Assessing Health and Human Services Needs to Support an Integrated Health in All Policies Plan for Prince George's County, Maryland

by Ashley M. Kranz, Anita Chandra, Jaime Madrigano, Teague Ruder, Grace Gahlon, Janice C. Blanchard, Christopher J. King

This Article

RAND Health Quarterly, 2022; 9(3):11

Abstract

With evolving demographics and a changing health system landscape, the Prince George's County Council, acting as the County Board of Health, is considering its future policy approaches and resource allocations related to health and well-being. To inform this path forward, the authors of this study used primary and secondary data to describe both the health needs of county residents and drivers of health within the county, inclusive of the social, economic, built, natural, and health service environments. This study integrates these findings, an analysis of budget documents, and a review of promising practices from other communities to situate recommendations in a Health in All Policies framework to foster aligned and integrated planning and budgeting across the county to promote health and well-being. Findings from the assessment indicate a shared interest among leaders and residents to embrace a holistic strategy for health and well-being in the county. Inefficient uses of the health care system are identified, highlighting a need to rebalance investments in health care use and drivers of health. Additionally, challenges in navigating health and human services and inequities in drivers of health across communities are noted, signaling broader concerns related to residents’ access to health and human services that influence health and well-being outcomes. Recommendations are provided for several paths forward for the county to pursue a more integrated policy approach to influence health and well-being outcomes.

For more information, see RAND RR-A647-1-v2 at https://www.rand.org/pubs/research_reports/RRA647-1-v2.html

Full Text

Overview

Prince George's County is at a critical crossroads with respect to its future health and well-being. Over the past decade, the demographics of the County have been evolving with a steadily growing number of seniors, Hispanic, and foreign-born residents. Additionally, the County's health care landscape has changed through hospital mergers and acquisitions and will continue to evolve with the expected 2021 opening of the University of Maryland Capital Region Medical Center. During this time, the Prince George's County Council has pursued an active approach to health promotion, convening health care providers in the community and considering legislation to promote healthy behaviors. Along with these developments in the County, broader societal changes are happening including national discussions regarding the increasing burden of chronic diseases, rising health care expenditures, and growing attention to the role of social determinants of health (SDOH). In this context, Prince George's County is poised to consider and pursue new approaches to promoting and budgeting for health.

This health and human services needs assessment is intended to assist the Prince George's County Council, acting as the County Board of Health, in their pursuit of Health in All Policies, an approach that aligns county funding, across departments and services, with needs and desired health outcomes. To inform these decisions, there is strong recognition of the need to not only understand the health needs of residents captured in prior health assessments, but to combine that with a more holistic analysis of the historical and systemic factors that influence health and well-being over generations. The aims of this assessment are to

  • Describe the health of County residents
  • Describe drivers of health within the County, inclusive of the social, economic, built, natural, and health service environments
  • Offer recommendations to foster aligned and integrated planning and budgeting across the County to promote health and well-being.

This study adds to a rich foundation of analyses, in particular the 2019 Community Health Needs Assessment led by Prince George's County Health Department (Prince George's County Health Department, 2019). We situate this study by highlighting the key features of this study that distinguish it from existing work:

  • Provides broad review of health influences from the social, economic, built, and natural environments
  • Offers insight into role of schools and human services departments in promoting health
  • Utilizes health care discharge data from both Maryland and District of Columbia (DC), highlighting key role of care provision from providers in DC
  • Examines health care provision outside of traditional health care providers, including schools, fire/EMS and corrections
  • Situates recommendations via Health in All Policies, inclusive of budget alignment and legislative action levers
  • Establishes a foundation for future integrated health planning for the County.

Key contributions of this study include its holistic examination of drivers of health, broad assessment of health care providers, and recommendations to support future integrated health planning in the County. By offering a deep dive into drivers of health (e.g., social, economic, natural, built, and health service environments) along with health and well-being, we seek to provide integrated information to inform the County's pursuit of a Health in All Policies approach to policymaking. Our recommendations are particularly focused on policy actions that involve cross-government department strategies, associated data, and financial alignment. With these recommendations, we provide examples used in other jurisdictions to help the County understand how these approaches have been practically implemented in other settings.

