Funder: Robert Wood Johnson Foundation
May 2018 | Case Study
Oregon’s state agencies are committed to working together with the mutual goal of improving population health for all Oregonians, achieving better quality of life, increasing health equity, and developing a healthier economy.
In 2012, Governor John Kitzhaber charged the Oregon Transportation Commission (OTC) with considering the connection and impact that transportation makes on the health of Oregonians. That year the OTC work plan included health as one of its six thematic priorities. Subsequently, agency leaders at the Oregon Department of Transportation (ODOT) and the Oregon Health Authority (OHA), which houses the Public Health Division (PHD), jointly began considering ways to improve population health and meet their respective agency goals. The pair of agencies acknowledged that there were reciprocal strategies that could help each agency reach its own goals, and those of its partners. Specifically, the availability of multiple transportation options, such as bike paths, walking paths, and use of public transportation, can increase the physical activity of a community. Conversely, health promotion efforts can have a positive impact on the goals of the transportation system, as more active transportation leads to less traffic congestion and pollution. In 2013, the agencies signed a memorandum of understanding (MOU) that formalized their interagency collaboration in the following areas: (1) communication and planning; (2) safe and active transportation[i]; (3) research and data analysis; and (4) leveraging opportunities.[ii]
The structure of the relationship between PHD and ODOT is straightforward. Each quarter, agency leadership meets to check in on the status of cross-agency efforts and to plan and prepare for additional collaborations. In between, PHD and ODOT staff responsible for cross-sector work ensure that their respective agency work plans move forward by participating in monthly internal meetings as well as cross-agency staff working sessions. On an ongoing basis, PHD and ODOT staff participate in a variety of advisory committees for the other agency, in order to embed the collaboration deeper in each organization. This practice allows the public health and transportation disciplines to impact specific cross-agency initiatives. A sustaining element to the cross-agency work is the reciprocal relationship across agencies and a shared commitment to their mutual goals.
The PHD has since replicated the model established with ODOT in its collaboration with the Oregon Department of Education (ODE). PHD and ODE have had a strong programmatic partnership since the late 1990s when collaboration was born out of shared work to support Coordinated School Health. From this effort, the Healthy Kids Learn Better Coalition (HKLB) was formed. HKLB is a statewide coalition of organizations and individuals working collectively to promote policies and programs that will reduce physical, social, and emotional barriers to learning.[iii] In 2012, these efforts received a boost when a new state law gave the governor’s office more direct oversight of the public education system, resulting in increased partnership activities, as well as greater ability to establish a lasting cross-agency collaboration. In 2014, ODE and PHD signed an MOU to formalize their collaboration and effect more lasting population health change. Since then, a primary focus across the two departments has been to improve high school graduation rates by reducing absenteeism.
This profile outlines key factors behind the success of Oregon PHD’s cross-agency collaboration with ODOT and ODE, details select activities, and explores achievements of the resulting partnerships.
Key Factors for Program Success
Oregon is tracking the percent of commuters who walk, bike, or use public transportation to get to work as part of its overall accountability metrics.
In Oregon, the establishment of cross-agency collaboration to address social determinants of health involves building relationships and aligning program goals. Contributors to program success include:
- MOUs to Reinforce Interagency Collaboration. In PHD’s coordination with ODOT and ODE, the existing relationship was formalized by an MOU between agencies. The development process of the MOU created the necessary dialogue to identify agreed-upon objectives, which include:[iv]
- Communication and planning. The MOU requires: (1) the maintenance of a work plan to ensure that coordination will be effective and efficient; and (2) regularly scheduled meetings to work together on program and policy issues as well as emergency preparedness planning.
- Each agreement outlines safety as a key area for collaboration, specifically safe and active transportation (PHD/ODOT) and safe and healthy educational environments (PHD/ODE). With transportation, the focus is on decreasing injuries and fatalities for users of any mode of transportation. Within education, the focus is on ensuring that educational settings across the age continuum are safe.
- Research and data analysis. With a data-sharing process incorporated as part of the MOU, the agencies agreed to collect and analyze data, share as needed, and, specific to education, collaborate on identifying tools to analyze the link between education and heath, including through school-based surveys.
- Leveraging opportunities to achieve shared goals. The agencies expect to leverage funding that supports the connection between health/transportation and health/education. In addition, the MOU helps ensure the sustainability of initiatives beyond current staff at each agency by providing a framework and expectation for ongoing collaboration that runs deeper than select individuals.
- Leverage Various “Colors of Money,” Even if Funds Cannot be Blended. Financing cross-agency collaboration can be complicated given that funding may come from a variety of sources, including local funding, the state budget, federal resources, and grant funding. Each agency typically has its own set of rules regarding use of these resources. ODOT identified that working to maximize the various “colors of money” is important for cross-agency collaborations and often requires that the agency that owns the funding oversee the expenditure in order to make sure that it is used as intended. For example, state gas tax funding is constitutionally limited for use on highway building and rehabilitation projects. Of that, one percent must be spent on bike/pedestrian initiatives, including efforts related to active transportation. Rather than blending these funds to support cross-agency goals, ODOT needs to keep these resources separate to ensure that these funds are only used for appropriate activities.
