Advisory Committee to CDC Director

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION

State, Tribal, Local and Territorial (STLT) Workgroup of the
Advisory Committee to the Director (ACD) of CDC

Summary Report
February 14, 2011
Atlanta, Georgia

State, Local, Tribal and Territorial (STLT) Workgroup

Summary Report

Table of Contents

February 14, 2011

Page

Acronyms

3

Introductory Remarks and Overview of Meeting Goals

4

OSTLTS Update

4

Presentation of Recommendations to Enhance CDC Support to
State, Tribal, Local, and Territorial Health Jurisdictions

8

Guidance for Refining the Recommendations to Enhance CDC Support to
State, Tribal, Local, and Territorial Health Jurisdictions

17

Brainstorming Regarding OSTLTS Priorities

28

Consolidated Chronic Disease Prevention Grant Program

34

Wrap-Up and Adjournment

41

Attendee Roster

45

Appendix #1: Road Map for Translating Evidence into Practice: CDC’s Use of Best and Promising Practices

46

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Acronyms Used in this Document

ACD
ASTHO
BRFSS
CDC
CEO
CPPW
FACA
FOA
FY
GHC
HHS
HRSA
IOM
IT
LHD
MCH
MMWR
NACCHO
NCCDPHP
OMB
OSELS
OSTLTS
PGO
PHAB
PPACA
PRC
PSR
REACH
RWJ
SHA
SMEs
SMO
STD
STLT
STLT
TB

Advisory Committee to the Director (CDC)
Association of State and Territorial Health Officials
Behavioral Risk Factor Surveillance Survey
Centers for Disease Control and Prevention
Chief Executive Officer
Communities Putting Prevention to Work
Federal Advisory Committee Act
Funding Opportunity Announcement
Fiscal Year
Global Health Center (CDC)
Department of Health and Human Services
Health Resources and Services Administration
Institute of Medicine
Information Technology
Local Health Department
Maternal and Child Health
Morbidity and Mortality Weekly Report
National Association of County and City Health Officials
National Center for Chronic Disease Prevention and Health Promotion (CDC)
Office of Management and Budget
Office of Surveillance, Epidemiology, and Laboratory Services (CDC)
Office for State, Tribal, Local and Territorial Support (CDC)
Procurement and Grants Office (CDC)
Public Health Accreditation Board
Patient Protection and Affordable Care Act
Prevention Research Center
Prevention Status Report
Racial and Ethnic Approaches to Community Health
Robert Wood Johnson Foundation
State Health Agency
Subject Matter Experts
Senior Management Official
Sexually Transmitted Disease
State, Tribal, Local and Territorial (STLT) Workgroup
State, Tribal, Local and Territorial
Tuberculosis

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Introductory Remarks and Overview of Meeting Goals
David Fleming, MD
Director and Health Officer, Public Health – Seattle and King County
Chair, State, Tribal, Local and Territorial Workgroup of the Advisory Committee to the Director

At 8:40 AM, Dr. David Fleming welcomed the group to the meeting, and requested that
attendees introduce themselves. Following the introductions, he called for any announcements
from the group. Lillian Rivera, RN, MSN, PhD, Administrator, Miami-Dade County Health
Department, announced the upcoming 19th Annual Sterling Conference on Memorial Day
Weekend. The conference will include Chief Executive Officers (CEOs) from the private sector
to examine healthcare reform issues and to consider how to apply medical quality and
performance management concepts.
Dr. Fleming then offered introductory remarks. He emphasized that public health is in a time of
crisis, but also it is a time of opportunity. The State, Tribal, Local, and Territorial (STLT)
Workgroup has had a chance to make a difference. This workgroup advises the Director of
CDC, Dr. Tom Frieden, and they have latitude in how they move forward on their charge. He
explained that during this meeting, they would create a process for moving recommendations
from the workgroup to a forum where they can be adopted by the Advisory Committee to the
Director (ACD). The plan was to review recommendations regarding their charge from the ACD
to provide initial advice to CDC regarding how to improve its working relationships and granting
relationships with the OSTLTS community. He thanked the workgroup that has begun working
on this charge. Their goal is to create a product to present to the ACD. They also planned to
consider impacts that likely budget cuts will have on all of public health, and he asked attendees
to think about their recommendations for public health priorities. Finally, they would hear from
Dr. Ursula Bauer, Director, National Center for Chronic Disease Prevention and Health
Promotion (NCCDPHP) regarding the consolidation of chronic disease grants.

OSTLTS Update
Judy Monroe, MD
Deputy Director, Centers for Disease Control and Prevention
Director, Office for State, Tribal, Local and Territorial Support
Dr. Judy Monroe thanked the attendees for their participation. She stressed that the Office of
State, Tribal, Local and Territorial Support (OSTLTS) is in a developmental stage, and
expressed her hope for the group’s advice and input.
Recently, OSTLTS made changes to its structure. OSTLTS is placing Senior Liaisons
throughout CDC and has been charged to form stronger alliances between CDC and the
regional offices. They are engaging in cross-cutting work, realizing that they need to build
bridges between science and capacity development and practice. Further, the office is placing
an Associate Director for Tribal Affairs in the Office of the Director at CDC. She addressed the
Prevention Status Report (PSR), which will be released to states at the end of February. Seven
states have been heavily involved in the report’s development. This report focuses on CDC’s
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Winnable Battles and includes recommendations from the Institute of Medicine (IOM). Dr.
Monroe noted that Branch Chiefs report directly to her so that she can have a better, more indepth understanding of work being done in the office. She also noted that accreditation efforts
are also moving forward.
She requested feedback regarding best practices. OSTLTS created a “road map” to help them
think about moving its products from evidence to practice [See Appendix A]. The “road map”
begins with “Evidence of What Works,” which includes the science that shapes
recommendations in the Guide to Community Preventive Services (Community Guide), the
Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports, and the Vital
Signs Report. In order to ensure that science gets into the field, the first step is awareness.
OSTLTS wants to do its part to raise visibility. One of their strategies is “Did You Know?,” a
weekly email with three bullet points on a given topic that drives readers to Vital Signs and the
Community Guide. Another example of their awareness-building efforts is the State Health
Official Welcome Packet, which highlights the Community Guide.
Dr. Monroe described Vital Signs, the monthly four-page publication from MMWR. In
December, OSTLTS began hosting Town Hall Meetings via conference call on the Vital Signs
publication. Recent subjects of the calls have included HIV, motor vehicle injury prevention, and
cardiovascular disease with a focus on cholesterol. OSTLTS invited medical educators and
physicians to join the calls on cholesterol and hypertension. The results were fruitful, so when it
is appropriate, public health and medicine will both join these calls. Subject matter experts
(SMEs) from CDC talk about the topic, and the calls include implementation “success stories”
from the field. OSTLTS works closely with the Office of Surveillance, Epidemiology, and
Laboratory Services (OSELS), she noted, as OSELS creates tools, and OSTLTS reaches out to
the field to help them use those tools.
Turning to another OSTLTS focus area, Dr. Monroe briefly described the Public Health
Associate Program. There are 65 new associates who have been placed in the field, and
feedback has been good. Fifty more bachelor-level associates will be hired. The process is
open for health departments to compete for Associates.
OSTLTS is charged with grants optimization, and is taking into consideration efforts that CDC
can make to have a better impact in the field, as well as a larger impact with its dollars.
Discussing this charge, and having a better understanding of how CDC dollars are used, should
be a significant part of the STLT Workgroup’s deliberations. A related subject regards how to
survive the current financial crisis.
In closing, Dr. Monroe invited suggestions and discussion regarding what OSTLTS should do in
terms of their various efforts, how they should communicate, and other ideas. She emphasized
the challenges that they face in the current fiscal climate.

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Discussion Points
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Mary C. Selecky (Secretary of Health, Washington State Department of Health) commented
that the turnaround time for states to offer feedback on the PSR was very short.

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Dr. Monroe replied that in the future, they would endeavor to offer more time for feedback on
the PSR.

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Dr. Paul K. Halverson (Director of Health and State Health Officer, Arkansas Department of
Health) clarified that the PSRs would be distributed to state health officials, not the
Governor’s Office. He also inquired about any planned follow-up after the reports are
published.
Dr. Monroe confirmed that the reports would go to state health officials. The PSRs have
changed based on feedback they have received. Regarding planned follow-up, Dr. Monroe
said that OSTLTS, Public Health Law, and the Robert Wood Johnson (RWJ) Foundation are
assessing ways to provide technical assistance to states on policy issues. They intend to
offer support, which will vary by state, after releasing the reports. Further, OSTLTS is
interviewing for new Directors of Public Health Law.
Dr. Eduardo J. Sanchez (Vice President and Chief Medical Officer, Blue Cross and Blue
Shield of Texas) wondered whether the PSR is a public document. He noted that his state’s
State Health Officer is not in a position to “move the needle.” Others would be better able to
make the report visible and to formulate policy strategies.
Dr. Monroe said that the PSR was intended for use as an advocacy tool. The states
recommended that the report first go to the State Health Officers, and states may choose
different ways to disseminate the report’s information. In the future, the reports may be
available on a website or in a public forum, but vetting is needed from the states before they
proceed.
Dr. Jonathan E. Fielding (Director and County Health Officer, Los Angeles County
Department of Public Health) asked about plans to create a “Welcome Packet” similar to the
one designed for State Health Officials for Local Health Officers.
Dr. Monroe replied that a welcome packet for Local Health Officials would occur in Phase
Two of this effort. She hoped that Local Health Officials were receiving the “Did You
Know?” emails. The emails are sent to members of the National Association of County and
City Health Officials (NACCHO) in the hope that they will forward the information to their
contacts. Ms. Selecky pointed out that only NACCHO members would receive the emails,
so some people are likely to be left out.
Dr. Halverson wondered whether OSTLTS had considered implementing peer reviews of
“promising practices.” He noted that the process of naming “best practices” can be long.
Frequently, best practices are published, but there is no dedicated follow-up to learn who is
adopting those practices and whether they are being adapted and improved.
Dr. Fielding asked about the OSTLTS goals of cost reduction—health care and preventive.
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February 14, 2011

Dr. Monroe clarified that the point aims toward greater efficiency in the system. Further, if
their process works, they can reduce the cost of healthcare through prevention.
Melissa Gower (Group Leader, Cherokee Nation Health Services and Government
Relations) asked about the new tribal position in the Office of the Director, and whether it
was a reorganization of a current position.
Dr. Monroe replied that the position in OSTLTS was a Senior Tribal Liaison, and it was
located within a branch in OSTLTS. That position is being eliminated to create the
Associate Director for Tribal Affairs in the Office of the Director.
Mr. John M. Auerbach (Commissioner, Massachusetts Department of Health and President,
Association of State and Territorial Health Officials (ASTHO)) observed that OSTLTS had
accomplished a great deal in less than one year, and thanked them for working to establish
meaningful partnerships. He wondered whether the STLT Workgroup could play an active
role as an advisory group, especially in considering budget uncertainties and other
unpredictable factors that would arise in the coming months. He hoped that they could
support OSTLTS, either as a group or on an ad hoc basis.
Dr. Monroe welcomed that assistance and expressed her hope that they could convene
calls for advice as needed, as long as it was within the scope of the STLT Workgroup’s
charge and aligned with the rules that govern these groups.
Amy Loy (Senior Public Health Analyst, OSTLTS) confirmed that the vision of the group was
to offer support and advice to ACD, and that giving this support to OSTLTS was within its
mission as well.
Dr. Fleming added that working groups also advise the Office of Surveillance, Epidemiology,
and Laboratory Services (OSELS) and the Global Health Center (GHC). Those groups are
working in two areas: 1) where they feel that official recommendations to be adopted by
CDC would have value; and 2) in a more informal manner, giving advice to Directors. He
then asked about the potential effect of budget reductions on the OSTLTS budget and the
office’s ability to carry out its mission.
Dr. Monroe answered that because OSTLS is new, its budget is not robust. Budget cuts
may, however, limit their growth.
Dr. Fielding commented that states, tribes, local areas, and territories are united by budget
issues. The STLT Workgroup could be helpful in making the case for the benefit of public
health. Their work would not be advocacy, but they could work with NACCHO and ASTHO
to focus on evidence of public health’s benefits.
Ms. Selecky said that ASTHO and NACCHO are working together, and broadening those
efforts to include STLT Workgroup feedback would be beneficial.