This study is organized around a framework that can be used by the County to implement Health in All Policies, which is defined as a “collaborative approach that integrates and articulates health considerations into policymaking across sectors to improve the health of all communities and people” (Centers for Disease Control and Prevention, 2016). The framework emphasizes the interconnectedness of health and well-being, systemic factors that influence health over generations, drivers of health, and health systems (Figure 1), and illustrates how health and well-being cannot be considered independently from historical and systemic inequities and drivers of health that shape opportunities and environments. As articulated in this framework, health and well-being are downstream outcomes and are described by quality of life, physical, mental and behavioral health, healthy behaviors, and community engagement (given links between connection to community and health outcomes) (Nelson, Sloan, & Chandra, 2019). While health and well-being are influenced by genetic composition, health and well-being are largely affected by upstream factors and drivers in the broader environment.

Figure 1. Improving Health and Well-Being Through an Integrated Health in All Policies Approach

Improving Health and Well-Being Through an Integrated Health in All Policies Approach

NOTES: Bulleted items in italics are examples only. Our framework was informed by the Bay Area Regional Health Inequities Initiative’s Public Health Framework for Reducing Health Inequities (Bay Area Regional Health Inequities Initiative, 2019), and modified specifically for Prince George’s County.

Approach

To describe the health and human services needs of County residents, we relied on both primary and secondary data. Primary data collection involved obtaining input via a Town Hall meeting; online survey of residents conducted after the Town Hall meeting; three focus groups composed of adult residents; one focus group composed of adolescents and young adults; and 23 interviews with individuals from organizations knowledgeable about the health and human services needs of County residents. The study team combined notes from all sessions, reviewed notes, and categorized key themes from the work.

In addition, county and sub-county secondary data were collected from a variety of public and proprietary sources to describe the current and historical health and human services needs of County residents. Data were obtained from numerous county agencies (e.g., Departments of Health, Corrections, Family Services, Social Services), public sources (e.g., American Community Survey, Behavioral Risk Factor Surveillance Survey), and proprietary sources (e.g., Maryland Healthcare Services Cost Review Commission and the District of Columbia Hospital Association). Together, these data describe drivers of health impacting County residents, the health systems serving County residents, and the health and well-being of County residents.

Finally, to inform our recommendations, we reviewed Prince George's County's operating budgets from fiscal year (FY) 2007 to 2019 and proposed operating budget from FY2020 determine where funding was allocated across county departments. We also reviewed promising practices from other communities and regions in the United States, highlighting those with similar challenges that Prince George's County faces with respect to integration of health and human services, such as data systems, financing, and related policy interventions.

Key Findings

In the text below, we summarize key findings related to the health and well-being and the drivers of health impacting health and well-being of County residents.

Health and Well-Being

We observed positive findings and improvements in the health and well-being of Prince George's County residents for numerous indicators. The County has a lower rate of years of potential life lost, a measure of premature death, than the state average, and most adults in the County (83.9 percent) described their health as “good,” “very good,” or “excellent.” Positive metrics of well-being include a 17.8 percentage point increase in voter turnout in 2018 compared to the last non-presidential general election and stakeholders expressing a high interest in volunteer opportunities.

Inefficient uses of the health care system remain despite improvements.
  • One in four emergency calls for medical services were for non-urgent needs.
  • EDs continue to be used for preventable issues, such as asthma and dental care.

Highlights need to rebalance investments in health care use and drivers of health.

Residents encounter challenges in navigating health and human services.
  • There is a lack of health insurance for some groups, including noncitizen immigrants, and insufficient funding to support the needs of these groups.
  • Transportation barriers hinder residents obtaining health and human services.
  • Residents are often unaware of available services and resources or may not know how to access or navigate known services and resources.
  • Shortages of primary care providers, behavioral health providers, and dentists impact access, as does the cultural competency of providers.

Offers insight into why some residents may use costly and inefficient emergency services when primary care is a better option.

