21st Century Learning Community

Public health transformation cannot happen in isolation; innovation, collaboration, and shared learning are essential to drive the changes we need to meet current and future public health needs. Since 2015, PHNCI at PHAB has been home to the 21st Century Learning Community (21C), a group of states focused on intentional state-wide public health system transformation. Members include representatives from state health departments, local health departments, State Associations of County and City Health Officials, academic partnerships, partner organizations, and/or local leaders in public health transformation. In the context of 21C, states refer to these members.

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New Jersey State Profile

New Jersey became a 21C state in 2022.

21C states are leaders in developing an understanding of a state’s approach to transformation, conducting capacity and costing assessments, making the case for sustainable funding for core public health, advancing equity, and exploring various models for workforce and service sharing. Through 21C, PHNCI will drive public health transformation and modernization.

The eighteen 21C states are all at various stages in their transformation journey

“This investment gives us the opportunity to not only build back better, but build back more equitably. By investing in public health and presentation, we save lives.”

How: Process for Transformation

  • Define your state’s goal for public health transformation. For example, California’s Future of Public Health Workgroup aspires that Californians, working together, can enable all to live happier, healthier, and longer lives by closing the gap in life expectancy by 50 percent and reducing the disease burden by 15 percent within the next decade.
  • Use a transformation framework to guide your work and make necessary adoptions to fit your state’s unique needs. Transformation frameworks include the Foundational Public Health Services, PHAB accreditation, Public Health Forward, and Public Health. 3.0, among others.
  • Engage existing partners and develop partnerships with new and varied organizations; this requires investing in relationships and building trust. This includes engaging local public health departments in the process of identifying priority areas.
  • Establish plans and processes and identify resources needed to conduct a statewide assessment. This may consist of engaging a contractor or partner to develop and implement the assessment or deciding to do this work with in-house staff time. In addition, this could include developing planning criteria to help guide the process (e.g., designing/tailoring the assessment tool, developing and implementing assessment activities, providing training and technical assistance, reviewing and analyzing the results, and preparing reports and other materials).
  • Complete the assessment that is appropriate for your state context. The results could reveal gaps in your system, as well as the cost to implement capacity and capability needs in order to fill those gaps.
  • Secure funding and policy support. Initial funding may be short term, so consider needs to establish a plan for sustainability.
  • Continuously reevaluate your transformation efforts based on existing needs. Public health transformation does not end; efforts must continue to evolve. Innovation is one mechanism to support this continuous process.

Additional Factors

  • Timing plays a role in transformation
    • For example, the COVID-19 pandemic created challenges and opportunities for all 21C states
  • Develop consistent messaging about the need for transformation, your efforts, and your successes
  • Consider the role shared services may play in your transformation work

A transformation framework can guide a state’s efforts. Several states have adapted a framework and made necessary adjustments to meet their state’s unique needs. The following have been used to guide 21C states:

  • The Foundational Public Health Services (FPHS) framework outlines the unique responsibilities of governmental public health and can be used to explain the vital role of governmental public health in a thriving community; identify capacity and resource gaps; determine the cost for assuring foundational activities; and justify funding needs. The FPHS provides cross cutting capabilities and various areas that are needed in all communities – and to ensure that all communities have these, 21C states are using the FPHS model shape their transformation efforts.
Foundational Public Health Services

Additional models that support overall public health transformation include:

  • The 10 Essential Public Health Services (10 EPHS) provides a framework for a public health system to protect and promote the health of all people in all communities.
  • While not explicitly a framework, Public Health Accreditation Board (PHAB) accreditation has also been used a guide for transformation. PHAB’s Standards & Measures align with the 10 EPHS and the FPHS’ Foundational Capabilities.
  • Public Health Forward provides recommended actions to policymakers and public health leaders to steward the use of the one-time infusion of COVID-19 relief funding to provide long-term strategic benefits to state, territorial, and local public health systems.
  • Public Health 3.0 refers to a new era of enhanced and broadened public health practice that goes beyond traditional public department functions and programs. Cross-sectoral collaboration is inherent to the Public Health 3.0 vision, and the Chief Health Strategist role requires high-achieving health organizations with the skills and capabilities to drive such collective action.