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Presentation of Recommendations to Enhance CDC Support to
State, Tribal, Local, and Territorial Health Jurisdictions
John Auerbach, MBA
Commissioner, Massachusetts Department of Public Health
President, Association of State and Territorial Health Officials
Carol Moehrle, BSN, RN
District Director, Public Health, Idaho North Central District
President, National Association of City and County Health Officials
Ms. Carol Moehrle began by describing the charge put to the workgroup from the ACD by Drs.
Monroe and Fleming. She and Mr. Auerbach co-led a group of five members of the STLT
Workgroup to consider how the STLT Workgroup as a whole might generate recommendations
in several areas for the ACD at their April meeting. The assignment was open-ended, focusing
on how the current CDC cooperative agreements and grants work with state, local, tribal, and
territorial health entities. They were asked to create action steps or recommendations on how
to improve these processes. They were also asked to “look at the bigger picture” of policy
issues. The group included the following:

John Auerbach, Commissioner, Massachusetts Department of Public Health (Co-lead)
Carol Moehrle, District Director, Public Health, Idaho (Co-lead)
Bruce Dart, Health Director, Tulsa, Oklahoma
Melissa Gower, Group Leader, Cherokee Nation Health Services
Paul Halverson, State Health Officer, Arkansas

They held multiple conference calls, exchanged emails, and convened one in-person meeting in
Phoenix, Arizona. Their timeline for a product was 60 days.
In order to assess current CDC funding characteristics, they began with the understanding that
many types of cooperative agreements and grants come from CDC. Some of these grants and
agreements are generalized, which can obscure differences and subtleties. There are
numerous timelines with these programs, and they are not consistent. Further, project officers
at times have uneven skills and approaches. The group also considered whether appropriation
language requires categorical funding. Congress dictates these appropriations, not CDC. Few
grant opportunities focus on social determinants of health or offer flexibility to address root
cause issues. In the future, they hope that the changes and recommendations that they
suggest can help focus grant and agreement programs to focus on social determinants of health
and achieve Healthy People 2020 objectives and goals.

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CDC operates in an environment of a recovering economy. Further, CDC is affected by efforts
in Congress to repeal parts or all of the Patient Protection and Affordable Care Act (PPACA). It
is likely that CDC will have further cuts to its budget. Funding decisions are shared and are not
always within CDC’s control. Some are determined by Congress, some by the Administration.
The small group understood these limitations as they formulated their recommendations.
The current environment at the state, tribal, local, and territorial levels is affected by economic
issues and budget cuts as well. Core public health efforts are at risk because of funding cuts,
and hiring has slowed or is nonexistent. The public health infrastructure is fragile and has
eroded with decreases in funding. Additionally, requirements from outside forces are increasing
and are stressing the system. The workforce is aging, and there is need for continued training
and education. Over the last few years, 20% of State Health Agencies (SHA) and 15% of local
health departments (LHD) have been lost. Services and programs are being cut. Over onethird of SHAs and nearly one-quarter of LHDs have imposed furloughs or layoffs in the last year.
These factors at the CDC, SHA, and LHD levels informed the small group’s discussions and
recommendations. Before presenting the recommendations, Ms. Moehrle described a few
caveats. Particular issues affect tribal and territorial funding, and the group felt that these
issues should be addressed separately. Political and economic issues are constantly changing,
so the small group suggested that the recommendations should be revisited frequently to reflect
those changes. The small group also discovered that some issues were too complex to handle
in a small group in a short turnaround time. The issues that they chose to address another time,
or in another forum included the following:

Eligible applicants for CDC grants

The need for collaboration between SHAs, tribal entities, LHDs, and territorial entities on
contract engagement, as the collaboration between CDC and the states

Competitive versus formula-driven funding
Further, the group emphasized that these recommendations were a beginning to the
conversation. They need to continue to “chip away” at the complex issues.
The small group developed a Vision Statement to guide their deliberations that included the
following concepts:

Funding should be targeted to the most pressing health needs of the nation
Funding should provide pooled funding as needed, unconstrained by categorical “silos”
Clear goals and objectives should have measurable outcomes
The partnership between CDC and STLT entities needs to continue to grow and develop
Evidence-based and community insights are important in work at the local level
Funding should be long-term and reliable
Funding should allow for critical expenditures such as infrastructure needs.

The small group discussed infrastructure needs, knowing that funding often does not have the
flexibility to fund these eroding needs. The group defined infrastructure to include critical,
indirect activities, which may include information technology (IT), communication, facilities,
training, and general administration. Agency-wide needs are rarely considered in grants. Some
allowable infrastructure needs are capped if they are directly tied to a program area, limiting
agencies’ ability to use them as needed. The group created four emphasis areas, or categories,
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for the recommendations, including: Flexibility, Outcome-Focused and Accountable, Substantial
Engagement, and Technical Assistance.
Mr. Auerbach then explained the small group’s ideas regarding a process for the workgroup’s
discussion. The small group generated 26 recommendations across the four categories. He
explained that following the presentation of recommendations, the full group would engage in
discussion. The discussion would be open and would not necessarily end in a vote. They
would not “wordsmith” or try to come to a consensus on every point; rather, the small group
would hear the Workgroup’s feedback, redraft the recommendations, and share the revisions for
final feedback. The recommendations would then be submitted to Drs. Fleming and Monroe for
their consideration and comments regarding how to raise the recommendations to the ACD.
He then explained the concerns that the small group had identified for the first category,
“Flexibility.” These included the following:

Most grants and cooperative agreements are categorical in nature and focus on a particular
health issue or disease entity. Each year, the general rule is to “start from scratch,”
identifying goals, plans, and outcomes for each of the grants.

Allowable expenditures on these grants and cooperative agreements are confined to a
particular area of work, with some exceptions.

Expenditures tend to be focused on a specific area of programmatic activity. There is little
opportunity to find common efforts that might have a positive impact across an array of
different health concerns. For example, a focus on healthy eating and active living would
have to be addressed separately in each categorical area, even if some of the efforts have a
beneficial purpose for a variety of different approaches. Each project officer makes a
separate decision in this area.

Infrastructure is thought of as both program-specific and agency-wide. In general,
infrastructure-related or indirect costs are allowable in grants, but are often capped at an
insufficient level, and the only allowable infrastructure is directly related to the program goals
and objectives. At times, necessary agency-wide activities are not allowable within a
program-specific grant.

At times, the interpretation of what is allowable in a grant is not clear. The interpretations
can be made at the agency level, at CDC, at a particular sub-section of CDC, or individually
by a project officer. Different states or localities may receive different advice.

Opportunities for activities that cross jurisdictional lines are limited. For example, if a few
states wanted to address an issue in a unified effort, few funding opportunities are available
for them.

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The recommendations under the “Flexibility” category included the following:

CDC should work with Congress to achieve greater flexibility in the awarding of funds
without categorical and other constraints imposed by Congressional language. CDC is
limited by Congressional language, and the small group does not want to make
recommendations to CDC that are blind to this reality.

CDC should move to awarding grants with a bundled or integrated approach, rather than a
limited categorical approach. This approach could include, for instance, having a blended
Chronic Disease grant category. In other instances, grant opportunities could be populationspecific. Flexibility will lead to a more effective response to health issues that is mindful of
the pyramid of interventions.

When funding cannot be blended, CDC should maximize the degree to which there is
flexibility in using funds that might cut across categories. For instance, a project focused on
healthy eating and active living could be beneficial for grants in heart disease, diabetes, and
obesity. CDC is encouraged to pull project officers together, or even to have a single project
officer, in order to have more flexibility in the way that grants are structured and
expenditures are allowed so that activities can easily occur across grant areas.

CDC should address the issue of infrastructure costs so that it is possible to incorporate a
portion of agency-wide infrastructure costs within programmatic grants or cooperative
agreements. IT funding is a good example of how this recommendation might work, as all
agencies are changing their health information systems and reporting requirements are
changing. Expenditures to accomplish these goals are incurred at the agency level, not the
program level. In the past, each program developed its own IT system and its own means
for gathering information. Agency-wide systems could better communicate with other
entities, and building a portion of those costs into each grant would be helpful and practical.
Further, greater flexibility is needed in capping those infrastructure costs, especially when
there is a significant initial outlay of costs in order to build a foundation for the grant
expectations.

CDC should develop ways of encouraging innovative and new cross-jurisdictional
approaches where possible. For example, several Southern states have discussed
examining infant mortality issues and prenatal health concerns with a regional approach.
There should be a mechanism to help counties, states, or other entities to work
collaboratively.

CDC should create a new appeal process in which challenges can be made quickly and
without fault or penalty. This point relates to the earlier concern regarding different
interpretations of which expenditures are allowable.

An over-riding recommendation is that CDC support a more interactive process that favors
openness and alternative approaches to program implementation.

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Ms. Moehrle explained that under the “Outcome-Focused and Accountable” category, the small
group’s concerns included the following:

In order to justify funding, clear evidence of beneficial outcomes must be demonstrated.
Sometimes, it takes a long time to establish the science behind best practices.

Best practices and evidence-based approaches should inform, but not limit, the work that is
done.

A “culturally sensitivity filter” is needed on best practices to ensure that they fit within
different jurisdictions, such as tribes, different ethnic groups, or rural or urban areas.

Sometimes promising or innovative practices are not eligible because they have not
undergone the rigor of evidence-based testing.
The small group created a number of recommendations out of the above concerns, including
the following.

Incentives and support should be created for programs that focus on the social determinants
of health in both the long- and short-term.

Guidance is needed to balance the use of process as well as outcome measures.

The public health enterprise should be considered so that goals are not just established by
CDC or Congress. The federal, state, local, tribal, and territorial levels should work on the
same objectives, measures, and metrics so that outcomes can be shown across the
spectrum.

The importance of having evidence-based criteria must be recognized, but also it is
important to have respect for the community development process and the culturallyoriented best practices that are created where they are implemented: at the state and local
levels. Community approaches may not be “best practices,” but they can be effective,
innovative, and culturally and ethnically sensitive.

Public Health Accreditation Board (PHAB) accreditation is supported as a necessary
measure of infrastructure investment. The PHAB standard will allow states and locals to
show that their infrastructure is robust enough to support public health functions.
Mr. Auerbach described the concerns the small group expressed with regard to the category of
“Substantial Engagement,” including the following:

Often from the design of grant programs through their implementation and evaluation, there
is insufficient input from states, locals, territories, and tribal communities.

Without sufficient input from these entities, they cannot operate as efficiently or effectively
as possible. Sometimes, periods of adjustment need to occur after the funding has been
released.
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The recommendations for this category highlight different activities that would benefit from more
substantial engagement from the STLT population, including the following:

Whenever possible, the cooperative agreement approach is preferred to the grant approach.
The definition of a cooperative agreement is more aligned with the idea of a partnership,
with interaction between grantor and grantee, to achieve the desired outcomes. The grant
approach includes less cooperative decision-making.

Members of the STLT community should be drawn into the identification of health priorities
and the feasibility of solutions.

A collaborative effort should be promoted in setting goals and objectives beyond the current
cooperative agreement approach.

There are inconsistencies in the ways that cooperative agreements are released and
implemented. Consistent principles should be applied to the cooperative agreement
approach.

STLT populations should be involved in the design of both formula and competitive grant
programs. STLT communities should be involved in evaluating the appropriateness of the
intervention selection and the assessment of the application capacity through issues related
to sustainability.