- Shared Accountability Metrics. Oregon is modernizing its public health system. As part of this effort, public health accountability metrics are being used to: (1) track progress toward population health goals; (2) detect the need for change if goals are not being achieved; and (3) emphasize population health priorities including areas where cross-sector collaboration can be used to achieve shared goals.
In June 2017, Oregon’s Public Health Advisory Board established a set of accountability metrics to reflect priorities for a modernized public health system. In March 2018, the OHA released a baseline report on these metrics to inform interventions.[v] Improving the accountability metrics will require long-term focus and must be a collaborative effort with other state agencies in order to align priorities to achieve shared goals. For example, Oregon will track the percent of commuters who walk, bike, or use public transportation to get to work.[vi]
The state is investing $10M annually for the next five years, increasing to $15M annually in 2023 to support infrastructure development for the Safe Routes to School program.
The Public Health Division of the Oregon Health Authority works with other state agencies to address population health issues. Below are highlights from initiatives focused on: active transportation, climate change, and chronic absenteeism.
Supporting Active Transportation
In 2017, the state legislature passed HB2017, a landmark transportation funding package totaling $5.3 billion.[vii] The comprehensive package included grants to local communities and schools to improve active transportation pathways through the Safe Routes to School program. Safe Routes to School includes activities that support children safely walking or biking to school and includes both infrastructure and non-infrastructure programs. Starting in 2018, HB2017 provides $10 million per year to support infrastructure development projects such as investing in sidewalks, bike lanes, crossings, and flashing signals. In 2023, the allocation will increase to $15 million annually.[viii] The program also includes non-infrastructure programs that raise awareness through education and outreach. Communities can conduct walk audits, develop school action plans, and teach students about using walking and biking options as a healthy and safe way of getting to school.
Ensuring Safety in Response to Serious Climate Events
In response to a series of serious climate events, PHD and ODOT staff jointly developed a climate adaptation case study to inform future planning. In December 2015, ongoing rainstorms, including dangerous winds and high sea levels, resulted in floods and landslides in Tillamook County, an Oceanside community. As a result, road closures led to impacts such as delay or cancelation of public service delivery, compromising overall public safety. The two agencies worked together to identify lessons that could support each agency to adapt and respond to crises more effectively to protect Oregonians during and after serious climate events. The process of developing the case study helped to: (1) identify ways to strengthen the relationship between state agencies and the local community; (2) improve coordinated response; and (3) earmark resources to support recovery efforts.[ix]
Addressing Chronic Absenteeism
In Oregon, as many as 26 percent of students do not graduate on time. Oregon is using its cross-agency collaboration approach to share data and design targeted initiatives to decrease chronic absenteeism, a contributing factor to the graduation rate.
Missed school days are a major concern in Oregon, contributing to 26 percent of students not graduating on time.[x] After identifying markedly low high school graduation rates as a shared priority for cross-agency collaboration, PHD and ODE came together to review options to address the problem. Using a data-oriented approach to tackle the issue of chronic absenteeism, PHD and ODE collaborated on the development of school strategies and student/family supports to address high rates of student chronic absenteeism. PHD regularly shares data on health-related issues that impact student attendance at school, such as lack of physical activity, inadequate nutrition, substance use, safety concerns, and unintended pregnancies. The information is used to design targeted initiatives, including the implementation of a statewide “breakfast after the bell” initiative to ensure kids begin their school days fed and ready to learn. The cross-sector partnership around chronic absenteeism has influenced the creation of the Oregon Chronic Absenteeism State Plan.[xi] The plan includes recommendations for addressing chronic absences across five topics identified in the legislation requiring the report.
Since signing the initial MOU to foster collaboration between PHD and ODOT, the agencies have developed resources to help transportation planners and public health professionals assess and improve the health impacts of transportation policies and projects. The Health Impact Assessment program developed a series of briefs to provide transportation specific (walking, biking, driving) health resources for professionals in the health and transportation fields.[xii] Further, the state has adopted a tailored version of the Integrated Transport and Health Impact Model, a widely-used approach for quantifying health impacts related to proposed changes in transportation systems.[xiii]
Looking forward, Oregon will continue to pursue opportunities to improve population health through traditional and less traditional collaborations between state agencies. For more information on collaboration within the health and human services realm, see the sidebar on the state’s Cross Agency Health Improvement Project (below), a collaboration between the Oregon Health Authority and the state’s Department of Human Services. The Oregon approach to cross-agency collaboration includes a focus on relationships, formalized agreements, targeted initiatives, and tracked progress that will continue to be used by the state’s Public Health Division as a way to improve the health of Oregonians.