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HomeMy WebLinkAbout2008- November File Copy • Jefferson County Board of 3-fealth .Agenda & Ivlinutes • .fovember 20, 2008 • • JEFFERSON COUNTY BOARD OF HEALTH Thursday November 20,2008 Pope Marine Building 100 Madison St. Port Townsend, WA 2:30—4:30 PM DRAFT AGENDA I. Approval of Agenda II. Approval of Minutes of October 16,2008 Board of Health Meeting III. Public Comments IV. Old Business and Informational Items 1. Substance Abuse Relapse Prevention Program—Jefferson County Jail 2. Main Street Program Letter V. New Business • 1. Public Health Fee Review 2. Puget Sound Partnership: Draft Action Plans for Strait of Juan de Fuca and Hood Canal 3. 2008 Solid Waste Program Report 4. Emergency Preparedness Mutual Aid Agreements: Multi-County and Multi-Tribes 5. Expedited Partner Therapy Program 6. Potential Appointment of Substance Abuse Advisory Board Member 7, 1:)Q pt ;_e_ror,, - 12_,L park VI. Activity Update VII. Agenda Planning VIII. Next Scheduled Meeting: December 18, 2008 2:30—4:30 PM Pope Marine Building • %%ct'A • JEFFERSON COUNTY BOARD OF HEALTH %%° MINUTES Thursday, October 16, 2008 2:30 PM—4:30 PM Pope Marine Building, Port Townsend Board Members Staff Members Phil Johnson, County Commissioner District#1 Thomas Locke,MD,Health Officer David Sullivan, County Commissioner,District#2 Jean Baldwin,Public Health Services Director John Austin, Chair, County Commissioner,District#3 Andrew Shogren,Environmental Health Director Chuck Russell,Hospital Commissioner,District#2 Julia Danskin,Nursing Services Director Michelle Sandoval,Port Townsend City Council Sheila Westerman, Vice Chair,Citizen at large(City) Roberta Frissell, Citizen at large(County) Chair John Austin called the meeting of the Jefferson County Board of Health to order at 2:35 PM in the Pope Marine Building, Port Townsend, WA. Members Present: John Austin, Roberta Frissell, Chuck Russell, Michelle Sandoval, David Sullivan, Sheila Westerman Members Excused: Phil Johnson • Ad Hoc Member Present: Frances Joswick, Substance Abuse Advisory Board Staff Present: Jean Baldwin, Dr. Thomas Locke, Andrew Shogren, Julia Danskin A quorum was present. APPROVAL OF AGENDA Chair Austin stated that there had been a request from the public to move Public Comment to the end of the meeting. Member Sheila Westerman made a motion to that effect,which was seconded by Member Russell and approved unanimously. APPROVAL OF MINUTES A typographical error was noted on page 3: 207 changed to 2007. A motion was made to approve the September 18, 2008 minutes, as amended. The motion was seconded and approved unanimously. • Page 1 of 9 October 16, 2008 4 OLD BUSINESS Public Health Funding News • Dr. Locke stated that there is an estimated $30 million shortfall in local health department budgets across the State and is concentrated in some of the largest counties. This reflects reductions in federal, state, and local funding and will impact core programs such as communicable disease control and maternal child health. The Washington Association of Counties (WSAC)and the Washington Association of Local Health Officials (WSALPHO) has asked the Legislature to revisit the issue of local public health funding. Dr. Locke referred to the WSAC/WSALPHO letter in the Board packet. He said that although the $100 million request may not be realistic in the face of an anticipated $3.2 billion state budget gap, the hope is to keep some of the critical programs pending continuing attempts to find a stable public health funding source. Jean Baldwin pointed out that larger health departments are subject to greater volatility than smaller ones, which have more diversified funding sources for services such as Family Planning. The larger counties have urging legislative action that would allow them to become junior taxing districts. She said that even if that happens, it can not help them right now. Both Snohomish County and King County were directed to spend down their reserves in anticipation of increased state funding; now both are in serious financial difficulty. Dr. Locke discussed another development related to finding the right source of funding. He said that at the recent annual meeting of the Washington State Medical Association (WSMA), a resolution was introduced to reaffirm WSMA's longstanding support for increased public health funding. Amendments were offered from the floor to link the public health funding to the overall health system budget. This is a significant step in the direction of viewing public health as an essential part of the overall health care system. Dr. Locke said that many public health • officials support this idea. Having only 1% of the state health care budget would be a major step forward. He said that most developed countries allocate 3 to 6 % of their health care budget to public health services. Member Westerman asked current levels of health care funding in Washington State. Dr. Locke said that nationally, 1% of health care funding is spent on public health and prevention. 96%is spent on personal medical care services and 3% is spent on research and training. In Washington State the proportions seem to be similar. He said that many public health proponents believe that public health is the key to cost containment and achievement of universal access to health care services. There must be a conscious plan for reducing demand for expensive services by effective illness and injury prevention programs. There is concern by some that funding public health as part of the larger health care system will created conflict with health care provides such as hospitals. Dr. Locke said that many believe that, at$2.2 trillion annually, there is sufficient existing funding to provide health care for everyone in the US and fund a world class public health system. Reprioritization and reallocation will be necessary and extremely difficult. Member Russell added that the system has been broken for many, many years. Member Austin asked if other programs such as Nurse Family Partnerships also have a wide variety of funding sources. Jean Baldwin said that that program is limited to first time mothers with low income. She said that DSHS and Maternal-Child Health allocations are first exhausted and then some funds come from General Fund or Child Protective Services contracts. The County General Fund is sprinkled throughout most of Maternal-Child Health and family support Page 2 of 9 October 16, 2008 programs/services. In response to a question about the overall General Fund contribution, she • indicated that to be about $900,000, which includes Environmental Health. Letter re: Mental Health and Substance Abuse Treatment Funding Jean Baldwin noted that the text of the letter to Lynn Kessler was included in the packet. Members made two corrections to the letter and Jean Baldwin suggested that the Chair sign on behalf of the BOH. David Sullivan moved for approval of the letter,which was seconded by Roberta Frissell. Sheila Westerman proposed a friendly amendment that the letter be signed by all members,which was accepted by Mr. Sullivan. The motion,with amendment,was approved unanimously. Public Health's "Ah-Ha" Moment Jean Baldwin called attention to an excerpt from a 1910 PT Leader article in the packet, and the persistence of certain fundamental issues facing the Health Department. Dr. Locke discussed the article "Public Health's A-ha! Moment and What it Means for the American People" by Dr. Risa Livizzo-Mourey. He called attention to the paradox: This is a moment of crisis, under-funding and potential collapse for public health just at the moment in history when increased investment in public health is being seen as a key strategy in resolving the broader health care access crisis. He noted that the methods and information technology used by public health are not applied as widely to our national health goals as they could and should be. John Austin cited an example involving a State Board of Health recommendation to the Legislature for school health and safety measures; he noted the challenge to provide funding and • the repercussions when needs, regulations and funding are not in alignment. NEW BUSINESS 2008 Standards for Public Health Practice: Jefferson County Public Health Site Report Jean Baldwin acknowledged the challenge of explaining the Standards, which are performance management indicators for the Public Health system, both state and local. There are 12 standards and a variety of measures for each one. Every local health department or district is visited every three years to evaluate their performance with respect to the Standards. She said that Jefferson County Public Health documents much of its standards performance on its web site and in paper archives. Ms. Baldwin said that the standards have changed significantly since the last review in 2005 with the addition of 7 new categories for evaluation. She referred to "Standards for Public Health in Washington" slides, which list the 12 standards and summarizes the purpose, scope and process. The goal is for Public Health infrastructure to be consistent in all counties throughout the State, although the funding is very different across the state. The Standards review process evaluates progress towards this goal and allows comparison within peer groups of local health jurisdictions. Strengths and areas in need of improvement are indicated by the reviewers. Ms. Baldwin briefly reviewed key elements of the Fact Sheet and the Questions and Answers provided in the packet. Standards were developed to provide consistent health and safety standards across the State. For example,restaurant patrons are assured of proper food handling • and preparation wherever they travel in Washington State. She explained that the survey is done by an independent firm, MCPP Healthcare Consulting, Inc., along with state and local reviewers; Page 3 of 9 October 16, 2008 i the resulting report has been used by JLARC (Joint Legislative Audit and Review Committee)as a basis for evaluating the public health system. Each county receives its own scores and the overall State scores. She reviewed the list of 12 standards and a sampling of the measurements. • With regard to "Address gaps in critical health services", she noted that Dr. Locke works with Jefferson Healthcare and several state and regional health access partnerships and the Health Department has stepped in to provide services as needed. She reminded that evaluators base their review on activities that have been documented. Jefferson County did very well in comparison to both its peer group (Small Town/Rural) and the combined LHJs (Local Health Jurisdictions) across the State. Ms. Baldwin said that one of the key strengths cited was the involvement of the BOH in health department activities and decisions, including the review of community health data. Jean reviewed the areas for improvement and discussed the next steps development of work plans. This particular audit looked at the Food program, the Maternal/Child Health program and the Communicable Disease program; Ms. Baldwin commended those teams for their achievements. She also noted that a large number of forms and policies/procedures will be listed as Exemplary Practices on the State DOH website. Member Westerman asked about the rationale for not sharing or publishing all county scores. She said this information would be of interest to businesses or individuals who are considering locating in a particular area and could be helpful if used in a collaborative spirit statewide. Staff • noted that informal collaboration among jurisdictions does occur at the operational level. Dr. Locke said all of this information is publicly available and could be compiled and published in the media, if so desired. The argument for a less than totally open approach rests on the fact that these are "stretch standards", or optimal practices, not minimum standards that should be met. No county would wish to see itself at the bottom of a ranked list. Dr. Locke added that the more detailed report was in excess of 60 pages long; copies can be provided for those who would like to read the full report. Chair Austin suggested that a press release could be developed to share this positive news. Member Westerman agreed, noting the need to make it easily understood. Staff agreed to draft such a press release. Immunization Program Update: Immunization Program Review, 5930 Funding Activities, and Adult Vaccination Program Immunization Program Review—Jean Baldwin referred to the Site Visit Summary Report for the Immunization Program and CHILD profile. She noted the excellent results of this State review: The Jefferson County Health District Immunization Program is in full compliance, and no further follow up is required in 2008. According to the report, "This program has the highest standards of practice for immunization service delivery and program administration." Lisa McKenzie provided additional information on the program and the annual review, noting the limited State funding of$11,000/year for the program. She credited Jane Kurata for her huge • contribution in ensuring the quality and effectiveness of this program. Page 4 of 9 October 16, 2008 • Hepatitis Vaccines—Ms. McKenzie gave an overview of new hepatitis-related services. She said that in the past there have always been state subsidized vaccine programs for children, 18 and under, but there has been no subsidized vaccine or testing for adults. There are two new programs for high risk adults age 19 and over available. Free adult Hepatitis A& B combination vaccine (Twinrix) and free adult Hepatitis C testing are available. Outreach is being done to health care providers to encourage referral for these services. Member Austin asked if working in areas following floods and hurricanes is considered a risk factor for hepatitis. Ms. McKenzie said that medical workers should be vaccinated for Hepatitis B. Some public health experts recommended Hepatitis A vaccination for Hurricane Katrina responders although no outbreaks of Hepatitis A were documented. Dr. Locke noted that exposure to fecal material after a flood is a potential risk factor but Hepatitis A is quite rare in the US. It has been shown that sewage workers, who are routinely exposed to sewage, do not have increased risk of contracting Hepatitis A. However, there is a strong recommendation for vaccination when traveling in other parts of the world where Hepatitis A is more common. A third program is expected to provide free HPV vaccine (Gardasil) for low income, uninsured women age 19—26, and will be available later in the year through the State DOH and Merck Pharmaceuticals. The vaccine is expensive, $130 per dose, and three doses are required. Since this is a six month pilot program, extensive outreach efforts will be necessary. The Health Department has been collecting names of interested patients and providers who will be contacted when the program gets underway. Gardasil is effective against two cancer causing strains and • two venereal warts strains of HPV. Dr. Locke said that another less expensive vaccine designed to be effective only against the two cancer causing strains of HPV will soon be marketed. 5930 Funding Activities—Ms. McKenzie called attention to the three Immunization Program BOH Updates. The first is about the HPV Vaccine program which started in May 2007. The Health Department administered the vaccine to girls of ages 11- 18 at a rate of about 5 to 13 doses per month. In March 2008, JCPH Family Planning Nurse Practitioners began administering the vaccines in Family Planning Clinics. The rate now is between 23and 30 doses per month. In response to a question about State Funding, Jean Baldwin said the 5930 money ($103,000) was appropriated by the Legislature in lieu of more comprehensive public health system funding and is being used statewide to improve immunizations and communicable disease control. If statewide progress is achieved, additional funds may follow. There are various sources for vaccine funding, including Vaccines for Children, a federal program for those meeting low income criteria. The State money comes from the State General Fund and is applicable for all children. Dr. Locke said that Washington is one of a dwindling number of states with what is known as "universal distribution" system for childhood immunizations—all childhood vaccines are paid for by either federal or state funding. Julia Danskin pointed out that Jefferson County has melded Family Planning with Communicable Disease and Immunization in a unique way allowing more effective use of resources. Lisa McKenzie briefly described how the department has also increased the use of Rotavirus vaccine since it became available from the State. The new South County Immunization Clinic was initiated and organized by Jane Kurata and • local nurse Dyan Arnesen in response to the low immunization rates of children in the area. This Clinic is operating collaboratively with the Brinnon and Quilcene schools, as well as the JCPH Page 5 of 9 October 16, 2008 WIC and Family Planning clinic in Quilcene, who provide referrals for the State supplied vaccine program. Ms. McKenzie also discussed additional training to help school secretaries and others support the program by following up with parents and guardians. She also mentioned the • efforts to reduce the number of immunization exemptions in the population. The school exemption rates for all schools, (not including home schools), is about 11-12%. The immunization rates for two-year olds, County-wide, is among the worst in the State. Jean Baldwin said that the department is moving more services to school age children, since parents are more open to immunization at this stage. There was further discussion about conflicting philosophical positions that can be taken by parents with regard to certain immunizations. Michelle Sandoval suggested that sensitivity to parents' fears and concerns would be advisable; she suggested that philosophical choices should not be labeled as problems or non-compliance. Dr. Locke said that, based on new state data, the vaccination exemption trend in Jefferson County is going in the wrong direction. The exemption rates are climbing state-wide. As greater percentages of the population become susceptible to vaccine-preventable diseases, the risk of disease outbreaks like mumps and measles increases. He said there is a new initiative by the American Academy of Pediatrics and Academy of Family Practitioners to address this at a one- on-one encounter level. For those who have philosophical objections, it is important for health care providers to listen to these concerns and address them directly. Ultimately, parents are urged to base their decisions on the best available information regarding the benefits and risks of vaccines. He said the link between autism and the vaccine preservative has been conclusively disproven. With regard to exemptions, there are three categories allowed by state statute: medical (i.e. patient is allergic to the vaccine), religious, which are rare; and philosophical or personal, the most common type of exemptions. The third update concerns the state-wide web-based CHILD (Children's Health Immunizations • Linkages and Development) Profile Immunization Registry. Ms. McKenzie said that this database has been in use in Jefferson County since 1991. Recently,there has been intensified training and follow up to ensure that all Jefferson Healthcare Clinics and the South County Clinic, in addition to the Health Department, use this system. The great advantage of this registry is that immunization records are available for children wherever they move within the State. Substance Abuse Advisory Board Presentation Frances Joswick, Chair of the Substance Abuse Advisory Board (SAAB), reported on the new prevention program at the County Jail. She said the program design and implementation had been approved by the SAAB and had begun three weeks ago. A group of women meet with their Safe Harbor counselor weekly, and a separate group of men meet also weekly with their counselor. There is also a mid-week AA group for men with intentions to form a women's AA group as well. She said this program was requested by the jail inmates. Nurse Pat Wiggins assesses each new inmate for substance abuse and mental health issues, so is able to provide current and relevant data. According to Steve Richards, Supervisor at the jail, there are indications that the recidivism rate is 70%. He is currently verifying that the recidivism rate includes only those admissions that relate to drug and alcohol abuse, not assaults or other types of crimes. Housing following discharge has been a challenge. It is expected that the first"sober house" will • be available in Quilcene within the next several months,to be provided by a nurse who is herself Page 6 of 9 October 16, 2008 in recovery. There will be accommodations for up to four women; establishment of a weekly 12- • step AA meeting is also planned. Ms. Joswick said that the SAAB is excited about being able to take tangible steps toward reducing the recidivism rate, and to increase outreach and education within the community about these issues. Jean Baldwin commented that there is a Board that oversees the administration of the one tenth of one percent tax authorized by the BOCC. The composition includes two people each from the SAAB (Ann Winegar and Catharine Robinson) and the BOH (Sheila Westerman and John Austin), two people from the law and justice community (Barbara Carr and Conner Daly) and one person from the City (Catharine Robinson). The jail nurse, Pat Wiggins, is paid through a portion of this funding. Member Westerman said she believes that this has been a very good use of the funds to focus on prevention, and agrees that Ms. Wiggins is absolutely perfect for this position. Ms. Joswick pointed out that although Ms. Wiggins is only paid for 20 hours per week, she is always available for day time meetings/hours and works many additional hours. Public Health Fees Discussion Jean Baldwin said that every two years, fees are updated based on review of actual costs. This was not done last year, as scheduled, for Environmental Health. Also, the State DOH required a cost analysis for Community Health Family Planning program using a specific proscribed method; a very in-depth analysis was done for Family Planning. When complete, the same process will be followed for Environmental Health. This consists of a comparison with other counties' current charges; a differential based on the cost of living index; and