from chronic underfunding and fragmentation in public health delivery systems. Information about the relative value in the implementation of recommended population health capabilities can help communities prioritize their use of limited time and resources and identify the most effective pathways for building a stronger public health system. METHODS: We used a longitudinal cohort design with data from the National Longitudinal Survey of Public Health Systems to examine longitudinal and geographic trends in the delivery of population health capabilities and their impact on system strength across communities in the United States. We used linear probability models to ascertain whether the delivery of certain capabilities added value to public health system strength. FINDINGS: Those communities with the strongest classification of public health system structure in both urban and rural areas implemented the largest set of population health capabilities. Results from the linear probability model indicate that a set of population health capabilities are associated with increased public health system strength. Key activities include allocating resources based on a community health plan, surveying the community for behavioral risk factors, analyzing the data on preventive services use, and engaging community stakeholders in health improvement planning (p < 0.01). CONCLUSIONS: The results of this study suggest that public health systems can be strengthened through the targeted implementation of high-value population health capabilities. Prioritizing the delivery of value-added population health capabilities may help communities increase their public health system's capacity and improve health outcomes.

Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge-Trust Matters, Too.

BACKGROUND: As health systems shift toward value-based care, strategies to reduce readmissions and improve patient outcomes become increasingly important. Despite extensive research, the combinations of transitional care (TC) strategies associated with best patient-centered outcomes remain uncertain. METHODS: Using an observational, prospective cohort study design, Project ACHIEVE sought to determine the association of different combinations of TC strategies with patient-reported and postdischarge health care utilization outcomes. Using purposive sampling, the research team recruited a diverse sample of short-term acute care and critical access hospitals in the United States (N = 42) and analyzed data on eligible Medicare beneficiaries (N = 7,939) discharged from their medical/surgical units. Using both hospital- and patient-reported TC strategy exposure data, the project compared patients "exposed" to each of five overlapping groups of TC strategies to their "control" counterparts. Primary outcomes included 30-day hospital readmissions, 7-day postdischarge emergency department (ED) visits and patient-reported physical and mental health, pain, and participation in daily activities. RESULTS: Participants averaged 72.3 years old (standard deviation =10.1), 53.4% were female, and most were White (78.9%). Patients exposed to one TC group (Hospital-Based Trust, Plain Language, and Coordination) were less likely to have 30-day readmissions (risk ratio [RR], 0.72; 95% confidence interval [CI] = 0.57-0.92, p < 0.001) or 7-day ED visits (RR, 0.72; 95% CI, 0.55-0.93, p < 0.001) and more likely to report excellent physical and mental health, greater participation in daily activities, and less pain (RR ranged from 1.11 to 1.15, p < 0.01). CONCLUSION: In concert with care coordination activities that bridge the transition from hospital to home, hospitals' clear communication and fostering of trust with patients were associated with better patient-reported outcomes and reduced health care utilization.

Understanding the groups of care transition strategies used by U.S. hospitals: an application of factor analytic and latent class methods.