Input is also needed from the STLT population in identifying proposed criteria for grant
review. Efforts should be made to determine how best to allow meaningful input in
considering grant criteria.

In this environment, it is important to create a business case for CDC’s funding programs.
The case should address the cost-effectiveness of the efforts and how the efforts result in
the reduction of expenditures that would otherwise occur. STLT populations should be
involved in making those cases.

STLT communities should be invited to participate in program evaluation activities. In a
difficult economic period, it is important to have strong evaluation activities that are
developed collaboratively.
Ms. Moehrle presented the category of “Technical Assistance,” noting that the concerns in this
category were as follows:

Current technical assistance in the mechanics of grants is strong; strength is lacking in
program content and in best practices.

There is a divide between research and practice.

There needs to be a hybrid approach to technical assistance internally at CDC, and also
with external technical assistance for STLT populations.
The small group recommendations for this category were as follows:
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Steps should be taken to ensure that project officers have the necessary qualifications to
conduct program design, implementation, and evaluation. More expertise is needed in
program content, rather than solely in grants management. There seem to be
inconsistencies in project officers’ training, orientation, and skill level.

Project officers with knowledge of current and emerging best practices, and extensive
understanding of diversity issues in the field, would be able to give assistance to STLT
populations on those areas.

Internal CDC resources are relied upon for technical assistance. It is also valuable to have
external stakeholder organizations available for technical assistance that may be more
hands-on.

There should be continuous improvement of program effectiveness. A feedback loop will
help them learn how to provide technical assistance better.

Grants management should be coordinated with program technical assistance.
Ms. Moehrle noted that they might combine recommendations 25 and 26, as recommendation
26 focuses on the research base and acknowledges the need to link academic public health and
all levels of public health practice.
In closing, Mr. Auerbach reiterated the small group’s intent. Drs. Monroe and Fleming gave
them an open-ended invitation to address a wide variety of different contract activities. Their
first task was to make the assignment manageable, so they deliberately did not take on certain
issues. These issues should be addressed, but the small group did not have the resources or
capacity to do so. Therefore, he recommended that their discussion begin with the workgroup’s
input and observations on the 26 recommendations by category area. Then, they could discuss
other issues that should be included in the next steps.
Discussion Points
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Ms. Selecky commented that it would be helpful if CDC staff were aware of the capacity
changes that have taken place at the state and local levels. Past presumptions about how
to interact with SHAs and LHDs are no longer valid. For instance, some officials are
prohibited from traveling outside the state. The funding environment has changed. Dr.
Monroe agreed that information should be shared on all levels. It is easy to forget that
others do not know what they know.
Dr. Sanchez made a comment regarding the first recommendation under the “Flexibility”
category. Deborah Lapin, a former ACD member, worked with Jack Lord on a report to the
ACD about the challenge of the budget process and CDC’s budget structure. He felt that
this report would be helpful. It was reported to ACD at Dr. Tom Frieden’s first meeting as
CDC Director. Ms. Loy said that she would retrieve the report.

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Regarding the second recommendation under the “Outcome-Focused and Accountable”
category, Dr. Halverson commented that outcomes cannot always be achieved in the initial
grant period, but they should focus on the processes that are shown to be effective. It is
understood that they are moving toward outcomes, but attention should be paid to process.
Regarding the third recommendation under “Outcome-Focused and Accountable,” Dr.
Halverson added that they hoped for explicit alignment between federal, state, and local
goals. There is an impression that CDC has a set of goals independent from other agencies
and groups in the field. While the “winnable battles” are important, thought must be given to
how they fit with work at the state and local levels, and what type of collaborative process
might be utilized to integrate strategies.
Dr. Fleming asked whether there are already established public health system enterprise
objectives, or whether they need to call to create them.
Dr. Halverson answered that they do have goals. Healthy People 2020 goals included input
from across the country and from various stakeholders. At the highest level, the objectives
are set; however, he felt that they should “drill down” more specifically.

•

Ms. Moehrle said that they do not need to create new objectives; rather, they need to agree
on priority areas.

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Regarding the “Substantial Engagement” category, Dr. Halverson suggested re-wording the
first recommendation to read “contract” rather than “grant.”

•

•

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Regarding the “Substantial Engagement” category, Dr. Halverson added that the small
group recognized the “rush to get the money out the door,” which is frequently a reason
given for not gathering substantive engagement or involvement. He suggested that they
work proactively with CDC to develop mechanisms in advance of grant opportunities, in full
consideration of procurement rules as well as conflict of interest prohibitions. They should
ensure that sufficient expertise is available in advance so that stakeholders can be engaged
early, often, regularly, and in a substantive manner.
Dr. Sanchez suggested that a standing workgroup might be needed in this area.
Stakeholder involvement could simply include engaging health departments, but he felt that
there is a need to identify functional expertise for this purpose. People are needed with
functional expertise, evaluation expertise, legal expertise, experience in finance at the state
and local level, and more. Procurement issues exist at the state and local levels. A
standing workgroup with this functionality can help all parties be better prepared to move
quickly.
Dr. Halverson agreed, noting that the small group had extensive discussion in these areas.
They recognized that a great deal of pre-planning and careful selection would be required in
a host of areas. The group needs not only program expertise, but strength in other areas.
Further, the distinction must be made between program-specific knowledge and knowledge
of health officers at every level.

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Dr. Bruce D. Dart (Director, Tulsa City / County Health Department) suggested that a new
business model needs to be created to allow them to achieve health outcomes across the
country. This new model will have to be accepted.
Mr. Auerbach added that at CDC, there is unevenness in efforts to embrace some of these
recommendations. Some areas have become more inclusive, where others have not. As
states are releasing grants, they are uneven in their success at involving local health
departments and community-based agencies. Looking at where these efforts have worked,
and where potential conflicts of interest have been successfully identified, will be helpful.
On the subject of improving “Technical Assistance” and the project officer system, Dr.
Halverson noted that persons in this role might not be those who are currently considered to
be project officers. They hoped for people with recognized expertise in the program area.
These people could bring more value than officers who may know something about the
program area, but who focus more on process.
Dr. Fielding added that the current stimulus funding provides technical assistance from
subject matter experts early in the process. He thought this model deserved careful
thought. He expressed hope that they would discuss the flexibility issue, noting that
“flexibility works both ways.” They will have to decide what they are willing to cut in favor of
flexibility.
Dr. Sanchez said that not only are project officers variable in their skill levels, but also they
vary in how they utilize resources within CDC. A project officer should be expert in how to
mobilize resources to make a project work. One individual may not have all of the
necessary talents.
Dr. Halverson agreed that they may not need project officers, but instead need project
experts or subject matter experts who bring value with technical assistance, focusing on
how to deliver services.
Ms. Selecky noted that the experiences of the Senior Management Officials (SMOs) could
be a model to examine, given that this program was very effective.
Dr. Dileep G. Bal (District Health Officer, Island of Kauai, Hawaii) commented that the
caveats listed at the beginning of the presentation seemed moot. He recommended that the
caveats be removed from the presentation, as they are addressed in the recommendations.
Ms. Selecky observed that while the recommendations address program and technical
assistance, they have not given much focus to financial aspects of these projects. There is
a need for assistance regarding the complexities of these financial systems and structures.
Dr. Halverson added that the gap is widening between public health practice and public
health research and academia. He hoped they could create links so that schools of public
health do not operate independently from the practice of public health.
Dr. Sanchez suggested that the Prevention Research Centers (PRCs) are places where
links between academics and public health practice are created.

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Dr. Halverson reported that $20 million of new funding is to be awarded this year for public
health practice-based research. One way to address this issue would be not to award those
monies to academic institutions, but to award the monies to state and local health
departments. This technique “forces” an explicit partnership between the state health
department and the academic institutions so that real issues that affect practice are being
addressed. The approach has its problems, but it is an opportunity to focus on communitybased public health.

•

Ms. Gower said that she had created a page with eight specific tribal recommendations,
which would be part of the written document.

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Mr. Auerbach noted that those recommendations were specific and helpful and would be
brought to the attention of Drs. Monroe and Fleming.

Guidance for Refining the Recommendations to Enhance CDC Support to
State, Tribal, Local, and Territorial Health Jurisdictions
David Fleming, MD
Director and Health Officer, Public Health – Seattle and King County
Chair, State, Tribal, Local and Territorial Workgroup of the Advisory Committee to the Director

During this session, Dr. Fleming suggested working through the recommendations to provide
guidance and input to inform the small group’s revisions. He congratulated the small group on
their hard work in such a short timeframe, and opened the floor for general observations as well
as input on specific categories.
General Observations
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Ms. Selecky commented on the use of the word “infrastructure,” which raises many capacity
issues on the state and local levels.
Dr. Thomas Farley (New York City Health Commissioner) noted that many of the
recommendations overlap with each other. They may have more impact if they are
collapsed to have a smaller number of recommendations.

Flexibility
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Dr. Farley commented on the common concern that moving from a narrow, categorical grant
to a more general grant brings with it the potential for losing advocacy that is often the
genesis of grant funds. If all communicable disease areas are combined, for instance, then
the tuberculosis (TB) advocates may no longer lobby Congress for TB funds. He did not
necessarily agree with this assessment, adding that it is possible to maintain advocacy and
maintain core activities. The concern of loss of advocacy will be presented. He pointed to
Recommendation 6, concerning an appeals process. He disagreed with the
recommendation, as he was concerned that establishing an appeals process would make
the entire granting process too complicated and bureaucratic. He did not feel that an
appeals process could be “quick and easy.”
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Mr. Auerbach clarified that the recommendation did not refer to who was awarded the grant.
Rather, their intent was to create a process by which grantees could shift funds into a
different program area, if need be.
Dr. Farley agreed, and added that the language “appeals process” sounds too bureaucratic.
They want more flexibility in spending within categories.
Dr. Halverson said that the small group discussed creating an appeals process using an
ombudsman-type approach so that grantees could get an expedited review. If a response to
an inquiry does not make sense, there should be a mechanism to appeal it quickly without
jeopardizing future grants. They do not want to create a “super-structure” that will move
slowly.

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Mr. Auerbach wondered whether the term “expedited review” would be preferable to
“appeal.”

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Dr. Farley favored language to emphasize flexibility in how grant monies are spent. With
more flexibility, an appeals process would not be needed.

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Regarding flexibility, Dr. Fielding was less concerned about a loss of advocacy, and more
concerned about overall budget cuts that might reduce overall funds to increase efficiency.
Without agreement on metrics and clarity regarding necessary resources, the situation lends
itself to “slashing.”
Dr. Farley concurred and noted that many attempts to cut budgets are on-going, so
advocacy is needed to prevent cuts. He believed that they could maintain the needed
advocacy within a more flexible structure, but reiterated that they must be aware of these
issues and potential risks.
Mr. Auerbach said that the small group felt that flexibility could be addressed within a
blended grant mechanism that includes disease-specific outcomes, or outcomes that are
easily tracked to an area of interest of a constituency. For instance, in communicable
disease areas, required goals related to TB may be established. Metrics are critical.
Dr. Fleming turned to Recommendation 4. Giving broad license to use resources for
agency-wide infrastructure is an important, and is an age-old issue. At issue is a definition
of “infrastructure” as well as the extent to which the federal government should pay for a
majority of agency infrastructure, versus the support being a state or local responsibility.
Broadening the ability to use federal dollars for infrastructure may enable state and local
policymakers not to cover these areas. They should move in a direction that specifies
where dollars should go, in a manner that does not enable a “swap-out” at the state and
local level.

