Working Strategically Across Agencies to Maximize Investments in the Social Determinants of Health

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson. On this episode, making the most of federal and state programs to improve housing, transportation, and other social determinants of health.

ELIZABETH HERTEL:
Having access to safe, healthy, affordable housing is critical. The critical element of having positive health outcomes, both for a family and an individual, and on a community level.

ADM RACHEL LEVINE:
This is an interagency effort that we're working to incorporate this into the federal mindset, skill set, and work systems, and I really think it's transformational.

DANIELLE NELSON:
Instead of focusing solely on improving federal policy, we decided to follow the money.

JOHNSON:
Welcome to Public Health Review. A podcast brought to you by the Association of State and Territorial Health Officials.

With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, how federal and state agencies are teaming up to improve the condition of communities in the name of better public health. We discuss a housing initiative in Michigan with Elizabeth Hertel, Director of the State's Department of Health and Human Services. Danielle Nelson with the Federal Transit Administration tells us about the Federal Fund Braiding Guide, and Admiral Rachel Levine covers the People and Places Thriving approach, a coordinated effort that brings together 47 federal departments and agencies.

We begin there with Admiral Levine, Assistant Secretary for Health at the U. S. Department of Health and Human Services.

LEVINE:
During my time as the Secretary of Health of Pennsylvania and work with ASTHO, there was the beginnings of the discussion of the social determinants of health, and I think that, that has accelerated, uh, especially over the last number of years. Clearly, COVID 19 highlighted these issues because very much what determined In many cases, whether an individual or family or community was even more severely impacted by the pandemic depended upon the social determinants of health. So, I think that there's more and more discussion of this issue.

I do want to point out that from our perspective, there's what I consider a new social determinant of health, and that is actually the legal and political climate of the state that you live in. And so, if you live in some states, women do not have the right to the full range of reproductive health choices.

Transgender individuals might not have the ability to access transgender medicine in some states, and they do in other states. And so, um, in my travels, particularly with Secretary Becerra, we have seen that. And in a trip a year or so ago, we saw that in Minnesota and Wisconsin. I have seen that in Missouri and Illinois, contiguous states that because of the political and legal climate, it impacts the health care for women and for LGBTQI plus people.

JOHNSON:
Tell us about some of the barriers that we might expect to deal with if we try to make these connections.

LEVINE:
Well, the challenges that I found in Pennsylvania and certainly here in the federal government is that many of those social determinative health issues are beyond the scope, for example, of the Department of Health and Human Services. So, we have very little impact in terms of housing, in terms of education, in terms of economic opportunity, but it does highlight how all of the different departments and branches. in the federal government, you know, do function together and how important that is as we try to break down those silos so that, um, we can, you know, work with our colleagues at HUD, work with our colleagues at the Department of Education to try to think holistically about public health.

JOHNSON:
There is an effort that has been underway for a couple of years now related to that very point. It was originally referred to as the Federal Plan for Equitable Long-Term Recovery and Resilience. Can you tell us how that's going now?

LEVINE:
That program, as you said, ELTRR, is, may I say, thriving. And it has been renamed, so ELTRR, a typical federal acronym, was not as descriptive as we want it to be, so it is now called People in Places Thriving.

People in Places Thriving. And this has been an effort which started during the pandemic. And then has continued and accelerated over the last three years, looking to support all people in every community as they work to achieve and sustain. What we are calling is well being. We are looking at well-being.

We're looking at justice. We're looking at health and the vital conditions of health, well-being in injustice. This people in places thriving initiative serves as a vision. It serves as an operational road map as a framework for how we would look at and care for. People in all ways. And it truly does break down silos.

It looks at how the federal departments can work together to maximize the impact of existing resources and existing authorities through that unified action. To me, it is the evolution of the concept of the social determinants of health, but it shifts the focus away from limitations and it looks at foundational system capabilities that people and families and communities depend on.

So, this is an interagency effort that we're working to incorporate this into the federal mindset, skill set, and work systems, and I really think it's transformational.

JOHNSON:
And what about recommendations? Are there any that have come out of the process that you're focused on or that you like to talk about when you have the chance?