actual costs. She noted that the fees may not actually match the actual cost in today's market. Julia Danskin explained that in Community Health nursing, typically and historically, fees were based on what was reimbursable by Medical Assistance. Sixty percent of clients qualified for Medical Assistance. Since 2001, federal requirements have been that fees should be based on cost analysis. Last year, the State provided tools, i.e. formulas and templates, and required that cost analysis be done; Jefferson Public Health agreed to do so within about one year of October 2008. Jean Baldwin noted that moving to full actual costs likely needs to be done in a step-wise fashion over 2 or 3 years. Kitsap County also plans to phase in fee increases. The figures shown for Kitsap have been passed by their Board, but actual costs are higher. Julia Danskin said Gray's Harbor is involved in a similar process. Mason, Clallam and Island Counties do not have Family Planning programs or federal contracts in their health departments. Jean Baldwin noted that gaps on the draft sheets will be filled in; fees will also be developed for Immunizations and Environmental Health. Mr. Morley asked for clarification on the fees shown in column 2 versus the number of years expected for phase-in. Veronica Shaw said she had assumed 3 years, although the calculations must take into account annual CPI allowances and other factors, as well. Additionally,the economy has shifted dramatically during the period of analysis. Jean Baldwin added that the time period of three years would need to be approved by the BOH. Member Sullivan suggested adding a column showing the actual cost on the spreadsheet. Member Russell asked how often • this fee is actually paid. Julia Danskin noted that in 2007 Family Planning had 2012 visits. Of those visits, 66%were Medical Assistance patients. There was a brief discussion about the Page 7 of 9 October 16, 2008 remaining 34% and sliding scale fees. Member Westerman asked if a phased in approach is possible for different categories of patients. She asked if the full cost can be charged to those with private insurance and the Medical Assistance related charges can be phased in. Jean Baldwin pointed out that if insurance denies a charge, the Health Department then rebills on a sliding scale, based on federal poverty guidelines. Staff does not anticipate increases in reimbursement from Medical Assistance. Jean Baldwin said that the Health Department is permitted to raise its fees monthly or quarterly to remain in synch with increases in Medical Assistance allowances. Staff indicated that they would follow up on Michelle Sandoval's inquiry about the "Other" category, i.e. she wished to know if this was a Paid category. Member Russell noted that the Hospital's sliding scale goes up to 400%of federal poverty guidelines, per the recommendations from the State Hospital Association. Member Austin asked if staff believed that patients may be scared away by the size of the full fees. Veronica Shaw said that staff routinely explains the sliding scale fees, which usually allays any concerns on the part of the patients. Medicare patients are referred to other providers who have Medicare contracts, but encouraged to come back if they cannot obtain medical services elsewhere. Jean Baldwin noted that travelers have complained about paying the $60 nurse visit fee. However, she said this is an expensive visit, actually not fully covered by the fee. Other counties generally charge more. One accommodation is to charge less for the second person, when two people are traveling together. There was acknowledgement that even these visits are subsidized by taking advantage of State supplied vaccines. Staff also mentioned that reviewers have been impressed by the insurance billing infrastructure; • over 30 insurers are accepted and billed. Jean Baldwin said that the department saves money by maximizing this process. There was further discussion regarding the plan for phasing in the full fee and consideration of whether or not to do this all at once or over a three year period. Member Westerman was concerned that the existence of the Family Planning program would be threatened by under funding. She urged that there be further discussion about the strategy and projections. Veronica Shaw noted that there would be better information by the next meeting after all the line item costs and fees have been determined. Member Westerman said she agreed with Member Sullivan that actual costs would be helpful, and that the comparison with other counties was very useful. As possible, staff will gather comparison data from other counties with Family Planning services or Planned Parenthood. They will also show impacts on patients paying partial fees and data about percent of paid, etc. If possible, staff will set up the modeling software tools so that various parameters can be changed and viewed dynamically during the meeting. Chair Austin suggested postponement of the Environmental Health data discussion until the following meeting. BOH members were asked to retain their copies of the most recent versions of the packet sheets. Jean Baldwin said that the intention is to provide better information on real costs, especially Environmental Health whose fees have not been based on actual costs in the • past. Page 8 of 9 October 16, 2008 Several members recalled that a similar cost analysis had been done by a task force six years ago. • Member Westerman said it is important to acknowledge that work and for the public to understand the policy basis for fees and fee increases. She said that group had represented a cross section of the community and, by the end of that process, had come to agreement that fees should be based on costs. Jean Baldwin added information about timing. She said that usually fee changes are made only once per year in January. She said it would be well to link the fee discussions to the budget process and complete the determination of new fees by December. Agenda item, Expedited Partner Therapy program, was postponed until the next meeting. Staff also called attention to Flu vaccine and tire recycling event fliers. PUBLIC COMMENTS Norman MacLeod referred to an earlier mention of mental health parity. He said that the recent financial bailout provisions had been tacked on as an amendment to an existing Senate bill, i.e. the Mental Health Parity bill. Mr. MacLeod said he was pleased to hear that certain government officials within the County and the State recognize the existence of a serious economic problem. ADJOURNMENT • Roberta Frissell moved to adjourn and David Sullivan seconded. Chair Austin adjourned the meeting at 4:44 PM. JEFFERSON COUNTY BOARD OF HEALTH John Austin, Chair Sheila Westerman, Vice Chair Roberta Frissell, Member Chuck Russell, Member Excused Phil Johnson, Member David Sullivan, Member Michelle Sandoval, Member • Page 9 of 9 October 16, 2008 l • JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, October 16, 2008 2:30 PM—4:30 PM Pope Marine Building, Port Townsend Board Members Staff Members Phil Johnson, County Commissioner District#1 Thomas Locke,MD,Health Officer David Sullivan, County Commissioner,District#2 Jean Baldwin,Public Health Services Director John Austin, Chair, County Commissioner,District#3 Andrew Shogren,Environmental Health Director Chuck Russell,Hospital Commissioner,District#2 Julia Danskin,Nursing Services Director Michelle Sandoval,Port Townsend City Council Sheila Westerman, Vice Chair, Citizen at large(City) Roberta Frissell, Citizen at large(County) Chair John Austin called the meeting of the Jefferson County Board of Health to order at 2:35 PM in the Pope Marine Building, Port Townsend, WA. Members Present: John Austin, Roberta Frissell, Chuck Russell, Michelle Sandoval, David Sullivan, Sheila Westerman Members Excused: Phil Johnson Ad Hoc Member Present: Frances Joswick, Substance Abuse Advisory Board Staff Present: Jean Baldwin, Dr. Thomas Locke, Andrew Shogren, Julia Danskin A quorum was present. APPROVAL OF AGENDA Chair Austin stated that there had been a request from the public to move Public Comment to the end of the meeting. Member Sheila Westerman made a motion to that effect,which was seconded by Member Russell and approved unanimously. APPROVAL OF MINUTES A typographical error was noted on page 3: 207 changed to 2007. A motion was made to approve the September 18,2008 minutes, as amended. The motion was seconded and approved unanimously. • Page 1 of 9 October 16, 2008 r OLD BUSINESS Public Health Funding News • Dr. Locke stated that there is an estimated $30 million shortfall in local health department budgets across the State and is concentrated in some of the largest counties. This reflects reductions in federal, state, and local funding and will impact core programs such as communicable disease control and maternal child health. The Washington Association of Counties (WSAC) and the Washington Association of Local Health Officials (WSALPHO)has asked the Legislature to revisit the issue of local public health funding. Dr. Locke referred to the WSAC/WSALPHO letter in the Board packet. He said that although the $100 million request may not be realistic in the face of an anticipated $3.2 billion state budget gap, the hope is to keep some of the critical programs pending continuing attempts to find a stable public health funding source. Jean Baldwin pointed out that larger health departments are subject to greater volatility than smaller ones, which have more diversified funding sources for services such as Family Planning. The larger counties have been urging legislative action that would allow them to become junior taxing districts. She said that even if that happens, it can not help them right now. Both Snohomish County and King County were directed to spend down their reserves in anticipation of increased state funding; now both are in serious financial difficulty. Dr. Locke discussed another development related to finding the right source of funding. He said that at the recent annual meeting of the Washington State Medical Association(WSMA), a resolution was introduced to reaffirm WSMA's longstanding support for increased public health funding. Amendments were offered from the floor to link the public health funding to the overall health system budget. This is a significant step in the direction of viewing public health as an essential part of the overall health care system. Dr. Locke said that many public health officials support this idea. Having only 1% of the state health care budget would be a major step forward. He said that most developed countries allocate 3 to 6 % of their health care budget to public health services. Member Westerman asked about current levels of health care funding in Washington State. Dr. Locke said that nationally, 1% of health care funding is spent on public health and prevention. 96% is spent on personal medical care services and 3% is spent on research and training. In Washington State the proportions seem to be similar. He said that many public health proponents believe that public health is the key to cost containment and achievement of universal access to health care services. There must be a conscious plan for reducing demand for expensive services by effective illness and injury prevention programs. There is concern by some that funding public health as part of the larger health care system will created conflict with health care provides such as hospitals. Dr. Locke said that many believe that, at $2.2 trillion annually, there is sufficient existing funding to provide health care for everyone in the US and fund a world class public health system. Reprioritization and reallocation will be necessary and extremely difficult. Member Russell added that the system has been broken for many, many years. Member Austin asked if other programs such as Nurse Family Partnerships also have a wide variety of funding sources. Jean Baldwin said that that program is limited to first time mothers with low income. She said that DSHS and Maternal-Child Health allocations are first exhausted and then some funds come from General Fund or Child Protective Services contracts. The • County General Fund is sprinkled throughout most of Maternal-Child Health and family support Page 2 of 9 October 16, 2008 programs/services. In response to a question about the overall General Fund contribution, she • indicated that to be about $900,000, which includes Environmental Health. Letter re: Mental Health and Substance Abuse Treatment Funding Jean Baldwin noted that the text of the letter to Lynn Kessler was included in the packet. Members made two corrections to the letter and Jean Baldwin suggested that the Chair sign on behalf of the BOH. David Sullivan moved for approval of the letter,which was seconded by Roberta Frissell. Sheila Westerman proposed a friendly amendment that the letter be signed by all members,which was accepted by Mr. Sullivan. The motion,with amendment,was approved unanimously. Public Health's "Ah-Ha" Moment Jean Baldwin called attention to an excerpt from a 1910 PT Leader article in the packet, and the persistence of certain fundamental issues facing the Health Department. Dr. Locke discussed the article "Public Health's A-ha! Moment and What it Means for the American People"by Dr. Risa Livizzo-Mourey. He called attention to the paradox: This is a moment of crisis, under-funding and potential collapse for public health just at the moment in history when increased investment in public health is being seen as a key strategy in resolving the broader health care access crisis. He noted that the methods and information technology used by public health are not applied as widely to our national health goals as they could and should be. John Austin cited an example involving a State Board of Health recommendation to the • Legislature for school health and safety measures; he noted the challenge to provide funding and the repercussions when needs, regulations and funding are not in alignment. NEW BUSINESS 2008 Standards for Public Health Practice: Jefferson County Public Health Site Report Jean Baldwin acknowledged the challenge of explaining the Standards, which are performance management indicators for the Public Health system, both state and local. There are 12 standards and a variety of measures for each one. Every local health department or district is visited every three years to evaluate their performance with respect to the Standards. She said that Jefferson County Public Health documents much of its standards performance on its web site and in paper archives. Ms. Baldwin said that the standards have changed significantly since the last review in 2005 with the addition of 7 new categories for evaluation. She referred to "Standards for Public Health in Washington" slides, which list the 12 standards and summarizes the purpose, scope and process. The goal is for Public Health infrastructure to be consistent in all counties throughout the State, although the funding is very different across the state. The Standards review process evaluates progress towards this goal and allows comparison within peer groups of local health jurisdictions. Strengths and areas in need of improvement are indicated by the reviewers. Ms. Baldwin briefly reviewed key elements of the Fact Sheet and the Questions and Answers provided in the packet. Standards were developed to provide consistent health and safety standards across the State. For example, restaurant patrons are assured of proper food handling • and preparation wherever they travel in Washington State. She explained that the survey is done by an independent firm, MCPP Healthcare Consulting, Inc., along with state and local reviewers; Page 3 of 9 October 16, 2008 the resulting report has been used by JLARC (Joint Legislative Audit and Review Committee) as a basis for evaluating the public health system. Each county receives its own scores and the • overall State scores. She reviewed the list of 12 standards and a sampling of the measurements. With regard to "Address gaps in critical health services", she noted that Dr. Locke works with Jefferson Healthcare and several state and regional health access partnerships and the Health Department has stepped in to provide services as needed. She reminded that evaluators base their review on activities that have been documented. Jefferson County did very well in comparison to both its peer group (Small Town/Rural) and the combined LHJs (Local Health Jurisdictions) across the State. Ms. Baldwin said that one of the key strengths cited was the involvement of the BOH in health department activities and decisions, including the review of community health data. Jean reviewed the areas for improvement and discussed the next steps development of work plans. This particular audit looked at the Food program, the Maternal/Child Health program and the Communicable Disease program; Ms. Baldwin commended those teams for their achievements. She also noted that a large number of forms and policies/procedures will be listed as Exemplary Practices on the State DOH website. Member Westerman asked about the rationale for not sharing or publishing all county scores. She said this information would be of interest to businesses or individuals who are considering locating in a particular area and could be helpful if used in a collaborative spirit statewide. Staff • noted that informal collaboration among jurisdictions does occur at the operational level. Dr. Locke said all of this information is publicly available and could be compiled and published in the media, if so desired. The argument for a less than totally open approach rests on the fact that these are "stretch standards", or optimal practices, not minimum standards that should be met. No county would wish to see itself at the bottom of a ranked list. Dr. Locke added that the more detailed report was in excess of 60 pages long; copies can be provided for those who would like to read the full report. Chair Austin suggested that a press release could be developed to share this positive news. Member Westerman agreed, noting the need to make it easily understood. Staff agreed to draft such a press release. Immunization Program Update: Immunization Program Review, 5930 Funding Activities, and Adult Vaccination Program Immunization Program Review—Jean Baldwin referred to the Site Visit Summary Report for the Immunization Program and CHILD profile. She noted the excellent results of this State review: The Jefferson County Health District Immunization Program is in full compliance, and no further follow up is required in 2008. According to the report, "This program has the highest standards of practice for immunization service delivery and program administration." Lisa McKenzie provided additional information on the program and the annual review, noting the limited State funding of$11,000/year for the program. She credited Jane Kurata for her huge • contribution in ensuring the quality and effectiveness of this program. Page 4 of 9 October 16, 2008 . Hepatitis Vaccines—Ms. McKenzie gave an overview of new hepatitis-related services. She said that in the past there have always been state subsidized vaccine programs for children, 18 and under, but there has been no subsidized vaccine or testing for adults. There are two new programs for high risk adults age 19 and over available. Free adult Hepatitis A & B combination vaccine (Twinrix) and free adult Hepatitis C testing are available. Outreach is being done to health care providers to encourage referral for these services. Member Austin asked if working in areas following floods and hurricanes is considered a risk factor for hepatitis. Ms. McKenzie said that medical workers should be vaccinated for Hepatitis B. Some public health experts recommended Hepatitis A vaccination for Hurricane Katrina responders although no outbreaks of Hepatitis A were documented. Dr. Locke noted that exposure to fecal material after a flood is a potential risk factor but Hepatitis A is quite rare in the US. It has been shown that sewage workers, who are routinely exposed to sewage, do not have increased risk of contracting Hepatitis A. However, there is a strong recommendation for vaccination when traveling in other parts of the world where Hepatitis A is more common. A third program is expected to provide free HPV vaccine (Gardasil) for low income, uninsured women age 19—26, and will be available later in the year through the State DOH and Merck Pharmaceuticals. The vaccine is expensive, $130 per dose, and three doses are required. Since this is a six month pilot program, extensive outreach efforts will be necessary. The Health Department has been collecting names of interested patients and providers who will be contacted when the program gets underway. Gardasil is effective against two cancer causing strains and • two venereal warts strains of HPV. Dr. Locke said that another less expensive vaccine designed to be effective only against the two cancer causing strains of HPV will soon be marketed. 