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Dr. Fielding agreed, adding that they should reach agreement on what “infrastructure” is. In
general, he felt that federal funding should be contingent not only on maintenance of effort,
but also on a minimum percentage allocation from the authority receiving funds. He felt that
states and localities should have “skin in the game” at a level that does not change from
year to year. Recognizing that this point was beyond the charge of this group, he stressed
that it represents the other side of flexibility—shared investment.
Dr. Bal said that a key issue pertains to the question: What do you spend the money on?
Many state and local entities are “on the ropes” and are under pressure to bring in funds to
use as a revenue offset for the General Fund. When discretionary monies are given, either
state and local jurisdictions will make a philosophical commitment to public health, as
opposed to other funding areas, or they will not make that commitment. He offered an
example of cuts in programs in Hawaii. The private sector took over the responsibility. He
was concerned that business models are used to abuse public health more often than not.
Recommendation 4, therefore, should make it clear that funds should be used for the
purpose that CDC intends and should not be redirected.
Ms. Selecky recalled that funds for preparedness have been beneficial for her jurisdiction.
The funds were broad and not tied to a disease. They realized that they needed capacity for
quick reporting and needed to invest in electronic data and reporting systems. These
systems benefitted the entire enterprise, including diseases and conditions such as
hepatitis, TB, smallpox, and others. The definition of “infrastructure” is important, and she
suggested that federal contributions to an agency’s infrastructure could depend upon the
percentage of the agency that is federal. Definitions of infrastructure will vary from place to
place.
Mr. Auerbach clarified that the small group’s intent focused on the non-programmatic
elements of an infrastructure that have a direct and definable relationship to programs, but
are not program-specific. For example, if an IT system is required to be developed that is
compatible with federal reporting systems and is uniform across programmatic areas, and
there are no funds to support the effort, it will not get done. He offered an example of an
HIV prevention grant from CDC in which his agency engages in work related to needle
exchange. There are near-constant legal challenges to this program, and they retain legal
counsel to deal with these issues. That lawyer would not be considered a “direct expense”
in the CDC cooperative agreement, but if they do not have the lawyer, then needle
exchange will cease. The definition of agency-wide infrastructure should not be so wide as
to not be traceable to a specific function that is being purchased, but more flexibility is
needed.
Dr. Dart said that the issue boils down to the question: What is the cost of doing business?
Grantees need the flexibility to use funds for the costs of doing business, linking the costs to
line items so they can be specific about the costs of implementing and supporting grants
and projects. “Infrastructure” not only is the cost of doing business, but it also adds
accountability for identifying costs.

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Dr. Fielding noted that their budget submissions do not refer to “infrastructure.” Instead,
they refer to specific capacities and capabilities, defining specifically what they are.

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Dr. Halverson said that a number of factors relate to an agency’s ability to be effective that
are not directly program-related. He offered the example of policy development, in which an
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injury prevention grant may include forming coalitions and passing legislation. His Injury
Prevention Director cannot go to the legislature, so the work must be accomplished through
coordinated policy development efforts at the Director level. It must be recognized that
there are shared leadership responsibilities that make an agency function. He realized that
a certain level of funding should come from states and local entities, but in reality, their
budgets are being decimated. In this climate, states are going to decide whether to maintain
their funding levels and support. If, for instance, the federal government decides to
eliminate family planning, there will be no family planning in his state.
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Dr. Bal agreed, but returned to the notion of having “skin in the game if you want to play.”
Responding to Dr. Halverson question regarding what to do if states do not want to play, Dr.
Bal said that this issue comes to light with states opting out of PPACA. The extent of federal
jurisdiction versus state jurisdiction in areas where health is a right and not a privilege will be
determined by the courts. If all entities are “broke,” then they have to scale down their
expectations, and states must have “skin in the game” or they should not play.
Dr. Halverson said that by making cuts, many states are saying that they are not “playing.”
At some point, they will need to point to a certain level of public health functionality that must
be provided by someone, regardless.
Ms. Selecky asked about Recommendation 7, noting that having flexibility regarding how to
approach coalitions would be helpful.
Dr. Sanchez said that looking at the “play or no play” issue in those terms means that states
or entities are making decisions that affect people. States have faced situations in which
decisions made by elected officials are not in the best interests of the health of the
population. He proposed that grants include enough flexibility so that money can be
allocated where needed in order to achieve public health objectives. At times, state
agencies do not want to “play” in one program or another, despite a need. There should be
a way to create a flexible system that has engagement with state health officers and
stakeholders that helps develop a set of objectives about the people in the state, not
necessarily the organization or prevailing ideology.
Dr. David L. Lakey (Commissioner, Texas Department of State Health Services) concurred
with Dr. Halverson’s observations related to flexibility. States cut programs as tax dollars
decrease, and he was concerned about issues regarding maintenance of effort.

Outcome-Focused and Accountable
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Dr. Farley felt that the recommendations in this category indicate that grantees should be
held accountable for outcomes of their work, and should have flexibility to achieve those
outcomes. He suggested that the recommendations regarding balancing the use of
evidence-based criteria and community-developed, culturally oriented best practices be
collapsed into one statement.
Dr. Fielding said that many people to whom they report do not understand public health,
especially the outcomes to expect. Formalizing and coming to agreement on outcomes is
important. Incentives are important as well. Evidence-based approaches are important for
practice, and “community-developed practices” is a broad category. Clear logic models are
often needed. In some cases, process measures will be intermediaries, but the process is
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still outcome-focused. There is a difference between adapting an evidence-based practice
for a particular circumstance, and just trying a practice that seems promising.
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Dr. James Nicholson (Nick) Baird (President, Stillwater Solutions LLC) valued supporting the
evidence base. He also noted the tremendous value in the creativity and innovation of the
private sector. Promising practices may not be evidence-based, but they can become so.
Not allowing some of these practices to be implemented while waiting for peer review, for
instance, misses an opportunity to engage in promising practices that may improve health
earlier than waiting for a scientific base. He felt that there is a way to “marry” science with
innovation and creativity, and he supported the balance.
Dr. Rivera said that it is difficult to be outcome-focused and accountable in good times,
especially at the local level. She turned to Recommendation 12, supporting the PHAB
accreditation process. In these uncertain times, she was not sure whether health
departments would engage in the process because they are focused on critical issues of
survival. PHAB may be seen as an addition to their workload. However, uncertain times are
the most important times to become more focused and accountable. These messages must
be delivered through state organizations, and must go beyond support to encouragement
and motivation.
Ms. Selecky felt that supporting PHAB as part of infrastructure is as important as supporting
PHAB accreditation. The accreditation process is a systemic assessment of how an
organization does business, including finding opportunities for improvement. They should
be careful that the recommendation is not read as a mandate.
Dr. Bal supported Recommendation 11, balancing the evidence base with communitydeveloped approaches. The translation of science to public policy is never as unequivocal
as they would like it to be. He recalled an empirical tobacco intervention in 1990. It was a
risk to implement it, but it worked. Many public health and medical advances began with
empirical evidence.
Dr. Fielding said that there are times when it is appropriate to act based on limited evidence,
especially when a problem is of large dimensions. For example, they are acting in the area
of childhood obesity without clear evidence of effectiveness. He noted occasions in which
“innovative” approaches were used where evidence-based approaches were available and
could have been used, and he hoped to avoid those situations.
Mr. Auerbach agreed that some of the recommendations needed clarification. Some of the
recommendations embrace the conversations taking place regarding the Community
Transformation Grants, which are viewed as focusing on changing policy as opposed to
metrics, and focusing on grassroots community involvement as a driving force behind
decision-making. The first approach raises the question of the right metric. Now, grants and
cooperative agreements tend to require a specific, quantifiable deliverable. This
requirement is different from a policy change that could take three years to become
successful. Recommendation 9 attempts to capture this shift. Recommendation 11
addresses the notion that involving community-level entities and telling them that their only
options are evidence-based work. This will result in pushback from the community that their
input was not really sought, and that they were only included to pick from a list of
interventions. Communities know what works in their communities, and there should be
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flexibility and respect for that knowledge as well as for what has been researched and
studied.
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Dr. Fielding said that in his experience, providing “menus” has been helpful. Otherwise,
efforts can go in any direction. Providing a “menu” with the understanding that the
interventions can be tailored has made a difference by setting parameters and helping
people start with a common base of understanding. The approach is useful and does not
eliminate creativity and innovation, but channels it.
Dr. Karen Remley (Virginia Health Commissioner) said that without local government and
legislative earmarks or an evidence base, it is difficult to conduct projects. They need
evidence that an intervention will work. She further noted that politicians are involved in how
grants are distributed and the degree of flexibility they have. Without some requirement of
an evidence base, she was concerned that the field would be wide open for legislators to
earmark their own projects that may or may not be what is needed or effective.
Dr. Dart recognized that external dynamics have changed and will probably continue to
change, and he hoped that they would be responsive to the new environment. They need
flexibility to adapt to changing dynamics and to continue to perform at the optimum level.
Dr. Fleming suggested that the system was broken in this area partially because CDC is
decentralized, so different parts of CDC deal with this issue in different ways, making it
difficult at the state and local level to operate grants with different philosophies. He was
convinced that there is a tension between being “outcome-focused” and wanting to be held
accountable. It is not possible to do both at the same time in public health. Obesity is a
good example. Nobody knows what obesity rates will be in five years if nothing is done
about the problem, so it is difficult to be held accountable for an outcome if something is
done. The effect sizes in different communities of proven interventions in tobacco are
unpredictable and are different. There are no proven practices in obesity, so they need to
be experimental. For many people, accountability centers around distal health outcomes
that may take place years or decades down the road. He believed that they need to agree
with funders and policymakers regarding the outcomes that they hope to change, while
accountability is actually for the strategies being put in place. Ultimately, grantees should be
held accountable for those activities that are agreed to be their “best shot,” deliver on those
strategies and evaluating whether change is taking place.
Dr. Fielding agreed, adding that Dr. Fleming’s point applied differently to different subjects.
In obesity, for instance, syntheses of promising practices have been created. For TB or
sexually transmitted diseases (STDs), they know outcomes. Another discussion concerns
priorities for what they do. Should they consider preventable burden or other metrics? He
commented on the underlying physical determinants, noting that social and physical
determinants are long-term. Their strategies are important, and one of the problems with
policies is that their success is measured by whether or not they are accomplished, not by
“how hard they try.”
Dr. Halverson said that as they agree to be held accountable for evidence-based strategies,
it raises the need for increased, better, and more contemporary research in these areas.
Frequently, they work at the limits of research that has been completed and that is not
necessarily updated or contemporary to today’s challenges. There needs to be greater
alignment between what is being done in practice, the study of evidence, and the
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documentation of evidence to be modified over time. Public health practice research needs
real strength and it needs to be robust enough to keep up with the practice. He was
concerned that they would be confined to old practice and old research.
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Dr. Farley noted that the issue is terminology. States, locals, and CDC need to agree on the
metrics that will define success. Some might call the metrics process measures, others
might call them outcome measures. When the metrics are defined, then there should be
flexibility to achieve them. In the area of TB, the metrics would probably be agreed-upon as
treatment completion rates and contact treatment rates. In obesity, they could likely agree
upon the most useful metrics to use, given the current state of knowledge.
Dr. Lakey asked for clarification on the thinking behind Recommendation 8.
Mr. Auerbach answered that the recommendation focuses on moving away from categorical,
year-by-year work plans that assess grant success based upon concrete deliverables or
outcomes that are received in a relatively narrow, discrete time period. The
recommendation suggests replacing these work plans, where appropriate, with the notion of
changing conditions in people’s communities and lives, thinking about environmental
change in which an effective strategy must be recognized where activities take place over a
given year. This approach is a different way of defining an outcome. The outcomes may be
related to establishing coalitions or drafting regulations and introducing them for the first
time, in contrast to developing guidelines that are distributed to clinicians’ groups or
educational materials that are circulated.
Dr. Lakey understood the importance of the recommendation, but cautioned them to
articulate their outcomes carefully. He recounted a conversation with a legislator who saw
these areas as “fuzzy.” When the areas are “fuzzy” or “squishy,” they can become
vulnerable in funding allocations. Mr. Auerbach thanked him and noted that they would be
sensitive to that point.
Dr. Fielding said that the whole notion of policy is “squishy.” Public health work includes
agriculture, housing, and transportation. Some need convincing of these connections. CDC
and the STLT community need to come together to recognize that the issues are public
health, and how public health can have a role in them.