LEVINE:
Well, I think that the framework itself almost is the recommendation, because it provides this roadmap for how we can leverage assets and it is asset focused. And it creates the structure that could lead to complimentary actions across departments, braided funding, and it is focused on the long game.

It is not a short-term initiative. It is looking really 10 years out to enhance resilience of individuals, but particularly communities. And, you know, this cross-department collaboration is again, unique.

JOHNSON:
It's always great when agencies can work together. It actually does seem like more gets done. You said earlier you thought it was thriving.

Can you give us an example of how you've seen that?

LEVINE:
Well, a number of our state partners and actually some city health departments are using this framework to advance a statewide cross sector approach. Using the vital conditions to develop their ships, their state health improvement plans, and building new models of collaboration.

So, you know, I think that we have seen states do this. We've seen cities do this. We've seen other departments do this. You know, there's impacts again, across the federal government in terms of HUD, the department of transportation and more. So, I think we're going to see more and more about this initiative, this whole of government approach. Over the next year and beyond, because again, it's a long game perspective.

JOHNSON:
And because this is a framework, an agency or jurisdiction that maybe has not discovered it yet, they can get in on it any time, correct?

LEVINE:
Absolutely. And so you can go to healthcare. gov and search for either ELTRR or People in Place is thriving now as we rebrand it to get more information. And our team is very pleased to talk with any state, a health official or other state official, to discuss how you could be using this framework and the vital conditions of health, well-being, and justice, again, as the evolution of the social determinants of health.

JOHNSON:
You mentioned earlier that this is a long-range vision for how we ought to go about all of this.

Does the framework change, then, or is it locked down? Are there revisions that are constantly being made? Is it a living document? How would you describe it?

LEVINE:
It is a living document, so there have been countless changes and, and revisions, and I expect that to continue because if you have the long game, you know, one thing I can guarantee you, five years from now and ten years from now, is that everything changes.

Now, I, I was, you know, the secretary of health of Pennsylvania, before COVID. And then during the first year of COVID, I can tell you from personal experience that everything changes. So, a static document would not be nearly as helpful. It has to be a living, evolving framework.

JOHNSON:
What do you hear from agencies who've taken a look at this? What are they telling you about it?

LEVINE:
We are hearing very, very positive feedback. At the APHA conference in November, I kind of, People and Places Thriving, at least as a branding, was launched and you know, we've heard nothing but positive feedback since that time.

JOHNSON:
As we wrap up here, give us your best elevator speech on behalf of the framework.

LEVINE:
Well, I think I've given you the elevator speech, is that this is transformational, it is a strength-based approach, and it is really a vision for how we care for the American people as a federal government, and then can be applicable to states and cities and other communities.

JOHNSON:
In Michigan, the Good Housing, Good Health initiative is about six months old. But already, it's helping people in hundreds of households across the state. This is Elizabeth Hertel, Director of the Michigan Department of Health and Human Services.

HERTEL:
Having access to safe, healthy, affordable housing is a critical element of having positive health outcomes, both for a family and an individual and on a community level. We see a number of people in health departments or in clinicians offices, sometimes in emergency rooms, where negative health outcomes are prompting acute emergency situations or adding to chronic health problems like asthma because they don't have Healthy housing. So, we partnered with MISHDA, the Michigan State Housing Development Authority, to develop the Good Housing, Good Health program to take a look at the housing across the state of Michigan and work with local health departments to Provide access to healthy housing.

JOHNSON:
When you talk about healthy housing, I think we need a definition. Can you tell us what it means?

HERTEL:
Healthy housing would be housing where you have a good HVAC system, the ventilation is good, so that you don't have dust in the vents around the house, there isn't mold in the house, you don't have lead paint, so children aren't being exposed to lead paint chips.

The plumbing is updated and safe in the house and you have, you know, heat and electricity to make sure that you have access to temperature control for the weather.

JOHNSON:
So, it has more to do with the environmental factors then versus the fact that having a roof over your head helps you stay healthy.

