摘要：Objectives. We examined the effect of a state law in Colorado that required local public health agencies to deliver a minimum package of public health services. Methods. We used a longitudinal, pre–post study design, with baseline data collected in 2011 and follow-up data collected in 2013. We conducted means testing to analyze the change in service delivery and activities. We conducted linear regression to test for system structure effects on the implementation of core services. Results. We observed statistically significant increases in several service areas within communicable disease, prevention and population health promotion, and environmental health. In addition to service and program areas, specific activities had significant increases. The significant activity increases were all in population- and systems-based services. Conclusions. This project provided insight into the likely effect of national adoption of a minimum package as recommended by the Institute of Medicine. The implementation of a minimum package showed significant changes in service delivery, with specific service delivery measurement over a short period of time. Our research sets up a research framework to further explore core service delivery measure development. Between 1948 and 2007, Colorado law supported a legal distinction between 2 common types of local public health agencies (LPHAs): the “organized health department” 1 and the “nursing service.” 2 Over time, the different agency types led to different governance, structure, administration, financing, authority, services, and activities. Typically, nursing services served rural and frontier counties, and organized health departments served more populated, urban areas. Organized health departments served 85% of the state’s population, and were required by law to provide basic public health services and to have independent boards of health. 1 Nursing services typically provided only public health services that fell into the scope of public health nursing and services deemed necessary by the local board of health, which was comprised of 3 elected county commissioners. 2 In 2008, Colorado passed the Public Health Act of 2008 (heretofore “the Act”), 3 which incorporated key portions of the Turning Point Model State Public Health Act, 4 including the Core Services provision in the Model Act. The Act both standardized the legal structure for LPHAs in Colorado, removing the determination of organized health department 1 and the nursing service, 2 and also required the promulgation of a rule that set out a list of core services that should be provided to all Colorado residents and visitors. Under the new statutes, all LPHAs were required to provide or assure the provision of a set of comprehensive public health services (core services) that were promulgated into rule in October 2011. 5 The Colorado core services were developed by a taskforce of state and LPHA leaders and included stakeholder input. The core services were mapped to the Ten Essential Public Health Services 6 and were intended to be tangible, prioritized guides for LPHAs to follow. The core services, listed broadly, included administration and governance, assessment and planning, vital records, communicable diseases, prevention and population health promotion, environmental health, and emergency preparedness and response. The core services rule contains more detail on the work to be done within each of the core services listed. 5 In 2012, not long after the promulgation of core services in Colorado, the Institute of Medicine (IOM) released “For the Public’s Health: Investing in a Healthier Future,” 7 the third report in a series of reports aimed at improvement in the public health system. 8 This report called for the creation of a minimum package of public health services (heretofore “minimum package”) to parallel the essential benefits package established in the Affordable Care Act. 7,8 The IOM report heightened the need both to define a minimum package and to create valid measurement of these services. This report also highlighted the need for LPHAs to withdraw from the provision of direct health care services to focus on population health services. 7 Soon after the IOM called for a minimum package, the National Association of County and City Health Officials (NACCHOs) echoed the call for a minimum package and released a statement of policy defining LPHA foundational capabilities and basic programs that should be mandatory services within a minimum package. 9,10 The NACCHO statement of policy was the first response from a national public health organization stating what a minimum package should entail and how it should be defined. Several of the basic programs listed in the NACCHO statement are similar to the Colorado core services, including communicable disease control, environmental health, public health preparedness and response, vital statistics, community health assessment (similar to assessment and planning in Colorado), and chronic disease (listed specifically in prevention and population health promotion in Colorado). 9 Many of the foundational capabilities listed in the NACCHO statement can be found in the Colorado Administration and Governance Core Service. The similarities between the Colorado core services and the NACCHO statement of policy for a minimum package put Colorado in position as a case study for how the implementation of core service requirements could create change in public health service delivery. Determination of how public health agency structure affects performance was the top-ranked research priority by a consensus process in the early mid-2000s 11 and has been called for in the National Research Agenda for Public Health Services and Systems Research (PHSSR), 12 but has not yet been fully answered and will be informed by this study. In addition, the call for a minimum package and measurable service delivery changes upon implementation of a minimum package have not been recorded nor understood in the context of the IOM recommendations. To date, PHSSR has primarily been descriptive or cross-sectional in nature. Current literature supports that LPHAs can adapt, 13 are influenced by various structural capacity components, 14–17 and have a wide level of variability in services, performance, and interaction between structural capacity and processes. 18–21 Research on the impact of modernizing laws such as the Act in Colorado has been specifically called for in research needs and prioritization by experts 22 and by the National Research Agenda for PHSSR. 12 One method to guide system change toward the provision of a minimum package is codifying a state law or regulation that requires the provision or assurance of the minimum package. The long-term ability to measure and track service delivery change requires foundational work to determine appropriate, reliable, and valid measures. Because of the policy work to develop a new regulation on a minimum package, the resulting publicity, and potential system change momentum, we may see some initial service delivery changes, and can expect that incremental change will continue. Our research presented in this study established a research framework to further explore service delivery measure development, helped to improve our understanding of how public health practice is evolving in the midst of a changing field, and prepared Colorado for future tracking of service delivery change. Our research had 2 specific research questions. First, what is the effect of a new state-level regulation of core services for LPHAs on the adoption or assurance of said core services? Second, how do LPHA-level structural capacity factors affect the change in the level of adoption or assurance of core services by LPHAs? We outlined this longitudinal, pre–post study of core service adoption and the relationship of core service changes with structural capacity components and filled in some of the research gaps noted in the literature.