Spending on health and human services is low.
  • Estimated County spending on health and human services departments is $39 per person, about one-third to one-seventh the per-person spending of surrounding Maryland counties.

Inefficient health-services use is suggestive of reduced access to health and human services, which can contribute to inequities in health and well-being.

Systemic inequities in drivers of health place some communities farther behind in building healthy futures.
  • Districts are differentially impacted by drivers of health and thus encounter different health challenges.
    • District 2 has high rates of uninsurance and is predominantly Hispanic, a population with a teen birth rate more than double the County rate.
    • District 3 has the highest poverty rate and numerous community “hot spots” of low-income individuals with poor access to healthy food.
    • District 7 is predominantly Black, has low health literacy and the highest ED visit rates for adults and children in the County.

We also identified opportunities for improvement. As has been highlighted in the prior health assessments of Prince George's County, Prince George's County has high rates of incidence and mortality for select cancers. These data reflect stakeholder concerns about men's health, as prostate cancer incidence and mortality rates are considerably higher in Prince George's County than rates observed across Maryland or the United States. Additionally, stakeholders emphasized the need for resources and education to promote healthy behaviors like exercise and healthy eating. This is essential to address the high rates of obesity among county residents, which is concerning because it increases the risk of worse health, including poor birth outcomes, cancer, and cardiovascular disease. Stakeholders also expressed concerns about the mental and behavioral health of children and adolescents in the County. In analysis of secondary data, we observed high rates of bullying and suicidality among middle school students, with almost one in four reporting bullying at school and almost one in four reporting seriously thinking about attempting suicide. Finally, there are widespread concerns about inequity in health and well-being. High rates of many chronic diseases and unhealthy behaviors were more likely to be reported by among racial/ethnic minorities. Additionally, birth outcomes, including low birthweight and mortality, were significantly higher among Black infants than White infants.

Drivers of Health

Health Service Environment

The health care delivery system in Prince George's County includes more than just hospitals and other traditional medical providers. Collaboration across multiple agencies is a growing and important part of health care delivery in Prince George's County. In examining health care services offered to County residents, we find challenges related to access to care and system confusion indicated by use of emergency services for non-urgent needs. Stakeholders expressed concern about access to care, frequently related to access to primary care and mental and behavioral health services. The primary care needs of the County are well-documented and nearly all districts have some communities designated as shortage areas. It is possible that lack of access to primary care may be driving some of the racial/ethnic inequities observed in utilization of the ED for potentially preventable conditions. For example, rates of asthma-related ED visits and inpatient hospitalizations were more than four times higher for Black and Hispanic children compared to White children. Although few communities in the County are designated as mental health shortage areas, stakeholders mentioned challenges in accessing mental and behavioral health services for children and adolescents, individuals with severe mental illness, and reentering populations. County rates of adult ED visits for mental and behavioral health conditions were more than double that of visits for heart disease and nearly four times greater than the rates of visits for diabetes. Additionally, there is system confusion as evidenced by use of inappropriate health care systems. One example of this is the amount of calls for non-urgent medical services received by EMS. The majority of 911 calls for EMS (80.3 percent) resulted in the provision of medical services, and about one in four of these calls were considered to be for non-urgent medical services. Because EMS agencies provide an entry way into EDs, these are also a key entity of the health care system for helping to reduce the number of ED visits that are treatable outside EDs.

Social and Economic Environments

The County has experienced some positive trends when it comes to the social and economic environments, but still faces higher rates of poor social and economic drivers that influence health than neighboring counties. The percentage of residents who are unemployed or “working poor” has declined since 2014 yet remains higher than that seen in neighboring counties. Stakeholders noted that County residents, who face underemployment, may experience negative impacts to their physical and mental health due to psychological stress and difficult trade-offs that are needed to seek out care when it competes with employment schedules or because of lack of insurance. Although the County offers services to promote employment, stakeholders noted that many residents are unaware of these programs. This relates to broader comments we heard regarding unmet need for social services, but quantifying unmet need is challenging because individuals in need may not interact with the County and therefore may be uncounted. Improvements were observed for school and public safety, with fewer high school students reporting sexual dating violence and a lower violent crime rate. However, self-reported data from middle school students suggests safety concerns, as one in four County middle school students reported carrying a weapon to school and two in three County middle school students reported having been in a physical fight.