HERTEL:
Having a roof over your head, no question helps you stay healthy, but the condition of that roof and the rest of the home have a direct effect on people's health and their outcomes.

So, if you are asthmatic, for example, and you have bad ventilation, there's a lot of dust, we can see over and over people having asthma attacks because of the homes that they're living in.

JOHNSON:
What was the condition of the housing in Michigan when you began the project? Is there a real need for this kind of program there?

HERTEL:
We knew even prior to starting this project that the housing stack in Michigan is old and that we have a need to create better environments in this housing stack that we have as well as create more housing in the state of Michigan. And so, the governor has made that a priority in the budget proposal that she put out for fiscal year 25 to be able to add additional housing across the state and then additional housing rehab and that sort of thing so that we can improve the condition of the stack that we have.

JOHNSON:
And of course, the weather in Michigan is known to be cold, rainy, snowy. I assume that doesn't help.

HERTEL:
Absolutely not. We, you know, simple things like making sure that the roof is up to date, windows are updated, houses have insulation that potentially doesn't have asbestos in it are really important elements of good housing.

JOHNSON:
So, you may have talked about this already, but sometimes it is good to circle back so that we can just really emphasize for everyone listening, what we're talking about here, the program itself, the initiative. Give us the goals of the project. What are you trying to accomplish?

HERTEL:
Fundamentally, we are working to increase access to safe and healthy housing.

We're working to provide education and resources to individuals and families so that they don't lose their housing. And we're working to strengthen the health and well-being of households facing those highest barriers in making sure that they're maintaining. Safe and affordable housing.

JOHNSON:
So, you're working with Michigan's housing agency. But what is the role of your department in all of this

HERTEL:
The state health department? It works to collaborate with our local health departments who participate in this program on the ground? So, we've got 20 local health partners currently that are working to implement the good housing Good health program, and we work as a collaborator with Mischa and then facilitator with those local health departments who are reaching people in their communities.

JOHNSON:
You've been at this since October of 2023. What have you been able to accomplish so far?

HERTEL:
That is a fantastic question and I'm really impressed with what we have been able to do. So far, we've been able to serve 634 households across the state. 23 of those received housing stabilization so they could remain in their home. We had quarterly outreach with communities to support households around 90 of every quarter. And again, we have 35 established partnerships among those 20 health departments. So, we've been very successful and we've actually seen at least two families where we were able to prevent their eviction and prevent homelessness for those families.

JOHNSON:
You have partnerships as part of this project, you're working with local health departments, but you also have organizations from outside of government who are taking part in this. Can you tell us how you identified those and what they do as part of this initiative?

HERTEL:
We have to work outside of government in all of our initiatives because so many organizations contribute to public health outcomes, honestly.

So our local health departments outside of government work with those community organizations who, you know, homeless shelters emergency shelters for families to make sure that they're creating a strong network that when people are experiencing hardship, they have access to the services that they need as soon as they need them.

JOHNSON:
This is all funded by the American Rescue Plan, and we all know those dollars are limited. They also, in the case of this project and perhaps with others, they expire at the end of this year. So, September is the effective date. How are you hoping to continue this work beyond that time frame?

HERTEL:
So, we know that housing and safe housing is so important for families. We have a number of different initiatives. Currently, and things that we're asking for in the upcoming budget to ensure that homes are being abated for lead, that we are able to provide an assist with remediating plumbing so that that is safe for families. We're also asking for about 18 million in the coming fiscal year 25 budget to help continue those services for Families who may experience homelessness, emergency housing support, so that we can prevent that eviction, make sure that people actually have a first month's rent and a deposit.

Family shelters are really, really important. We don't have enough of those, that transitional housing piece, so we're requesting around 2 million to help provide those sorts of services. resources for families in the state. So we continue to focus on and ask our legislature to partner with us to ensure that we can provide these services moving forward and that it's not a year to year project that we're trying to scrape by.

JOHNSON:
How important is this program to the people of Michigan?

HERTEL:
It's vital. We know, again, that invite the environmental factors of your home have a direct impact on your physical health outcomes. The location and the safety of your neighborhood have an impact on things that can happen from accidents that are preventable.

