North Carolina Public Health: Agencies, Disparities, and Policy Frameworks

What is the primary agency responsible for public health in North Carolina?

North Carolina Department of Health and Human Services (NCDHHS)

What are the key characteristics shaping public health solutions in North Carolina?

Majority rural counties, high reliance on safety-net programs, and political compromise in policy design.

What are the core mechanisms driving rural health disparities in North Carolina?

Geography, provider maldistribution, insurance mix, hospital financial instability, aging populations, and economic constraints.

What are the consequences of rural health challenges in North Carolina?

Higher rates of heart disease and infant mortality, more uninsured adults, and ongoing rural hospital closures.

What role does NCDHHS play in addressing public health problems?

It addresses systems-level problems affecting marginalized populations through various core functions.

What are the core functions of NCDHHS?

Information Technology, Technical Assistance, Continuous Quality Improvement (CQI), and Policy & Training.

What is the NC Healthy Opportunities Pilot (NCHOP)?

A Medicaid initiative that pays for non-medical services to improve health outcomes. Improve health outcomes for medicaid members, promote health equity in communities served, and reduce costs in North Carolina's Medicaid program

What eligibility criteria must be met for NCHOP?

Health needs (physical and behavioral health) and social risk factors (housing instability, food insecurity, transportation needs, interpersonal violence).

What types of services does NCHOP provide?

Food support, housing supports, transportation, and evidence-based non-medical interventions.

What is the difference between Fee-for-Service (FFS) and Value-Based Care?

FFS pays for quantity of services, while Value-Based Care pays for outcomes, quality, and cost control.

What are Accountable Care Organizations (ACOs)?

Provider-led organizations that focus on shared savings and shared risk with broad patient choice.

What are Managed Care Organizations (MCOs)?

Insurance-led organizations that operate on capitated payments and have narrower networks.

Why is SNAP important in North Carolina?

1.4+ million people rely on SNAP, making it a major economic driver in rural areas.

What are the key changes introduced by H.R. 1 regarding SNAP?

Expanded work requirements, fewer exemptions, stricter non-citizen eligibility, and funding changes.

What does the Payment Error Rate (PER) measure?

It measures incorrect benefit determinations driven by agency and client errors. results in overpayment or underpayment; NCDHHS aims to hit under 6% PER

What are the types of public health governance?

Centralized, Decentralized, Shared, and Mixed governance.

What roles do local public health agencies play?

Disease prevention, health promotion, community engagement, crisis response, data collection, and policy implementation.

What is the Durham HEART Program?

A community-based crisis response program focused on mental health crisis support without law enforcement.

What is the PDCA/PDSA Framework used for?

It is used for iterative improvement in processes.

What are the steps in the CDC Program Evaluation Framework?

Engage stakeholders, describe the program, focus evaluation design, gather evidence, justify conclusions, ensure use & share lessons.

What is the difference between Quality Assurance (QA), Quality Improvement (QI), and Evaluation?

QA meets minimum standards, QI is a continuous process change, and Evaluation determines effectiveness and impact.

What are the characteristics of local public health efforts?

Highly fragmented, multi-funded, multi-actor, and flexible but hard to measure.

What is moral injury in public health?

The inability to act according to one's values.

What is burnout in the public health workforce?

Emotional exhaustion and depersonalization due to crisis demands.

What are the three phases of public health frameworks?

PH 1.0: infectious disease and sanitation, PH 2.0: chronic disease and prevention, PH 3.0: systems thinking and equity.

What is mutual aid?

A voluntary, community-driven exchange of resources rooted in solidarity, not charity.

When does mutual aid typically emerge?

When formal systems are too slow, restrictive, or untrusted.

they arise directly from needs of community or individuals and often respond immediately and quickly

What characterizes centralized public health systems?

More state employees per capita, higher labor expenditures, smaller populations, and less local autonomy.

What are the features of decentralized public health systems like in North Carolina (NC)?

More local government employees, more contracting, greater county autonomy, and greater variability between counties.

How many local health departments are there in North Carolina?

86 local health departments across 100 counties.

What are the CDC's 10 Essential Public Health Services?

A set of services that local health authorities are responsible for meeting.

What is a pro of decentralized public health governance?

Flexibility and responsiveness to local needs.

What is a con of decentralized public health governance?

Inequities across counties and wide variation in capacity.

What percentage of public health funding in NC is federally funded?

67% federally funded.

What is the average public health spending per person in NC?

$78 per person, compared to the national average of $124.

What is the purpose of County Health Assessments?

To monitor health status every 3-5 years.

What is an example of diagnosing and investigating health hazards?

