Public Health 3.0: Integrating Primary Care and Mental Health Tools for the 21st Century

Abstract

Modern public health faces evolving challenges that necessitate a shift towards more integrated and community-focused strategies. The Public Health 3.0 model emerges as a response, urging leaders to become Chief Health Strategists who foster cross-sector partnerships and utilize data-driven approaches to tackle social, environmental, and economic factors impacting health and health equity. This article, based on national listening sessions and expert insights, explores the core principles of Public Health 3.0 and emphasizes its crucial role in integrating primary care with mental health tools to effectively address 21st-century health demands. We delve into key recommendations and actionable steps to realize this vision, ensuring communities are equipped to promote holistic well-being for all.

Introduction

The United States has witnessed significant strides in public health over the past century, marked by increased life expectancy and reduced rates of smoking and uninsurance (1, 2, 3). However, these advancements have not uniformly benefited all populations. Persistent racial, ethnic, and socioeconomic disparities in health outcomes, including life expectancy and infant mortality, highlight the limitations of the current system (4, 5). The stark reality is that a person’s zip code can often be a more potent predictor of health than their genetic makeup, underscoring the profound influence of social determinants of health (6, 7).

Addressing these deep-seated challenges requires a comprehensive approach that extends beyond traditional healthcare interventions. Factors such as education, safe environments, housing stability, transportation access, economic opportunities, and access to nutritious food—the social determinants of health—significantly shape an individual’s overall health and well-being (8). Recognizing this, communities across the nation are pioneering initiatives to improve health by positively influencing these determinants. These efforts range from enhancing educational attainment to fostering economic empowerment and building environments that support both physical and mental health. This proactive, community-centric approach is at the heart of Public Health 3.0, especially crucial as we consider integrating Primary Care Meets Mental Health Tools For The 21st Century.

The Pivotal Role of Social Determinants in Shaping Health Outcomes

The healthcare landscape is evolving, moving towards value-based care models that necessitate collaboration with community-based initiatives. The Centers for Disease Control and Prevention (CDC) has developed a framework that underscores the importance of integrating clinical interventions, community-based care extensions, and population-wide strategies (9). Public Health 3.0 primarily focuses on the latter two areas, recognizing that true population health improvement requires addressing factors beyond the confines of traditional clinical settings.

Alt: CDC’s Prevention Buckets Model: Clinical Interventions, Extended Care, Community-Wide Approaches for Public Health.

To achieve equitable health for all Americans, we must broaden our scope to encompass factors outside of healthcare. This necessitates building upon past successes and forging collaborations across diverse sectors to realize the fundamental essence of public health: Public health is our collective societal endeavor to create conditions where everyone can thrive healthily (10). This definition inherently incorporates the importance of mental health as a crucial component of overall well-being, demanding that primary care meets mental health tools for the 21st century within this framework.

The Evolution of Public Health Paradigms

The expanded mission of public health was initially highlighted in the 1988 Institute of Medicine (IOM, now the National Academy of Medicine) report, The Future of Public Health (10). This vision is even more critical today as communities demonstrate the tangible impact of local public health departments leading integrated health initiatives (11).

The 2002 IOM report, The Future of the Public’s Health in the 21st Century (12), further emphasized the need to strengthen governmental public health capacities and ensure accountability across all public health system sectors. However, chronic underfunding has plagued public health. Compared to healthcare spending, investments in upstream, non-medical determinants of health—such as social services, education, transportation, environmental protection, and housing programs—have been insufficient. This underinvestment has demonstrably hindered population health improvements (13). Furthermore, the 2008 recession triggered significant and sustained reductions in state and local public health expenditure (14). By 2012, nearly two-thirds of the US population resided in areas where local health departments reported budget-driven cuts to essential programs (15).

The fragility of the public health system and the consequences of its neglect are often starkly revealed during crises. Hurricane Katrina underscored that restoring healthcare services alone is inadequate to revitalize a community’s health system. Similarly, the Flint, Michigan, water crisis highlighted the devastating repercussions of neglecting health and environmental considerations in public decision-making. A robust public health infrastructure, effective leadership, actionable data, and adequate funding are paramount for communities to address fundamental health drivers and build resilience against crises, including those impacting mental health and demanding better integration of primary care meets mental health tools for the 21st century.

Public Health 3.0: A Modernized Approach for Contemporary Challenges

Public Health 3.0 builds upon the significant achievements of its predecessors (Figure 2). Public Health 1.0, spanning from the late 19th century through much of the 20th century, established modern public health as a core governmental function with specialized agencies at federal, state, local, and tribal levels. This era saw the systematization of sanitation, improvements in food and water safety, expanded understanding of diseases, development of crucial prevention and treatment tools like vaccines and antibiotics, and advancements in epidemiology and laboratory science. These scientific and organizational advancements made comprehensive public health protection—from effective primary prevention to science-based medical treatment and tertiary prevention—accessible to the general population.