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Substantial Engagement
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Mr. Auerbach suggested that they could collapse a number of the recommendations in this
category.
Ms. Selecky referred to Slide 27, noting that in her experience, subject matter experts have
almost always been internal and CDC-focused. She hoped to bring more people “under the
tent” and she hoped that the message would reach CDC personnel.
Dr. Fleming observed that they were in agreement that CDC should better engage with the
STLT community. The flip side of the issue is that the STLT community should be ready for
that engagement. He asked for the group’s comments on a process or mechanism for CDC.
Ms. Selecky said that the regions are very different. She recalled Dr. Monroe’s comments
regarding engaging the CDC regional offices in a meaningful way. Perhaps a trial could be
undertaken in a region, bearing in mind that there are different dynamics within regions.
Dr. Fielding said that creating a standing group that could be called upon for rapid response,
including representatives from different types of organizations, would be helpful. Trying to
collect comments from the entire community, or trying to collect official comments, might not
be the best way to approach the issue.
Dr. Farley asked whether the main problem was a lack of response, or of conflicting
responses.
Dr. Fleming replied that the latter was more of a problem. It is often possible to predict the
response that will be given by different people, so it is possible to choose a certain group to
get a certain response. A pre-established, quick-responding group that synthesizes a
number of opinions would be ideal.
Dr. Farley said that setting up a structure is key to making the group doable.
Dr. Halverson pointed out that key focus areas are known in advance. It would be possible
to create a panel of people who could be called upon prospectively at first, but then on a
reactive basis as necessary. If they really want engagement, they should design a
mechanism that makes engagement possible. Waiting until the last minute to gather input
will result in a predictable response, but thinking proactively by assembling state health
officials, local health officials, program experts, and others who could serve in an advisory
function, could provide perspective from the field. The group should be changed regularly to
ensure that different voices are heard. There may be issues with Federal Advisory
Committee Act (FACA) rules as well as with procurement and conflict of interest rules, but
there should be a way to work within the confines of the federal rules to create this group.

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Dr. Fleming noted that many of these decisions are made outside of CDC by others in the
federal system, so any input would be in the nature of an advisory group.

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Dr. Monroe asked whether any proactive group like this had been attempted in the past.

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Ms. Selecky replied that attempts were episodic. She recalled from her time at the local
level that a group of people would be asked to weigh in on a given topic or direction. This
group differed from what they were discussing.
Dr. Bal said that such a group would be difficult to create, unless the group was large
enough. The heterogeneity of the STLT community is significant and is stratified by a
number of factors, areas, and perspectives. In order to represent the whole, opposing
viewpoints must be included.

Technical Assistance
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Ms. Moehrle suggested that some of these recommendations could be condensed, as some
seem to overlap.

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Dr. Monroe reminded them that OSTLTS is charged with improving project officers.

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Dr. Farley agreed with the problem presented by the category, but he was not fully in
agreement with the proposed solutions. When he was at the state level, he was
disappointed that he could not turn to his project officer for advice on how to handle
problems with his project. The project officers were often young and inexperienced, and
many had never worked at the state level. He hoped for a senior person who might be able
to provide advice and suggestions. Such individuals may not be found in Atlanta, since
many staff in Atlanta have spent their entire careers there. The most useful conversations
he had when he was at the state level were with people in other states. Some manner of
peer technical assistance system is more valuable than hoping to create a project officer
system with officers who will be able to provide experienced advice. He suggested that
project officers be as expert as possible, but they are not likely to achieve what they want by
themselves.
Dr. Monroe said that there were over 600 project officers at CDC, and it is possible that so
many are not needed. Dr. Farley added that they have added little value.
Mr. Auerbach said that two approaches were recommended. First, they recommended
strengthening the project officer system as much as reasonable. Second, they note that
project officers are not able to provide what is needed. It is important to commit to
identifying external parties where the needed expertise may exist. This could take place
through contracts with individuals or organizations, or via peer-to-peer networks. It does,
however, need to be part of somebody’s job to ensure that someone is available.
Dr. Halverson said that using the label “project officer” might be a problem. The
recommendations refer to receiving technical expertise from CDC. He agreed that the need
was a hybrid. CDC has a responsibility to develop expertise in its subject areas, recognizing
that not all expertise will come from CDC.
Dr. Monroe noted that they recommended creating an “expertise system,” not necessarily a
group of experts.
Dr. Halverson added that the government needs a procurement officer to deal with the
grants, but these persons should not be expected to be technical experts. Decoupling these
roles will allow the work to be accomplished with fewer people.
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Dr. Sanchez returned to his earlier comments regarding functionality versus job description.
It is important to begin with asking what functions are essential for the enterprise, and then
how to assemble a team to deliver those functions. Within CDC, are some working better
than others? Are any states doing anything like this? Consulting organizations live with the
challenge of organizing their resources with a project manager working within the assets of
the organization. Can any lessons be learned from these organizations? Further, health
plans administer their vast numbers of accounts with a system of account managers who
know how to avail themselves of the needed expertise in clinical questions, for instance.
These models, and others, may inform what CDC does to ensure that project officers are
deployed in a manner that adds more value.
Ms. Moehrle agreed that the team approach is critical. Experts are often found at the local
level, because they are the ones implementing the best practice or evidence-based
interventions. At times, the expertise and technical assistance is not found at the state level,
but through NACCHO.
Dr. Bal felt that the project officer system had been blown out of proportion, observing that
the problem may not lie with the project officers themselves, but with the expectations of
CDC. He never expected technical assistance from CDC, because public health
interventions came from the field. Technical assistance came from other areas. He further
noted that CDC’s technical assistance depends on CDC leadership, especially regarding
policy.
Dr. Fielding pointed out that there are different kinds of technical assistance. For most
grants, it is helpful to encourage grantees to work closely with their peers, given that they
deal with similar problems. It would also be helpful to develop national experts who could
be available. For major bureaucratic problems, technical assistance can come from
colleagues and professional associations.
Dr. Fleming observed that the group’s comments reflected a degree of caution regarding
whether they should strengthen or streamline the project officer system. In an era when
CDC’s budget is being reduced, and they will have to examine areas in which they are not
getting value from their dollars, there was agreement that the current, very distributed
project officer system seems to be taking more resources than it provides in value. With that
in mind, they should be careful that this recommendation is not read as, “make more project
officers,” but rather that a smaller number of project officers could be assigned to
jurisdictions to break down categorical barriers across grants.
Dr. Fielding suggested a system of generic project officers. They could develop expertise in
different areas. This approach is very different from the current model.

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Summary Report

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Ms. Selecky was working in the area of reshaping public health, and one aspect of that work
is “doing business differently.” When there are reductions at the federal level, how will
public health do business differently, and what is the definition of a project officer? So far,
the project officer is the person assigned to the grantee for a contract or cooperative
agreement. Preparedness grants were broad, so project officers had to learn quickly how
the systems worked.
Dr. Halverson suggested an approach that assigned one senior person to each state who
could represent CDC in a number of project areas.
Mr. Auerbach said that the issue of project officers could be addressed with the notion of
blended grants and cooperative agreements. His state, Massachusetts, is one of the four
that are piloting chronic disease integrated grants. They have half a dozen different grants
and half a dozen different project officers, and the biggest impediment to their progress is
the fact that there are six different officers with different perspectives. It would be simpler to
have a single project officer for all of the grants who was cross-trained in the chronic
disease agreement. The other states in the pilot program are Colorado, Wisconsin, and
North Carolina. He did not speak on their behalf, but he surmised that the other states
would agree with him in this area.
Dr. Monroe compared these ideas to the medical model with a general or family practitioner
who works in the medical home and who uses the resources of subspecialists when
needed.
Dr. Farley reminded them that people with the necessary in-depth experience at the state
and local level are not likely to be found in Atlanta.
Dr. Sanchez suggested instituting a six-week deployment at the state level for project
officers so that they may have a sense of state and local systems. Further, a “project
manager lead” could be created as a coordinator at the state level so that there is one go-to
person.
Dr. Baird asked about the SMO project and whether lessons were learned from it.
Dr. Sanchez replied that there are lessons to be learned from the SMO idea and how it
played out in practice. Those lessons could be applied to this new way of thinking, as the
same challenge drove the SMO concept. Ms. Selecky added that reports about the SMO
project were created.
Mr. Auerbach said that the SMO program was costly, and a way of offsetting the cost of their
proposed changes would be to have fewer project officers.
Dr. Bal commented that the SMO system does not do the “meat and potatoes” of work. He
noted the long timelines to get things accomplished, as the officials are at a senior level. He
suggested that people at the state level could be helpful.
Dr. Halverson clarified that he was not suggesting that the SMO model would work as it was
implemented; rather, the model could be modified to include new duties.

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Dr. Remley commented that Dr. Monroe functions in this role for all of them. She has seen
performance improvement. The more time spent in this realm, the more one learns about
what works at the state level. The project officer model was strong when it was begun, with
the intent that it was a starting point for CDC staff in their careers, but it is flawed because
the role truly requires knowledge and expertise that a person beginning at the “ground floor”
does not have.
Mr. Auerbach said that the small group would be challenged to sort through the differences
of opinions reflected in the workgroup’s comments and reactions to the recommendations.
He surmised that they would create a process that does not result in a “watered-down”
product that tries to merge contradictory opinions. As they send revisions to the larger
group, he asked them to think about how to finalize a report that does not have absolute
consensus.

•

Dr. Farley observed that the group agreed with 80% of the content of the recommendations,
and he suggested that they focus on expressing themselves clearly.

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Ms. Moehrle was encouraged that the small group’s work resonated with the rest of the
workgroup. She thanked them for the rich discussion.

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Dr. Fleming thanked the small group members for their hard work.

Brainstorming Regarding OSTLTS Priorities
David Fleming, MD
Director and Health Officer, Public Health – Seattle and King County
Chair, State, Tribal, Local and Territorial Workgroup of the Advisory Committee to the Director

Dr. Fleming indicated that the group’s next task was to discuss how best to use their collective
resources in the future to provide advice to OSTLTS and CDC. He asked Dr. Monroe for her
thoughts regarding areas in which OSTLTS would most need advice.
Dr. Monroe began by thanking the group for their morning’s work. She noted another product
coming from OSTLTS and its partners—an online CDC directory for departments of health. She
thought that the morning’s discussion regarding project officers had been exciting and helpful,
and they were already thinking about how to approach and redesign the system.
Other areas in which the workgroup’s help was needed include:

Policy, including public health law and technical assistance
Managing the financial crisis in terms of what CDC should be doing
How CDC might approach direct assistance
Quality of field staff