Food and vendor inspections at the NC State Fair.

What is a key focus of the mobilizing community partnerships service?

Counties cannot do everything alone; partnerships are essential.

What does the 'linking people to care' service entail?

Connecting individuals to follow-up care, such as WIC enrollment and vaccination sites.

What are some examples of subversive strategies in public health?

Actors operating outside formal authority to fill gaps left by institutions.

What is required for eligibility in the Healthy Opportunities Pilot?

At least one social risk factor and one health condition.

What does the term 'subversive' mean in the context of public health?

Operating outside of formal authority structures and challenging the status quo of how problems are defined or addressed.

Actors who meet the needs that public health institutions are not; i.e not profits, grassroots organizations

They push systems to change by applying pressure, creating alternatives, or exposing gap

What is the goal of the Durham Vision Zero initiative?

To achieve zero pedestrian deaths through infrastructure redesign.

What is an example of a successful coordination in public health?

NYC Health + Hospitals with planned purposeful coordination, funding, messaging, data sharing, and referrals.

What is a common failure in linking people to care?

Failing to connect individuals to follow-up care.

What is the role of local health departments in the opioid response?

Often barred from harm reduction, relying on nonprofits and grassroots groups.

What is the significance of the Good Samaritan law in NC?

It enabled naloxone access and third-party prescribing. It was a subversive strategy that allowed for EMS, non-profits, and grassroots organizations to administer naloxone

What is the main criticism of mutual aid organizations?

Lack of oversight, which is often viewed as a feature rather than a flaw.

What does the term 'social districts' refer to?

Policies that balance economic activity and safety, originating in Wake County.

What is the purpose of the Child Fatality Task Force?

To investigate every child death and understand causes for prevention.

What is a challenge faced by counties in public health?

Funding cuts can reduce inspection capacity and overall service delivery.

What are the pilot services provided in the pilot region?

Housing, Food, Transportation, Interpersonal safety, Cross-domain supports (e.g., medical respite, legal services)

What is NCCARE360?

The nation's first statewide closed-loop referral system that tracks whether people actually receive services.

It's an online telephonic and interfaced IT platform providing a robust statewide resource database and a referral platform.

NCDHHS and Unite Us work together to make it functional

What is the purpose of the Evaluation Framework in public health?

To assess health outcomes, utilization, costs, sustainability, and cross-sector effects.

What is a key outcome of the pilot program?

$85/month cost reduction per participant and reduced ED visits and hospitalizations.

Define Quality Improvement (QI) in public health.

A deliberate and defined improvement process focused on community needs and improving population health through continuous, measurable improvements.

What distinguishes Quality Improvement from Quality Assurance?

QI is proactive and continuous and deliberate and prospective, focusing on process improvement, combining content from SMART goals and logic models

while QA checks outputs against standards.-- includes quality controls, like yes/no against a standard

What is the Quality Improvement Continuum?

A spectrum from small, program-level improvements to organization-wide QI tied to strategic plans.

What does the PDCA/PDSA Framework stand for?

Plan-Do-Check-Act / Plan-Do-Study-Act, a cyclical model for testing changes.

What is the purpose of Cause-and-Effect (Fishbone) Diagrams?

To identify root causes of a problem and support systems thinking.

Why is Quality Improvement essential in public health?

It allows public health systems to adapt to changing community demographics, health needs, resources, and evidence.

What is the aim of the South Carolina STI Clinics case study?

To increase slots for symptomatic STI patients through a QI strategy called Fast Track.

What are the components of the HEART Program?

Crisis Call Diversion- CCD embeds licensed mental health clinicians into Durham's 911 Call Center to triage, assess, and respond to behavioral and mental health-related 911 calls for service.

Community Response Teams (CRTs)-- provide rapid, trauma-informed care for 911 calls for service involving non-violent behavioral and mental health needs and quality of life concerns by dispatching teams of unarmed, skilled, and compassionate staff (Licensed Clinician, Peer Support Specialist, and EMT) as first responders.

Care Navigation--Care Navigators follow up with people after meeting with one of their first responders to help connect to the community-based care they need and want.

Co-Response--Pairs a HEART clinician with a CIT-trained officer to respond to the highest risk calls involving mental and behavioral health needs.

IVC Response Team--Provides specialized expertise in managing mental health emergencies that may require involuntary evaluation and commitment.

What is the goal of the HEART Program?

To match response to actual need, reduce harm, avoid unnecessary police and ER involvement, and provide compassionate care.

What is the Overton Window?