Alt: Public Health Evolution Diagram: From Sanitation (1.0) to Chronic Disease Focus (2.0) to Social Determinants (3.0).

Public Health 2.0 emerged in the latter half of the 20th century, significantly influenced by the 1988 IOM report The Future of Public Health (10). This report argued that public health authorities were burdened by safety-net clinical care demands and ill-prepared to tackle the rising burden of chronic diseases and emerging threats like the HIV/AIDS epidemic. The IOM declared a national lapse in public health goals and a system in disarray.

In response, the IOM defined core public health functions, and practitioners developed performance standards for governmental public health agencies at all levels. The 2.0 era saw increasing professionalization within governmental public health agencies.

Public Health 3.0 represents a new era of expanded public health practice that transcends traditional departmental functions and programs. Cross-sectoral collaboration is central to Public Health 3.0, and the Chief Health Strategist role requires high-performing health organizations capable of driving collective action. Pioneering US communities are already implementing this approach, supported by various national initiatives, including those focused on integrating primary care meets mental health tools for the 21st century. This integration is vital as mental well-being is increasingly recognized as a fundamental aspect of public health.

Lessons from the Field: Community-Driven Public Health

Public Health 3.0 is fundamentally rooted in the idea that local communities will spearhead the advancement of public health. During the spring and summer of 2016, community visits across the US were conducted to assess the validity of the 5 key components of the Public Health 3.0 framework and to gather firsthand insights on policy and other changes needed to support and sustain community-level Public Health 3.0 efforts.

Five geographically and demographically diverse communities were selected, and listening sessions with approximately 100 participants in each were convened. Each session showcased successful multisectoral collaborations aimed at addressing social determinants of health. The communities included Allegheny County, Pennsylvania; Santa Rosa, California; Kansas City, Missouri; Nashville, Tennessee; and Spokane, Washington. They were chosen for their national recognition in multisectoral collaboration, strong local public health leadership, innovative data utilization, and funding models. They also had experience with public health department accreditation. Allegheny County, Pennsylvania, serves as a model, notably for its structured partnership supporting health and blending funding across governmental jurisdictions (16).

These listening sessions provided a platform for local leaders to share their knowledge, strategies, and ideas for effective Public Health 3.0 implementation. Participants represented diverse expertise beyond public health and healthcare. While each region presented unique challenges and successes, several common themes emerged across all meetings, particularly concerning the growing need to integrate primary care meets mental health tools for the 21st century within public health strategies.

Recommendations for Realizing Public Health 3.0 and Integrating Mental Health

Drawing upon insights from the public health community, leadership discussions, and reviews of frameworks for strengthening public health, five broad recommendations are proposed to establish the necessary conditions for health departments and the broader public health system to transition to the Public Health 3.0 model. Detailed actions are available in the Appendix and the full report (16).

1. Public health leaders must embrace the role of Chief Health Strategist for their communities. This involves collaborating with all relevant partners to drive initiatives that explicitly address upstream social determinants of health, including mental health. Specialized Public Health 3.0 training should be developed for the public health workforce and students, emphasizing the integration of primary care meets mental health tools for the 21st century.

   • While the local health officer often assumes this role, leadership can emerge from other sectors. Regardless, the public health workforce needs to enhance its knowledge, skills, and tools to address evolving population health challenges. This includes building strategic partnerships for collective impact, leveraging new data types, and adopting a systems perspective. A robust pipeline into the public health workforce and ongoing professional development resources are crucial, especially in areas like mental health integration with primary care.

2. Public health departments should actively engage community stakeholders to form structured, cross-sector partnerships. These partnerships, encompassing both public and private sectors, should be designed to guide Public Health 3.0 initiatives and foster shared funding, services, governance, and collective action, particularly in integrating primary care meets mental health tools for the 21st century.

   • Communities should develop innovative, sustainable organizational structures that include agencies and organizations across multiple sectors with a shared vision. This allows for blending and braiding funding sources, reinvesting savings, and creating long-term roadmaps for community health, equity, and resilience, including specific mental health initiatives and the primary care meets mental health tools for the 21st century paradigm.

3. Public Health Accreditation Board (PHAB) criteria and processes should be enhanced to foster Public Health 3.0 principles. This is essential to ensure that every person in the United States is served by nationally accredited health departments, equipped to address modern challenges including mental health needs and the integration of primary care meets mental health tools for the 21st century.