Dr. Fleming asked each workgroup member to share suggestions and thoughts regarding how
to spend the next six months, whether as recommendations for OSTLTS or for CDC via the
ACD.
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Discussion Points
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Dr. Baird said that it would helpful to get a sense of what the CDC and the Director see as
doable or realistic, so they can know the agency’s priorities.
Dr. Monroe answered that the areas she mentioned were all priorities for Dr. Frieden. There
is question, however, of what is doable and reasonable within certain timeframes. Dr. Baird
said that they should focus on what they can really accomplish.
Dr. Rivera referred to the areas of policymaking and managing the financial crisis. In her
state, they have problems because it is not clearly delineated where health policy is made.
The SDH is not heavily involved in health policymaking. The State Health Officer functions
at the level of a Chief Operating Officer. She hoped that CDC would understand how policy
is made at the state level. In terms of managing the crisis, she emphasized that CDC
should have an understanding of what will happen in states that have new governors. She
expressed uncertainty for her own state, pointing out that the new governor’s philosophies
regarding public health are not clear. Recognizing what will happen state by state will help
CDC, but she was not sure how to get the information unless the State Health Officer
communicates with them. She predicted difficulty in managing the financial crisis in the
absence of the right data or information.
Dr. Halverson suggested that they have a constructive discussion regarding the notion of
the “enterprise” and the “system,” including a discussion of the expansion or contraction of
direct funding. How big is big enough? How small is too small? Other issues concern the
states and territories and their relationship to the local health departments, and tribes’
relationships. Another focus is providing direct funding from CDC while trying to create and
maintain a system. He suggested that they create a framework to have discussions around
these potentially divisive topics.
Dr. Fielding agreed that they should discuss what the new health department looks like.
Many different factors are affecting this structure, including health reform, the roles of
accountable health organizations, how to interface given the “Meaningful Use” requirement,
inevitable reductions in direct service provision, and increased capacities to do surveillance.
Also important to consider is what role they should play in quality assurance for the medical
system. Where are there voids? He felt they should also consider the role public health has
in intersectoral work and the underlying determinants of health. He also offered the topic of
combining the evidence base from population health with what is known from clinical work,
both in prevention and in treatment.
Mr. Auerbach suggested that they prioritize taking advantage of the possibility that they will
keep the Public Health Trust. He hoped that they would think critically and collaboratively
about the best use of those funds. Also, they should understand the implications of likely
reductions in funding and how they will affect the way CDC works as an organization. This
period is historic, and decisions made in the next 12 months will have long-term impact on
the shape of CDC and its priorities.
Ms. Moehrle said that they should assess the whole enterprise to determine where they are
moving. ASTHO and NACCHO have had discussions about what public health should look
like in these changing times, and these discussions should include CDC so that the
continuum is pointing in the same direction. They can then agree on metrics or outcomes.
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Dr. Remley hoped that they would not use optimism and forward motion. The funding for
public health prevention is not gone yet. She agreed with working on the concept of
focusing state, federal, and local energy around the public health initiatives that lead to
impacts that are visible to the public. They may have common themes, but they are also
beset with real political issues, so they should choose key areas that are critically important
and align policy around them. Her state’s health department is an informal policymaker in
that it provides recommendations around policy, but is not tasked with being the
policymaker.
Dr. Sanchez reminded them that CDC is part of the larger enterprise of the Department of
Health and Human Services (HHS). They should appreciate that the priorities of the larger
enterprise, to some degree, drive what they will be able to do. All health departments get
funding from other parts of the larger enterprise, and he wondered whether as they work
within CDC, other lessons might be learned for other pieces of the federal funding portfolio.
He referred to “lumping” across categories and jurisdictions. For example, El Paso, Texas
could work better with Las Cruces, New Mexico than with any other city in Texas. Many
programs preclude that kind of conversation. Regarding project management functions, he
reiterated that the job is not about a person, but about the elements that are needed to
optimize the grant. He also raised the issue of portfolio management, perhaps state by
state. If the Project Manager functions at a higher level, then the role will be portfolio
management. The role is not only an information broker, but has the ability to make
decisions at the programmatic level that could result in the reallocation of funds.
Dr. Farley hoped that there would not be huge budget cuts in public health, but realized that
there probably would be cuts. This group could help prioritize among CDC’s public health
programs, contributing insight from a broad perspective. He noted that there has never
been a clear, agreed-upon national strategy in certain areas, such as chronic disease
prevention. It would be helpful to create recommendations for how national strategies are
developed with appropriate input from the STLT community and CDC. He felt that CDC was
the best organization in the world in the area of epidemiology and describing health
problems. However, that expertise does not translate to knowing how to solve the
problems. Bringing expertise from outside CDC would be worthwhile, and this workgroup
could assist in that effort. In his state, he observed that when budgets are collapsing, policy
change represents a way to move forward, as policy change costs little or nothing. Most
jurisdictions do not have the capacity to discover policies that could be put in place or to
develop coalitions to advocate for them successfully. CDC could help jurisdictions develop
that capacity. Creating a system for a range of expert assistance could help those with little
capacity. There is a great deal of informal expertise and experience in implementation
strategies around the country. Because of the high turnover at the state level, creating a
system for sharing and transferring that information would be worthwhile.
Ms. Selecky suggested starting with “low-hanging fruit.” ASTHO Senior Deputies created a
list of recommendations for CDC to consider. For instance, one of the problems with the
grant and cooperative agreement program is that timelines are numerous and often
unpredictable. CDC could generate common dates and agree upon them internally. She
also returned to the issue of budget cuts and whether the Director’s office would share a
common message or recommendations for how to deal with those reductions. They should
also consider immediate as well as long-term impacts.

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Dr. Monroe said that the top five “low-hanging fruit” recommendations from the ASTHO
Senior Deputies were being worked through the Procurement and Grants Office (PGO).
She said the process has been delayed, observing that even the “low-hanging fruit” has
taken time. They hope to announce changes by the end of March.
Dr. Dart appreciated that comments were coming from a systems perspective, and that they
were thinking broadly along the enterprise. They have an opportunity to discuss what they
realistically can accomplish, for instance, in rural America versus urban America where
capacities are so different. Grounding their conversations in this approach will help ensure
that changes can occur on the ground level. The provision of public health services,
although it will vary from place to place, needs continuity. There is a disconnect between
rural and urban areas, not just in funding areas, but in capacity. He suggested that they
define “capacity” in the same manner that they are discussing defining “infrastructure.”
Dr. Bal said that not only is there no heterogeneity in the field, but also there is no
heterogeneity within CDC. The agency has become a bureaucracy. One key function of the
workgroup could be to recommend the same commitment to intervention across the agency.
This factor affects funding and has been a problem at CDC for some time. He suggested
that they create a recommendation for the ACD meeting in April concerning these questions:
What do you want? How will you break it down? (e.g., through block funding, formulaic
funding, state and local funding). Policy is a significant priority of the CDC Director, and
they have not addressed how to accomplish it. The external environment of policy is part of
public health’s job. The bureaucracy impedes their progress and interference from HHS,
Congress, and even the White House affects policy intervention. Rather than avoiding the
issue, he encouraged them to meet the problem head-on, insisting that public health should
be proactive. They also have a right to voice their opinions and work as “citizen public
health workers.” Given the pressure that CDC is under, he felt that it was unrealistic to
expect “political cover” from the agency. Public health vibrancy and leadership must come
from the local level. This stridency has eroded in recent years, and it could be due to a loss
of leadership, but it also could be in response to “what the people want.” The debate in
public health has always centered around individual rights versus community responsibility.
If one believes that the community is responsible for the most disadvantaged among them,
then there must be strong public health intervention. He shared a list of potential issues and
roles for the Workgroup to consider, including the following: block versus categorical,
consolidation and inefficiencies, state versus local, current funding, future funding, priorities,
Project officers (process perfect / product poor), chronic disease versus communicable
disease versus emergency preparedness, CDC role versus state / local role (laboratory
function), health insurance (new ball game), PPACA, non-public health functions and
partners, and the rich get richer (formula funding versus competitive funding).
Ms. Gower had provided a list of specific tribal recommendations, which was distributed to
the group via email. She commented on the uniqueness of tribal populations which can be
difficult for the general population to understand. Issues such as tribal sovereignty, federal
trust responsibility, and others influence and affect recommendations for tribal populations.
Regarding her participation in the small working group, she felt that she was representing
tribal nations and the Indian perspective. She felt the need to represent territorial issues as
well, but she was concerned that she did not have adequate knowledge to do that. One of
the tribal recommendations focuses on how the STLT community is comprised of four
separate entities, each of which needs full representation. She said there should be full
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territorial representation, acknowledging that they may have some common issues with
tribes. She also appreciated the new tribal position in OSTLTS. They have a different
project officer for each of their many grants from CDC, but none of the officers comes with a
basic understanding of, or orientation to, tribal nations. She encouraged OSTLTS to ensure
that the position was filled by someone who does understand and advocate for tribal
positions.
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Dr. Fleming expressed gratitude for the rich discussion and noted that they have a great
deal of work ahead. He observed two common themes in their reflections: 1) The public
health system, with involvement from states, tribes, locals, territories, and CDC, needs a
better way to assess its enterprise and figure out how to do business better; and 2) The
public health system is confronting crisis. Many at the state and local levels have been
dealing with huge budget pressures, and an unprecedented budget crisis is impending at
the federal level. At the same time, there are new resources. He was concerned that, if left
to their traditional means for managing crisis, especially at the federal level, the system
could become very divided. Because so many people at CDC have spent their careers at
CDC as opposed to in the field, when the times comes to identify how to allocate fewer
funds, there will be an outside perception of lack of attention and perhaps unfairness
regarding how CDC distributes money to the public health system. They must establish a
process to prevent that reality and that perception. They need to assess whether CDC
leadership is interested in action in the area of combining the urgent crisis of budget
reductions with creating a system for looking broadly at the public health jurisdictions in the
United States. He asked whether the group felt that they should engage Dr. Frieden to
generate a process to enable Dr. Monroe and OSTLTS to have a voice with CDC to help
manage budget reductions in a way that does the least harm to the overall public health
system. There was general agreement from the group regarding this direction for their
efforts. He noted that if they postponed taking on these issues, they may be too late when
they do take up the issues. He suggested that they begin by communicating with CDC
leadership to determine whether this charge was feasible. They do not want to give advice
where it is not needed, and the realities of the federal system may mean that CDC may not
want to take on the charge. He asked for ideas from the group regarding how to assist CDC
and how to provide input from the STLT community.

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Dr. Fielding agreed that their next priority should be the issues that Dr. Fleming named. He
wondered how much of this work comes from CDC alone versus CDC and others, both
inside and outside the federal government. Now is the time for CDC to join with both
external and internal partners. He was not sure whether it was possible to engage the
Secretary of HHS in these issues, and he noted that the Assistant Secretary of HHS,
Howard Koh, is an important ally. They are not only trying to prioritize in the face of budget
cuts, but they are also establishing the value of core public health so that people know what
they are potentially losing. Priorities will differ from place to place, so it is important to give
people a sense of what public health is. Everyone has seen significant reductions in recent
years. What has been lost as a result of those cuts? They should articulate those losses in
a meaningful, logical way to create messaging that resonates at all levels. They can try to
reduce the decline through negotiations, hoping to improve the outcome. The STLT
community can advocate through its legislators. They can also help shape priorities among
core public health. The United States is spending more on health and is getting less. Public
health and policy solutions will emphasize the role of public health. Otherwise, every
marginal dollar without an appropriation will go into the healthcare system as opposed to
public health. There are strong partnerships with the healthcare system that have not been
maximized.
Mr. Auerbach suggested that the STLT Workgroup agree to be flexible in how they address
this issue so that they are most useful to OSTLTS. It is beneficial for them to meet in
person, so that they can have formal discussion as well as informal talks. They are in
difficult political situations and need to think about ways to coordinate their efforts at different
levels. In order to be helpful, they must offer their assistance not as a narrowly-defined
interest group, but as a group that wants to do what is best for the public health enterprise at
large.
Dr. Farley observed two separate discussions. One is recommendations to CDC regarding
priorities after budget cuts, and the other is an advocacy discussion that they cannot have
with CDC. Advocacy should happen in another forum. He agreed that their work with CDC
should not take the form of advocating for their own agencies.
Dr. Sanchez mentioned materials that he had from the Texas Association of Local Health
Officials. A public health coalition is examining the legislative and characterizing the
challenges that the state faces regarding the budget crisis. There may be value in knowing
what is being contemplated and having a sense of the challenge that the STLT community
will face so that they can shape how to respond to a set of expectations from the White
House and / or HHS. It will be helpful to have objective information from the states to learn
how they depend on their resources.
Ms. Selecky said that ASTHO will conduct a budget survey, which will provide important
background information. She built on the idea of advocating and meeting with the Assistant
Secretary of HHS. She noted that both CDC and the Health Resources and Services
Administration (HRSA) fund AIDS work. She wondered whether the two agencies would
make different decisions. This is an area for systemic conversations. The Maternal and
Child Health (MCH) block grants is influenced by decisions in Immunization, she added.
She encouraged conversations concerning the impacts to the STLT community across HHS.