5930 Funding Activities—Ms. McKenzie called attention to the three Immunization Program BOH Updates. The first is about the HPV Vaccine program which started in May 2007. The Health Department administered the vaccine to girls of ages 11- 18 at a rate of about 5 to 13 doses per month. In March 2008, JCPH Family Planning Nurse Practitioners began administering the vaccines in Family Planning Clinics. The rate now is between 23and 30 doses per month. In response to a question about State Funding, Jean Baldwin said the 5930 money ($103,000) was appropriated by the Legislature in lieu of more comprehensive public health system funding and is being used statewide to improve immunizations and communicable disease control. If statewide progress is achieved, additional funds may follow. There are various sources for vaccine funding, including Vaccines for Children, a federal program for those meeting low income criteria. The State money comes from the State General Fund and is applicable for all children. Dr. Locke said that Washington is one of a dwindling number of states with what is known as "universal distribution" system for childhood immunizations—all childhood vaccines are paid for by either federal or state funding. Julia Danskin pointed out that Jefferson County has melded Family Planning with Communicable Disease and Immunization in a unique way allowing more effective use of resources. Lisa McKenzie briefly described how the department has also increased the use of Rotavirus vaccine since it became available from the State. The new South County Immunization Clinic was initiated and organized by Jane Kurata and 1111 local nurse Dyan Arnesen in response to the low immunization rates of children in the area. This Clinic is operating collaboratively with the Brinnon and Quilcene schools, as well as the JCPH Page 5 of 9 October 16, 2008 WIC and Family Planning clinic in Quilcene, who provide referrals for the State supplied vaccine program. Ms. McKenzie also discussed additional training to help school secretaries and . others support the program by following up with parents and guardians. She also mentioned the efforts to reduce the number of immunization exemptions in the population. The school exemption rates for all schools, (not including home schools), is about 11-12%. The immunization rates for two-year olds, County-wide, is among the worst in the State. Jean Baldwin said that the department is moving more services to school age children, since parents are more open to immunization at this stage. There was further discussion about conflicting philosophical positions that can be taken by parents with regard to certain immunizations. Michelle Sandoval suggested that sensitivity to parents' fears and concerns would be advisable; she suggested that philosophical choices should not be labeled as problems or non-compliance. Dr. Locke said that, based on new state data, the vaccination exemption trend in Jefferson County is going in the wrong direction. The exemption rates are climbing state-wide. As greater percentages of the population become susceptible to vaccine-preventable diseases, the risk of disease outbreaks like mumps and measles increases. He said there is a new initiative by the American Academy of Pediatrics and Academy of Family Practitioners to address this at a one- on-one encounter level. For those who have philosophical objections, it is important for health care providers to listen to these concerns and address them directly. Ultimately, parents are urged to base their decisions on the best available information regarding the benefits and risks of vaccines. He said the link between autism and the vaccine preservative has been conclusively disproven. With regard to exemptions,there are three categories allowed by state statute: medical (i.e. patient is allergic to the vaccine), religious, which are rare; and philosophical or personal, the most common type of exemptions. The third update concerns the state-wide web-based CHILD (Children's Health Immunizations • Linkages and Development) Profile Immunization Registry. Ms. McKenzie said that this database has been in use in Jefferson County since 1991. Recently, there has been intensified training and follow up to ensure that all Jefferson Healthcare Clinics and the South County Clinic, in addition to the Health Department, use this system. The great advantage of this registry is that immunization records are available for children wherever they move within the State. Substance Abuse Advisory Board Presentation Frances Joswick, Chair of the Substance Abuse Advisory Board (SAAB), reported on the new relapse prevention program at the County Jail. She said the program design and implementation had been approved by the SAAB and had begun three weeks ago. A group of women meet with their Safe Harbor counselor weekly, and a separate group of men meet also weekly with their counselor. There is also a mid-week AA group for men with intentions to form a women's AA group as well. She said this program was requested by the jail inmates. Nurse Pat Wiggins assesses each new inmate for substance abuse and mental health issues, so is able to provide current and relevant data. According to Steve Richards, Supervisor at the jail, there are indications that the recidivism rate is 70%. He is currently verifying that the recidivism rate includes only those admissions that relate to drug and alcohol abuse, not assaults or other types of crimes. Housing following discharge has been a challenge. It is expected that the first"sober house" will • be available in Quilcene within the next several months, to be provided by a nurse who is herself Page 6 of 9 October 16, 2008 in recovery. There will be accommodations for up to four women; establishment of a weekly 12- • step AA meeting is also planned. Ms. Joswick said that the SAAB is excited about being able to take tangible steps toward reducing the recidivism rate, and to increase outreach and education within the community about these issues. Jean Baldwin commented that there is a Board that oversees the administration of the one tenth of one percent tax authorized by the BOCC. The composition includes two people each from the SAAB (Ann Winegar and Catharine Robinson) and the BOH (Sheila Westerman and John Austin), two people from the law and justice community(Barbara Carr and Conner Daly) and one person from the City (Catharine Robinson). The jail nurse, Pat Wiggins, is paid through a portion of this funding. Member Westerman said she believes that this has been a very good use of the funds to focus on prevention, and agrees that Ms. Wiggins is absolutely perfect for this position. Ms. Joswick pointed out that although Ms. Wiggins is only paid for 20 hours per week, she is always available for day time meetings/hours and works many additional hours. Public Health Fees Discussion Jean Baldwin said that every two years, fees are updated based on review of actual costs. This was not done last year, as scheduled, for Environmental Health. Also, the State DOH required a cost analysis for Community Health Family Planning program using a specific proscribed method; a very in-depth analysis was done for Family Planning. When complete, the same process will be followed for Environmental Health. This consists of a comparison with other counties' current charges; a differential based on the cost of living index; and actual costs. She noted that the fees may not actually match the actual cost in today's market. • Julia Danskin explained that in Community Health nursing, typically and historically, fees were based on what was reimbursable by Medical Assistance. Sixty percent of clients qualified for Medical Assistance. Since 2001, federal requirements have been that fees should be based on cost analysis. Last year, the State provided tools, i.e. formulas and templates, and required that cost analysis be done; Jefferson Public Health agreed to do so within about one year of October 2008. Jean Baldwin noted that moving to full actual costs likely needs to be done in a step-wise fashion over 2 or 3 years. Kitsap County also plans to phase in fee increases. The figures shown for Kitsap have been passed by their Board, but actual costs are higher. Julia Danskin said Gray's Harbor is involved in a similar process. Mason, Clallam and Island Counties do not have Family Planning programs or federal contracts in their health departments. Jean Baldwin noted that gaps on the draft sheets will be filled in; fees will also be developed for Immunizations and Environmental Health. Mr. Morley asked for clarification on the fees shown in column 2 versus the number of years expected for phase-in. Veronica Shaw said she had assumed 3 years, although the calculations must take into account annual CPI allowances and other factors, as well. Additionally, the economy has shifted dramatically during the period of analysis. Jean Baldwin added that the time period of three years would need to be approved by the BOH. Member Sullivan suggested adding a column showing the actual cost on the spreadsheet. Member Russell asked how often • this fee is actually paid. Julia Danskin noted that in 2007 Family Planning had 2012 visits. Of those visits, 66%were Medical Assistance patients. There was a brief discussion about the Page 7 of 9 October 16, 2008 remaining 34% and sliding scale fees. Member Westerman asked if a phased in approach is possible for different categories of patients. She asked if the full cost can be charged to those with private insurance and the Medical Assistance related charges can be phased in. Jean • Baldwin pointed out that if insurance denies a charge, the Health Department then rebills on a sliding scale, based on federal poverty guidelines. Staff does not anticipate increases in reimbursement from Medical Assistance. Jean Baldwin said that the Health Department is permitted to raise its fees monthly or quarterly to remain in synch with increases in Medical Assistance allowances. Staff indicated that they would follow up on Michelle Sandoval's inquiry about the "Other" category, i.e. she wished to know if this was a Paid category. Member Russell noted that the Hospital's sliding scale goes up to 400% of federal poverty guidelines, per the recommendations from the State Hospital Association. Member Austin asked if staff believed that patients may be scared away by the size of the full fees. Veronica Shaw said that staff routinely explains the sliding scale fees, which usually allays any concerns on the part of the patients. Medicare patients are referred to other providers who have Medicare contracts, but encouraged to come back if they cannot obtain medical services elsewhere. Jean Baldwin noted that travelers have complained about paying the $60 nurse visit fee. However, she said this is an expensive visit, actually not fully covered by the fee. Other counties generally charge more. One accommodation is to charge less for the second person, when two people are traveling together. There was acknowledgement that even these visits are subsidized by taking advantage of State supplied vaccines. Staff also mentioned that reviewers have been impressed by the insurance billing infrastructure; • over 30 insurers are accepted and billed. Jean Baldwin said that the department saves money by maximizing this process. There was further discussion regarding the plan for phasing in the full fee and consideration of whether or not to do this all at once or over a three year period. Member Westerman was concerned that the existence of the Family Planning program would be threatened by under funding. She urged that there be further discussion about the strategy and projections. Veronica Shaw noted that there would be better information by the next meeting after all the line item costs and fees have been determined. Member Westerman said she agreed with Member Sullivan that actual costs would be helpful, and that the comparison with other counties was very useful. As possible, staff will gather comparison data from other counties with Family Planning services or Planned Parenthood. They will also show impacts on patients paying partial fees and data about percent of paid, etc. If possible, staff will set up the modeling software tools so that various parameters can be changed and viewed dynamically during the meeting. Chair Austin suggested postponement of the Environmental Health data discussion until the following meeting. BOH members were asked to retain their copies of the most recent versions of the packet sheets. Jean Baldwin said that the intention is to provide better information on real costs, especially Environmental Health whose fees have not been based on actual costs in the past. • Page 8 of 9 October 16, 2008 Several members recalled that a similar cost analysis had been done by a task force six years ago. 4111 Member Westerman said it is important to acknowledge that work and for the public to understand the policy basis for fees and fee increases. She said that group had represented a cross section of the community and, by the end of that process, had come to agreement that fees should be based on costs. Jean Baldwin added information about timing. She said that usually fee changes are made only once per year in January. She said it would be well to link the fee discussions to the budget process and complete the determination of new fees by December. Agenda item, Expedited Partner Therapy program, was postponed until the next meeting. Staff also called attention to Flu vaccine and tire recycling event fliers. PUBLIC COMMENTS Norman MacLeod referred to an earlier mention of mental health parity. He said that the recent financial bailout provisions had been tacked on as an amendment to an existing Senate bill, i.e. the Mental Health Parity bill. Mr. MacLeod said he was pleased to hear that certain government officials within the County and the State recognize the existence of a serious economic problem. ADJOURNMENT Roberta Frissell moved to adjourn and David Sullivan seconded. Chair Austin adjourned the meeting at 4:44 PM. JEFFERSON.COUNTY BOARD OF HEALTH \ji bike/tAr19.3....p. I. John Austin, Chair S eila We to ma , Vi hair Alf Roberta Frissell, Member Chuck Russell, Member Excused Phil Johnson, Member David Sullivan, Member C?fh Michelle Sandoval, Member • Page 9 of 9 October 16, 2008 0 Board of 3-feaCt( Old Business .Agenda Items # IT., 1 • Substance Abuse Relapse Prevention Program - Jeffe. rson County .Tail November 20, 2008 • 1 Peninsula Daily News Page 1 of 4 This is a printer friendly version of an article from www.peninsuladailynews.com To print this article open the file menu and choose Print. • Article published Oct 27, 2008 Program aims at reducing repeat offenders in Jefferson County's jail By Jennifer Jackson Peninsula Daily News PORT HADLOCK -- Of the 772 new bookings at the Jefferson County jail in the last fiscal year, almost three-quarters had a connection to drugs and alcohol. Some were arrests for drug and alcohol crimes. Others were people under the influence when arrested, or who stated they had used alcohol and-or drugs prior to arrest. Of those bookings, 67 percent were people who had been in the county jail at least once during the past three years. And these statistics made Fran Joswick, chairwoman of the county's Substance Abuse Advisory Board, angry. "I was appalled that Jefferson County has such a high recidivism rate," Joswick said, "when it is so easily prevented." Joswick is a retired social worker who designed and implemented programs in Hawaii that channeled people trapped in the backwater of poverty, crime and drug abuse into healthy lifestyles. Under her guidance, the local Substance Abuse Advisory Board has launched a relapse prevention program in the Jefferson County jail to reach people at the point when it will help the most. "We're reaching them when they are sober," said Pat Wiggins, an registered nurse who works with inmates. "You're talking to a person." The goal of the program, which started in October, is to decrease the repeat-inmate rate at the jail by breaking the cycle of substance abuse and crime. Collaborative effort A collaborative effort with Ford Kessler, director of Safe Harbor, an outpatient drug and alcohol addiction treatment center, it is being conducted at no cost to the county. • Kessler is donating the time of Safe Harbor counselors to lead the weekly group meetings. http://www.peninsuladailynews.com/apps/pbcs.dll/article?AID=/20081027/news/310279... 10/30/2008 Peninsula Daily News Page 2 of 4 Unlike other programs offered at the jail, the meetings have no connection to the corrections system, no effect on sentencing and do not qualify for "good time," a procedure in which inmates get time off their sentences for good behavior. "It's not forced, it's voluntary," Wiggins said. "People are here because they want to be." Wiggins said a survey she conducted showed that the jail's Alcoholics Anonymous/Narcotics Anony-'mous meetings -'-- held twice weekly for both men and women -- were not viewed as helpful by the inmates younger than 40 years. Relapse prevention, which younger inmates requested, consists of weekly group meetings, one for men and one for women. According to Kessler, they are designed to help people recognize patterns of behavior and connect with support systems to help them change those patterns when they get out of jail. "Relapse prevention focuses on the future, on hope," Kessler said. "The individuals themselves learn to recognize the signs of relapse." Ten-step program The program is composed of 10 steps, the first being that the person is sober. Then Wiggins, who works with inmates on substance abuse and mental health issues, i interviews the person, compiling an "honest history" of substance abuse. Some inmates tell her they have been in jail 20 to 30 times, she said, including stays in other counties. The average in the Jefferson County jail is about four times. Jail Superintendent Steve Richmond confirms that the people who come through the system are regulars. "We're on a first-name basis with all of them," he said. In the past, the transitory nature of the jail population precluded success in dealing with addiction problems, Kessler said. But relapse prevention is designed to give inmates the tools they need to break their addiction cycle even if they only attend one, hour-long meeting. Early signs There are already early signs of success, Kessler said. Of the four women who came to the first session, three signed up for in-patient treatment. The fourth was released and went straight to Safe Harbor. • http://www.peninsuladailynews.com/apps/pbcs.dll/article?AID=/20081027/news/310279... 10/30/2008 10 Peninsula Daily News Page 3 of 4 • "She made contact immediately," Kessler said. • "This is the goal, to keep them from making the same mistakes. When they walk out of here, they have some support group to go to." The men's group has met three times, Kessler said, starting with six men. The next week there were seven, then nine. Now, 11 men are signed up, Joswick said, with 12 the maximum, which means a second group may need to be formed. Typically, many of the male inmates have children, Joswick said, but have been written off by their partners and feel like failures because they can't support their families. As a result, they have no place to live when they get out of jail, no job, no support system, no options. Feeling hopeless, they turn to drugs and alcohol. "Without this program, chances are when they get out, they will go right back," Joswick said. The relapse prevention program will continue for a year, in which time Joswick hopes that it will have an affect on the recidivism rate, even if it's only to reduce it to 60 percent. The beauty of the program is that it costs the county nothing, Joswick said, so can't fail to • save money. "The cost of housing an inmate is $69.50 a day," she said. Pierce County is the only other county Kessler knows of that offers a similar substance abuse program at the jail. Both Jefferson and Clallam counties impose a one-tenth of 1 percent tax to fund programs to address drug abuse and mental health issues. Both counties approved the tax in 2006. Kessler and Joswick are now working on developing a continuum of components needed when the person released from jail to break the crime-substance abuse cycle. Through the local AA chapters, they hope to create a base of sponsors who will provide support, starting with picking people up and helping them find a place to live when they get out of jail. Options for group housing also are being explored, Joswick said. "What we are trying to do is build a coalition of agencies and people who have a real effect on one or more aspects of the social and economic travesty we have in Jefferson County," Joswick said. http://www.peninsuladailynews.com/apps/pbcs.d11/article?AID=/20081027/news/310279... 10/30/2008 11°- Peninsula Daily News Page 4 of 4 On Maui, Joswick ran "Ka Hale A Ke Ola," meaning "House of Hope," where she administered a two-year program designed to get people who were homeless or mentally ill off the street. Between 75 and 80 percent needed some form of substance abuse treatment, Joswick said. The program, which had an 11 percent recidivism rate of the nearly 500 people it served, also provided housing, three meals a day and assistance in completing high school and entering vocational school or community college to learn a trade. "Amazingly," Joswick said, "they became self-supporting. All materials Copyright © 2008 Horvitz Newspapers. • S http://www.peninsuladailynews.com/apps/pbcs.dll/article?AID=/20081027/news/310279... 