We also know that stable housing is it's one of the key elements to keep families together. We know that it's one of the key elements for people who are in recovery to maintain their recovery and their sobriety. Um, housing is just one of those fundamental pieces that is foundational for people's success in, in their life goals and in their health outcomes.

JOHNSON:
If a federal agency has the legal authority to pay for transportation services, it's Danielle Nelson at the Federal Transit Administration most likely knows about it. That's because it's her job to coordinate those activities as the staff lead for the Coordinated Council on Access Mobility. She understands the importance of making sure people can get a ride if and when they need it.

NELSON:
It's definitely a challenge when you don't have it, and I think a lot of people take it for granted when you don't have to think about it, you can get in your own personal vehicle, or you may live in a community with robust public transit. So we forget about those communities, maybe a rural community, for example, who might either not have transportation, or it's transportation program that doesn't have capacity to run, for example, seven days a week.

Or. overnight, and you might be an overnight shift worker. So there's always room for improving public transportation, and that takes partnerships and additional funding. And that's what we're trying to do through our Coordinated Council on Access Mobility work to really help increase the transportation network outside of just engineers and planners, trying to get the human services, the aging network, the disability network, the veterans workforce, really trying to broaden that.

JOHNSON:
Can you tell us more about the Coordinating Council? What it is, who's involved, its goal, its mission.

NELSON:
So the Coordinating Council on Access Mobility or CCAM for short, it's a federal interagency council, so it's led by the U. S. Department of Transportation, where I work. It was started way back in 2004 under George W. Bush, through an executive order. And most people ask, why are you still working on something that old? Well, Congress put it in our authorizing legislation at USDOT. And so it's been reinvigorated and it is comprised of 11 federal member agencies. So led by USDOT with partnership through the departments of agriculture, education, health and human services, housing and urban development.

The Interior, Justice, Labor, Veterans Affairs, and it also includes two agencies, so the National Council on Disability, and the Social Security Administration. And the whole goal is about improving Human Services Transportation for three populations. They're called disadvantaged populations, but it's basically older adults, people with disabilities, and individuals of low income.

JOHNSON:
What are discussions like at the Coordinating Council? Give us a feel for the kind of work the Council does.

NELSON:
So, originally, it was really about policy, and we have switched things a bit instead of focusing solely on improving federal policy, we decided to follow the money. So back in 2019, we mapped across all of those 11 departments.

And those 30 sub agencies under those departments, we decided to map the money, which federal agency grant programs can fund human services transportation. And we were shocked it's 130 And that was as of 2019. We're now updating this inventory we developed, and we already know we have 138 right now in the update.

And so, by following the money, we're able to see which sub agencies across these departments fund the most transportation. And most people are shocked to find out when they see the CCAM program inventory, it's not actually the U. S. Department of Transportation that's the largest funder. It's actually the U. S.

Department of Health and Human Services with 66 different programs that can fund human services transportation. And the largest funder, a single program funder, is again, not at DOT, but actually HHS. It's the Medicaid program because it funds through an assurance for non-emergency medical transportation for those Medicaid beneficiaries.

JOHNSON:
Why do we need an inventory like that? Can you tell us what you do with the information?

NELSON:
So when Congress put the CCAM into our authorizing legislation, they required that we have a strategic plan. So, before we developed that, we went out and we did five state capital listing sessions. So, we traveled out to communities and we met with CCAM grantees.

So, again, multiple different networks, so you've got in there Medicaid, aging, disability, the justice piece, veterans, etc. And we met with each of those stakeholders, and we asked, what's your biggest barriers to coordinating implementing transportation programs for your network? The number one barrier reported was that they don't know what programs can fund transportation.

They have a huge need, but how do they fund the programs? Whether it's a volunteer driver program, travel training, etc. And so that's when we decided we needed to do an inventory. We need to let communities know what federal dollars can be spent to help meet these transportation needs. One of the other biggest barriers was most of these programs we have heard of require a local match.

