'Passion for data' spurs public/private partnership
'Passion for data' spurs public/private partnership
Reinventing public health in Hartford
In Hartford, CT, "making government work" isn't just an idle phrase; it's a fairly precise description of what the director of the city's health department, Katherine McCormack, RN, MPH, has been doing lately. It's difficult to find a part of the public health process, including tuberculosis control, left untouched by the process.
"Katherine's a type triple-A, if such a thing exists. She's the proverbial bull in the china shop," says Joseph Marino, the state's TB controller. "She has such a forceful personality, there's almost no aspect of public health in the city she hasn't influenced."
To hear others tell it, McCormack hasn't just reinvented public health in Hartford; she's come close to reinventing the whole city. "People decided that since public health was the only neutral ground left, it should be the arena where all the issues got hashed out," says a research consultant who's spent the last two years working with McCormack.
By the time McCormack arrived on the scene several years ago, there were a lot of issues to hash out, including poverty, the highest TB rates in the state, and a shrinking public-health infrastructure officials seemed determined to prune back more and more every year. On top of all this was a problematic system of local governance that tended to dilute power among warring forces.
"This was the worst city to live in you could imagine," says McCormack. "There was poverty, there were the politics, and basically, people had given up hope. Everything was headed downhill."
More bad news arrived with the announcement that Hartford now led the nation in infant mortality. To address the city's mounting health care woes, the outgoing mayor appointed a blue-ribbon task force. An especially urgent problem was how to fill the post of health department director, also soon to be vacant.
"This was a job absolutely no one wanted; it would be death," says McCormack, who by this time was director of ambulatory care at one of the city's two biggest health care providers, St. Francis Hospital and Medical Center. When asked by her supervisor what the task force should do about the leadership vacuum in the city health department, McCormack, fresh from 20 years' experience as a public-health nurse in Waterbury, paused for a moment, then replied: "I know public health. Why not lend me to the city for awhile?"
So tight-fisted about money she thinks twice about hopping on a plane to accept an award if she can't use airline mileage awards, McCormack admits her first few months on the job were rocky. "I found a budget packed with money that wasn't doing anything," she says. And in a department known for its poor morale, she had two rules that were never negotiable: "One, if you have a job here, you come to work. And two, while you're here, you work."
Feathers were ruffled. McCormack spent several months being hauled before civil-rights commissions and labor boards defending her actions. Finally, the dust began to settle and the city convinced her to come aboard as its full-time health department director.
At about the same time, the mayor's task force and the health department together decided to bring in Allentown, PA-based Fields and Burdine, a research and consulting firm that specialized in creating public/private partnerships. Executives from St. Francis Hospital and its chief competitor in town, Hartford Hospital, had attended an earlier workshop conducted by the firm and supported the decision to hire the company.
By 1996, consultants at Fields and Burdine had laid the groundwork for a coalition of powerful players from public, private, and community-based operations to address the city's health care concerns. The firm was then asked to conduct a citywide population-based health survey. In all, 1,147 adult residents completed written surveys that collected data on demographic characteristics, community issues, chronic diseases, health care access, health risk behaviors, screenings, and residents' subjective ratings of many of these issues.
The resulting set of raw data, for sheer size and scope, was "somewhat intimidating," says Amy Abel, a Fields and Burdine researcher. McCormack, however, was delighted.
Data as the starting point
"Not all public-health decisions are data-driven," she says. "The Hartford reaction in the past was based on perception. But I don't operate on perception; I use data."
It's simply the way McCormack operates.
Thus, when several TB cases were linked to a homeless shelter, she met with the shelter managers, poked around, asked questions, met with heads of other shelters - and finally came up with a list of problems and solutions. Shelters that comply are rewarded with freebies, such as germicidal ultraviolet fixtures. (See related story, p. 113.)
It was the same thing when residents complained of health hazards from a nearby landfill. Instead of arguing, McCormack wrangled some money from the Environmental Protection Agency to study the landfill; so pleased was the agency, it awarded McCormack funds to investigate environmental problems on a regular basis.
Eventually, the community partners made the commitment to begin living by the same rules: that is, they pledged to use the data from the health survey as a basis for all policy decisions and long-range planning. The task force also pledged to return to the community every three years to conduct the entire survey all over again, says McCormack. "We have to wait three years so we can see whether the interventions are working," she says, making it clear that otherwise, she wouldn't mind going back even sooner.
Should that same patient be placed on medication but prove to be nonadherent, chances are excellent she'll see McCormack once again.
When the state passed a new TB statute including provisions that allow an emergency 96-hour quarantine, Marino recalls, McCormack predicted, "We'll be the first city to use this." She's used the statute 15 times since then, and worked out the kinks, devising the needed paperwork as she goes, Marino says. Now, if a noncompliant patient threatens to walk, physicians know to pick up the phone and call McCormack.
McCormack emphasizes that she's only part of the team. "I couldn't do this without the partners," she says. "It's an inclusive process. That's something we can't forget."
Underneath the partnership, though, is the data, the starting point for what's going on in Hartford these days. "By evaluating and affecting health status, we affect quality of life," McCormack says. "That's what public health is: quality of life. "Rename public health 'quality of health'? I don't know. Maybe we should talk about the issue of public health a lot more."
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