   • As of August 2016, approximately 80% of the US population was served by health departments accredited or in the process of accreditation (17). Achieving universal coverage by accredited health departments requires significant investment and political will. While accreditation supports quality improvement and capacity building (18), its health impact and return on investment should be continuously evaluated, especially concerning its effectiveness in promoting mental health integration in primary care.

4. Timely, reliable, granular-level, and actionable data should be accessible to communities nationwide. Clear metrics to document success in public health practice are needed to guide, focus, and assess the impact of prevention initiatives, including those targeting social determinants of health and enhancing equity, and crucially, those integrating primary care meets mental health tools for the 21st century.

   • Public and private sectors must collaborate to enable real-time, geographically granular data sharing, linking, and synthesis to inform action, while safeguarding data security and individual privacy. This includes developing core metrics encompassing healthcare, public health, social determinants, environmental outcomes, and health disparities, with specific indicators for mental health access and outcomes within primary care settings.

5. Funding for public health should be enhanced and substantially modified. Innovative funding models should be explored to expand financial support for Public Health 3.0 leadership and prevention initiatives, especially those focused on integrating primary care meets mental health tools for the 21st century. Blending and braiding funds from multiple sources, including revenue recapture and reinvestment, should be encouraged. Funding should support core infrastructure and community-level work addressing social determinants of health, including dedicated funds for mental health services and primary care integration.

   • To secure sufficient and flexible funding in a constrained environment, local public health needs a concrete definition of minimum capabilities, service delivery costs, and a structured review of funding streams to prioritize mandatory services and infrastructure building, with a strong emphasis on mental health and primary care integration initiatives.

Early Actions and Commitments

Following the report’s release, numerous public and private organizations pledged to advance its recommendations. The American Public Health Association endorsed it as a blueprint for public health’s future (19). Organizations committed to developing training for Chief Health Strategists (20) and building bridges between public health and clinical care systems (21). The US Department of Health and Human Services (HHS) implemented three priority recommendations, including extending accreditation status reporting to federal entities, establishing a social determinants of health workgroup, and initiating discussions on state-based opportunities to leverage health and human services resources to improve public health (21). Additionally, CDC’s Health Impact in 5 Years (HI-5) initiative (22) provides community-wide toolkits to address social determinants of health, demonstrating both health improvement and cost-effectiveness within five years. Community uptake of these resources can accelerate the impact of Public Health 3.0 collaborations, including those focused on primary care meets mental health tools for the 21st century.

Key Challenges and Barriers

Transitioning to a Public Health 3.0 model will be challenging for many communities. Despite funding stabilization, local health departments still face resource constraints, and potential federal public health spending reductions could have significant local impacts (23). Despite advancements like the Big Cities Project, the lack of nonproprietary tools for data, analytics, and metrics hinders actionable information access for many localities (23). Furthermore, daily statutory public health responsibilities and a lack of experience in cross-sector collaboration prevent many local health leaders from effectively acting as Chief Health Strategists, particularly in emerging areas like integrating primary care meets mental health tools for the 21st century. Finally, the basic structure of local governmental public health may itself impede efficient and cost-effective local coordination, especially when addressing complex issues like mental health integration.

Conclusion: A Vision for Equitable and Integrated Health

Public Health 3.0 represents an exciting era of innovation and transformation. This framework envisions a robust local public health infrastructure in every community, with leaders serving as Chief Health Strategists partnering across sectors to address social determinants of health, including mental health. Guided by principles of equity and social determinants of health, every individual and organization can share accountability for creating conditions where everyone can be healthy, regardless of background or circumstance, and where primary care meets mental health tools for the 21st century becomes a standard of care. Successful transformation can establish a foundation for an equitable, health-promoting system where stable, safe, and thriving communities are the norm. The Public Health 3.0 initiative seeks to inspire transformative successes seen in pioneering communities and replicate these triumphs across all communities, ensuring health for all. The urgent need now is to institutionalize this expanded community-based public health practice and broadly implement approaches that ensure primary care meets mental health tools for the 21st century, for the health of every person.

Acknowledgments

We thank the numerous communities and leaders who contributed to this work. The views expressed are those of the authors and do not necessarily represent the views of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). This article is intended to inform and stimulate discussion and is not a report of the NAM or the National Academies.

Author Information

Corresponding Author: Karen DeSalvo, MD, MPH, MSc, Former Acting Assistant Secretary of Health, US Department of Health and Human Services, 121 Rio Vista Ave, New Orleans, LA 70121. Telephone: 504-957-7094. Email: Karen.DeSalvo@gmail.com.

Author Affiliations: 1New Orleans, Louisiana. 2Columbia University, Mailman School of Public Health, New York, New York. 3Washington, DC. 4Trust for America’s Health, Washington, DC. 5Atlanta, Georgia. 6The Task Force for Global Health, Decatur, Georgia.

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