10/30/2008 Board of Health Old Business .agenda Item # 1'V., 2 • .Main Street Program Letter November 20, 2008 • JEFFERSON COUNTY BOARD OF HEALTH • November 20, 2008 Mari Mullen Executive Director Port Townsend Main Street Program 211 Taylor St., Suite 1 Port Townsend, WA 98368 Dear Mari, Once again we extend our heartfelt thanks to you and the Main Street Program for all you did to make Girls' Night Out another huge success this year! The $3,140 raised during the event will insure that women have access to Health screenings in our county. October is Breast Cancer Awareness Month and it's a good reminder that early • detection is the best protection. It is wonderful to work with such a caring community. Thank you for all the time and effort devoted to this life-saving cause. We look forward to working together again in the future. Sincerely, John Austin, Chairman Jefferson County Board of Health 615 Sheridan• Castle Hill Center• Port Townsend• WA• 98368 (360)385-9400 • Board of.9-feaCt( Netiv Business .agenda Item # `V., 1 Public 3-fealth Fee Review • November Zo, 2008 • JEFFERSON COUNTY PUBLIC HEALTH �s Ne:s°$ 615 Sheridan Street • Port Townsend • Washington • 98368 www.jeffersoncountypublichealth.org TO: Jefferson County Board of Health FROM: Veronica K.Shaw, Chief Operations Director DATE: November 14,2008 SUBJ: 2009 FEES The following spreadsheets were created to assist you in continuing the discussion with the proposed fee ordinance and to provide specific information requested by members of the Board during the October meeting. This coversheet will help you understand the complex information and my distinct format. The first spreadsheet provides details of services,procedures,and medications. Column A identifies how many times,during the calendar year,we provided that particular services. Column B is the service rate,which is calculated using the cost analysis worksheet,provided by the State Department of Health. The cost analysis detects this rate as being the appropriate fee based on actual program expenses and the value of each service. Column C is the current fee we charge. Column D identifies the variance between the service rate calculated by the cost analysis and our current fee. Column E reflects what we were able to bill in 2007 and the remaining columns,F, G, and H indicate the annual amount that can be billed to Medicaid,private insurance companies,and clients. Columns F, G,and H provide the figures based on whether the Board adds 50%of the fee variance, 75%, or 100%. The second sheet shows the details of possible client impacts by category;private insurance,client's who pay full fee,and those who pay a portion of the fee. The section"Estimated Billable Amount"is how much we would be able to bill,by category,based on the decision of the Board. The area under"Projected Possible Revenue"is calculated on the estimated billable amount and reflects approximately 33%of the amount billed,which is historically the%received after adjustments,denials,and write-offs. The table labeled"2009"compares actual revenue collected in 2007 to the projected possible revenue of 50%, 75%,or 100% of the identified fee variance proposed for 2009. The variance shows client impact by category. The table at the bottom indicates the average annual impact per client by category. If you choose to collect 75% of the fee variance in 2009,a client who pays full fee would pay approximately$11.12 more per year for our services. I hope this coversheet has been useful. If you have questions or need additional information you may contact me at 360-385-9409. • COMMUNITY HEALTH ENVIRONMENTAL HEALTH DEVELOPMENTAL DISABILITIES PUBLIC HEALTH WATER QUALITY MAIN: (360)385-9400 ALWAYS WORKING FOR A SAFER AND MAIN: (360)385-9444 FAX: (360)385-9401 HEALTHIER COMMUNITY FAX: (360)379-4487 JEFFERSON COUNTY PUBLIC HEALTH BOH COMMUNITY HEALTH FEE PRESENTATION November 14,2008 _ -- - - - -- A B C D E F G H CALCULATED SERVICE SVC COST FEE CURRENT UTILIZATION FROM COST CURRENT VARIANCE AMOUNT 50%OF 75%OF ' 100%OF SERVICE/PROCEDURE (FREQUENCY) ANALYSIS FEE (B-C) (AxC) INCREASE INCREASE INCREASE NEW PATIENT-BRIEF 194 92.86 48.00 44.86 9,312 13,664 15,839 _ 18,015 NEW PATIENT-LIMITED EXAM 39 159.80 82.00 77.80 3,198 4,715 5,474 6,232 NEW PATIENT-INTERMEDIATE EXAM 9 229.16 122.00 107.16 1,098 '1,580 1,821 2,062 NEW PATIENT-COMPREHENSIVE 14 354.40 186.00 168.40 2,604 3,783 4,372 4,962 CONTINUING PATIENT-BRIEF 298 45.06 27.00 18.06 8,046 10,737 12,083 13,429 CONTINUING PATIENT-LIMITED 778 92.86 49.00 43.86 38,122 55,184 63,715_ 72,246 CONTINUING PATIENT-INTERMEDIATE 168 154.80 80.00 74.80 13,440 19,723 22,865 26,007 CONTINUING PATIENT-COMPREHENSIVE 62 233.54 120.00 113,54 7,440 10,960 12,720 14,480 Preventive visit, new, 12-17 25 239.87 130.00 109.87 3,250 4,623 5,310 5,997 Preventive visit,new, 18-39 60 239.87 135.00 104.87 8,100 _11,246 __ 12,819 __14,392 Preventive visit,new,40-64 45 279.88 155.00 124.88 6,9_75_ _9,785 _ 11,190_ 12,594_ Preventive visit,est, 12-17 39 211.88 110.00 101.88 4,290 6,277 7,270 8,263 Preventive visit,est, 18-39 236 211.88 115.00 96.88 27,140 38,571 44,287 50,003 Preventive visit,est,40-64 107I 231.79 125.00 106.79 13,375 19,088 21,945 24,801 IUD INSERTION 44 157.12 59.00 98.12 2,596 4,755 5,834 6,913 IUD REMOVAL 14 220.89 64.00 156.89 896 1,994 2,543 3,092 DIAPHRAGM/CERVICAL CAP FIT 10 141.82 58.00 83.82 580 _ 999 1,2091,418 DEPO PROVERA INJECTION - 247 56.74 54.00 2.74 13,338 13,676 13,846___14,015 HORMONE IMPLANT 5 284.72 77,00 207.72 385_ 904 1,164 1,424 HORMONE IMPLANT REMOVAL 1 331.34 90.00 241.34 90 211 271___ 331 Condyloma Treatment(Destruction,vulva I 31 301.76 80.00 221.76 2,480 5,917 _ 7,636 9,355 Individual Counseling:Approx.15 minutes 2 77.07 23.35 53.72 47 100 127 __154 Calkydia/Gonorrhea(amplified)combint 119 82.92 80 2.92 9,520 9,694 9,781 9,868 tocrit or Hemaglobin 12 1.91 5 60 60 60 60 Hepatitis B(surface ag) 14 18.62 21 294 294 294 294 HSV Culture-State 26 13.62 --- -- _ - tate 73 26.82 HPV Typing 5 48.27 19 29.27 95 168 205 241 Pap Smear - -- 456 17.17 17 0.17 7,752 7,791 7,811 7,830 Pregnancy Test-Urine 375 5.11 10 -4.89 3,750 2,832 2,373 , 3,750 Thin Prep 92 46.06 35 11.06 3,220 3,729 3,983 4,238 Dip Stick 75 6.59 5 1.59 375 435 465 495 UA Culture Routine 23 19.66 20 _ 460 460 460 460 Wet Mount 55 3.44 _ 5 275 275 275 275 Routine Venipuncture - 87 1.73 10 -8.27 870 510 331 870 HSV2 Herpes Select 40 36.09 24 12.09 960_ 1,202 1,323 1,443 HSV1/2 Herpes Select 20 56.54 44 12.54 880 1,005 1,068 1,131 HEP C 24 25.69 19 6.69 456 536 576 617 TSH 21 23.92 20 3.92 420 461 _ 482 502 - UA Culture If Indicated/Complete 13 12.12 20 260 260 260 260 T-4 Free 2 33.76 20 13.76 40 54 61 68 HCG,Serum Test 11 32.40 22 10.40 242 299 328 356 CBC(DIFF/PLT) 0 9.63 ---^ - - - VDRL State 52 7.82 CT&GC State 418 91.19 RPR VDRL Syphilis Quest 12 7.82 9 108 108 108 108 H nest Lab 21 26.82 20 6.82 420 492 527 563 CONTRACEPTIVES(High Cost) 64 30.85 29 1.$5 1,856 1,915 1,945 1,974 ORAL CONTRACEPTIVES(Low Cost) 241 9.65 17 4,097 4,097 4,097 4,097 STATE DONATED MEDICINE 31 6.28 JELLIES 9 8.50 5.55 _ 2.95 50 63 70 77 DIAPHRAGMS 5 28.34 45 225 225 225 225 IUD 42 291.96 380 15,960 15,960 15,960 15,960 MIRENA IU __ _ 51 500.33 415 8-5.33-- 21,165 23 341 24,429 I Z5,517 CYCLE BEADS _ 8 11.80 111 0.80 88 91 93 94 CONDOMS(each) 21000 0.11 0.3' 6,300 t 6,300 6,300 6,300 MEDS/VAG INFECTION-cream/supp 18 4.32 8144 144 144 144 MEDS/VAG. INFECTION-oral 63 615 10 630 630 ( 630 630 MEDS/STD 26 8.63 8; 0.63 208 216 220 224 lli1CAL CAP _ 5 68.34 47 21.34 235 288 _ 315 342 E CONDOM 200 1.92 1 0.92 200 292 _ 337 383 HORMONE IMPLANT KIT 6 801.26 523 278.26 3,138 3,973 4,390 4,808 DEPO 247 13.97 _ 54 13,338 13,338 13,338 13,338 Ortho EVRA Patch 26 22.98 5 17.98 130 364 481 597 Nuva Ring 146 42.64 27 15.64_ 3,942 5,083 5,654 6,225 ECP_ 586 12.03 10 2.03 5,860 _ 6,454 6,751 7,048 Metrogel 6 11.17 13 78 78 78 - -78 1 274,903 1 352,011 1 390,566 i 431,675 • • s f)Fr) -0 n f) 'O Z A A m Z co r i r- 73 1_ r O r r 70 O O m rn m C rn m < L-1- m m < =Z Z m m > � m • Z Z _ _ n m N N 0D C Z D C Z D C N - qZM H r C -4 r C n _-I r C n A D -n y D -n D Co D m > c O r m z r m a r m NO 0 c m m ti m oo z O� > N Z CO W I F�-k N n 1 I" N O •--I N U'7 4-1. A t0 V O 1 0 N �O O C h+ UI V m _ ro• v+ 100 0o rn V > C , v, W 00 v w I- COsJ N) 0 V r -, N) UUiIN 0 3 ,0) D O Iz -I Let VIr) W on w `00 0 C w 0 P.Fi N V p N N V Cr 3 N 00 VH W W ' U'I (D 3 O - vi I-- � 1-' co O O c > C e3 < 0 O ,C IQ a N W lD D Q `U .O" O Ci V V O' WItD1N Z 'a ...__Ln 00 lO p '=r V :VI tOrO1tO; m O 0 ODIC 0 S LU > N 1 N .A A. U1 CO1 I t *o 130 g I � > 0 I 1 a ! z U1 z4. W (II v 00 t0 W • W U1 (.0 N [1 V O O O C,, > (D X) u I-a ►-' A - A N w D 0 N w N N w CO w toQ. %� v (.0 VI 3 N N V CO U I Ui = 0 C11 N m ti U7 1-4 o A rt Z3 O- 1 N `QC o O of O v l� v o ter+ A W N A W 54 \ V 1-+ N V Q' A V 1-+ ( W U'1 t0 Ln (D < m D z 70 C Q, V 1-' m A w 1.f) p a) ON Cu N 00 A A V N s • STATE OF WASHINGTON JEFFERSON COUNTY BOARD OF HEALTH AN ORDINANCE ESTABLISHING A FEE Ordinance No. SCHEDULE FOR JEFFERSON COUNTY PUBLIC HEALTH Section 1 —Purpose Section 2—Hearing Section 3 —Effective Date Section 4—Fees Section 5 —Severability Section 6—Prior fee schedule repealed Section 1 —Purpose • The purpose of this ordinance is to set the fee schedules for Jefferson County Public Health. Section 2—Hearing December 18, 2008 Section 3—Effective Date January 1, 2009 Section 4—Fees All of the services/fees listed for Jefferson County Public Health are hereby being set by the Jefferson County Board of Health as follows: A cost analysis will be completed annually to set reimbursement rates for Community Health including family planning services, birth control methods, and immunizations. * Fees for medications, antibiotics, and treatment methods will be based on cost of acquisition unless acquired by an outside vendor at no cost to Jefferson County Public Health. All fees for immunizations not subsidized by the Washington State Department of Health will be the cost of the vaccine plus handling, shipping, and nursing time.* • Jefferson County Board Of Health Ordinance No.99 999 Page 1 of 2 Laboratory Services are based on the actual fees of laboratory contractors, price lists are available upon requests. The Clinical Services Financial Guidelines policy is in place, reviewed and updated annually, using • the Federal Poverty Guidelines to establish the sliding fee schedule. A copy of the sliding fee schedule will be available upon request. The sliding fee schedule will not be available or offered for privately purchased vaccines administered for international travel or outside laboratory cost. Certain services, provided for communicable disease prevention cases, medication, laboratory services or vaccines to prevent outbreaks of communicable disease, where personal insurance denies reimbursement, fees may be waived. Jefferson County Public Health will automatically implement future modifications to fees for vaccines, medications, and medical supplies when any of the following changes occur: 1. The actual cost of the service provided by an outside vendor, the supply, medication, vaccine, and laboratory charges, and like costs plus shipping and handling fees. 2. Any new Federal Poverty Level Guidelines that are published annually. 3. The maximum allowable Medicaid reimbursement rate. *The sliding fee schedule may apply. Services will not be denied due to clients in ability to pay. Fees for Vital Records are set by the RCW 70.58.107. The cost sheet is available by request. Environmental Health fees, established by this ordinance, shall be adjusted annually on the first business day of January (Adjustment Date) by the amount of the increase in the Consumer Price Index as reported for the month of September preceding the Adjustment Date, following the annual fee indexing criteria established in Jefferson County Ordinance #12-1209-96. A cost analysis for Environmental Health will be completed every 2 years. Section 5—Severability A determination that any fee or fees adopted as part of this Ordinance is unlawful or illegal shall not cause any other fee or fees adopted as part of this Ordinance not affected by that determination to be repealed, revised, or reduced. Section 6—Prior Fee Schedules Repealed Any prior fee schedule previously adopted by this Board that contains or reflects fee amounts that are less than those adopted herein is hereby repealed and replaced by this Ordinance. • Jefferson County Board Of Health Ordinance No.9979279 Page 2 of 2 • 4*- JEFFERSON.JEFFERSON COUNTY PUBLIC HEALTH 615 Sheridan Street • Port Townsend •Washington • 98368 www.jeffersoncountypublichealtkorg • Memorandum To: Jefferson County Board of Health From: Andrew Shogren, MPH Environmental Health Director Date: November 13, 2008 Re: Environmental Health Fee Discussion Environmental Health sets fees that seek to cover 100%of all direct services. Traditionally, Environmental Health (EH) has charged fees based on the actual costs to do services, adjusted yearly by Consumer Price Index (CPI). After doing a cost analysis, we will bring to the board proposed changes based on the CPI. The CPI for September 2008 to September 2009 is 4.9%. • COMMUNITY HEALTH PUBLIC HEALTH ENVIRONMENTAL HEALTH DEVELOPMENTAL DISABILITIES AIN: 360-385-9400 ALIdAYSWORKING FOR ASAFER AND WATER QUALITY MAX: 360385-94011 HEALTHIER COMMUNITY MAIN: 364487 X: 3600.379-379-4487 t JEFFERSON COUNTY PUBLIC HEALTH ENVIRONMENTAL HEALTH DIVISION III Jefferson Fees with Jefferson Additional Fees 2009 CPI Additional Fees ENVIRONMENTAL HEALTH FEES 2008 Fees and Other increase of and Other Information 4.9%(Sep. Information 2007-Sep. 2008) GENERAL Administrative Hearings • Health Officer Administrative Hearing 274.00 289.00 Technical Assistance/Plan Review--Minimum 65.00 65.00 Technical Assistance/Plan Review--Per Hour 65.00 65.00 Filing Fee 39.00 41.00 17NSITESEVIWAGE CISPOSAV , ;a,, v,T,'. Sewage Disposal Permits New Conventional 465.00 Valid for 3 years 488.00 Valid for 3 years New Alternative 561.00 Valid for 3 years 588.00 Valid for 3 years Issued in conjunction Issued in conjunction New septic tank and/or pump chamber only 205.00 with an existing sewage 215.00 with an existing sewage Plus$78 per connection- Plus$82 per connection- New Community or>1000 G.P.D.(base fee) 465.00 valid for 3 yrs 488.00 valid for 3 yrs New Commercial>1000 G.P.D. • Conventional 561.00 Valid for 3 years 589.00 Valid for 3 years Alternative 602.00 Valid for 3 years 631.00 Valid for 3 years 109.00 Applies to existing 115.00 Applies to existing installed sewage installed sewage disposal system disposal system Repair/Upgrade/Modification/Designate Reserve Area Expansion 369.00 387.00 Applies to pending or Applies to pending or Redesign 109.00 active but not installed 115.00 active but not installed Reinspection 137.00 144.00 Evaluation of Existing System/Monitoring Inspection Septic system only 274.00 287.00 Septic system plus water sample 285.00 298.00 Retest/Reinspection 96.00 100.00 On Site Sewage On Site SPAAD 274.00 287.00 Septic Permit with SPAAD(conventional) 205.00 215.00 Septic Permit with SPAAD(alternative) 308.00 323.00 Subdivision Review Base Fee 354.00 Plus$70.00 Per Lot 372.00 Plus$73.00 Per Lot Boundary line adjustment review fee 140.00 146.00 Pre application meeting fee 140.00 146.00 Planned rural residential development review fee 140.00 146.00 Density exemption review fee 70.00 73.00 Density exemption review fee requiring field work 140.00 146.00 i Jefferson County Board of Health 1:08 PM 11/14/2008 Page 1 of 2 • Other WaiverNariance Application 164.00 172.00 WaiverNariance Hearing 274.00 287.00 Wet season evaluation 369.00 387.00 Revised building application review fee 140.00 146.00 . New building application review fee: Residential 70.00 73.00 Commercial 140.00 146.00 General environmental health review fee 70.00 73.00 Licenses Installer,Pumper,Operator(maintenance person) 369.00 387.00 Retest 150.00 158.00 Annual Renewal 260.00 273.00 Delinquent Renewal after January 31 369.00 387.00 FOOD SERVICE ESTABLISHMENT FEES PERMIT FEES • Immediate Consumption Limited 130.00 136.00 Non-Complex 166.00 174.00 Complex: 310.00 0-50 seats 296.00 51-100 seats 355.00 372.00 101-150 seats 402.00 422.00 Alcohol served in multiple areas 130.00 136.00 Not for Immediate Consumption 136.00 Limited 130.00 Non-Complex 166.00 174.00 Complex 402.00 422.00 50%of Annual Permit 50%of Annual Permit Annual Permit Issued after September 1 50%of fee Fee 50%of fee Fee Late Fee(Paid after January 31) +25%of fee Additional to Permit Fee +25%of fee Additional to Permit Fee Late Fee(Paid after February 28) +50%of fee Additional to Permit Fee +50%of fee Additional to Permit Fee Temporary Permit 112.00 Non-Complex 106.00 Limited 59.00 62.00 Additional(Paid when Additional(Paid when application is submitted application is submitted less than 7 days prior to less than 7 days prior to • Late Fee +50%of fee the event) +50%of fee the event) Other Food Fees 37.00 Waiver 35.00 Reinspection 87.00 First Inspection 83.00 Second Inspection 142.00 149.00 Food Handler Card 10.00 10.00 Reissue Unexpired Food Handler Card 4.00 4.00 Manager's Course 201.00 211.00 SOLID WASTE . .,; Landfills requiring environmental monitoring 485.00 508.00 Inert Landfills 307.00 322.00 Biosolid Utilization 426.00 446.00 Other Solid Waste Facility Permits 307.00 322.00 Drop Boxes 142.00 149.00 409.00 New Facility Application 390.00 WATER ' • , r , "- ; ..: , , , 4 Inspection of well Inspection of well Ins P construction, construction, decommission& decommission& Application Fee 142.00 reconstruction 149.00 reconstruction Determination of Adequate Water Supply 59.00 Building Permit Process 62.00 Building Permit Process Well Site Inspection-Proposed public water supply 284.00 298.00 LIVING ENVIRONMENTS„(Annual Permit), _ f , Pool 260.00 273 00 Spa 260.00 273.00 Pool/Spa Combined 355.00 372.00 Indoor Air(tobacco) 65.00 Per Hour Compliance Enforcement 65.00 Per Hour 73.00 Reinspection 70.00146.00 Rebuttal Application 140.00 • Jefferson County Board of Health 1:08 PM 11/14/2008 Page 2 of 2 • Board of 3{eaCtfi Netiv Business .agenda Item #17., 2 Puget Sound Partnership: � Draft .fiction PCans for Strait of . Tuan de Fuca & 3foodCanal November 20, 2008 Revised 11/13/08 No substantive changes were made, only minor grammatical and typographic edits. • DRAFT 2020 Action Agenda for Puget Sound Today, November 6th, 2008, the Puget Sound Partnership is releasing a draft 2020 Action Agenda for Puget Sound recovery. Over the next two weeks,we are asking for public input on the draft prior to adoption by the Leadership Council and transmittal to the Washington State Legislature on December 1, 2008. When the Puget Sound Partnership was created in 2007,we were given the charge to look at Puget Sound as a whole, from the crest of the Cascades and Olympics to the floor of Puget Sound and the Strait of Juan de Fuca, and develop an integrated approach for rebuilding and sustaining ecosystem health.This may be our last, best chance to implement actions that will help us turn the tide on the decline of Puget Sound health. The attached Puget Sound Action Agenda is the comprehensive roadmap for moving toward a healthy Puget Sound by 2020. "[It is our task]to ensure that the Puget Sound forever will be a thriving natural system, with clean marine and freshwaters, healthy and abundant native species, natural shorelines and places for public enjoyment, and a vibrant economy that prospers in productive harmony with a healthy Sound." ---Governor Christine Gregoire The Puget Sound Partnership is a catalyst for action. Our job is to bring together all the groups, interests and agencies to work together toward a shared vision for Puget Sound recovery. • Thousands of people—from scientists to citizens, from Bellingham to Olympia to Hoodsport to the San Juan Islands—have helped the Partnership during the past 18 months to develop an Action Agenda for Puget Sound, It's the most comprehensive appraisal of Puget Sound ever conducted. We are grateful for their contributions and appreciate how much people want to help us"get it right". People have told us that they want their own time and energy focused on what matters and makes a difference. Our entire region working together with a shared commitment to save the Sound is what makes the Partnership different. We are focusing on what we can do—all of us as citizens—individually and collectively, to ensure that the rivers, streams, lakes and bays that make up Puget Sound are healthy for orcas,fish, birds and people for generations to come. We can do this work. In 1958, the voters of the Seattle metropolitan area agreed to spend $140 million to halt the flow of untreated sewage to Lake Washington that was discharged from Seattle and other communities surrounding the lake. The closed beaches, murky waters, and offensive odors along the Lake Washington shoreline were effective arguments in the campaign to create Metro and build sewage treatment systems. Scientists offered additional evidence that the lake was degraded but that recovery was still possible.Although the proposed rescue of Lake Washington was the most expensive environmental project in the nation's history at the time, the voters believed that the threat to the lake and their quality of life was well worth the investment. By 1968, sewage discharge to the lake had dropped from 20 million gallons per day to zero, and the clarity of the lake had returned to 10 feet. It is now a healthy, well managed body of water. • Draft Action Agenda Introduction I Page 1 November 6,2008 t Now it's time for Puget Sound. • Introduction to the Puget Sound Action Agenda The Partnership was given three charges from the Legislature: 1)to define a 2020 Action Agenda to guide efforts to protect and restore Puget Sound, based on science and with clear and measurable goals for recovery; 2)to determine accountability for achieving results including performance, effectiveness, and the efficient use of money spent on Puget Sound;and 3)to promote public awareness and communication to build support for a long-term strategy. In creating the Action Agenda,we collaborated with all affected parties, used the experience and expertise of existing regional agencies, and involved local communities and scientists in crafting regional solutions. The Partnership sought practical solutions with reasonable expectations for implementation, building on existing programs that are working wherever possible,and continually sought scientific input about the risks facing Puget Sound, the potential certainty for actions, and risks of continued inaction. The final Action Agenda is intended to be a living and adaptable guide to be used by federal and state agencies,tribes, city and county governments and other agencies, businesses and environmental organizations,watershed groups and individual landowners as they take action to protect and restore the Puget Sound. It serves as a statement of common purpose across the Sound and sets the stage for cooperation and collaboration among partners. Inside the Action Agenda The Action Agenda is structured around four basic questions: 1. What is a healthy Puget Sound? • 2. What is the status of Puget Sound and what are the biggest threats to it? 3. What actions should be taken that will move us from where we are today to a healthy Puget Sound by 2020? 4. Where should we start? 1. What is a healthy Puget Sound? A healthy Puget Sound includes a thriving natural world, high quality of life for people, and a vibrant economy. Using goals set out by the legislature, the Partnership has,for the first time in Puget Sound, identified measurable indicators that can be monitored over time to assess progress. We have also set targets and benchmarks to guide our actions. 