Built and Natural Environments

Features of the built and natural environments either increase health risk or serve to motivate health-promoting behaviors, and thus, may contribute to any health disparities that exist across the County. In the United States, spatial patterning of built and natural environment features have been influenced by historical patterns of discriminatory practices, and thus, this context is important when thinking about upstream drivers of health inequities in the County. In particular, households in District 2, where more than half of residents are Hispanic, experience more overcrowding than elsewhere in the County and housing structures in Districts 2, 3, and 5 have a higher potential for exposure to lead than other districts in the County, due to the age of these structures. Although the proportion of children in the County with concerning blood lead levels is low, a notable trend is that it appears to be on the rise over the last five to six years. Additionally, residents expressed concern about access to healthy food and physical activity opportunities and quantitative data support this concern. The density of fitness and recreation centers in the county is lower than the state of Maryland, on average, and “food deserts” exist throughout the county. Mixed-use neighborhoods with dense street connections can promote active transport and serve as a means of increasing access to physical activity opportunities. The majority of highly walkable neighborhoods in the county exist in Districts 2, 3, 5, and 7. Although, it should be noted that even within these districts, there exist pockets of “food deserts” and low walkability.

Exploring Prince George's County Budget for Health

Tracking the alignment of dollars across departments that contribute to health is a key first step in being able to understand the true accounting of health return on investment. Prince George's County's health and human services departments are majority grant-funded and, relative to Howard, Montgomery, Anne Arundel, and Baltimore Counties in Maryland, have the lowest general fund-approved health spending, as of FY2018, even after adjusting for population size. A broad array of departments within the executive branch of the County government contribute to residents’ health and health care utilization. Thus, budget allocations outside the health and human services departments are also influencing health outcomes, such as emergency medical services from the Fire/EMS Department, health care offered by Department of Corrections, public safety supported by the Police Department, and environmental efforts from the Department of the Environment. This preliminary budget review can be enhanced by a comprehensive review of spending on health and drivers of health across departments, which requires detailed budget information to understand when and where funds are having an impact on health. Moving forward, this detail can come from a second level of coding, which includes extensive review of the time spent by government staff as well as health-related objectives and outcomes of programs and other services.

Recommendations

The findings from this assessment offer many paths forward for Prince George's County, particularly as the County pursues a more integrated approach to influencing health and well-being outcomes. Building a Health in All Policies system does not happen in one step, but rather through many strategies and phases. In order to make progress, however, it is useful to consider a few first steps. Below we present initial steps to consider. Allocating funding to support these efforts is important to ensure staff time and resources are available to pursue this work.

Getting Started with Health in All Policies

County Council acting as the Board of Health:

  • Require a more detailed County inventory (government and ideally, nongovernment) of the places and programs in which health services (e.g., health education, health promotion, clinical services) are being provided and who is receiving these services (in order to measure and reduce inequities).
  • Align information about what is being spent on these health services and information on reach, effectiveness, and impact overall on reducing inequities.
  • Require all nongovernmental organizations receiving County funding to identify their role(s) in promoting health and well-being and reducing inequities.

County Departments within the Executive Branch:

  • Centralize data on drivers of health with information on health services and health outcomes, including requiring common reporting on drivers by each County agency.
  • Update the County website to coordinate information on what influences health across sectors. Offer resources organized by the health drivers to better support populations with health issues in more integrated ways (“one stop”).

Below, we provide a high-level overview of the recommendations for implementing a comprehensive Health in All Policies approach and include examples of how other communities have implemented similar approaches. Full details about these approaches are provided in the final chapter of this report. We organize findings into three categories: (1) creating a Health in All Policies system, (2) aligning investments, and (3) implementing new measurement and data systems. We use the acronyms LB and EB to help delineate primary roles for the County Board of Health (LB) versus activities of the Office of the County Executive (EB).