BACKGROUND: After activation of the Hospital Readmission Reduction Program (HRRP) in 2012, hospitals nationwide experimented broadly with the implementation of Transitional Care (TC) strategies to reduce hospital readmissions. Although numerous evidence-based TC models exist, they are often adapted to local contexts, rendering large-scale evaluation difficult. Little systematic evidence exists about prevailing implementation patterns of TC strategies among hospitals, nor which strategies in which combinations are most effective at improving patient outcomes. We aimed to identify and define combinations of TC strategies, or groups of transitional care activities, implemented among a large and diverse cohort of U.S. hospitals, with the ultimate goal of evaluating their comparative effectiveness. METHODS: We collected implementation data for 13 TC strategies through a nationwide, web-based survey of representatives from short-term acute-care and critical access hospitals (N = 370) and obtained Medicare claims data for patients discharged from participating hospitals. TC strategies were grouped separately through factor analysis and latent class analysis. RESULTS: We observed 348 variations in how hospitals implemented 13 TC strategies, highlighting the diversity of hospitals' TC strategy implementation. Factor analysis resulted in five overlapping groups of TC strategies, including those characterized by 1) medication reconciliation, 2) shared decision making, 3) identifying high risk patients, 4) care plan, and 5) cross-setting information exchange. We determined that the groups suggested by factor analysis results provided a more logical grouping. Further, groups of TC strategies based on factor analysis performed better than the ones based on latent class analysis in detecting differences in 30-day readmission trends. CONCLUSIONS: U.S. hospitals uniquely combine TC strategies in ways that require further evaluation. Factor analysis provides a logical method for grouping such strategies for comparative effectiveness analysis when the groups are dependent. Our findings provide hospitals and health systems 1) information about what groups of TC strategies are commonly being implemented by hospitals, 2) strengths associated with the factor analysis approach for classifying these groups, and ultimately, 3) information upon which comparative effectiveness trials can be designed. Our results further reveal promising targets for comparative effectiveness analyses, including groups incorporating cross-setting information exchange.

Improving evidence-based grouping of transitional care strategies in hospital implementation using statistical tools and expert review.

BACKGROUND: As health systems transition to value-based care, improving transitional care (TC) remains a priority. Hospitals implementing evidence-based TC models often adapt them to local contexts. However, limited research has evaluated which groups of TC strategies, or transitional care activities, commonly implemented by hospitals correspond with improved patient outcomes. In order to identify TC strategy groups for evaluation, we applied a data-driven approach informed by literature review and expert opinion. METHODS: Based on a review of evidence-based TC models and the literature, focus groups with patients and family caregivers identifying what matters most to them during care transitions, and expert review, the Project ACHIEVE team identified 22 TC strategies to evaluate. Patient exposure to TC strategies was measured through a hospital survey (N = 42) and prospective survey of patients discharged from those hospitals (N = 8080). To define groups of TC strategies for evaluation, we performed a multistep process including: using ACHIEVE'S prior retrospective analysis; performing exploratory factor analysis, latent class analysis, and finite mixture model analysis on hospital and patient survey data; and confirming results through expert review. Machine learning (e.g., random forest) was performed using patient claims data to explore the predictive influence of individual strategies, strategy groups, and key covariates on 30-day hospital readmissions. RESULTS: The methodological approach identified five groups of TC strategies that were commonly delivered as a bundle by hospitals: 1) Patient Communication and Care Management, 2) Hospital-Based Trust, Plain Language, and Coordination, 3) Home-Based Trust, Plain language, and Coordination, 4) Patient/Family Caregiver Assessment and Information Exchange Among Providers, and 5) Assessment and Teach Back. Each TC strategy group comprises three to six, non-mutually exclusive TC strategies (i.e., some strategies are in multiple TC strategy groups). Results from random forest analyses revealed that TC strategies patients reported receiving were more important in predicting readmissions than TC strategies that hospitals reported delivering, and that other key co-variates, such as patient comorbidities, were the most important variables. CONCLUSION: Sophisticated statistical tools can help identify underlying patterns of hospitals' TC efforts. Using such tools, this study identified five groups of TC strategies that have potential to improve patient outcomes.

Framework for Multisector Alignment Research.

CONTEXT: Public health collaboratives are effective platforms to develop interventions for improving population health. Most collaboratives are limited to the public health and health care delivery sectors; however, multisector collaboratives are becoming more recognized as a strategy for combining efforts from medical, public health, social services, and other sectors. PROGRAM: Based on a 4-year multisector collaborative project, we identify concepts for widening the lens to conduct multisector alignment research. The goal of the collaborative was to address the serious care fragmentation and conflicting financing systems for persons with behavioral health disorders. Our work with these 7 sectors provides insight for creating a framework to conduct multisector alignment research for investigating how alignment problems can be identified, investigated, and applied to achieve systems alignment. IMPLEMENTATION: The multisector collaborative was undertaken in Maricopa County, encompassing Phoenix, Arizona, and consisted of more than 50 organizations representing 7 sectors. EVALUATION: We develop a framework for systems alignment consisting of 4 dimensions (alignment problems, alignment mechanisms, alignment solutions, and goal attainment) and a vocabulary for implementing multisector alignment research. We then describe the interplay and reciprocity between the 4 dimensions. DISCUSSION: This framework can be used by multisector collaboratives to help identify strategies, implement programs, and develop metrics to assess impact on population health and equity.