2. What is the status of Puget Sound and what are the biggest threats to it? In synthesizing the information available about the condition of Puget Sound's health and the threats,we concluded that significant losses of our estuaries, rivers and floodplains, and forests combined with the slew of pollutants delivered to Puget Sound every day have had profound, and potentially some irreversible consequences on the present and future health of the region. Anticipated population growth and climate change will amplify the current situation.Compounding these challenges is the fragmented system now in place to manage natural resources. The region has not been equipped or organized to even solve the current problems facing Puget Sound, let alone the changes that will come. Draft Action Agenda Introduction I Page 2 • November 6,2008 • 3. What actions should be taken that will move us from where we are today to a healthy Puget Sound by 2020? The Partnership synthesized a significant amount of existing work and input received during the development of the Action Agenda to create five priority strategies. Together,these five priorities address major threats to ecosystem health and embrace a new approach to managing and sustaining the Puget Sound ecosystem. The list of things to do for Puget Sound is daunting and the actions cannot be tackled all at once. Building a comprehensive, consolidated list of actions is a significant step forward. Our strategies are to: A. Protect the intact ecosystem processes, structures, and functions that sustain Puget Sound. Avoiding problems before they occur is the best and most cost-effective approach to ecosystem health. B. Restore the ecosystem processes, structures, and functions that sustain Puget Sound. Protecting what we have left is not sufficient, and significant effort at an unprecedented scale is needed to undo past damage. C. Prevent water pollution at its source. Many of our efforts have focused on cleaning up degraded waters and sediments, but insufficient resources have been devoted to stopping pollutants before they reach our rivers, beaches, and species. D. Work together as a coordinated system to ensure that activities and funding are • focused on the most urgent and important problems facing the region. Our current management approach to the ecosystem is fragmented, programs and laws were established on a piecemeal basis to address individual problems, and the system does not address Sound-wide and local problems on a coordinated basis at an ecosystem scale. E. Build and implement the new system to support the implementation and continual improvement of the Action Agenda.This includes: 1) using a performance management system that includes adaptive management and clear pathways for decision making, coordinated monitoring, accountability for action, and coordinated data management; 2) providing sufficient, stable funding focused on priority actions; 3) implementing a focused scientific program with priorities for research, and developing appropriate measures to improve understanding of the ecosystem and the effectiveness of our actions; and 4) increasing and sustaining coordinated efforts for communication, outreach, and education. Each of these priorities is described in detail with Sound-wide applicable near-term actions. In addition, eight action area profiles describe the different benefits of each action area, the major local ecosystem stressors, and the local priority actions that mirror the regional priorities and reflect local conditions and issues. 4. Where should we start? This section of the Action Agenda is a priority near-term work plan that identifies priority actions among all the near-term actions, as well as implementation roles and responsibilities. . Draft Action Agenda Introduction I Page 3 November 6,2008 What else is included with the draft Action Agenda? • The draft Action Agenda includes a draft funding strategy and draft Biennial Science Work Plan, as well as technical back up materials for Action Agenda Question 1 and Question 2. How was the Action Agenda developed? The Puget Sound Action Agenda was developed in a fundamentally different way from traditional "top-down"planning approaches, using transparent public forums and soliciting extensive citizen and scientific input. During 2008,the Partnership took the four key questions for framing the Action Agenda on the road to listen to scientists,elected officials, businesses,volunteers, and local communities. Public workshops, expert topic forums, and implementer-focused action area meetings discussed the health of Puget Sound,future threats,what is being done, and what people think is needed. Over 1,600 people attended public workshops, 75 presentations were given to business and community organizations, and 8,223 public comments were received in writing or on- line with ideas and comments on the Partnership's work. • Implementer-focused workshops were held in the seven action areas of Puget Sound to discuss the important features of the action area, local stresses and threats, and their top priorities for action.This work is primarily reflected in the action area profiles. • Topic forums of regional experts were convened to analyze six issues that reflect ecosystem health: land use and habitat, species and biodiversity,water quality,freshwater quantity, human health, and human well-being. Findings on conditions, management approaches, and recommendations are described in the topic forum papers. The work of • the topic forums informed Questions 2 and 3 of the Action Agenda. • Scientific input was overseen by the Science Panel and included development of desired outcomes and indicators to measure ecosystem health, peer-review of the scientific elements of the topic forum papers, and the preparation of a biennial science plan that will help refine elements of the Action Agenda as the region moves forward. How is salmon recovery incorporated into the Action Agenda? In 2007,the Puget Sound Partnership became the regional salmon recovery organization.The Partnership is responsible for implementing the Chinook Salmon Recovery Plan that was approved by NOAA. One of the Partnership's jobs is to integrate salmon recovery into the broader efforts to sustain the Puget Sound ecosystem.The salmon recovery effort includes 14 watershed groups that have been working together for many years and accomplished a great deal by working collaboratively to prioritize and implement essential actions like restoring estuaries, removing passage barriers, and better managing hatcheries.This work will be integrated with the broader effort. Specific ways that the Action Agenda incorporates salmon recovery work: • What is a healthy Puget Sound?The Chinook recovery targets are being used as one measure of health. In addition,the importance of recreational, sustenance and commercial catch is also highlighted as a human well-being outcome. Draft Action Agenda Introduction I Page 4 • November 6,2008 • • What do we need to do and where should we start? Implementing the Salmon Recovery Plan, including the three-year work plans, is specifically called out in the Action Agenda, as well as implementing the hatchery recommendations and continuing to improve the integration of habitat, hatchery, and harvest actions. The Action Agenda calls for continuing support of the local watershed groups that are key in driving the local collaborative efforts and points out that the region needs a prioritized protection and restoration strategy that goes beyond salmon recovery and incorporates new information. The existing work will be a foundation for this strategy. • Performance management. The salmon recovery effort has a required monitoring and adaptive management program and has embarked on pilot report cards. Both of these efforts will be included in a more coordinated monitoring and accountability strategy for Puget Sound. How to use this draft document The draft document will be refined and completed by the December 1 deadline. In addition to refining the information in the draft Action Agenda,the final document will include a much shorter, very accessible summary, graphics that show how the actions link to threats and help reach the goals of a healthy Puget Sound. The Partnership welcomes input on the draft Action Agenda, draft funding strategy, and draft Biennial Science Work Plan.We are accepting comments through November 20, 2008.We will make changes to the draft based on comments received in writing and in person at the November 11th and November 21st Leadership Council meetings, and the November 10th Ecosystem • Coordination Board meeting.The Partnership's Science Panel will also review the scientific portions of the Action Agenda during the public review period. We will continue to work with the Leadership Council to refine nuances of the draft and prepare the final version of the Action Agenda for release on December 1, 2008. Comments can be submitted on the draft Action Agenda through Partnership's Web site at www.psp.wa.gov. Hard copy comments must be received by November 20th, and can be mailed to: Puget Sound Partnership PO Box 40900 Olympia,WA 98504 • Draft Action Agenda Introduction I Page 5 November 6,2008 _ . o m To g o •.x3`.O.O...''... QEa RHmmU�cm'.�.9gm''C0n OH! o -a5m Eam m3cc- mc E mydofc S Nt € a ;H + -@y 't— g t c. 02 III t n N-,,, 6 m rnN 7 H ' aE a scma On 2o., w m ` v Q ,m mSIII om - N� 30m N = V-E.E . cQ . m EcEaavy, ya,E mO v .- E . mm Einn m a ` roOQ cvNy r. 2 . • • o a. 8 a : � 0 oaco wn E` mUNofec c € c zc Ea 5 mE OU mU a o mm`U3 m a Ea2mn3 Z3Qdm m= a E oaEFmLLommEcc ` Efm m Y vaEw am . mo87,15EEmmd� o �o5'2 E .HL W -20 E iaEo2o EmmU A gab o0E t ocEc _ E e mS = g i o0 2, m P. 2im£H0oo °'am2o3 .. ` mdyN,anE W_ ? 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PURPOSE The undersigned Party HDs confront numerous threats to public health, including but not limited to, Public Health Incidents, Emergencies and/or Disasters that could overwhelm the capabilities of an immediate local or regional response. None of the Party HDs to this Agreement possesses all of the necessary resources to cope with every possible Public Health Incident, Emergency or Disaster by itself, and a more efficient, effective response can best be achieved by the application and leveraging of collective resources. Each Party HD desires to voluntarily aid and assist each other by the interchange of public health resources and services in the event that a Public Health Incident, Emergency or Disaster situation should occur. The Party HDs find it necessary and • desirable to execute this Agreement for the interchange of such mutual Assistance on a county, regional and/or statewide basis. The Party HDs to this Agreement have determined it is in their collective best interest to develop and implement a Plan, and incorporate mutual aid response into their existing emergency response plans. Training and exercising Mutual Aid protocols, in advance of a Public Health Incident, Emergency or Disaster, will enhance the efficiency and effectiveness of each responding party. The Party HDs desire to cooperate with one another to receive state and/or federal resources provided such cooperation does not compromise a Party HD's public health response. The Party HDs desire to engage in frequent consultation and to allow free exchange of information, plans, and resource records related to Assistance activities. ARTICLE I DEFINITIONS Assisting Party HD: A Party HD providing Assistance to a Requesting Party HD from another jurisdiction that has requested Assistance to confront a Public Health Incident, Emergency or Disaster. S 1 t , Assistance: Assistance means personnel, equipment, materials, supplies, facilities, services, and/or related resources. • Authorized Representative: The person or persons designated by each Party HD in the Plan to request Assistance from or grant Assistance to another Party HD pursuant to the terms of this Agreement. Mutual Aid: A prearranged written Agreement and Plan whereby Assistance is requested and may be provided between two or more jurisdictions during a Public Health Incident, Emergency or Disaster under the terms of this Agreement. Period of Assistance: The period of time beginning with the departure of any personnel, equipment, materials, supplies, services, and/or related resources of the Assisting Party HD from any point for the purpose of traveling to provide Assistance exclusively to the Requesting Party HD, and ending on the return of all of the Assisting Party HD's personnel, equipment, materials, supplies, services, and/or related resources to their regular place of work or assignment, or otherwise terminated through written or verbal notice of the Authorized Representative of the Assisting Party HD. With respect to facility use, the Period of Assistance shall commence on the date agreed upon between the Requesting and Assisting Party HD and shall end when the Requesting Party HD returns possession of the facility to the Assisting Party HD, or when otherwise terminated through written or verbal notice of the Authorized Representative of the Assisting Party HD. Plan: a written public health inter jurisdictional Mutual Aid Plan that meets the • requirements set forth in Article VII. Public Health Incident, Emergency, or Disaster: Any occurrence, or threat thereof, whether natural or caused by man, in war or in peace, to which any Party HD may respond pursuant to its authority under chapter 70.05 or 70.46 RCW, or other applicable law, and that, in the judgment of the Requesting Party HD, results or may result in circumstances sufficient to exceed the capabilities of immediate local or regional public health response. Requesting Party HD: A Party HD that has requested Assistance from a Party HD from another jurisdiction participating in this Agreement. ARTICLE II IMPLEMENTATION This Agreement shall become effective immediately upon its execution by any two Party HDs. After the first two such executions, this Agreement shall become effective as to any other Party HD in the State of Washington upon its execution by such Party HD. The Agreement shall remain in effect as between each and every Party HD until participation in this Agreement is terminated by a withdrawing Party HD in writing pursuant to Article • 2 XVII. Termination of participation in this Agreement by a withdrawing Party HD shall not affect the continued operation of this Agreement as between the remaining Party • HDs. ARTICLE III PARTICIPATION The Party HDs have a desire to be of help to one another in response to a request for Assistance related to a Public Health Incident, Emergency or Disaster. The Party HDs agree that this Agreement, however, does not create a legal duty to provide Assistance. The Party HDs agree that any and all actions taken pursuant to this Agreement shall be voluntary and in each Party HD's sole discretion. A Party HD may elect to voluntarily furnish such Assistance to another Party HD as is available, and shall take into consideration whether such actions might unreasonably diminish its capacity to provide basic public health services to its own jurisdiction. ARTICLE IV HOW TO INVOKE ASSISTANCE The Authorized Representative of a Party HD may request Assistance of another Party HD by contacting the Authorized Representative of that Party HD. The provisions of this Agreement shall only apply to requests for Assistance made by and to Authorized • Representatives or their designee. Requests may be verbal or in writing. If verbal,the request shall be confirmed in writing before the Period of Assistance begins to the extent it is practical. ARTICLE V LIABILITY RELATED TO DELAY OR FAILURE TO RESPOND No Party HD shall be liable to another Party HD for, or be considered in breach of or default under this Agreement on account of any delay in or failure to perform any obligation under this Agreement, except to make payment as specified herein. Nothing in this Agreement shall be construed to create any rights in or duties to any third party, nor any liability to or standard of care with reference to any third party. This Agreement shall not confer any right or remedy upon any person other than the Party HDs. This Agreement shall not release or discharge any obligation or liability of any third party to any Party HD. • 3 ARTICLE VI • WITHDRAWAL FROM ASSISTANCE An Assisting Party HD may withdraw Assistance by giving verbal or written notice to the Requesting Party HD. Each Assisting Party HD that is providing Assistance to a Requesting Party HD agrees to give reasonable notice to the Requesting Party HD under the circumstances as they exist at the time before withdrawing Assistance. No Party HD shall be liable to another Party HD for, or be considered in breach of or default under this Agreement on account of, any withdrawal of assistance. ARTICLE VII PLANNING, MEETING AND TRAINING Party HDs are expected to: 1) ensure that other Party HDs have their most current contact information; 2) participate in scheduled meetings to coordinate operational and implementation matters, and 3) participate in the creation of a public health inter jurisdictional Mutual Aid Plan that will contain, among other things, current contact information, inventory of resources available for Assistance, training planning, and agreed upon forms to be used related to this Agreement. • Party HDs agree to incorporate protocols related to this Agreement into regular emergency preparedness exercises and trainings, and will train in accordance with the Plan. Requesting Party HDs agree to provide "Just In Time Training" during Public Health Incidents, Emergencies or Disasters on their policies, procedures and protocols for Assisting Party HD personnel. Party HDs agree to exchange their emergency preparedness plans, and other documents that may be beneficial in preparing personnel from another Party HD to respond to a request for Assistance. ARTICLE VIII COMMAND AND CONTROL Resources from the Assisting Party HD shall be under the operational control of the Requesting Party HD's public health leadership. All personnel provided by an Assisting Party HD will be under the authority of the Local Health Officer in the Requesting Party HD. The Party HDs intend to follow the National Incident Management System's "Incident Command System" when such system is activated. • 4 ARTICLE IX • ASSISTING PARTY EMPLOYEES Employees of an Assisting Party HD shall at all times while performing Assistance continue to be employees of the Assisting Party HD for any purpose. Wages, hours and other terms and conditions of employment of Assisting Party HD shall remain applicable to all of its employees who perform Assistance under this Agreement. Assisting Party HD shall be solely responsible for payment of its employees' wages, any required payroll taxes and any benefits or other compensation. Requesting Party HD shall not be responsible for paying any wages, benefits, taxes or other compensation to Assisting Party HD's employees. ARTICLE X INJURY COMPENSATION AND DEATH BENEFITS Each Party HD shall provide for the payment of Workers' Compensation benefits to its own injured personnel and/or to representatives of its own personnel in case such personnel sustain injuries or are killed while rendering aid under this Agreement, in the same manner and on the same terms as if the injury or death were sustained within its own jurisdiction. Nothing in this Agreement shall abrogate or waive any Party HD's right to reimbursement or other payment available from any local, state or federal governments or abrogate or waive the effect of any waiver, indemnity or immunity • available to a Party HD under local, state or federal law or other governmental action. To the extent that such reimbursement, payment, waiver, indemnity or immunity does not apply, then each Party HD shall remain fully responsible as employer for all taxes, assessments, fees, premiums, wages, withholdings, Workers' Compensation, and other direct and indirect compensation,benefits, and related obligations with respect to its own employees. Each Party HD shall provide Workers' Compensation in compliance with the statutory requirements of the State of Washington. ARTICLE XI REIMBURSEMENT OF COSTS AND CONDITIONS OF LOAN The Requesting Party HD agrees to reimburse the Assisting Party HD for the costs of personnel, equipment, materials, supplies, facilities, services, and/or related resources used during the Period of Assistance on the basis of mutually accepted costs associated with these resources. When an Assisting Party HD deploys employees under the terms of this Agreement to a Requesting Party HD,the Assisting Party HD will be reimbursed by the Requesting Party HD equal to the Assisting Party HD's full cost, including employee's salary or hourly wages, call back or overtime costs, benefits and overhead, and consistent with the Assisting Party HD's personnel union contracts, if any, or other conditions of employment. Reuseable materials and supplies that are returned to the Assisting Party HD in clean, damage free condition, excepting normal wear and tear, • 5 shall not be charged to the Requesting Party HD and no rental fee shall be charged. The Assisting Party HD shall determine whether items are returned in clean and damage free condition, and any items found to be damaged shall be treated as partially consumed • and/or as non-returnable materials and supplies. The Assisting Party HD shall be entitled to receive payment for the cost of repair or replacement of damaged and consumed materials and supplies. The Assisting Party HD shall send the Requesting Party HD an invoice or invoices for all valid Assistance Costs and the Requesting Party HD shall pay the invoice(s) within sixty (60) days of receipt of each invoice. ARTICLE XII WORKER REGISTRATION, LIABILITY AND DISPUTE RESOLUTION 1. WORKER REGISTRATION AND LIABILITY. The Party HDs to this Agreement agree that each will take all actions necessary to qualify and maintain qualification of its own personnel, employees and volunteers as emergency workers, or covered volunteer emergency workers, as appropriate, pursuant to RCW 38.52 et seq., WAC 118-04 et seq., and any other applicable statute, regulation or law. The Party HDs agree that prior to invoking a request for Assistance under this Agreement, the Requesting Party HD,through its local department of emergency management, will request the issuance of a mission number from the Washington military department, emergency management division. A Party HD may condition its willingness to respond and the continuance of its response under this Agreement on the issuance of a mission number, and compliance with RCW 38.52 et seq., WAC 118-04 et seq., or other • law, by the Assisting and Requesting Party HDs. 2. In the event local, state and/or federal governments or laws provide waiver, immunity, indemnification, reimbursement or other payment related to liability that would otherwise be the responsibility of a Party HD, then such waiver, immunity, indemnification, reimbursement or other payment shall limit a Party HD's liability. The Party HDs agree to exhaust their rights to waiver, immunity, indemnification, reimbursement or other payment from local, state, and/or federal governments. However, to the extent that local, state or federal governments or laws do not provide complete waiver, immunity, indemnification, reimbursement or other payment related to Party HD liability, then the following provisions will apply: A. Each party to this Agreement shall be legally responsible for its own acts and omissions arising under this Agreement, and that of its respective appointed and elected officials, employees, officers, agents, agencies, assigns and representatives. Each party agrees to defend, indemnify, and hold harmless the other party, and its respective appointed and elected officials, employees, officers, agents, agencies, assigns and representatives from and against any and all liability, loss, cost, damage and expense • 6 arising or alleged to have arisen directly or indirectly out of or in consequence of the performance of this Agreement by the indemnitor. • B. GROSS NEGLIGENCE OR WILLFUL OR WANTON MISCONDUCT. Any Party HD shall not be required under this Agreement to release, indemnify, hold harmless or defend any other Party HD from any claim, loss, harm, liability, damage, cost or expense caused by or resulting from the activities of any Party HD's officers, employees, or agents acting in such a manner that constitutes willful misconduct, gross negligence or bad faith. C. LIABILITY FOR PARTICIPATION. In the event of any liability, claim, demand, action or proceeding, of whatever kind or nature arising out of the rendering of Assistance through this Agreement, the Requesting Party HD agrees, to indemnify, hold harmless, and defend, to the fullest extent of the law, each signatory to this Agreement, whose only involvement in the transaction or occurrence which is the subject of such claim, action, demand, or other proceeding, is the execution and approval of this Agreement. D. LITIGATION PROCEDURES. Party HD's personnel shall cooperate and participate in legal proceedings if so requested by another Party HD, and/or required by a court of competent jurisdiction. • E. TORT CLAIMS ACT. No provision of this Agreement shall remove from any Party HD any protection provided by any applicable Tort Claims Act. F. WAIVER OF RIGHTS. Any waiver at any time by any Party HD of its rights with respect to a default under this Agreement, or with respect to any other matter arising in connection with this Agreement, shall not constitute or be deemed a waiver with respect to any subsequent default or other matter arising in connection with this Agreement. Any delay in asserting or enforcing any right, except those related to the statutes of limitations, shall not constitute or be deemed a waiver. 