1. Create a Health in All Policies system

1.1. Develop a coordinated Health in All Policies system that creates guidelines for governance (LB)

A key issue noted in this assessment was the challenge of connecting and coordinating residents across departments that address health and human services needs. In order for Health in All Policies to most effectively work, there is often a structure that defines a shared set of health goals across departments, a clarity on how information is shared to achieve those goals, and accountability across departments on how health will be integrated into policy design and development. These governance guidelines can ensure a more coordinated approach to integrated planning for health and are fundamental when making decisions about health-resource allocations. Examples of successful integration from other communities that can inform the County's next steps include efforts in integrated governance and health promotion in San Diego (Live Well San Diego, 2014) and Seattle & King County in Washington state (King County, 2013).

1.2. Create a strategic plan for all health and human services departments (EB)

While Prince George's County has a robust Community Health Needs Assessment led by the County Health Department, there is no such comparable assessment from Social Services or Family Services. Developing a comparable assessment and strategic plan for those departments can be used to organize investments, data, and programmatic decisions across health and human services. Further, it is key for moving towards Health in All Policies to have actions that bring in departments beyond health and human services, such as Police, Corrections and Fire/EMS. Montgomery County, Maryland offers an example for integration, having merged four county departments (Social Services, Public Health, Family Resources and Addictions, and Victims and Mental Health Services) into a single department and unified electronic records to better allocate resources based on client need and capacity (Hencoski, Ahluwalia, Seling, & Buckland, 2017).

1.3. Implement policies that promote health equity, including design and economic environment decisions (LB)

Stakeholders highlighted concerns related to the design of the physical and built environments. Across these topics, stakeholders recommended policies around enhancing walkability and environmentally friendly communities; implementing health equity guidelines with new economic investment; and harnessing whole community approaches to place-based investment. Examples for community design come from the Vermont Department of Health, which produced a guide to help towns design health communities (Vermont Agency of Transportation, 2019). Examples of using equity lenses on community investment and policy decisions include Multnomah County, Oregon, which developed the Equity and Empowerment Lens, a tool to ensure policies, programs, and processes are equitable for all populations within the communities (Multnomah County Health Department, 2012). Finally, place-based investment is a popular strategy in Prince George's County and elsewhere. In 2016, Detroit launched a public-private partnership to promote neighborhood revitalization and improve walkability. This effort pools funds for park improvements, streetscape improvements, commercial corridor development, and affordable single-family home stabilization (Invest Detroit, 2019).

1.4. Improve the delivery and coordination of health services, including better screening for social needs (EB)

There was general agreement across stakeholders and in our data that while there are efforts to coordinate some health services, there is a need to do more, including helping residents access services, particularly within underserved populations and for mental and behavioral health needs. Seattle & King County in Washington state offers an example for promoting coordination via data integration, in which they aggregate medical, mental and behavioral health, social service, and health assessment data to provide clinical decisionmakers with a holistic view of a patient's risk factors, health outcomes, and service utilization (Washington State Department of Health and Human Services, 2014). Expanded screening is essential, but should be accompanied by funding to support the delivery of needed services.

1.5. Improve the accessibility, clarity, and usability of health and human services promoting resources and related civic engagement opportunities among County residents (EB)

With only 52 percent of County residents having above-average health literacy, combined with stakeholders noting residents’ confusion and lack of knowledge about County resources, the County has the opportunity to strengthen its outreach and communication efforts. In considering how to address these issues, the County can learn from efforts intended to improve health literacy. For example, the Horowitz Center for Health Literacy at the University of Maryland School of Public Health is developing a framework for “community health literacy,” which emphasizes the variety of sources of and channels for information and communication and the interconnectedness of people and organizations (Horowitz Center for Health Literacy, 2019). Beyond health literacy, local governments are increasingly using multiple channels of communication (e.g., text messaging, online apps, and social media) to improve residents’ knowledge of and use of services. Using a variety of communication channels is essential for ensuring messages reach the correct populations. For example, communicating volunteer opportunities to seniors necessitates a different communication strategy than communicating about service availability to young adults.