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February 14, 2011

Dr. Baird said that they could consider other partners that have leverage with Congress. He
wondered whether CDC still had a Corporate Round Table. These partners have clout and
could carry CDC’s message to directional leaders.

Consolidated Chronic Disease Prevention Grant Program
Ursula Bauer, PhD, Director
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
Dr. Bauer expressed gratitude for being invited to the meeting. She noted some features of the
National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) budget as
reflected in the President’s proposed budget released that morning. There has been a cut to
NCCDPHP’s base of $140 million, which is concerning. They have a budget of approximately
$1 billion. That figure is inflated with $650 million in stimulus dollars. Those funds end in March
2012. With the cut to the base came additional dollars from the Prevention and Public Health
Fund. Their net budget for 2012 is larger than 2010, not including the stimulus dollars. The
new dollars are for new programs, so they will examine the NCCDPHP budget to determine how
to manage their resources. They will probably not continue to support all of their programs.
The President’s budget collapses about 40 individual budget lines into about five budget lines,
Dr. Bauer explained. The lion’s share of those lines are collapsed into the “Consolidated
Chronic Disease Prevention Grant Program.” This line includes the following: Nutrition and
Physical Activity, Diabetes Prevention, Heart Disease and Stroke, Cancer, School Health, and
Arthritis. Tobacco, Oral Health, Safe Motherhood, Infant Health, and Community
Transformation Grants are separate lines. Most of the Prevention and Public Health dollars are
allocated to this area. $52 million was appropriated in 2011 to jump-start the State Chronic
Disease Prevention Program, and another $157 million in 2012 is allocated to fully flesh the
program out. This program is a grant opportunity for state health departments that currently
receive a number of categorical chronic disease program grants.
The key feature of the State Chronic Disease Prevention Program is the Center’s ability to
support chronic disease capacity in state health departments for the first time. They have
always funded categorical programs, but they have never supported overall chronic disease
prevention capacity. With the $50 million in 2011, and some portion of the $157 million in 2012,
NCCDPHP looks to strengthen existing, or build where there are not existing, overarching
chronic disease programs in state health departments that can support cross-cutting skills such
as surveillance and epidemiology, policy, communications, evaluation, community mobilization,
and others. Their categorical programs will be affiliated with, and work under, the State Chronic
Disease Program. The categorical programs can focus their dollars on their disease- and riskfactor specific work. She hoped that with enhanced chronic disease capacity, they would be
able to foster more coordination and collaboration among those programs. By building crosscutting skills and resources, the programs will work more efficiently together.
Dr. Bauer noted that four “negotiated agreement” states (Massachusetts, North Carolina,
Wisconsin, and Colorado) currently have broad flexibility in how they manage, distribute, and
coordinate their categorical chronic disease dollars. The states are halfway through their threeyear cooperative agreement. All four states were convened in October 2010 for a reverse site
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visit to hear lessons learned, strategies that were used, and details regarding how they
reorganized their chronic disease programs to take advantage of the opportunity. The states
are doing strong work and are pleased with the flexibility. They have approached the
opportunity in different ways, so an immediate lesson is that CDC will not be able to pull a
process or structure from the four states to pass on to other states. Different structures and
processes work differently in every state, but they can share the lessons learned. A lesspositive experience has come from the collaborative chronic disease Funding Opportunity
Announcement (FOA), which combined diabetes, tobacco, the Behavioral Risk Factor
Surveillance Survey (BRFSS), and Healthy Communities. The grouping was not ideal, and
CDC did not provide helpful guidance. This program resulted in one FOA with four discrete sets
of activities, and it did not enhance collaboration. NCCDPHP will release an FOA for the $52
million overarching chronic disease program, and they will design a full FOA for the
consolidated chronic disease grant program.
Another new grant program, the Community Transformation Grants, is not the traditional
cooperative agreement. Communities Putting Prevention to Work (CPPW) is a hybrid. A
specific component goes to state health departments, and another component goes to
communities, either directly or via a state health department in the case of rural communities.
Community Transformation Grants will build on experience with CPPW as well as on experience
with a number of different Healthy Communities programs. $145 million is allotted in 2011 for
this activity, and the President’s Budget provides $221 million. She expressed hope that the
fund would continue to grow over time. They expect to scale the Community Transformation
Grant program nationally, so they look for increases as the Prevention and Public Health Fund
grows over time. The President’s Budget offers direction regarding where to make reductions.
NCCDPHP will run into difficulty if the Prevention and Public Health Fund does not materialize.
The center has a net increase, but a cut to its base. At this point, they are grappling with what
the budget looks like and how to design their programming. They hope to address new issues
with the consolidated grant. For instance, many states do not have grants for nutrition and
physical activity, heart disease and stroke, arthritis, and others. Through the Consolidated
Grant Program, they hope to extend that activity to all states.
Discussion Points
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Ms. Selecky asked whether there is a strong rationale for why tobacco is a separate line.
Dr. Bauer was not aware of a rationale. One might think that tobacco causes heart disease
and cancer, so it is related to those diseases. They must group programs somehow, and
even though there are different groupings from different entities, NCCDPHP has flexibility in
how they operationalize their programs. They are collaborating and coordinating with
tobacco.

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Mr. Auerbach requested clarification regarding the Consolidated Chronic Disease Grants,
asking whether there would be expectations that each of the six areas would have discrete
activities and program goals that would co-exist with efforts to integrate efforts where
appropriate.
Dr. Bauer said that the program will evolve over time, and will launch in 2011 with the
establishment of the overarching chronic disease component. The other programs will
continue to exist within their current cooperative agreements. Some programs are already
bundled together in cooperative agreements. Over time, there would potentially be one
FOA to include all programs. They will not necessarily organize the programs along specific
disease and risk factor categories, but possibly along functional lines. Instead of building a
nutrition and physical activity program, for instance, they might support policy activities to
promote nutrition and physical activity. Instead of supporting a separate breast and cervical
cancer early detection program, they might fund a set of activities in clinical preventive
services to include those kinds of activities. Because all of their activities are linked to
Healthy People 2020 goals, performance and outcome measures will relate to the range of
chronic disease prevention activities. They will hold themselves and their grantees
accountable for reductions in heart disease, stroke, diabetes, et cetera.
Mr. Auerbach asked whether there would eventually be a single, inclusive consolidated
grant, or whether the grants would always be separate and distinct.
Dr. Bauer replied that transitioning from 40 budget lines to one budget line is a challenge,
and starting the effort in 2011 is an even greater challenge. Currently, they are establishing
the overarching chronic disease component. In 2012, they will be able to plan how to
structure a new program, including whether separate FOAs are needed. A complicated
program such as the National Program of Cancer Registries should not be included in a
huge FOA, for instance. They are considering how to support the needed activities in a
process that makes sense to state health departments. Both Congress and the Executive
Branch are moving in the direction of collapsing budget lines, reducing the number of
cooperative agreements, and forming a coherent program around the myriad chronic
disease activities.
Ms. Selecky said that her state has been adopting this approach. Four states are going
through a pilot of integrated programs, and others are doing their own “look-alikes.” She
suggested that those states could offer advice on the process, including stumbling blocks.
For instance, her state requires her locals to report as if the programs are still categorical,
but also asks them to do broader assessments in their communities. There have been
disconnects and frustration as a result.
Dr. Farley asked whether states would receive guidance regarding how to interact with local
health departments. He wondered whether states were free to bypass the LHDs entirely,
pass the dollars to community-based organizations, or adopt other approaches.

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Dr. Bauer replied that when grants are awarded to state health departments, there is not
generally an expectation that the monies will go to state-based, community-based, or local
health organizations. When localities receive grants, they do not necessarily fund district
health offices in their jurisdictions. They expect states to implement programs with
population-wide impact. Some states may accomplish that goal by providing sub-grants to
health departments within their jurisdictions, others may decide to undertake policy
initiatives at the state level. Some states do not have local health departments.
Dr. Bal asked about the procurement and rollout of the Community Transformation Grant.
Dr. Bauer explained that the Transformation Grant is completely separate from CPPW,
although there will be an overlap. They hope to release $145 million this year, and if they
are successful, there will be a 6- to 9-month overlap with CPPW, which ends in March 2012.
The Transformation Grant is a new procurement and a new application. There is not an
expectation that current CPPW grantees will have an advantage in funding.

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Ms. Gower asked whether tribal governments are eligible for these grants. Dr. Bauer replied
that they are.

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Dr. Fleming asked about the $140 million reduction in NCCDPHP’s base and whether the
center has created a process for determining how to make that reduction.

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Dr. Bauer answered that NCCDPHP has budget lines that do not appear in the President’s
Budget; therefore, the President does not expect to see those activities continue. In some
cases, when an existing line has no funding in 2012, as with the Racial and Ethnic
Approaches to Community Health (REACH) program, language says that the activity should
be included in the Community Transformation Grants. Current grantees under REACH will
not be funded under the Community Transformation Grants; rather, the kinds of activities
supported under REACH will be supported under the Community Transformation Grants.
The statutory language around the Community Transformation Grants directs CDC to use
the funds to achieve reductions in health disparities as well as population-wide change.
Other programs are not included in the President’s Budget, such as inflammatory bowel and
psoriasis programs. In areas such as these, the public health message and public
interventions were not clear. Perhaps the programs were not a good fit, so those programs
will not be prioritized in the new, smaller core budget.
Dr. Bal asked whether the Community Transformation Grants focus only on the states, or on
states and locals.
Dr. Bauer answered that they focus on both state and local entities. The statute stipulates
that eligible entities include state and local governments, state and local non-governmental
organizations, and tribal organizations. The duration depends on how long the Prevention
and Public Health Fund lasts. NCCDPHP envisions a new five-year cooperative agreement
for eligible grantees.
Dr. Fielding asked how NCCDPHP will promote the new grants that are available to states,
localities, and others, when there will likely be competition within a geographic area.
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Dr. Bauer replied that the FOA is in the clearance process through HHS and OMB. It builds
on the approach of Communities Putting Prevention to Work, in which communities needed
to assemble a multi-sectorial team with many partners in order to achieve and implement
policy change. They hope not to see competition within a jurisdiction; rather, the hope that
grantees will work together to determine the best agency to apply for the grant and the best
members to tap for the coalition. CDC cannot prohibit competition, so there may be
competition, but they expect to see multiple sectors and many organizations working
together on the applications.
Ms. Selecky asked whether a private, non-profit entity applying for the grant was compelled
to reach out to the state and local health department. Even if the groups have a good
relationship, they might opt to compete for a strong grant opportunity.
Dr. Bauer answered that the FOA has not been cleared, so she was not sure of its final
iteration. They do, however, often require a letter of intent. They hope to ask every
applicant to file a letter of intent and that applicants give permission to post that information.
There will be a website that those interested in the funding opportunity can consult to learn
who has submitted letters of intent and contact those entities to work together.
Dr. Fleming said that the workgroup has been tasked with providing OSTLTS and CDC with
useful advice. He asked Dr. Bauer if there were areas in which she felt she could use
advice from states, locals, territories, and tribes. There is a strong Chronic Disease Director
program already, but he wondered about additional areas for consultation.
Dr. Bauer offered two areas in which the group could be helpful. First, as NCCDPHP thinks
through the development of the large, consolidated chronic disease grant program, they
would appreciate input on what the program will look like and how state health departments
will be able to make the program work for them. State health departments and NCCDPHP
may not currently have the expertise, skills, and staff to get where they envision themselves
in five years. NCCDPHP looks forward to the expertise that it needs to ensure the STLT
helps them form that vision and make changes over time. Another area in which advice
would be welcomed concerns the project officer program. They are reorganizing how they
train, manage, and support project officers so they can deliver better services to grantees.
This challenge has been on-going across CDC. It was addressed in the past by the Project
Officer of the Future program, which has worked well, but the program has been small.
They have not been able to retrain the existing cadre of project officers through that
program. They plan to continue to locate the project officers within the programs they serve.
Further, they plan to provide oversight training, orientation, and skill-building more centrally.
It would be helpful to identify the needs and gaps in the system.
Dr. Bal noted that many people do not understand what public health aims to achieve,
noting that every level, from the federal to the local, has its own problems and priorities. He
asked about CDC’s plans to get where it wants to be, given this confusion.
Dr. Bauer replied that the agency has thought about how they message about their work.
NCCDPHP focuses on demonstrating demand. The “nanny state” is a phrase on many lips,
and there is a perception of an overbearing, paternalistic government that tells people what
to do. She did not believe this was the case. The reason there are smoke-free laws and
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nutrition policies is because the people demand these efforts. They need to message the
demand and benefit more clearly so the government can deliver what the people ask for.
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Dr. Farley said that the group had discussed project officers earlier in the day. As they are
consolidating across several grants, he wondered whether they were considering collapsing
the number of project officers as a result and if system-wide lessons could be learned.
Dr. Bauer said that NCCDPHP was in the initial stages of thinking about the project officer
system, and she welcomed input into the issue. One source of frustration is trying to get
project officers to work together across programs. Every program “carves up” the country in
a different way, making that collaboration difficult. Each project officer has a different group
of states with which they work, so each officer belongs to different teams, which does not
make sense. If all programs carved up the country in the same way, then teams of project
officers could be built and they could cross-message and complement each other’s activity.
They are also considering instituting a “Lead Project Officer” for each state. The individual,
potentially a higher grade than most project officers, could act as the team lead and the “goto” person for the grantees. They are considering these two approaches and whether they
would result in fewer project officers and clear lines of responsibility.
Dr. Sanchez told Dr. Bauer that the workgroup discussed the idea of a lead project officer.
They also discussed the notion of project manager as a function, rather than a person.
They had discussed whether all the necessary functionality and capacity was comprised in
the team, or readily available. Expertise in health, procurement and contracts, policy and
legal areas, and even evaluation may not all be found in one individual, but in teams that
bring subject matter expertise in these, and other, functionalities.
Dr. Bauer said that the subject matter expertise could come from outside the project officer
cohort. Project officers cannot be expected to be experts in all of the areas, but their
expertise needs to be developed in cross-cutting areas as they are empowered to refer
grantees to subject matter experts at CDC and elsewhere when needed.
Ms. Gower spoke as one of the representatives for tribal governments in the workgroup. As
they think about dividing up the country, she suggested that they consider a specific tribal
recommendation, which includes specific training for project officers in tribal sovereignty,
federal trust responsibility, and government-to-government relationships with tribal nations.
Perhaps all officers could receive that orientation, or a set of project officers could focus just
on tribal governments. Dr. Bauer liked the latter idea.
Dr. Fielding reiterated that the CPPW funds end in March 2012; however, all grantees will
not have spent all of their money by then. He asked about efforts to recapture that money.

