1.

Public Health Ambulatory Services

The delivery of ambulatory health services by state, county, or municipally supported governmen- tal
entities has its roots in the early American ethic of community responsibility for the care of needy
residents. Since the colonial period, altruistic citizens sought the charity of the community to provide for
the less fortunate by supporting the development of almshouses to care for the needy and for orphaned
children. Many of these institutions became the precursors of community hospitals.

With the evolution of state and local governments’ roles in providing welfare services, and the
development of the public health discipline in the late 1800s and early 1900s, tax-supported state and LHDs
began providing ambulatory personal health services. The public health community’s successful campaigns
in controlling childhood and other communicable diseases were rapidly followed by the recognition of the
emergence of chronic disease by the medical-care community. This recognition resulted in major shifts of
resources toward specialized medical care, to the detriment of public health’s preventive agenda. 105 In
addition to maintaining its basic mission to promote and protect the public’s health and safety, the public
health community was expected to mount new initiatives to promote healthy lifestyles, provide safety-net
services to needy populations, and expand regulatory oversight to accommodate the rapidly expanding
medical care industry.105

Ambulatory health services that became the domain of health departments included the administration of
preventive public health measures such as cancer and chronic disease screening, immunization, high-risk
maternal and infant care, family planning, tobacco control, and tuber- culosis and sexually transmitted
disease screening and treatment. Some LHDs also established FQHCs or other types of community health
centers to provide a range of primary care services to needy individuals of all ages.

Today the scope of ambulatory care services delivered by public health departments ranges across a wide
spectrum from prevention-oriented programs, such as immunizations, well-baby care, smoking cessation,
and cancer and chronic disease screening and education, to a full range of personal health services offered
through ambulatory care centers. Historically, support for ambu- latory public health services has included
combinations of city, county, and state funding, plus federal and state disease-specific or block grant funds.

Public health ambulatory services staff may include physicians, nurses, aides, social workers, public health
educators, community health workers, and clerical and administrative staff, who function under the overall
administrative direction of a local health officer. This health officer may or may not be a physician,
depending on the population size of the jurisdiction and individual state or municipal requirements.
Depending on the geographic area, the governmental aegis may be state, county, or city.

Findings of the National Association of County & City Health Officials (NACCHO) 2013 National Profile
of Local Health Departments reveal the extent to which LHDs are providing ambulatory services.106 The
following data is gleaned from the profile. With responses from 2,000 LHDs of 2,532 surveyed, the report
reveals that a significant proportion of local public health agencies continues to provide directly an array of
ambulatory services. As examples of the services most frequently provided, adult and child immunizations
top the list at 90 percent of respondents. Eighty-three percent of LHDs reported services to screen for
tuberculosis and 76 percent provided tuberculosis treatment. Sexually transmitted disease screening and
treat- ment were offered by 64 percent and 60 percent of LHDs, respectively. Fifty-five percent of
respondents reported providing family planning services. Few LHDs provide direct clinical ser- vices to
mothers and children, such as obstetrical care (8 percent), prenatal care (27 percent), and well-child clinics
(32 percent).

In 2015, NACCHO released results from another report, Findings from the 2015 Forces of Change Survey,
which highlights changes in LHD’s service constellations resulting from economics and the reforming
healthcare delivery system.107 The survey findings note that some LHDs have decreased clinical services
and that more than one-third of LHDs are serving fewer patients in clinics compared with the prior year.
Examples of changes include 14 per- cent reductions in immunizations, maternal and child health services,
and diabetes screen- ings. Possible reasons cited for service reductions and decreased clinic volume include
newly insured patients’ options due to the ACA, the growing availability of alternative providers such as
urgent care clinics, and LHD staffing constraints. Noting concomitant increases in population-oriented
services such as obesity prevention (24 percent) and tobacco, alcohol, and other drug prevention (23
percent), the report suggests that the ACA’s population empha- sis is influencing LHDs’ decisions about
use of resources in population-based, rather than individual service directions.

Ambulatory services of public health agencies are facing many challenges including con- strained resources
and the need to adapt to changes in the healthcare delivery system. LHDs rec- ognize their roles in
sustaining essential public health services in their communities and continue seeking additional revenue
streams, including billing for some clinical services, in order to remain as important resources for their
communities’ most vulnerable citizens.