2. Align Investments

2.1. Break down silos between funding streams for health and human services, particularly in ways that can better leverage and coordinate grant funding (LB)

Prince George's County's health and human services departments are majority grant-funded, and Prince George's County has the lowest general fund approved health spending, as of FY2018, relative to Howard, Montgomery, Anne Arundel, and Baltimore Counties in Maryland. Trying to fund initiatives that encourage innovation or advance a Health in All Policies approach may be difficult with some grant restrictions. Moreover, grants are time-limited and the efforts they supported may cease when the grant ends if they are not supported by other funding streams. To break down funding silos, other communities have blended external grants and donations into a single fund to provide long-term and flexible support, blended finances for select populations across agencies (e.g., Virginia pools funds for services for at-risk youth), created a well-being trust, and levied taxes to support funding for select populations (e.g., Florida counties can levy taxes to support children's services) (Stafford County, 2019; Trust for America's Health, 2018).

2.2. Engage the nontraditional health sector to participate in “health mapping” and analysis (LB and EB)

To move toward a full Health in All Policies approach that links sectors and data systems that inform and influence health and well-being outcomes, sectors beyond the Health Department should be engaged. One approach to this is organizing budgets using a common health framework. For example, “health mapping” is an approach that can include coding all agency or department budgets for those programs that influence health outcomes or have health as part of an objective or mission, in order to capture a true accounting of health spending. This approach has been used for federal coding of Health in All Policies and can be used at the County level. Another approach used in Massachusetts mandates that health impact assessments be conducted for every transportation project, thus engaging agency officials from transportation, health and human services, energy and environment, and public health (Massachusetts Department of Transportation, 2011).

Additionally, Vermont created a workgroup that conducted a series of health impact assessments, focused on midstream and upstream determinants and drivers of health, which were then used to develop policy recommendations (Vermont Department of Health, 2018).

2.3. Better coordinate the nongovernmental organizations that address health and human service needs in the County and employ high-capacity nonprofits strategically (EB and LB)

There are a large number of nongovernmental organizations operating throughout the County and helping to address residents’ health and well-being. Stakeholders emphasized the important role these organizations play and also expressed concern that many of these organizations are often too small to support ongoing and large scale efforts. To better utilize these community partners, the County can look to examples of multi-stakeholder strategic partnerships throughout the country.

3. Implement New Measurement and Data Systems

3.1. Identify data gaps and implement systems to address gaps (EB)

In analyzing quantitative data for this report, we encountered two main challenges. First, there were limitations in the granularity of data at the sub-County level. Data analysis only at the County level will mask the experiences of some residents. Second, there were limitations in information that offer insight about broader health and well-being; thus, there remains a need for more detailed information about primary care access and use, prevalence of stress and behavioral health conditions, health literacy, and other indicators of well-being). A single, shared data system that allows joint or dual entry of information so that departments have a common operating picture of health needs may facilitate coordination of services and offer a clearer picture of the role of drivers of health in impacting the health and well-being of County residents. Examples of this include an effort in Massachusetts to implement a two-way electronic referral system where clinical providers can send referrals to community-based organizations for assistance with out-of-scope health needs (Commonwealth of Massachusetts Department of Public Health, 2015). The experience of Massachusetts may be relevant to the County as it develops a bidirectional referral system to connect clinicians and community-based organizations with funding from the CDC.

3.2. Improve structures that support health and well-being data transparency and stewardship (LB)

Stakeholders noted that the County's existing performance monitoring systems are disproportionately focused on administrative outputs, as opposed to outcomes of health and well-being. Relatedly, stakeholders indicated that information on the overall health and well-being of County residents was often not publicly available or easily accessible. Enhanced performance monitoring systems have been implemented in other communities to better describe and publicize the health and well-being of residents. For example, Santa Monica, California reports traditional health outputs and outcomes in physical, social, and emotional health in addition to broader well-being measures of community cohesion, the quality of the natural and built environments, and economic opportunity (City of Santa Monica, 2020). Additionally, Allegheny County has an office dedicated to the measurement and the tracking of key indicators of population health and well-being. The Office of Data Analysis, Research and Evaluation (DARE) is a joint endeavor from the Allegheny County Health Department, the Allegheny County Jail, the City of Pittsburgh, the Pittsburgh Bureau of Police, and Pittsburgh Public Schools (Allegheny County Department of Human Services, 2019). Information is conveyed to the public through its website, which offers maps and interactive and customizable dashboards to illustrate drivers of health and health outcomes, covering a variety of topics related to mental and behavioral health, child health, crime and justice, and education.