The Growing Divide in the Composition of Public Health Delivery Systems in US Rural and Urban Communities, 2014-2018.

Objectives. To examine changes in the scope of activity and organizational composition of public health delivery systems serving rural and urban US communities between 2014 and 2018.Methods. We used data from the National Longitudinal Survey of Public Health Systems to measure the implementation of recommended public health activities and the network of organizations contributing to these activities in a nationally representative cohort of US communities. We used multivariable regression models to test for rural-urban differences between 2014 and 2018.Results. The scope of recommended activities implemented in rural areas declined by 3.4 percentage points between 2014 and 2018, whereas it increased by 1.4 percentage points in urban areas. The rural-urban disparity in scope of activities grew by a total of 4.8 percentage points (P < .05) over this time. The disparity in network density grew by 2.3 percentage points (P < .05).Conclusions. Urban public health systems have enhanced their scope of activities and organizational networks since 2014, whereas rural systems have lost capacity. These trends suggest that system improvement initiatives have had uneven success, and they may contribute to growing rural-urban disparities in population health status.

Public Health Systems and Social Services: Breadth and Depth of Cross-Sector Collaboration.

Objectives. To examine the extent to which social service organizations participate in the organizational networks that implement public health activities in US communities, consistent with recent national recommendations.Methods. Using data from a national sample of US communities, we measured the breadth and depth of engagement in public health activities among specific types of social and community service organizations.Results. Engagement was most prevalent (breadth) among organizations providing housing and food assistance, with engagement present in more than 70% of communities. Engagement was least prevalent among economic development, environmental protection, and law and justice organizations (less than 33% of communities). Depth of engagement was shallow and focused on a narrow range of public health activities.Conclusions. Cross-sector relationships between public health and the housing and food sectors are now widespread across the United States, giving most communities viable avenues for addressing selected social determinants of health. Relationships with many other social and community service organizations are more limited.Public Health Implications. Public health leaders should prioritize opportunities for engagement with low-connectivity social sectors in their communities such as law, justice, and economic development.

Geographic Variation in the Structure of Kentucky's Population Health Systems: An Urban, Rural, and Appalachian Comparison.

Introduction: Research examining geographic variation in the structure of population health systems is continuing to emerge, and most of the evidence that currently exists divides systems by urban and rural designation. Very little is understood about how being rural and Appalachian impacts population health system structure and strength. Purpose: This study examines geographic differences in key characteristics of population health systems in urban, rural non-Appalachian, and rural Appalachian regions of Kentucky. Methods: Data from a 2018 statewide survey of community networks was used to examine population health system characteristics. Descriptive statistics were generated to examine variation across geographic regions in the availability of 20 population health activities, the range of organizations that contribute to those activities, and system strength. Data were collected in 2018 and analyzed in 2020. Results: Variation in the provision of population health protections and the structure of public health systems across KY exists. Urban communities are more likely than rural to have a comprehensive set of population health protections delivered in collaboration with a diverse set of multisector partners. Rural Appalachian communities face additional limited capacity in the delivery of population health activities, compared to other rural communities in the state. Implications: Understanding the delivery of population health provides further insight into additional system-level factors that may drive persistent health inequities in rural and Appalachian communities. The capacity to improve health happens beyond the clinic, and the strengthening of population health systems will be a critical step in efforts to improve population health.