Emerging from the Deepwater Horizon Medical Benefits Class Action Settlement, the Gulf Region Health Outreach Program (GRHOP) seeks to address the health needs of 17 coastal counties and parishes by informing communities about their own health and providing access to skilled, knowledgeable health care providers.1 Addressing health in these communities is critical, given the region's history of health disparities. Most counties and parishes in GRHOP report higher age-adjusted mortality rates from cardiovascular disease and cancer2 and higher prevalence rates of obesity and hypertension than the national average.3 Alabama, Louisiana, and Mississippi also report higher age-adjusted mortality rates for cardiovascular disease, cancer, and diabetes2 and higher prevalence rates of obesity and hypertension3 than the national average. These 3 states are also ranked among the worst states in terms of prevalence of mental illness and access to mental health care.4 Although some counties and parishes report better health outcomes than the state average for certain diseases,2 it is important to recognize the area's triple burden of vulnerability (Figure 1). In addition to historic health disparities, the region experiences significant persistent environmental health threats. For example, children in Louisiana have higher exposure to heavy metals than at national levels.5 Moreover, the geographic location is at increased risk for natural and technological disasters,6 with each disaster having significant consequences for health, the economy, and the environment. These negative impacts are felt disproportionately by vulnerable populations.7
Public Health Capacity Building by Design
Against this triple-risk burden, GRHOP is deliberately designed to bolster the public health infrastructure of the targeted region. The public health practice framework described by Baker et al8 features 3 layers: the public health infrastructure, the base of the pyramid; essential capabilities, the middle layer supported by that base; and specific health services undergirded by 2 well-functioning lower layers. As depicted in Figure 2, GRHOP represents a 3-pronged innovation: an embedded systems approach benefiting all 3 layers of the public health pyramid, essential capabilities tailored to the needs of vulnerable populations, and built-in community engagement.
Implications for Sustainable Public Health Capacity Building
The Louisiana's Public Health Institute Primary Care Capacity Project (PCCP) directed its support to all 3 infrastructure components: its investment in electronic medical records software at participating clinics laid the groundwork for incorporating mental and behavioral health records into standard primary care (information and knowledge systems). PCCP's human resources and financial support bolstered clinics' workforce and organizational functioning (workforce and organizational capacity). The program's transdisciplinary approach integrating mental and behavioral health and environmental health built essential public health capabilities in these fields and introduced new stakeholders into frontline primary care. A key example of integration is the Environmental and Occupational Health Education and Referral network. This nationally unique model exemplifies GRHOP's implementation of the entire public health pyramid.9 The environmental and occupational health continuing education modules expanded workforce capacity by strengthening health care providers' knowledge in environmental and occupational health (workforce competency), providers could avail themselves of expert occupational and environmental medicine consultation (essential capability), and clients could be referred for specialty services at no cost (public health service). Similarly, the Mental and Behavioral Health Capacity Project built infrastructure capacity through adding social work case managers10 (workforce competency) and providing services within primary care settings11 , 12 (essential capabilities) and expanded their reach to K-12 school systems13 (public health service). Illustrative examples of community engagement are the training and placement of community health workers and efforts managed by the Alliance Institute.14–16
GRHOP's deliberate systems approach led to interdependent and interconnected projects resulting in clinics with bolstered facilities and offering integrated health services, poised for continued growth. Health care professionals working in the clinics now have an expanded peer network, and most importantly, area residents have improved access to health services. Project leaders committed to evaluating the efficacy of our efforts by establishing project-based logic models with measurable, short- and long-term outcomes. These project-based logic models feed into an enterprise logic model assessing the projects' collective impact on community, clinic (system), and client levels. The goal of this approach is to monitor enterprise-wide sustainability and examine the program's contribution to community resilience in the aftermath of the oil spill. If GRHOP proves to demonstrably impact the health and well-being of vulnerable populations living on the targeted US Gulf Coast, the program can serve as a model investment for future medical benefit settlements. Building capacity during interdisaster periods in a disaster-prone region can indeed be seen as one of GRHOP's promising hallmarks nationally and globally.
1. Buckner A, Goldstein B, Beitsch LM. Building resilience among disadvantaged communities: GRHOP overview. J Public Health Manag Pract. 2017 (November/December: GRHOP Special Issue): S1–S4.
2. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying cause of death, 1999-2015. In: CDC WONDER Online Database. Atlanta, GA: Centers for Disease Control and Prevention; 2016.
3. Institute for Health Metrics and Evaluation. US Health Map. Seattle, WA: Institute for Health Metrics and Evaluation; 2016.
4. Mental Health America. The state of mental health in America: ranking the states. http://http://www.mentalhealthamerica.net
/issues/ranking-states. Published 2014. Accessed April 17, 2017.
5. Lichtveld M, Sherchan S, Gam KB, et al The Deepwater Horizon oil spill through the lens of human health and the ecosystem. Curr Environ Health Rep. 2016;3(4):370–378.
6. Arosemena FA, Fox L, Lichtveld MY. Reproductive Health Assessment After Disasters: embedding a toolkit within the disaster management workforce to address health inequalities among Gulf-coast women. J Health Care Poor Underserved. 2013;24(4)(suppl):S17–S28.
7. Goldstein BD, Osofsky HJ, Lichtveld MY. The Gulf oil spill. N Engl J Med. 2011;364(14):1334–1348.
8. Baker EL, Potter MA, Jones DL, et al The public health infrastructure and our nation's health. Annu Rev Public Health. 2005;26:303–318.
9. Kirkland K, Sherman M, Covert H, Barlet G, Lichtveld M. A framework for integrating environmental and occupational health and primary care in a post-disaster context. J Public Health Manag Pract. 2017 (November/December: GRHOP Special Issue): S71–S77.
10. Rehner T, Brazeal M, Doty ST. Embedding a university-based social work (behavioral health) program within a primary care system: a 2012-2018 case study. J Public Health Manag Pract. 2017 (November/December: GRHOP Special Issue): S40–S46.
11. Osofsky HJ, Osofsky JD, Hansel TC, Flynn T, Speier A. The MBHCP-LA trauma-informed integrated care and improved posttraumatic stress outcomes. J Public Health Manag Pract. 2017 (November/December: GRHOP Special Issue).
12. Langhinrichsen-Rohling J, Selwyn C, Jackson S, et al The prevalence and mental and physical health correlates of post-traumatic stress symptoms in vulnerable and under-resources primary care patients referred to a behavior health provider. J Public Health Manag Pract. 2017 (November/December: GRHOP Special Issue): S32–S39.
13. Hansel TC, Rohrer G, Osofsky JD, Osofsky HJ, Arthur E, Barker C. The integration of mental and behavioral health in pediatric care clinics. J Public Health Manag Pract. 2017 (November/December: GRHOP Special Issue): S19–S24.
14. Sherman M, Covert H, Fox L, Lichtveld M. Successes and lessons learned from implementing community health worker programs in community-based and clinical settings: insights from the Gulf Coast. J Public Health Manag Pract. 2017 (November/December: GRHOP Special Issue): S85–S93.
15. Nicholls K, Picou JS, McCord SC. Training community health workers to enhance disaster resilience. J Public Health Manag Pract. 2017 (November/December: GRHOP Special Issue): S78–S84.
16. Gonzalez J. BP settlement money targets eastern N.O. health care. New Orleans City Business. http://http://www.theallianceinstitute.org
/news/. Published 2014. Accessed June 3, 2017.