While each framework is unique, they all capture what is needed to successfully serve a community.

“Just like our Covid-19 response, transformation of the governmental public health system takes grit and grace among partners.” Sarah Reese, Director, Polk County Public Health

21C states are embedding a variety of innovative strategies into their transformation efforts, with a focus on the areas of health equity, Foundational Capabilities and workforce, and accreditation. Examples of each are shared below:

Health Equity

  • Many states have incorporated and specifically called out health equity in their state FPHS models, which serves as a lens through which all public health services should be assured.
  • The Minnesota Legislature provided funding for local and Tribal public health projects to build public health capacity and pilot new organizational models in health equity. The state is providing training and technical assistance to build knowledge, skills, and abilities across the state, and is also working to increase racial/ethnic diversity in workforce.
  • Missouri has developed a facilitated workshop that walks public health professionals through a deeper self-assessment of health equity practices within their agencies. Using a step-by-step workbook, participants will develop action plans to build individual and organizational capacity to assure foundational public health services grounded in health equity.

Foundational Capabilities and Workforce

  • North Carolina has a Community Health Worker initiative across all 100 counties, as well as a public-private partnership with community-based organizations, to reach underserved populations. The state also recruits external advisors from historically marginalized populations to contribute to the State Health Improvement Plan and Healthy North Carolina 2030 goals.
  • Ohio has used federal and state workforce development dollars to add dedicated communications and regional support staff across the state. These positions help coordinate shared planning and implementation efforts between the state and local governments.

Accreditation

  • Nebraska’s strategy to transform and modernize public health includes a commitment to meeting national standards and measures for public health departments. This commitment continues with a vision to have every health department on a pathway to meeting national accreditation standards, which may include at a minimum engaging in regular community health assessment and health improvement planning activities or achieving and maintaining accreditation status.
  • Nevada is leveraging accreditation to transform its public health system. Through its commitment and investment in accreditation, Nevada plans to use accreditation as a means to achieve lasting, systemic changes, develop a culture of continuous quality improvement, and enhance performance management to better promote and protect the health of all Nevadans.
“Public Health Transformation is not only important but necessary in redefining public health’s role to acknowledge the social determinants of health and work collaboratively to remove barriers so individuals, families and communities can achieve optimal health.”

Public health transformation is a journey; it is important to acknowledge and celebrate successes and share details across states so that efforts may be replicated. The following examples of legislation, funding, and assessments in 21C states demonstrate the impact of transformation work:

  • Colorado
  • Kentucky
    • In 2020, House Bill 129 made public health transformation law. The state determined that 3 full-time equivalents (FTEs) per 15,000 population (with an additional FTE per 5,000 population) were needed to do this work, and the current cost per FTE to be $109,000. This cost must be recalculated for each two-year state budget cycle.
  • Massachusetts
  • Minnesota
    • In 2021, received $15 million annual increase, a historic investment to increase support of their public health system
      • $7 million increase to local public health (LPH) grants; this is an annual increase to the base of the LPH grant. The increase to each community health board is based on a percentage increase to the current award.
      • $500,000 increase to Tribal Health Grants; an increase to the base of the Grant. View bill language on page 450.21.
      • $6 million to New Public Infrastructure Funds; new funds for community health boards and Tribal governments to support their ability to build Foundational Capabilities and meet national public health standards. Minnesota Department of Health (MDG) will work with State CHS Advisory Committee to determine the process for distributing funds. View bill language on page 159.1.
      • $1.5 million to new MDH funding public health system and oversight; funds will be used to assess the capacity of the public health system, estimate costs, and oversee transformation. View bill language on page 451.1.
  • Ohio was one of the first 21C states
    • In 2022, they completed a joint Ohio Department of Health and Association of Ohio Health Commissioners (AOHC) Modernization Project.
      • Resulted in an environmental scan and recommendations for the legislature.
    • In 2022, they received $6 million for feasibility studies for smaller city health districts.
    • During COVID response, they used their gap analysis data to identify the gap between the existing contact tracing staff levels at the local level compared to the needed number, resulting in a $37 million investment for LHDs to conduct case investigation and contact tracing.
    • 2017-2019 state budget allocated $3.5 million to address accreditation fees and coordination, as well as infrastructure costs for mergers
    • The State’s Regents Program allocated $5 million to help local health departments become accreditation ready and support specific research projects
    • In 2020, they issued a report on the second Costing of FPHS tool and Annual Financial Report
    • In 2019, they issued a report on the first rollout of the Costing of FPHS tool and Annual Financial Report
    • In 2012, the AOHC released the Public Health Futures Report
  • Oregon was one of the first 21C states.
    • In the current biennium, the legislature invested $60.6 million, with the majority of funds allocated to the state’s 32 local public health authorities and some funds allocated to federally-recognized Tribes
    • In 2020, they created a new community engagement team that funds and supports a network of community-based organizations across the state to lessen the impact of the COVID-19 pandemic on black, indigenous, tribal, and people of color, as well as other groups experiencing health inequities.
  • Washington was one of the first 21C states.
    • In the 2021-2023 legislative cycle, they requested $285M for communicable disease, environmental health, assessment, and a portion of the cross-cutting capabilities; appropriated a total of $175M and in the subsequent biennium promised a total of $324M (72% of the need), ongoing.
    • In 2021, Engrossed Second Substitute House Bill 1152 was passed to diversify local boards of health to include more voices from the scientific community and community members to address equity as a part of its transformation process and establish a Public Health Advisory Board
    • In the 2019-2021 legislative cycle, they requested $296M for communicable disease, environmental health, assessment, and a portion of the cross-cutting capabilities; appropriated $28M per biennium ongoing.
    • In 2019, the governmental public health system, Foundational Public Health Services, the State’s role, and shared decision-making process for allocations were codified in state law (RCW 43.70.512 & 43.70.515).
    • A 2018 baseline assessment revealed that an additional $450M per biennium is needed to fully implement the FPHS in Washington.
    • In the 2017-2019 legislative cycle, they requested $60M for communicable disease; appropriated $15M one-time funding.
“Modernization of our public health system has been a need for decades, and that need has now become an imperative. PHNCI is providing a forum for states to collaborate. Bringing together entities that are structured and funded differently sparks conversation and innovation.” Krista Wasowski, Health Commissioner, Medina County, OH

Public health transformation cannot happen in isolation; innovation, collaboration, and learning together are essential to drive the changes we need to meet current and future public health needs. Since 2015, PHNCI at PHAB has been home to the 21st Century Learning Community (21C), a group of states focused on intentional state-wide public health system transformation; these states are driving transformation in their state and generating a knowledgebase for the field. 21C states are leaders in developing an understanding of a state’s approach to transformation, conducting capacity and costing assessments, making the case for sustainable funding for core public health, advancing equity, and exploring various models for workforce and service sharing. Through 21C, PHNCI will drive transformation and modernization. Learn more about our transformation efforts here.

PHNCI supports 21C states by:

  • Collecting and curating materials and learnings for learning community members
  • Providing technical assistance and access to subject matter experts
  • Hosting in-person and virtual convenings for members to collaborate, share, and find solutions together
  • Supporting coordination across various national and regional initiatives focused on public health transformation and modernization to share practices, data, and align efforts as appropriate


Is your state ready and interested in becoming a 21C state? 21C states have specific requirements to participate - view details here or email info@phnci.org for more information.