2. DISPUTE RESOLUTION. If a dispute between the parties to this Agreement arises out of or related to this Agreement, or the breach thereof, and if the dispute cannot be settled through direct discussions, the Party HDs agree to first endeavor to settle the dispute in an amicable manner by mediation. Thereafter, any unresolved controversy or claim arising out of or related to this Agreement, or breach thereof, may be settled in a court having jurisdiction thereof. The Party HDs may seek to resolve disputes pursuant to mediation or arbitration, but are not required to do so. • 7 ARTICLE XIII LICENSES AND PERMITS . When invoking Assistance,the Requesting Party HD shall define as precisely as possible the licensure requirements of personnel being requested from the Assisting Party HD. The Assisting Party HD agrees to exercise reasonable diligence in verifying personnel's licensure and in responding to the specific licensure requirements requested by the Requesting Party HD. ARTICLE XIV RECORD KEEPING Time sheets and/or daily logs showing hours worked and equipment and materials used or provided by the Assisting Party HD will be recorded on a shift by shift basis by the Requesting Party HD and/or the loaned employee(s) and will be provided to the Assisting Party HD as needed. Additionally, the Assisting Party HD will provide shipping records for materials, supplies, equipment and/or related resources, and the Requesting Party HD is responsible for any required documentation of use of materials, supplies, equipment, facilities, services, and/or related resources for state or federal reimbursement. Under all circumstances,the Requesting Party HD remains responsible for ensuring that the amount and quality of all documentation is adequate to enable state or federal reimbursement. ARTICLE XV • OTHER OR PRIOR AGREEMENTS This Agreement is not intended to be exclusive among the Party HDs. Any Party HD may enter into separate agreements with any other entity. No such separate agreement shall terminate any responsibility under this Agreement. ARTICLE XVI EFFECT OF DECLARATION OF EMERGENCY The Party HDs recognize that state or federal declarations of emergency, or orders related thereto, may supercede the arrangements made or actions taken for rendering Assistance pursuant to this Agreement. ARTICLE XVII MODIFICATION/TERMINATION OF AGREEMENT No provision of this Agreement may be modified, altered or rescinded by any individual Party HD without the unanimous concurrence of the Party HDs. Modifications to this • 8 Agreement must be in writing and will become effective upon the approval of the . modification by Party HDs. Modifications must be signed by each Party HD. A Party HD opting to terminate this Agreement shall provide written termination notification to the Authorized Representatives of all Party HDs. Notice of termination becomes effective upon receipt by all Authorized Representatives. Any terminating Party HD shall remain liable for all obligations incurred during its Period of Assistance until the obligation is satisfied. ARTICLE XVIII ENTIRE AGREEMENT This Agreement constitutes the entire agreement amongst the Party HDs. ARTICLE XIX SUCCESSORS AND ASSIGNS This Agreement is not transferable nor assignable, in whole or in part, and any Party HD may terminate its participation in the Agreement pursuant to Article XVI. ARTICLE XX • GOVERNING LAW This Agreement shall be interpreted, construed and enforced in accordance with the laws of the State of Washington. ARTICLE XXI INVALID PROVISION The provisions of this Agreement are severable. If any portion of this Agreement is determined by a court to be void, unconstitutional or otherwise unenforceable, the remainder of this Agreement will remain in full force and effect. ARTICLE XXII NOTICES Except as otherwise provided herein, any notice, demand, information, report, or item otherwise required, authorized or provided for in this Agreement shall be given in writing and shall be deemed properly given if(i) delivered personally, (ii) transmitted and received by telephone facsimile device and confirmed by telephone, (iii) sent by United States Mail, postage prepaid, to the Authorized Representatives of all affected Party HDs 9 at the address designated by such Authorized Representative, or(iv) sent by email with electronic signature of the Party HD's Authorized Representative. • ARTICLE XXIII NO DEDICATION OF FACILITIES No undertaking by one Party HD to the other Party HD under any provision of this Agreement shall constitute a dedication of the facilities or assets of such Party HD, or any portion thereof, to the public or to the other Party HD. Nothing in this Agreement shall be construed to give a Party HD any right of ownership, possession,use or control of the facilities or assets of the other Party HD. ARTICLE XXIV NO PARTNERSHIP This Agreement shall not be interpreted or construed to create an association,joint venture or partnership among the Party HDs or to impose any partnership obligation or liability upon any Party HD. Further, no Party HD shall have any undertaking for or on behalf of, or to act as or be an agent or representative of, or to otherwise bind any other Party HD. • • 10 IN WITNESS WHEREOF, this Agreement has been executed and approved and is effective and operative as to each of the Party HDs as herein provided. S Kitsap County Health District By: Its: Date: Public Health Seattle and King County By: Its: Date: Snohomish Health District • By: Its: Date: Tacoma-Pierce County Health Department By: Its: Date: • 11 FY2007 CDC Competitive Pan Flu Grant Project Writing Template f Name of Project: Mutual Aid Agreement between Public Health and Tribal Health Authorities Project Type (#1-7): Project Contact: Scott Lindquist MD MPH Project Abstract: Region 2 Public Health proposes to work with the Washington State Department of Health to create a model mutual aid agreement, which will be accepted and implemented by all eight tribes within Region 2. The tribes include the Suquamish, Port Gamble S'Klallam, Jamestown S'Klallam, Makah, Hoh, Lower Elwha Klallam, and Quileute tribes. Each of these eight tribes are independent tribes that have separate governance structures but each of these tribes share a common unified Public Health system (Region2). Region 2 Public Health will create a mutual aid agreement that is acceptable to each of the tribes. It is unclear if a single MAA will work for all 8 tribes, or if we will have to create several modifications of a base MAA. The majority of work during this project will include meeting with each of the eight tribes at their reservations and working out the details specific to each tribal entity. • Project Narrative: Kitsap, Clallam and Jefferson Counties are defined as Region 2 in the Washington State Public Health Emergency Response and Preparedness Program. Region 2 is the smallest region in Washington State with a population of approximately 341,900. The region is divided into two peninsulas. The Kitsap Peninsula is made up of Kitsap County and is the largest area comprised of 244,800 residents. The Olympic Peninsula is comprised of Clallam and Jefferson Counties and has 97,100 residents. This region is located directly west of Seattle and is a large landmass that includes National Park,National Forest as well as small towns and cities. Even though it is a rural setting,there are 8 tribal reservations interspersed within this region. a) Plan The plan is to develop a Mutual Aid Agreement (MAA) model. In Washington State, there is a template model MAA that was developed for use with a local health jurisdiction and tribal jurisdictions. It is our plan to use this MAA as a starting point for Region 2. Region 2 will work with a tribal liaison/contract specialist who was involved with the original Washington State MAA above. This will be the majority of the work for the first 2 months. In addition, the tribal liaison/contract specialist will make at least 3 site visits to each tribe with the local health jurisdiction Health Officer and Regional Emergency Response Coordinator. Region 2 staff will facilitate all logistics involving the tribal meetings and • joint authorship sessions. As this is a rural setting, many of the tribes are a full day journey to reach the reservations. This project accounts for a moderate amount of travel and overnight accommodations. We anticipate the next 6 months of the project will involve site visits and tribal meetings. This will continue into the 8th month of the project at which point we will spend the last 4 months of the project finalizing the agreement with each tribe, obtaining local health jurisdiction legal and insurance carrier review. We will also include a final site visit, MAA signing, and completion of the project. As this will likely take tribal legal resources, we have included compensation for each tribal entity legal resources b) Objective The Objective of the mutual aid agreement is to protect the health and safety of tribal members as well as Indian and Non-Indian employees, resident visitors, and guests on tribal lands within Region 2 Public Health. c) Methods The content of the mutual aid agreement(methods) will include provisions for epidemiologic research, investigation, prevention, containment, and treatment related to a communicable disease outbreak with particular emphasis on pandemic influenza. Provisions will include a designated liaison for each jurisdiction represented, and agreements on the subject of dispute resolution, indemnity, medical records, reimbursement, termination, and insurance coverage. d) Project Timeline: i. May 1 —June 30, 2008: Initial planning meetings between Region 2 and tribal liaison/contract specialist which will result in an agreed upon template MAA for Region 2 Public Health. ii. July 1 —December 31, 2008: Tribal site visits will occur during the next phase of the project, which involves the initial contact, proposed MAA, reworking of the MAA, and discussions with all involved stakeholders. This will be the majority of travel time, in addition to legal review by tribes, and reworking of the template MAA during joint authorship sessions. iii. January 1 —April 30, 2009 Final tribal site visits, MAA signing, and implementation will occur during this phase of the project. We will then measure our objectives, write a summary of the project and produce a model MAA for other local health jurisdictions to use as a proven MAA. • e) Staff: • The staff includes those mentioned above, with the lead provided by the Health Officer for each county (2 Health officers in Region 2), the Region 2 Regional Emergency Response Coordinator, and a tribal liaison/contract specialist. The majority of the cost will be in developing the MAA and subsequent travel and site visits. We do anticipate teleconferencing, telephone and Internet resources for communication during this project. 1) Performance Measures: The following performance measures will be utilized for this project to track progress: i. Attendance at meetings and minutes will be recorded; ii. A semi-annual report describing the status of the project will be provided utilizing a template provided by DOH: iii. Completion of a model MAA for Region 2 iv. Successful implementation of a MAA in at least 4 of the 8 tribal jurisdictions. g) Budget Justification See attached budget spreadsheet. • • yOh c o` Region 2 Public Health Emergency Preparedness & Response )tautivi. Region 2 ) p th p345 6 Street,Suite 300 — Bremerton,WA 98337 • M�A : Hon. Vivian Lee, Chair Hoh Tribal Council 2464 Lower Hoh Road Forks, WA 98331 Hon. W. Ron Allen, Chair Jamestown S'Klallam Tribal Council 1033 Old Blyn Hwy. Sequim, WA 98382 Hon. Frances Charles, Chair Lower Elwha Klallam Tribal Council 2851 Lower Elwha Road Port Angeles, WA 98363 Hon. Micah McCarthy, Chair Makah Tribal Council P.O. Box 115 Neah Bay, WA 98357 Hon. Ronald Charles, Chair Port Gamble S'Klallam Tribal Council 31912 Little Boston Rd. NE Kingston, WA 98346 Hon. Carol Hatch, Chair Quileute Nation Tribal Council P.O. Box 279 La Push, WA 98350 Hon. Leonard Forsman, Chair Suquamish Tribal Council 18490 Suquamish Way Suquamish, WA 98392 Dear Chairmen/Chairwomen [Name]: We are writing to ask for your guidance and support in addressing an important emergency preparedness need of tribal and local governments. We would like to propose the development of a comprehensive and universal Mutual Aid Agreement(MAA) amongst the three counties and seven tribal health jurisdictions on the Kitsap and Olympic Peninsulas. Development of an Olympic Regional Mutual Aid Agreement would enable us to be better prepared to meet the public health challenges of a natural disaster or a large scale disease outbreak. Disease outbreaks, • as well as other public health emergencies, know no jurisdictional boundaries, and can easily overwhelm the ability of individual governments to respond effectively. During a crisis, jurisdictions that want to aid one another confront issues that can become stumbling blocks to an effective and immediate response. Working out the details of these jurisdictional issues ahead of time will allow us to focus our efforts on urgent community health needs should we be faced with a future multi-jurisdictional health emergency. We propose the formation of a work group made up of one representative from each of the seven Tribes, the Health Officers for Clallam, Jefferson, and Kitsap Counties, , the Region 2 Public Health Emergency Preparedness and Response Coordinator, Jessica Guidry and a legal advisor and facilitator, Susan Ferguson. Susan Ferguson negotiated the MAA between the Puyallup Tribe and the Tacoma-Pierce County Health Department, and facilitated the creation of a recent model MAA amongst Washington counties. We propose rotating meeting locations so each jurisdiction has a turn not having to travel. We would ask that you delegate a Tribal representative to join in the discussions related to the development of such a regional Mutual Aid Agreement. The breadth, scope and content of the draft agreement will be developed by the participants, with continued communication and review by each respective Tribe. Of course, participants at the discussion table will not have the authority to bind their respective governments. The goal is to develop a draft agreement for review by the tribal and county decision-makers. We anticipate the focus of the agreement will be mutual aid related to disease containment, including epidemiologic research, disease investigation,prevention, and treatment, as well as emergency and disaster response. II0 We would like to support this request for your participation with funding to defray legal and staff costs. We have submitted a proposal to the Washington State Department of Health and included a request for funding to support Tribal participation. We have been assured that this project is a high priority for funding and expect its budget to be finalized in the near future. We would like to follow up this letter with a telephone call to discuss whether your Tribe is interested in participating in the Mutual Aid Agreement discussions, and, if so, who your appointed tribal representative will be. If you have any questions about the proposal, or would like more information, please feel free call us on our direct lines listed below. Otherwise, we look forward to talking with you in the weeks ahead. Sincerely, Thomas Locke, MD, MPH Scott Lindquist, MD, MPH Health Officer Health Officer and Director Clallam and Jefferson Counties Kitsap County Health District (360) 417-2437 (360) 337-5237110 • Board of Health Netiv Business .Agenda Item #`V., 5 Expedited Partner Therapy Program • November 20, 2008 • JEFFERSON COUNTY PUBLIC HEALTH 615 Sheridan Street • Port Townsend •Washington • 98368 www.jeffersoncountypublichealth.org Expedited Partner Treatment (EPT) A new initiative from Jefferson County Public Health (JCPH) and the Washington State Department of Health (DOH) helps ensure the treatment of partners of people diagnosed with gonorrhea and chlamydia. The health department recommends that all heterosexual patients be offered medications to give to their sex partners if the diagnosing clinician cannot otherwise be certain that partners will be evaluated and treated. This treatment method is called Expedited Partner Treatment (EPT). The DOH guidance for use of EPT is supported by the Washington State Medical Association and has been reviewed by the Washington State Board of Medical Quality Assurance and the Washington State Pharmacy Board. This initiative includes the following elements: • 1) New partner treatment recommendations: Most persons with gonorrhea or Chlamydia should be offered medications at the time of their diagnosis to give to their sex partners 2) Free medication for partner treatment: The health department is providing all clinicians in Jefferson County with access to free medications to give to patients for their sex partners 3) Referral of high risk patients: JCPH asks that providers refer selected, high-risk patients to receive assistance notifying partners 4) New case report forms: Providers are asked to indicate on new case report form how the patient's partners have been managed • COMMUNITY HEALTH ENVIRONMENTAL HEALTH DEVELOPMENTAL DISABILITIES PUBLIC HEALTH WATER QUALITY MAIN: (360) 385-9400 ALWAYS WORKING FORA SAFER AND MAIN: (360) 385-9444 FAX: (360) 385-9401 HEALTHIER COMMUNITY FAX: (360)379-4487 Board of Health �►�ledia Report • November 20, 2008 • Jefferson County Public Health October/November 2008 NEWS ARTICLES 1. "Free tire recycling for residents on Oct. 26," Port Townsend Leader, October 15th, 2008. 2. "Mental health services begin at PT, Chimacum high schools," Port Townsend Leader, October 15th, 2008. 3. "Arms out for flu shot clinics," Port Townsend Leader, October 15th, 2008. 4. "Tire disposal," Peninsula Daily News, October 16th, 2008. 5. "Flu clinics set in Jefferson County," Peninsula Daily News, October 22"d, 2008. 6. "Doomed," Port Townsend Leader, October 22nd, 2008. 7. "Fall flu shots ongoing in county," Port Townsend Leader, October 22"d, 2008. 8. "Tire recycling," Peninsula Daily News, October 27th, 2008. 9. "Program aims at curbing repeat inmates," Peninsula Daily News, October 27th, 2008. 10. "Still time for flu shots," Port Townsend Leader, October 29th, 2008. 11. "Quilcene Bay residents to share Hood Canal environmental awards," Port Townsend Leader, October 29th, 2008. 12. "Church volunteers boost food bank," Peninsula Daily News, October 30th, 2008. 13. "Algae still plagues lake," Peninsula Daily News, November 2"d, 2008. 14. "Flu shots available in Clallam, Jefferson," Peninsula Daily News, November 2"d, 2008. 15. "Awards given to eco-friendly Canal couples," Peninsula Daily News, November 3rd • 2008. 16. "Toxicity of Gibbs, Tarboo and Crocker lakes upgraded," Port Townsend Leader, November 3rd, 2008. 17. "Mats Mats Bay's pollution to be studied," Peninsula Daily News, November 4th, 2008. 18. "2,500 tires collected in roundup," Port Townsend Leader, November 5th, 2008. 19. "CDC recommends flu vaccines for children, teens," Port Townsend Leader, November 5th, 2008. 20. "Toxic lake algae persists," Port Townsend Leader, November 5th, 2008. 21. "Girls' Night out raises money for health screening," Port Townsend Leader, November 12th, 2008. 22. "Take your choice of flu shot clinics," Port Townsend Leader, November 12th, 2008. 23. "County freezes hiring," Port Townsend Leader, November 12th, 2008. 24. "Public health cuts directed by Snohomish County Health Board," Press Release for Snohomish County Health Board, November 4th, 2008. • • Free tire recycling for residents on Oct. 26 A free household tire-recy- Tires in Lakewood, where most cling event is set for Sunday,Oct. will be used for boiler fuel or 26,9:30 a.m.