And we just don't have that funding. For example, at federal transit administration, most of our programs operate a volunteer driver or public transit program, it's a 50, 50 match. And for a rural community to come up with 50 percent of the funds to run a program is a lot. So, Congress gave us statutory authority under three programs of ours to take other non DOT federal funds as local match, and that's huge. That means you can use an HHS grant to meet that local match, so you can have a hundred percent federally funded volunteer driver program or mobility management program, et cetera.

JOHNSON:
The issue then becomes knowing how to do that.

NELSON:
We went on to develop what's called a federal fund braiding guide, because a lot of the misconception was that you can't ever match one federal grant program with another, and there is the authority to do so when Congress has granted it in statute. And so, we mapped through this braiding guide. We got together the general counsel at U. S. D. O. T. And the general counsel of HHS and we sat down for these working sessions, and we met with 61 program managers. Of those 130 programs in inventory, we figured out which programs either have silence in the statute, meaning they don't have authority, nor do they have prohibition, and that was where the majority of the programs of the 61 lied.

It was silent. And then we had a handful of programs with explicit statutory authority, meaning Congress said, you may federally fund parade, and then the several programs had statutory prohibition. For example, the Department of Justice, the majority of their programs had prohibition, meaning you cannot do that.

Federal Fund Braid and so the guide maps out for those 61 programs when and how you can do Federal Fund Braiding. And when it is explicitly allowed, we have cited the statute. So, you can, for example, just google that statute and you'll see exactly how Congress has allowed it in the verbiage that's used in law.

And so, for one example at the Federal Trans Administration is our Section 5310 program, which is our Enhanced Mobility for Seniors and Individuals with Disabilities. And a program you can use to meet the local match of that program is the Old Americans Act Supportive Services. And so that's one example of two federal programs that can come together to match each other, the Old Americans Act funds being used to match your 5310 grant.

JOHNSON:
The guide came out about four years ago, in June of 2020. How are agencies reacting to it? Are they using it?

NELSON:
We have gotten a lot of feedback that it's very helpful. The number one feedback we receive is, so we have the CCAM program inventory, which is a searchable database of programs, and then we have the Federal Fund Braiding Guide, which is a PDF.

It's hard to go between the two. So, right now, the CCAM is working on combining those two resources into one searchable database. And that will be published in 2025. So, and we're also working to ensure that the Federal Fund Braiding Guide goes across all the programs. So, we're finishing what we started and only got through 61.

And so, in 2025, you'll be able to search a program to find out what's the local match of that program, and can that local match be met with another federal grant program? If so, which ones? And so that's going to be a helpful resource, and we're doing all that because local communities who are using it said, this is helpful, but we need you to help us more. We need to make it easier to have this information. So, when, for example, the local Department of Transportation needs local match, and they need to know what other programs can meet that match, they can go and say to the local area agency on aging “How can we partner to put in a grant for this program together”? And so it's basically a tool, a mapping tool, to map potential partnerships to increase transportation funding in local communities.

JOHNSON:
You are right in the middle of this. It's the work you're doing every day. Is it worth the effort to learn how to braid federal funding?

NELSON:
I think the communities that are investing the time are the ones that need it most. They have no other option. So maybe they've looked into foundation funding, you know, they've used all the in-kind match they can muster, and it is the next and only option for them because there is an administrative burden to it.

It's not necessarily easy. But if your other option is having your federal grant funds lapse because you can't find match, period, and you have to return these federal dollars because there's no match to be able to utilize them, Federal fund braiding is a better option than the alternative, which is lapsing the funds and returning them and not being able to implement a transportation program to help community members access their everyday destinations.

So it is an option for communities who need that local match and have no other options in essence.

JOHNSON:
Thank you for listening to Public Health Review. If you like the podcast, please share this episode with your colleagues on social media. And if you have comments or questions, please we'd like to hear from you. Email us at PR at ASTHO. org. That email again, PR at ASTHO. org. You can also follow us using the follow button on your favorite podcast player.

And be sure to stay up to date on everything happening at ASTHO by tuning in every morning for Public Health Review Morning Edition. We cover news like this every day. Check out the link in the show notes and let us know what you think. This podcast is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.