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Dr. Bauer had not heard of any such efforts, but not hearing about efforts does not mean
that the money will not be recaptured. They have monitored CPPW expenditures closely.
They got off to a slow start, and they are catching up, but it is likely that dollars will be left
over. She has heard discussions of no-cost extensions, as two years was a short
timeframe. She warned grantees not to rely on that extension, however.
Dr. Fielding asked about the approach to technical assistance in the CPPW grants, in which
all experts were convened at the first meeting. He wondered how well the experts had been
utilized and whether the model had worked well.
Dr. Bauer replied that CDC does not always have the expertise or the staff to provide
expertise to a range of grantees. For this reason, reaching out to national organizations with
the appropriate expertise who can focus on specific areas so that grantees can link to them
for needed technical assistance is the only way to do business in a grant program of that
size. With Community Transformation Grants, they are considering a similar model.
National support for CPPW was housed in HHS, but there were communication issues and
vision differences. Technical assistance will be better coordinated in-house.
Mr. Auerbach shared his experience from one of the integrated chronic disease states. He
said it is different to transform the way that people think about working in the consolidated
chronic disease approach. They have built “silos” and trained people to work within them
and to defend them. People’s initial instincts are still to protect the things with which they
are comfortable. The more flexibility that exists in working across areas, the better. While
the integrated approach has allowed for more flexibility, some rules prohibit some flexibility,
such as reallocating dollars, sharing expenses across too many grants, or getting all of the
project officers “on the same page” about making changes.
Dr. Bauer said that the problem of the ability to share resources across programs is
eliminated by the fact that there are not separate lines for each program—there is just one
line. Individual programmatic integrity is preserved by performance and outcome measures
for which grantees are held accountable. The grantee will decide how to allocate resources
in the cooperative agreement to best achieve those outcomes. NCCDPHP’s challenge will
be how to support the work through project officers and disease- and risk-factor-specific
Divisions. One of the reasons the collaborative FOA that she mentioned before was not
successful was that NCCDPHP did not model the behavior they were asking grantees to
adopt, she said. At this time, NCCDPHP is considering a reorganization to deliver programs
better. The four integrated states have commented that this is a different way of working
and thinking, and it is a process.
Dr. Rivera gave her thanks for the CPPW grant in Miami, Florida, which is showing great
accomplishments at the local level. She asked about whether policy and environmental
changes were being monitored across the nation.

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Dr. Bauer answered that they are frequently asked for successes and impacts achieved by
the community grantees. They have a one-year retrospective catalog of work, with an
impressive list of policies that have been advanced during the grant period. The multisectorial teams have come together well, she said, and they have high hopes for
achievements in the second year.
Dr. Farley asked whether the policy successes were helping or hurting them.
Dr. Bauer replied that because they committed to policy changes, they have been able to
say that changes were accomplished. Whether the efforts hurt the initiative in the long run
depends on how they message what they were able to deliver to the people because the
people demanded it.
Dr. Bal commented that much of the CPPW media messaging from CDC was out of sync. If
policy change is successful, then it will “spook” Washington. He implored them to stay the
course if the program is working.

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Dr. Bauer asked how she might stay in touch with the workgroup in order to ask for more
insights as the Center’s changes are considered.

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Dr. Monroe said that they would convene calls, and Dr. Farley added that they hoped to be
available for rapid response when needed.

Wrap-Up and Adjourn
David Fleming, MD
Director and Health Officer, Public Health – Seattle and King County
Chair, State, Tribal, Local and Territorial Workgroup of the Advisory Committee to the Director

Judy Monroe, MD
Deputy Director, Centers for Disease Control and Prevention
Director, Office for State, Tribal, Local and Territorial Support
Dr. Fleming asked if they could see a high-level summary of the President’s Budget. He then
asked for additional comments regarding the workgroup’s next directions as well as feedback
regarding what worked and what did not work in the day’s meeting.
Discussion Points
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Ms. Selecky wondered how many other areas of CDC were considering changes in the
project officer system. Further, she wondered about the choice to maintain separate officers
and to add a senior officer. They seem to have a supreme opportunity to make innovative
changes in the system.
Dr. Monroe answered that these changes are building upon past work in NCCDPHP with the
Project Officer of the Future. Ms. Loy commented that HIV may be making similar changes
to the project officer system.
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Dr. Fielding said that many different programs will be consolidated into, in essence, a block
grant for chronic disease prevention while significantly reducing funding. He hoped that they
would keep their expectations reasonable. The new grants bring more funds, but the base
is being reduced, he reminded them. Additionally, he felt that they should support keeping
the Prevention and Public Health Fund intact. He predicted that the fund would be a target,
and they need to unite to support it.
Mr. Auerbach added that it will be difficult for the workgroup to have a role in thinking about
how decision-making is made in response to shrinking budgets. At CDC, people are
thinking about how to make cuts and how to backfill and shift funds. It may not be realistic
for the workgroup to think that they can have a significant impact if things are moving
quickly, and in disparate ways, across the different centers at CDC.
Dr. Monroe agreed that CDC is a decentralized agency, and things are moving quickly. She
would meet with Dr. Frieden at the end of the week to learn his thoughts on this topic.
Dr. Farley said that the NCCDPHP grant probably should have been combined some time
ago, and he was glad to hear that NCCDPHP was reorganizing to match the grant. As other
grants are being combined, other centers will face the same issue. He felt that they should
encourage CDC and states to reorganize around this effort, otherwise they will not operate
efficiently.
In thinking about reorganizing, Dr. Monroe asked for feedback regarding the role of
performance managers and whether they may provide extra capacity at the state level: 49
states, 10 large cities, and 8 tribes accepted funds through the ACA to hire performance
managers to think about cross-cutting issues across their agencies.
Dr. Sanchez said that in reorganizing and consolidating, they should consider the
expectations of the grants. He recalled feeling frustrated when health department dollars
were being spent on cardiovascular disease and stroke, which are medical care delivery
system issues. He wondered whether there is a more logical way to think about differences
in the ACA environment that obviates the need for some programs and focuses more on
how to bring public health and medical care delivery together, rather than to support clinical
practice. In terms of performance management, there is value in determining priorities and
where to invest dollars. Further, when things are moving fast, OSTLTS may help the
workgroup determine areas in which they can help and make a difference.
Dr. Fleming noted on the President’s Budget that the Preventive Health and Health Services
block grant was eliminated. There is a $580 million reduction in CDC’s budget. Public
health leadership and support is being reduced. The group examined the budget together,
noting changes.
Dr. Bal emphasized that chronic disease has been underfunded; however, it is easy to show
the burden of disease. He wondered whether CDC would have any discretion in reconciling
the budget cuts between the House and President’s budgets.

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Dr. Monroe said that epidemiologic capacity is important to CDC, and chronic disease is
important as well. Beyond that, she was not certain where the cuts and priorities fall.

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Dr. Farley asked about potential for changing this budget.

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Ms. Selecky said that the processes are very different this year. In previous years, the
Prevention Block Grants have been zeroed out. Coalitions of health groups have advocated
for its reinstatement. This year is different. Any alignments between the President’s Budget
and the House’s Budget are likely to remain the same.

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Dr. Fleming said that Dr. Monroe and Dr. Frieden would assess where the workgroup has
the best opportunities to be of assistance.

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Dr. Bal asked about the process between then and the April 2011 ACD meeting.

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Dr. Fleming answered that the small working group would synthesize the larger group’s
feedback on the recommendations. This document will be circulated to the group and
presented for additional comments and input. They will have an opportunity to present the
recommendations to ACD, whether they are a final product, or whether additional vetting
within CDC is needed.
Dr. Sanchez said that if they intend to bring a recommendation to the ACD in April, they
should do so quickly in order to refine language and expectations so the recommendations
make sense for CDC.
Dr. Fleming asked for feedback about the general structure of the meeting, or for other
thoughts beyond the agenda.
Ms. Loy said that they would convene a phone call when the group had time to digest the
President’s Budget. Dr. Fleming said that after the discussions with Dr. Frieden, they could
set an agenda for the call and schedule it for when they can convene the most people.
Ms. Selecky recommended that OSTLTS connect with Preparedness. The preparedness
grants have built a systemic infrastructure process over the last nine years, and the
reduction in that area was $72 million. OSTLTS could think about systems more broadly.

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Dr. Monroe answered that the cut in preparedness did not come as a surprise. She noted
that OSTLTS has good connections with Preparedness.

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Ms. Selecky hoped that they would look more comprehensively, beyond preparedness to
include how the business of public health is done.

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Dr. Fleming expressed his gratification at the group’s willingness to devote their time to the
group. He asked for thoughts regarding how to improve the group’s productivity.

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Dr. Farley felt that the process had worked well, and he applauded the approach of creating
a smaller group to create recommendations to act as a springboard for discussion.
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Dr. Sanchez said that OSTLTS should ask itself whether the process had been productive
for them, for CDC, and for Dr. Frieden.

With that, Dr. Fleming and Dr. Monroe thanked the group for their rich discussion and the
meeting was officially adjourned at 3:15 PM.

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Attendee Roster
Insert attendee roster here

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Appendix A
Insert “road map” here

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