-2 p.m.at Jefferson baled and used for erosion con- County Transfer Station in Port trol,lightweight road fill,impact Townsend. barriers, retaining walls, levee County residents will be able core material, insulators or to dispose of up to nine regular- leachate systems. sized light truck, car or motor- The. event is sponsored by cycle tires per household. No Jefferson County Public Health tractor, large truck or oversized and the Jefferson County tires are accepted. Tires may be Sheriff's Office,and funded by a on rims but not on axles. grant from the Washington State "This event will allow hom- Department of Ecology. eowners to clean up the tires Last year Ecology worked on their properties," says with the Health Department to Anita Hicklin, a solid waste remove and properly dispose of code enforcement officer with more than 300 tons of tires from Jefferson County Public Health. five sites in Jefferson County. • "We will let them know where Those sites each had in excess they can dispose of the tires of 800 tires and were primarily properly in the future. connected to businesses. This "Tire piles provide habitat year's event is specifically for for rats and mosquitoes," warns households. Hicklin, and the eradication of People wanting to recycle such breeding grounds is "even oversized tires, as well as busi- more important now that West nesses desiring information Nile virus has been found in on disposal options can call Western Washington." Jefferson County Public Health Tires will be taken to L&S at 385-9444. •• /'T aceac Wednesday,October 15,2008•C 5 Mental health services begin at PT, Chimacum high schools Students from Chimacum and Port Comprehensive medical services will be health and chemical dependency services," Townsend high schools have access to free available in January. Blair added. mental health counseling starting this week. School administrators, counselors and Patricia Flowergrowing, a licensed men- The high schools, Jefferson Healthcare staff agree that many students are in need of tal health counselor from Kitsap Mental and Jefferson County Public Health have mental health services. Health, has been hired to provide the ser- formed a partnership to establish what they "The needs of young people today are vices. Flowergrowing has worked at the are calling School-Based Health Centers that significant,and we hope that this can be one Spectrum School-Based Health Clinic in offer medical and mental health services to piece of the pn771e of expanding resources North Kitsap School District. students. for youths in our community," said Mike Services offered are free, confidential After six months of planning,the centers Blair, superintendent of the Chimacum and sanctioned by Washington state law, open by offering mental health services two School District. which allows a minor 13 or older to access days a week at each high school. Services "Having mental health specialists in mental health treatment without parental are provided Monday and Wednesday in the schools was made possible with local consent. Port Townsend and Thursday and Friday in funding through the one-tenth-of-l-percent For more information, contact Jean Chimacum. county sales tax that is specified for mental Baldwin or Yuko Umeda at 385-9400. • f • /'7 f.ea& • • flu clinics • Arms out for Many flu shot clinics are • Port Hadlock Medical through 18 years at the follow- Physicians, 934 Sheridan, PT, scheduled in the area over Care, 121 Oak Bay Road, Port ing clinics. Call your provider 385-3500 the coming weeks. Continue Hadlock. No long lines; call for an appointment. • Children's vaccines are to check The Leader for any 379-6737 for appointment. • Jefferson Medical & also available through Jefferson changes in this information.For Bring insurance cards, as some Pediatric Group, 834 Sheridan County Public Health, 615 questions about influenza or the insurers may pay.Flu shots$25. St.,PT,382-4848 Sheridan St., PT. Walk-in vaccine, call Jefferson County Public welcome. •Olympic Primary Care,1010 immunization clinics are every Public Health,385-9400. • Port Townsend Family Sheridan St.,PT,379-8031 Tuesday and Thursday, 1-4 • Jefferson Medical & Physicians, 934 Sheridan, Port • Port Townsend Family p.m. Pediatric Group, 834 Sheridan Townsend. Saturday, Nov. 1, 9 St., Port Townsend. Saturdays, a.m.-noon. Medicare patients Oct.25 and Dec.6,9 a.m.-noon. bring your Medicare cards. All Medicare patients bring your others$25 cash or check.Private Medicare cards; all.others $25 insurance is not billed. cash or check.Private insurance • Safeway Pharmacy, 442 is not billed. Sims Way, Port Townsend. •Madrona Hill Urgent Care, Saturday,Oct. 18,9 a.m.-5 p.m. 2500 Sims Way,Port Townsend. Walk-ins welcome for immuni- Flu vaccine available during zations from 10 a.m. to 6 p.m. clinic hours: Monday-Friday 9 Monday through Friday. No a.m.-7 p.m., Saturday 9 a.m.-4 appointment necessary.Medicare p.m.and Sunday 10 a.m.-2 p.m. and Medicaid accepted. Many Vaccine available for adults and insurances billed. Bring your children age 4 years and older. insurance card. Flu shots $30. Flu shots $25. Medicare billed. Pneumonia shots $45. Clients All others cash. must be at least 11 years old. • Monroe Street Medical • South County Medical Clinic, 242 Monroe St., Port Clinic, 294843 Highway Townsend. Limited supply 101, Quilcene. Flu clinics 4110 preservative-free vaccine. Flu Wednesdays, 1:30-4:30 p.m. shots $32. Call 385-5658 for Call 765-3111 for an appoint- an appointment. No insurance ment. Medicare patients, bring is billed your Medicare cards. All oth- •Olympic Primary Care,1010 ers $25 cash or check. Private Sheridan St., Port Townsend. insurance is not billed. Saturdays, Oct. 18 and Nov. 8, 9 a.m.-noon. Medicare patientsChildren's vaccine bring your Medicare cards. All State-supplied children's others$25 cash or check.Private flu vaccines are now available insurance is not billed. for all children ages 6 months • • Tire disposal PORT TOWNSEND—A • free tire recycling event will be held at the Jefferson County Transfer Station, 301 Landfill Road,from 9:30 a.m. to 2 p.m.on Oct. 26. Jefferson County house- holds can dispose of up to nine regular-sized light truck, car or motorcycle tires. No tractor,large truck or • over-sized tires will be accepted. Tires may be on rims,but not on axles. Collected tires will be taken to L&S Tires in Lake- wood to be used for boiler fuel,or baled and used for erosion control, lightweight road fill,impact barriers, retaining walls,levee core material,insulators and leachate systems. This disposal event is sponsored by Jefferson County Public Health and the Jefferson County Sheriff's Office. It is funded by a grant from the state Department of Ecology. • Last year,Ecology worked with the Jefferson County Health Department to remove and dispose of more than 300 tons of tires. People with over-sized - tires for disposal should call the health department at 360-385-9444. Peninsula Daily News 4 • /C//6/0 7 Flu clinics set in • Jet er s on Count y • PENINSULA DAILY NEWS Private insurance will not These influenza vaccine be billed. clinics s arescheduled .in Jef- Medicaid clients should ferson.care t phone 360-379-8031 to make appointments. Port Townsend IIIPort Townsend Family Physicians, 934 Sheridan, ■ Jefferson County Public from 9 a.m. to noon on Nov. 1. Health,615 Sheridan St. from Cost is $25. 1 p.m. to 4 p.m.,Tuesdays and Medicare patients should Thursdays. bring Medicare cards. Phone 360- 85,9400 !; Private insurance will not ■Jefferson;4Vredical&Fedi; be billed. atric Group,834 Sheridan St., Medicaid clients should 9-a.m. to noon on''Saturday phone:360-385-3500 to make and Dec. 6. appointments. Cost is $25. Medicare patients should "Port Hadlock bring Medicare cads. • ` port Hadlock Medical • Private insurance will 'not be billed. Care, 121 Oak Bay Road. Medicaid clients should Cost is $25. phone 360-385-4848 to make Appointments, phone 360- appointments. 379-6737. ■ Madrona Hill Urgent Open to the public. • Care,250.0 Sims Way,9 a.m.to. :port'Ludlow 7 p.m:;Mondays through Fri:.'. ,: days; from 9 a.m. to .4 p.m;.. .■ :,Jefferson Healthcare Saturdays; and from 10 a.m: offers flu shots at Port Ludlow to 2 p.m. Sundays. Fire Hall,7650 Oak Bay Road, Vaccines for ,adults and from 9 a.m .to noon Oct. 29. children 4 and older. Cost is $25. Cost is $25. .Medicare patients should Medicare will be billed. 'bring Medicare cards. ■ Monroe Street Medical Private insurance will not Clinic,242 Monroe St.' be billed. Cost is $32. No insurance will be' billed. Quilcene Limited supply preserva- ■ South County Medical tive-free vaccine. Clinic, 294843 Highway 101, Appointments, phone 300-, from 1:30 p.m. to 4:30 p.m. 385-5658. ,Wednesdays. I Olympic Primary Care, Appointments, phone 360- 1010 Sheridan St,, ..Port ;765-3111 Townsend,from 9 a.m.to noon Cost is $25. on Nov 8. Medicare patients should *4 Cost is $25. . ' bring Medicare cards. Medicare patients should Private insurance will not bring Medicare cards. be billed • .. , Doomed ' Editor,Leader: • Forced out of`my home of 19 years, my life is in chaos because of an absurd technical regulation about the septic • tank not being large enough for the number of people using it. Never mind that it was working just fine;the health department bureaucracy does not sanc- tion appropriate gray-water systems. Are these regulations designed to get rid of the people not paying as much tax as they would having a big house?This kind of malignancy is the primary caused of homelessness in Jefferson County. There is not enough low-income housing near Port Townsend,and Section 8 fund- ing may never happen because of the banking scams. Living under a bridge with my arthritic spine at the age of 60,I will be dead by Christmas. Will euthanasia be the final solution for poverty in the richest country in the world? Or will the problem be ignored as usual? Civilizations that do not take care of their citizens are doomed to entropy.Apparently it will take a mira- cle to change the money oligarchy. JOHN LINSEY Port Townsend • 4 • Fall flu shots ongoing in g g county • Flu shot clinics continue vaccine are available this the clinics posted on our web- throughout Jefferson County fall, according to the state site at www.ptleader.com. over the coming weeks. More Department of Health. For questions about influen- doses than ever of influenza The Leader this week has za or the vaccine,call Jefferson County Public Health, 385- 9400. Every year an average of 36,000 people in the United States die from flu-related ill- ness and more than 226,000 people are hospitalized. "The best way to avoid flu is to get vaccinated each year," said Washington Secretary of Health Mary Selecky. "Getting an influenza vaccine will ' protect you, your family and friends." 4 • , f f i fi f ':,-,,,I,,,,,,.„,,„:1,,,e4. -. ,'•:.=:s.'",..,;•,...:-.-:.--.;,:mrj!..,t4-re..,.::- .'":tr--.,-,....1. ...,,A-:, k r4,-;-,,,,,`%:-:.k.,:! :',......:,:> .:4, 4 M Mt ;.z:4,.,:1-i-,,- � y�f �3. ''3tiro " � .. ..a�" .r,`�� «G k ;�j.. >�a�. .°fig �'.:,f`. '?' 3 .�,'CF.ti..4.:.J{ E .Ff:: v � '.+. ..... .,.. _ - tr STEVE My 1.1 r NSKYIFOft PFxI\SL1.1.DAILY NEWS TIRE RECYCLING Brad Pearson, Jim Norberg, Tim Wardleigh and Jonah Billie (with tire behind Pearson), all inmate workers from the Jefferson County jail in Port Hadlock, unload nine tires brought in by Jim Barr of,Cape George, background center, to the tire recycling event held at the Jefferson County Transfer Station in Port Townsend on Sunday. The free event was sponsored by Jefferson County Public Health and the Jefferson County Sheriff's Ofce and funded by a grant from the Washington State Department of Ecology. The tires will be transported to L&S Tires in Lakewood, where they will be ground up and recycled for boiler fuel, road fill, impact barriers, retaining walls and other uses. • /O/22/�1? a) a)(11) • 3 da ° y 34 Nd O ° 00••-• ^ w0 "">' Go aN r. o 0 teqO •y03 d4.2„ c ? w � . v>q do v.y CD 0) . 8al002... � OtC `"'� : y C0 ,o O. 4acgO ›,to$ mp F aw+' "E.:-..4 R. 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All For questions about influenza or others$25 cash or check.Private the vaccine,call Jefferson County insurance is not billed.Medicaid Public Health,385-9400. clients call 385-3500 for an appointment. Clinics • Safeway Pharmacy, 442 • Jefferson Medical & Sims Way, Port Townsend. Pediatric,'.Group, 834 Sheridan Walk-ins welcome for immuni- St. Port Townsend, Saturday, zations from 10 a.m. to 6 p.m. Dec: 6, 9 a.m.-noon. Medicare Monday through Friday. No patients bring your Medicare appointment necessary.Medicare cards; all 't t, ers $25 cash or and Medicaid accepted. Many • check. Privte insurance is not insurances billed. Bring your billed.Medicaid clients call 385- insurance card. Flu shots $30. 4848 for an appointment. Pneumonia shots $45. Clients •Madrona Hill Urgent Care, must be at least 11 years old. 2500 Sims Way,Port Townsend. •South CountyMedical Clinic, Flu vaccine available during 294843 Highway 101,Quilcene. clinic hours: Monday-Friday 9 Flu clinics Wednesdays, 1:30- . a.m.-7 p.m., Saturday 9 a.m.-4 4:30 p.m. Call 765-3111 for an p.m. and Sunday 10 a.m.-2 p.m. appointment. Medicare patients, Vaccine available for adults and bring your Medicare cards. All children age 4 years and older. others$25 cash or check.Private Flu shots $25. Medicare billed. insurance is not billed. All others cash. •Olympic Primary Care,1010 Children's vaccine Sheridan St., Port Townsend. This year, flu vaccine is rec- Saturday, Nov. 8, 9 a.m.-noon. ommended for all children ages Medicare patients bring your 6 months to 18 years, expand- Medicare cards. All others $25 ing vaccination to all school- cash or check. Private insurance age children. State-supplied is not billed. Medicaid clients children's flu vaccines are now call 379-8031 for an appoint- available for all children in this ment. age range at the following din- •Port Hadlock Medical Care, ics. Call your provider for an 121 Oak Bay Road,Port Hadlock. appointment. No long lines; call 3796737 for • Jefferson Medical & appointment. Bring insurance Pediatric Group, 834 Sheridan cards,as some insurers may pay. St.,PT, 382-4848 Flu shots $25. Public welcome. •Olympic Primary Care,1010 • Port Ludlow Fire Hall, flu Sheridan St.,PT, 379-8031 shots by Jefferson Healthcare, • Port Townsend Family 7650 Oak Bay Road, Port Physicians, 934 Sheridan, PT, Ludlow. Wednesday, Oct. 29, ' 385-3500 9 a.m.-noon. Medicare patients • Jefferson County Public bring your Medicare cards. All Health, 615 Sheridan St., PT. others$25 cash or check.Private Walk-in immunization clinics are insurance is not billed.Medicaid every Tuesday and Thursday, 1- clients,call your regular medical 4 p.m. No appointment needed. provider. Call 385-9400 for information. • ?7-0/e et.41-ex-, 9/1,7 Port Townsend&Jefferson County Leader Quilcene Bayresidents to sh r share • • Ko o d C anal environmental awards The Hood Canal Coordinating in the stewardship of the Hood Oxygen Program. allowed regulators, the public Council conducts its 2008 Canal watershed," according to • Chris Daniels, who has and elected officials to better • Hood Canal Environmental the HCCC. worked with the Hood Canal understand their place within the Achievement Awards and To attend the daylong event, Salmon Enhancement Group to landscapes of Hood Canal. Conference on Friday, Nov. 7,9 registration must be completed develop and enhance education- • Raymond and Ann Morris, a.tn.-3:30 p.m.at the Inn at Port by Friday, Oct. 31. Cost is$15, al events for students. Beacon Point residents for near- Iladlock• which includes a continental • Water Resource Inventory ly four decades, who upgraded The awards program is an breakfast and lunch. To reserve Area 16 (Skokomish- their older septic system to pro- annual event that honors com- a spot, contact Robin Lawlis at Dosewallips) Planning Unit, tect nearly 1,600 feet of adjacent munities, individuals, groups 360-394-0046 or rlawlis@hccc. whose members have donated beach and its oysters. and agencies for their dedica- wa.gov. For more information 8,000 hours to oversee and corn- • Marty Ereth, who has been uon to protecting,enhancing and and to learn the full agenda,visit plete assessments, studies and a key participant in habitat pro- restoring the natural resources www.hccc.wa.gov. monitoring. tection and restoration of Hood and water quality of the Hood • David Nash, a Kitsap Canal, including development Canal watershed. Award recipients County employee who has con- and implementation of salmon • In addition to awarding these Receiving awards at the Nov. tributed to projects that have habitat recovery projects. honors, the conference this year 7 event are: • presents an update on the low •Larry and Arleen Schinke of dissolved oxygen issue, partner- Quilcene Bay,who are restoring ship action agenda, Hood Canal their land, 38 acres of coastal watershed planning, and a pub- wetland habitat, and then con- lic review of the Hood Canal serving it in perpetuity through Coordinating Council Strategic the Jefferson Land Trust. • Plan. • Randy Johnson, habitat Interested groups and individ- biologist with Washington Fish uals involved in the stewardship & Wildlife, who has been at the • of the Hood Canal watershed are forefront in planning and design invited to participate in this pub- of several large estuarine habitat lie review.The facilitated discus- restoration projects in Jefferson cion starts at 1:30 p.m. and is and Clallam counties. focused on the council's effort • Duane Fagergren of the to"create and maintain a`larger Puget Sound Partnership, who table' that is inclusive of all is one of the main driving forces .groups and individuals involved behindtheHoodCanalDissolved • 1 • • 7 / d- acdCW • %9/o ` Q• \O t' N a) N ' O c E 1 b coTTG U a N O O.— C ro mp FG °rNE7 NG• C " > 0 ' > o>,..0 C O C 0 U TJ m Oi w y+ 5 4 O C0 ° ° y4 °2 c ''s E ` ro by 7 y [ zS 111. rksci) C - ,, . . -;• E °).. c> n.",9 '' V. -E a) >, 17; �u U _.4C_0 on -��'ij' -tA O,..0 •of Z7 td O E O'O i. ° ,-, t, E U [ E4:10 Cal ° O N zi E Z Rf W E l C E ^ �; y.'o to 0 2; 0-o E b y o q ci o `/) 'O > ,- .J c,/,',2 1 ro `;' !,;(L'3 y L C U. ii 42. p O y ; 0.,xi c) y V t°,C A LJtL�fL E_. 3� G g 00I .0,, °22t 321 3 > Nr. 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'� a e . e- ,,... . 4iv r / �, f`,e' ' �' xq• ,. t t, t I.,a. } �4'':4 „ g C C pJ ro Iii r-a • Algae plagues lake County officials County are clearing during chilly Hadlock and Chimacum, comes as weather. the Jefferson County Public Health Public health officials are consid- Department on Friday upgraded mull solutions ering what to do about the toxic water-quality advisories on three algae in the popular trout-fishing county-owned lakes — Gibbs, Tar- for Anderson lake inside Anderson Lake State boo and Crocker—clearing them as Park—which closed for the season safe for recreational use, although on Saturday—after a year of weekly with cautions for Gibbs and Tarboo. BY JEFF Cnsw lake water sampling and testing. In Clallam County, health offi- PeNiNsuLA DAILY News Blue-green algae can produce cials say they are observing lakes and will test them if they see a blue- anatoxin-a, which can cause liver PORT TOWNSEND—Anderson damage or nerve impairment. green algae bloom. Lake,which has been closed because Small children and people with Unlike Lake Anderson — which of toxins since May 30, remains a liver disease,such as chronic hepa- is slowly filling in and stays rela- • conundrum for public health offs- titis, are most at risk from these tively warm — Clallam's lakes are cials, since it contains a dangerous toxins. deeper and colder and less condu- level of poisonous blue-green algae The unchanging status of Ander- sive to algal blooms,they say. even as other lakes within Jefferson son Lake, which is between Port '1 ouN To LAKE/A7 .1114 id wi' l1C ,�.�..., DANGER ` ' �, > �r ` • ...,„ moo r<tueR��. ,, M. JEFF CNF.W/PENI<SULA Dnu,Ni:ws The boat ramp to Anderson Lake has been closed since early summer because of highly toxic blue-green algae. A • • • ?2N /l/z/dF • Lakes: Cold weather no solution CONTINUED FROM Al It is considered too expen- cene, continues to be posted mer dairy near Lake Anderson • sive. with a yellow caution sign. could have been the source of Colder fall weather, which Treating the lake with alum Health officials said that phosphorous, which was last year was believed to have could cost hundreds of thou- the water in Lake Leland, a churned up when the lake nat- an adverse effect on the poten- sands of dollars, Harrington source of drinking water-for urally turned over during tern- tially toxic algae in Anderson said. some shoreline homes, is not peratures changes. Lake, has failed.to curb toxin "It's not a$200 fix." safe to drink. "What we want to know is levels in Anderson Lake this ' County officials have not Gibbs, Tarboo and Leland what's driving that spring year. discussed the options with lakes are cleared for recre- bloom, with the end game "Anderson is continuing to Washington State Parks. ational use with some cau- being of determining what do bloom despite the cold," said "What may make a lot of tions: • we do,"Harrington said. Neil Harrington,Environmen- sense,if we can't treat Ander- ■ Small children and pets All Jefferson County lakes tal Health's water quality son Lake,is to shift the time of should stay out of the water. monitored have the potential manager, who has closely year that fishing is done," said ■Avoid visible scums. to form dense scums of algae monitored lake water condi- Andrew Shogren,environmen- IIFish caught for consump- that pose a high risk and are. shore- tions since May 2006, when tal health/water quality direc- tion should be cleaned in fresh vsible around the lake's the lake was first closed after tor for Jefferson County Public water and the organs and skin lines. Health,in a written statement The scum can range in a dog died from drinking the discarded. appearance from pale cottony water. on Friday, Teal Lake,which is on state masses to green fuzzy blobs to Toxins remain at nearly land west of Paradise Bay,had slicks that look like paint double the threshold that Testing ends for the year high toxin levels in the sum- spills would make Anderson safe for Health officials have ended mer,but was found clear of all Anderson Lake State Park public use. their weekly county lakes' toxins in September, will reopen April 29. The most recently tested watersampling and testing Lake status and more sample of Anderson Lake until May. Anderson's future detailed recommendations can water. was found to 190,000 cells per milliliter.have "With the end of recre- Why has Anderson Lake be found on the Jefferson The threshold is ational season,we will-be end- remains toxic while algae-gen- County Public Health Web site cellsT per threshold milliliteAsa 100,0000 ing regular testing of the erated poison in other lakes at www.jeffersoncount,, lakes,"Shogren said. has succumbed to chillier• publichealth.org. testing at that level or above is "However,we will continue weather is uncertain. considered hazardous- to test,for nutrients•on a Edi- The highest cell count found monthly basis, and watch for Calling Anderson Lake "a Port Townsend-Jefferson County in the was 1.9 million blue-green algae blooms." big pond," Harrington said it tor Jeff Chew can be reached al 360-385 • - inth recorded lakeon June 23; the low- g has no inlet or outlet like other 2335 