A model representing what policies are considered politically acceptable, which shifts over time influenced by narratives.

it is not fixed; it is context-dependent

narratives and stories influence the overton window

What is the significance of 911 Call Data in Durham?

Over 98% of calls are non-violent, indicating a mismatch between police training and community needs.

What are the key characteristics of Quality Improvement?

Deliberate, structured, continuous, measurable change, equity-focused, and integrated into organizational culture.

What is the difference between Evaluation and Quality Improvement?

Evaluation assesses if a program met its goals, while QI focuses on improving processes for future outcomes.

What does QI seek to achieve?

Root causes identification and system redesign to improve public health outcomes.

What is a key metric for evaluating the success of QI initiatives?

Improvement in clinic availability, referral errors, time in clinic, and patient & staff satisfaction.

What is the role of narratives in public health policy?

Narratives shape public support and influence what policies are viewed as acceptable.

What is the focus of rapid-cycle evaluation in public health?

To quickly assess and iterate on interventions to improve health outcomes.

What does the term 'cross-domain supports' refer to?

Services that span multiple areas, such as medical respite and legal services.

How does QI contribute to sustainability in public health?

By ensuring continuous improvement and adaptation to meet community needs effectively.

What is the significance of stakeholder engagement in program evaluation?

It ensures that evaluations are relevant, practical, and reflective of community needs.

What is the impact of youth exposure to gun violence?

It leads to long-term mental health consequences and health disparities.

What is the HEART initiative?

A program that has rapidly increasing call volume, with responders reporting feeling safe, expanded with $2M funding, and serves as an example of local policy, evaluation, and community trust.

What is deep canvassing?

A method for changing attitudes through empathetic conversation, featuring story-based dialogue and focusing on lived experience for long-lasting persuasion.

What are the steps in deep canvassing?

1. Ask for opinion 2. Ask for a personal story or experience pertaining to issue 3. Share a related story to the initial opinion 4. Reflect together and engage with their initial concerns 5. Re-engage the issue and seek their opinion

Cone of Curiosity

What does the ORID framework stand for?

Objective, Reflective, Interpretive, Decisional

What is the purpose of the ORID framework?

Used for evaluation, reflection, and community engagement.

What is an example of an objective question in the ORID framework?

Can you describe how you came to believe this?

What is another example of an objective question in the ORID framework?

Which people, comments, ideas, or words caught your attention, and why?

What is an example of a reflective question in the ORID framework?

What feelings came up for you?

What is another example of a reflective question in the ORID framework?

How did this situation impact you?

What is an example of an interpretive question in the ORID framework?

What have you learned from this experience?

What is an example of a decisional question in the ORID framework?

What was the significance of this experience to your study/work/life?

What is another example of a decisional question in the ORID framework?

What will you do differently as a result of the experience?

What is yet another example of a decisional question in the ORID framework?

What would you say about the experience to people who were not there?

What kind of ORID question is this:

What types of 9‑1‑1 calls is HEART most often responding to (e.g., non‑violent mental health or quality‑of‑life concerns)?

Objective

3 multiple choice options

What type of ORID question is this?

How might you respond to a Durham resident who is skeptical of HEART but concerned about safety?

If you were advising Durham leaders, what would you recommend as the next evaluation, quality assurance, or QI priority?

Decisional

3 multiple choice options

What type of ORID question is this?

What does HEART suggest about the relationship between public safety and public health?

Interpretive

3 multiple choice options

What type of ORID question is this?

What emotions came up for you when learning that 98.7% of Durham's 9‑1‑1 calls were non‑violent?

How did you feel hearing the story of the neighbor whose repeated 9‑1‑1 calls were related to substance‑induced paranoia?

Reflective

3 multiple choice options

What is Appreciative Inquiry (AI)?

A strengths-based approach to change that starts with what's working, centers lived experience, and focuses on possibility rather than deficits.

Focusing on what is important and best in people

What is the core principle of Asset-Based Community Development (ABCD)?

Start with what's strong, not what's wrong.

How do deficit-based approaches differ from asset-based approaches?

Deficit-based approaches focus on needs and failures, while asset-based approaches emphasize community strengths and capacities.

What are the categories of community assets recognized by ABCD?

Individuals, Groups, Institutions, Physical assets, Relationships.

What is asset mapping?

A method to identify and mobilize existing community strengths, focusing on who and what already exists.

What are the steps in the ABCD process for social change?

1. Map assets 2. Build relationships & leadership 3. Mobilize community 4. Develop shared vision 5. Leverage outside resources after local capacity is activated.

What are the strengths of the asset-based approach?

Builds community capacity, promotes sustainability, is versatile, and enhances legitimacy and participation.