Limitations

This assessment should be considered in the context of its limitations. Few datasets enabled concurrent examination of health and drivers of health at a granular level. Therefore, we were unable to fully characterize how health behaviors, access to care, and health outcomes vary within the County. This data gap highlights the need for data sources that enable measurement of key drivers of health and health outcomes in a way that allows examination at a subcounty level and among specific subpopulations. Relatedly, more detailed and granular data need to be collected to fully measure several key areas of interest, including: use of outpatient health care; child health; and well-being. In addition, the qualitative data are a sample and do not necessarily capture opinions from all relevant stakeholders. We attempted to obtain feedback from a diverse and representative set of stakeholders, however, the views expressed by participants in interviews, focus groups, and the town hall meeting may represent the views of more engaged residents and may not be representative of all County residents. Moreover, while the town hall meeting featured a Spanish translator and a sign language interpreter, interviews and focus groups were conducted in English. Additionally, some populations are notoriously hard-to-reach, including individuals experiencing homelessness and undocumented immigrants.

Conclusions and Next Steps

With evolving demographics and a changing health care landscape, the Prince George's County Council, acting as the County Board of Health, is considering its future policy approach and resource allocations related to health and well-being. One of the most significant bright spots of this assessment process is the shared interest of leaders and residents to embrace a more integrated and holistic strategy for promoting health and well-being and addressing inequities in the County. This shared interest provides an excellent foundation for implementing and sustaining a strategic plan that can be executed.

As summarized in the recommendations, Prince George's County has opportunities to create a more cohesive governance structure focused on Health in All Policies and a robust budgeting process that codes, categorizes, and aligns funding against a shared health framework. This approach can be enhanced by a centralized and integrated data system that enables measurement of access and use of services, disease management, and indicators of quality of life and well-being that track real progress towards a thriving County. Given the motivations for this work came through legislative branch, the County has opportunities to leverage this interest via traditional legislative tools, such as spending policies. Building on a review of these data and recommendations, the next steps for the County are to determine what is structurally and financially possible to implement and what actions will bolster the County's goal of reducing inequities and promoting overall health and well-being.

References

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https://www.alleghenycountyanalytics.us/index.php/about/

Bay Area Regional Health Inequities Initiative, "Bay Area Regional Health Inequities Initiative Framework," other, 2019. As of October 1, 2019:
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Centers for Disease Control and Prevention, "Health in all Policies," other, 2016. As of January 10, 2020:
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City of Santa Monica, "Office of Civic Wellbeing," other, 2020. As of January 10, 2020:
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Hencoski, P., U. S. Ahluwalia, S. Seling, and V. Buckland, other, Successful Implementation of Integration and Interoperability in a Health and Human Services Enterprise, 2017. As of September 14, 2019:
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Horowitz Center for Health Literacy, "Community Health Literacy," other, 2019. As of September 12, 2020:
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Massachusetts Department of Transportation, "Healthy Transportation Compact Award," other, 2011. As of September 10, 2019:
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Multnomah County Health Department, "Equity and Empowerment Lens," other, 2012. As of August 10, 2019:
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Nelson, C., J. Sloan, and A. Chandra, Examining Civic Engagement Links to Health: Findings from the Literature and Implications for a Culture of Health, Santa Monica, Calif.: RAND Corporation, RR-3163-RWJ, 2019. As of January 15, 2020:
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Vermont Agency of Transportation, "Better Connections Program," other, 2019. As of December 15, 2019:
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This research was sponsored by the Prince George's County Council, acting as the County Board of Health, and conducted by the Community Health and Environmental Policy Program within RAND Social and Economic Well-Being.

RAND Health Quarterly is produced by the RAND Corporation. ISSN 2162-8254.