or at jeftchew®peninsula est cell count was in August at The test results collected lakes in the county, trapping dailynews.com. during the past year will help its waters. • 66.000,but it soared to 460,000 officials, Shogren said, "It's got quite a bit of nutri- shortly although he did not go into detail. ents in it,"he added. Alum treatment 'With this information, we High levels of phosphorous p can make decisions and rec- make it an ideal algae breed- One option under consider- canommake ons about the ing ground. ation is to treat Lake Ander- county's lakes,"he said. • Anderson is also about 25 son with alum to bind the feet at its deepest point.Shal- phosphorous generated by the Other lakes low lakes tend to have more algae and force it to fall to the algae growth than deep water, lake bottom. Public Health upgraded he said. If not carefully balanced Gibbs Lake, near Chimacum, County health officials are with other chemicals that neu- and Tarboo Lake, north of studying Sandy Shore Lake,in tralize some of its effects,alum Quilcene,to"caution,"marked the headwaters of Thorndyke will kill fish. by yellow signs,removing the Creek near state Highway - Improper treatment led to health advisory warning with 104, which has low levels of a large fish kill in July in red signs. . algae. Pierce County's Wapato Lake Crocker Lake was upgraded Harrington said the county after water acidity levels to clear, marked by a green is also,looking at"depressional soared. sign. Crocker was formerly in lakes"in Pierce,Kitsap,Skagit But the treatment may the red as well. and Snohomish counties. never be tried. Lake Leland,north of Quil- One thought is that a for- • • Flu• in Clallam ,. Jefferson Deterrent of flu virus he vaccine protects available in shots spray against three , of flu � flu that the were BY Rum HILL determined to he the most shot and the nasal spray pro- likely to causes illness this FOR PENINSULA DAILY NEWS tect against three strains of flu Clallam County's public that the were determined to be year, said Carol Burwell, health department has run out the most likely to causes ill- public health nurse for the of injectable flu vaccine for ness in 2008-2009, said Carol adults — but has plenty of Burwell, public health nurse Jefferson County Public anti-flu nasal spray. for the Jefferson County.Public Health Department. Jefferson County has a lira- Health Department. ited amount of vaccine left for She said the health depart- adults, but there is plenty ment generally does not.offer CDC's goal of encouraging vac- available in nasal form or at the flu shots to adults because cines for all school-age children. pharmacies or clinics. the shots are readily available According to Jane Kurata, And flu shots are available at throughout •the county at local Public health nurse for Jefrer- the public health departments pharmacies and clinics. son County, children's vaccine in both counties for children. Both Jefferson and Clallam shortages are not a problem Flu season has not hit Clal- counties health departments this year. offer the nasal spray, or flu The Clallam County public lam or Jefferson counties yet, so public health officials say mist, vaccines at their regu- health immunization schedule larly scheduled clinics. is as follows: it's a good time for people to be vaccinated. The flu mist is more expen- IIIn Port Angeles,8:30 to III While Clallam County is out sive than the shot, but some 11:30 a.m. Tuesdays, 1 to 4 his year's injectable vaccinePeople prefer it to an injection, p.m. Wednesdays and 1 to 6 adults,and does not plan to Burwell said. p.m. the second Wednesday order more — while Jefferson The mist is produced from a each month at Clallam County live virus,while the shots con- Courthouse,223 E. Fourth St.; County has a few doses left — tain the killed virus. Either is 360-417-2274. both provide a nasal spray, called a flu mist. considered to be effective. ■ In Forks, 9:30 to 11:30 Adults who want flu shots a.m. and 1 to 3:30 p.m. the are being referred to retail Children's flu shots third Tuesday of each month, pharmacies or clinics. Both counties offer chil- Forks Health Department, 140 Clallam County typically dren's flu shots as part of a C St.,360-374-3121. offers the injectable vaccines children's health program For other providers, phone throughout the season,but has administered by the state the public health clinics. chosen not to order more,said Department of Health and the ■ In Jefferson County, Christina Hurst,spokeswoman federal Centers for Disease walk-in clinics for children's for the Clallam County Health Control. immunizations are from 1 and Human Services. This year, the flu vaccine is p.ni. to 4 p.m. Tuesday and She said the injectable vac- recommended for all children Thursday. cine is less expensive at local from 6 months to 18 years old, For other providers for chil- pharmacies,so there is no rea- a change from previous years dren and adults in Jefferson son for the Health Department in which only children under 5 County, phone 360-385-9400, to offer it. years old were targeted. or check www.jeffersoncounty This year's vaccines in flu The change reflects the publichealth.org. • Awards given to eco-friendly • Canalcouples les Environmental ■ Larry and Arleen R �W 16 Planning jrinkeindividaial: Resi- Unit, nonprofit: Reprenta- dents of Quilcene Bay, the fives of local governments, efforts honored Schinkes are outstanding ahellfishgrowers farm stewards of their land,work- era, environmental groups In Jefferson ing toward restoration and mte ted residents all and permanent protection of came together to manage 38 acres of coastal wetland water resources and other PENINSULA DAILY NEWS habitat. environmental issues in Hood PORT HADLOCK— Two The project includes rernov Canal. The Watershed Resource Jefferson County couples will ing livestock from the restore- Inventory Area 16 group coy- groupamong individuals and a tion site, tearing out 3,000 erect an from tSkokom- C,group receiving eight Hood fleet of levees,reclaiming tidal yah to the area from llips water- heanalEnvironmentalAchieve- channels and rebuilding sheds. meat Awards on Friday. native plant communities. One project was to study The awards,for work that ■Duane F'ager'geen,gov- potential pollution on Webb helps protect Hood Canal and eatcraseot:A staff person with p° educates others about the the Puget Sound Pattnemhip, Hill,where septic wastes are unique waterway,will be pre- Fagergren was a driving fioree managed. gDavid Nash, govern- seated at lunch during a day- in starting the first program menta An employee of govern- long conference in Port Had- to address Hood C'anal's des - Kitsap soivedoxygenproblem,accord- County, Nash is an expert in lgeographic information sys- The conference, sponsored ing to judges of the awards by the Hood Canal Coordinat- program. He has conducted analyses ing Council, will inrinde a The award citation says akifls for many projects, including oxygen sine about dissolved page/vein's a the Hood Canal Nearshore oxygen problems in Hood helped to keep more than 30 Assessment, Alternative Canal, an update on Puget organizations involved in the Futures,watershed planning, • Sound Partnership efforts and effort. critical areas ordinance and an outline of the strategic He also has been active plan for the coordinatingconservation programs. council. with sewer projects and septic II Randy Johnson, gov- Reaervations for Friday's programs in Hood Canal. eminent: A habitat biologist conference at the Inn at Port ■ Chris Daniel, class- for the state Department of Hadlock 310 Hadlock Bay room:A former staff member Fish and Wildlife, Johnson Road, must be made by of the Hood Canal Salmon has been at the forefront of Wednesday by phoning Robin Enhancement Group, Daniel several large estuarine resto- Lawlis, 360-394-0046, or by developed a series of educe- ration projects, including e-mailing her at rlawlis@h.cec. tion events to connect stu- Jimmy-come-lately, Chi- dents with Hood Canal. mecum Beach,Salmon Creek wo you A$15 fee includes lunch. She also organized volun- and Big and Little Quilcene Award winners and specific teers for habitat and salmon estuaries. studies. She now works for He produces special slide categories: and Ann Paladin Data Systems in shows called"virtual restore- Morris, Residents .Poulsbo. tion," in which people can of Beacon Point near Srinnon, visualize and see the benefits the Morrises have protected of landscape changes. nearly 1,600 feet of pristine ■ Marty Ereth, individ- beach through the years l al:Abiologist for the Skokom- They were among the fust sh Tribe from 1992 until this to volunteer for a septic syr- year Ereth is respected for his tem upgrade under a new extensive knowledge of rivers loan program. and streams throughout Their new system is located southern Hood Canal. farther from shore and it lie has worked with prop- expected to improve shoreline arty owners and has been an habitat important player in habitat protection and restoration. He now works for Pierce County Public Works. For more information about the awards and the confer- ence, click on www.hcccwa. • Roy. //4/aa' .Toxicity of Gibbs, Tarboo and Crocker lakes upgraded Page 1 of 2 • A� t i - ' Voter:., ,rfr,',: :::',4.- L, ',,,,-, ,, :, :, ‘-,'ate LF,ADF1t 1_ T Guide ti 'home classifieds top jobs subscribe contact us`°` photos contests ferry&tides :RSS; Search " LraT 'Viler '"' We know you're busy. CIRCLE& _' `: ► Approved AutoRepair Search ��� aiCe "; 'w' Recognized as AAA's {� ,' #�Sop Shap in WA State Advanced Search Domesik&import Auto Carr - ,' y + +*..:"" ` e , 385.2070....PoRtiodc port Townsend _ ,Ii.::, r 47°F 'Wel( Accuwaa4rer< home:deify news Bash:daily news flash make lt' November 03,2008 e 7 '* quick " -- 11/3/2008 12:22:00 PM Email this article•Print this article ��*�� . � Toxicity of Gibbs,Tarboo and Crocker lakes upgraded � 7 Recent tests of water samples from Gibbs,Tarboo and Crocker lakes indicate a lower level of potentially toxic blue shopflocally,nz=. i green algae species,reports Jefferson County Public Health. - LEADER CLASSIFIEDS ✓. Public Health has removed the health advisory warning(red)from all three lakes,upgrading Gibbs Lake and (( { C t�//��/� local coupons Tarboo Lake to caution(yellow)and Crocker Lake to clear(green). {3�4�385'a�UQ "By gathering samples regularly,we have been able to see lower levels of potentially toxic blue-green algae in our :',-°Villi'',:i.„44 x� r'i'' i3eW5'„ s county lakes,"said Andrew Shogren,Environmental Health/Water Quality director."With this information,we can „ " make decisions and recommendations about the county's lakes.With the end of recreational season,we will ie uua»u Daily News Flash ending regular testing of the lakes;however,we will continue to test for nutrients on a monthly basis and watch for nshing,[hunting blue-green algae blooms." camping,outdoor Top Stones Arts&Entertainment Anderson Lake State Park closed Nov.1 for the winter season.It has been posted with a health advisory warning clothing,work t Gallery Walk since May 30.Recent testing continues to show high levels of blue-green algae. tCitlothing&MORE! Opinion Forum riiiiiir Lake Leland continues to be posted with a caution.The lake is not safe for drinking water.Along with Gibbs and ••`: "� , Our Place Tarboo,Lake Leland is OK for recreational use with some simple cautions:1)small children and pets should stay %h `tr1t 1G111 Columns out of the water,2)people should avoid visible scums,3)fish caught for consumption should be cleaned in fresh *4"' wt Sports water and the organs and skin discarded. Marketplace The algae problem forced restrictions at Gibbs Lake,Lake Leland and Teal Lake in April,Anderson Lake in May, Law&Justice Tarboo Lake in June,and Crocker Lake in July.The popular public swimming holes at Leland and Gibbs were t � Hood Canal Update closed all summer. • Citizen Journalist The problem at Teal Lake eased by August.Sandy Shore Lake remained the only algae-free freshwater swimming News Release Forms hole this year in lowland Jefferson County. ORT iGws<S N community P F F Communit Billboard Blue-green algae found in the lakes are from the genera Anabaena,Microcystis and Aphanizomenon.These algae f r 1',r$r r v ycan produce anatoxin-a,which can cause liver damage or nerve impairment. Community Calendar Online Calendar All of these lakes additionally have the potential to form dense scums of algae that pose a high risk.These scums Activities Guide are visible and can range in appearance from pale cottony masses to green fuzzy blobs to slicks that look like a paint spill.People should avoid coming in contact with any visible scums. Government Meetings ' Links Directory Current lake status and more detailed recommendations can be found on the Public Health website at 2008 Support Groups `Nww.leffersoncountypublichealth.org. visitors '' .;. 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III Interact with Staff PT High School Note:All information on this form is required.Your telephone number is for our use only,and will not be attached to your comment. http://www.ptleader.com/main.asp?SectionlD=4&SubSectionlD=4&ArticlelD=22282&T... 11/3/2008 1111115 .4P :,45 $1 .4' .3. .k.'4c5 (<1:' . q 43) gv 4-,:i• .itsli g ..... .„ 9 .A.4,, 8"cligil . 40 •.... . , • .._.,.. .,..„ 4, . ..c, . 8. 24, . Q. irt $ .4-g % 4• Milla o2ad.v°.44 a tx oDwba'wC roa5�..bv6 0 y .• F+ .0 b 4 d y by N p G7 O,p N a'U�.i,g „.� i 0. O �•0 !/7 $ al• b m '5'1' 4 ar 8 12 › 02/ EfoSgl Fdl pi0 t. '431 W O � Iy,b0 4 s. g 0 JO • Cl) •y8Oo Qu,„ c cd � 50 ' o g � � � r a)owc .3-0 onv (a• �� � g �cN �IIti1 ol 0 5.... 8 86t•S E.g.g>911 1.... .....4 g 4, 1(J.i 0 6 , 2 §'61" O C� a. .� d %�.., 0 0 _.ME. msa� g ^' O ct a. U N 0 0.-. of ° - __U,A vi CD % o al .$� 8 4> pm �F a> as o 3 aA oco W N , .g. : ,9 y w i,VI a) wby y 0001. • NN m'b mom V 8. 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The collection event, sponsored by Jefferson County Public Health, the sher • - iff's office and the public works department, collected more than . 2,500 tires. • The sheriff's department litter k s crew helped unload and stack tires, while public works and health department staff screened vehicles, directed traffic, and answered questions. "The purpose of the event was • twofold," said Anita Hicklin, a solid waste code enforcement officer with Public Health: "to enable homeowners to clean up their properties and to educate people about where they can dispose of tires in the future.Tire piles provide habitat for rats and mdsquitoes." Those who missed the event can find a list of disposal options at www.co.jefferson.wa.us/ publicworks/solidwaste/solid- wasteinfo.asp. Tires were taken to L&S Tires in Lakewood, where most will be used for boiler fuel or baled and used for erosion control, lightweight road fill,impact bar- niers, retaining walls, levee core material, insulators and leachate systems. The cost of hauling and dis- posal is covered by funding from Washington State Department of • Ecology. Last year, more than • 300 tons of tires were removed from five businesses in Jefferson County. This year's event was intended for homeowners. • p / ✓Oi2aedzt. ////O? CDC recommends Port Townsro- vider for an appointmenend; callt:your p • Jefferson Medical & flu vaccines for Pediatric Group, 834 Sheridan St,3 8. Olym •pic• •pic Primary Care, • 1010 Sheridan St,379-8031. children, teens • Port Townsend Family Physicians, 934 Sheridan, 385- The Washington State , 3500. Children's clinics Immunization Program and A limited amount of the nasal Adult clinics Centers for Disease Control spray flu vaccine is available at There are many local influ- (CDC) have expanded the rec- Jefferson County Public Health enza vaccine clinics remaining ommendations for children's immunization clinics. Its use is for adults. influenza vaccines this year. limited to children without the • Jefferson Medical & In the past, influenza vac- medical risk factors listed above Pediatric Group, 834 Sheridan cine was recommended for all who are age 3 through 18 years St., Port Townsend. Saturday, children younger than 5 because old.A small mist of vaccine in they can become very ill fromDec. 6, 9 a.m.-noon. Medicare each nostril can protect against patients bring your Medicare the virus. This year, the vac- influenza. cards; all others $25 cash or cine is recommended for all kids Jefferson County Public ages 6 months through 18 years, check. Private insurance is not encouraging vaccination for all Health offers children's influenza billed.Medicaid clients call 385- vaccines through walk-in i nmu 4848 for an appointment. school-age children or teens. nization clinics every Tuesday •Madrona Hill Urgent Care, Children age 5 and older catch and Thursday between 1 and 4 2500 Sims Way,Port Townsend. influenza at higher rates than p.m.No appointment is needed. Flu vaccine available during adults, even though they might Adult flu vaccines are not offered clinic hours: Monday-Friday 9 not get as sick as younger kids. at this time. For questions or a.m.-7 p.m., Saturday 9 a.m.-4 Vaccine shortages experienced more information,call 385-9400. p.m.and Sunday 10 a.m.-2 p.m. in the past are not a problem Children's flu vaccine is Vaccine available for adults and this year, according to Jefferson also provided through the three children age 4 years and older. County Public Health. Publicly Jefferson Healthcare clinics in Flu shots $25. Medicare billed. funded influenza vaccines for All others cash. children 6 months through 18 •Olympic Primary Care,1010 years of age are now in good sup- ply in the community. Sheridan St., Port Townsend. Influenza, or the flu, is a Saturday, Nov. 8, 9 a.m.-noon. respiratory infection caused by Medicare patients bring your a virus.The"stomach flu"is not Medicare cards. All others $25 • influenza and can be caused by cash or check.Private insurance several other viruses or bacteria. is not billed.Medicaid clients call Symptoms of influenza 379-8031 for an appointment. include fever,headache, cough, •Port Hadlock Medical Care, 121 Oak Bay Road,Port Hadlock. muscle aches and weakness,with nose, throat and lung conges- No long lines;call 379 6737 for tion lasting from a few days to appointment. Bring insurance two weeks.Children might have cards,as some insurers s might pay. nausea and vomiting, but these Flu shots$25.Public welcome. symptoms are rare in adults. • Port Townsend Family Any child or teen is eligible Physicians, 934 Sheridan, Port for the state-supplied influenza Townsend. vaccine.;_However,certain groups Achilland children's vaccines are still considered at risk for available for patients of Port complications of influenza and Townsend Family Physicians;call are highly encouraged to get 385-3500 for an appointment. immunized with the injectable • Safeway Pharmacy, 442 vaccine.These groups include all Sims Way, Port Townsend. children from 6 months to 5 years Walk-ins welcome for immu- old;children with chronic health nizations from 10 a.m. to 2:30 conditions, including asthma, p.m.Monday through Friday.No diabetes,heart,kidney, lung and appointment necessary.Medicare metabolic conditions and anemia; and Medicaid accepted. Many children with conditions that can insurances billed. Bring your lead to breathing or swallowing insurance card. Flu shots $30. problems, such as seizures and Pneumonia shots $45..Clients cerebral palsy;children receiving must be at least 11 years old. medical treatment that weakens •South C 10 ,Quillinic, their immune system;teens who 294843 Highway 101,ys, 1:30- season; will be pregnant during influenza Flu clinics Wednesdays, 1:30- season;children and adolescents 4:30 p.m. Call 765-3111 for an on long-term aspirin therapy; appointment.Medicare patients, pediatric residents of long-term- bring your Medicare cards. All care facilities. others$25 cash or check.Private insurance is not billed. ill Children's clinics A limited amount of the nasal curou flu uorr,n.ic o.,oilohl.of • . . ‘1 .,'z \ V1 `� o n a \ of) 0.2 c�-! > � g � b L _ o onel a) • ° � -4,4) b " 'w CM 8 CA cel 0 U G." g p N G A a (1) tol .8 g 4?'-2. 8 8 E 1 ') `4-' 'n' .5 gb " 8 — .1 -,2; a C ave �.5 tbwo Sfao2 -a . s ' . a�oi ani 3 •° y • ~_ .z •O >, v W Q ,CO v N • U O cd .. — Q •-• 2 cb �a' g a °u, a8 E ° 8 v. x .0. •— I) o 1 oM I oo g a- 1-4 - 1 a 1 • o o - 0 . Ct 0 v a2 � 2 ,`4 0HaocuOw � g ' ,, H � -5 49 . O a) Q -d � t .. • i ° gq tis).0 ia, r:, .i .5 ,c) .5 „) 4) ,.._,,h) § .8 - § -o — '. '71:-.), i V runimil a) 8 p A .D a) ~ c., U "0 p .s -A .0 0 3 .,4 46 `' p . .- E cad, . rRI OA • ° a s4 13 a . ' .5 bi) L N ° " n cti �Uh - ¶ 4ia▪ l °d (1) 16, - , -4 - - 1 1 , -0 •,,, .4 ..,:„ - a.) cli— ,° 0 cd ° c w 3 Ur ., c L. ct kJ 4- b 4 • 5 vc 5.:', ;.) .4, e 2 " .2 -F, \ O I ) cy U1 -0 � •� � rd g 7 Cul) •ELthil0 .2183i�• 0 Xi tbV' Ir - ! S2 & � 9el .8 C Ea -1 0 5b •— o, El.n oo >, � n w o ..... R4 •� °� y � ° b G 5 � owe • • d&Jefferson Coun Leader • Port7ownsen tY ra ew is ', :tz a i n tp 0.- ,4 i -, -4-- A i's>.••' qv ,' . .1,41',-. .. q,i, s, 4.;..,-,- vy4,,,..4 , as zkg' :.-' z,,, iF.-- _,10,.1„.,„„._,,,,,,t,,,t4 „ ,,,, ... .,,wv .. ,Ii .... ..„;, .:„.,,,. . , ..„.:„Ti. .,,,,t:,T.v.... ,,,.s„ _--,,,,,„_, ''-'4.0 , ‘ 1,. ., -.', :`,..4`71*,/,:k 'el r . , : t - ), ' •,, , ,,,,,„•,.:„. : . : .•,,,,,,„ .„,,,,,, :, , .. • f ,„,.,„,,,, ,...„.„.„,„.„,,.„ pin% . • - 0,,,,,,,,,x- '' t... 3 Nig• . � �,, mss'_ 9(,...,- -' , s ' v.,4.-' mop i s'; `. ., - - ". ';a; Girls'Night Out raises money for hedith screening Members of the Port Townsend Main Street Promotion Committee and merchant Gail Boulter-Bu el,„--,-,, 40 owner of The Clothes Horse,present a check for$3,140 to Julia Danskin,public health nursing director at Jefferson County Public Health.Money was generated from"goody bag"sales at Main Street's"Girls'Night Out"event Oct.2.Most goody bags contained a pair of socks contributed by The Clothes Horse,and other gifts donated by Port Townsend merchants.Pictured with Danskin second from left)and Boulter Bungler (third from left)are Kathy Decker and Donna Haynes of the Main Street Promotion Committee."The$3,140 raised during the event will•insure that women have access to health screenings in our count/. Out" was Breast Cancer Awareness Month,and it's a good reminder that early detection is the best protection,"said Danskin."It is wonderful to work with such a caring community." Submitted Photo / /1 r /i/,�-/°? � Take y our choice of flu shot clinics A limited amount of the nasal 4848 for an appointment. spray flu vaccine is available at • Madrona Hill Urgent Care, Jefferson County Public Health 2500 Sims Way,Port Townsend. immunization clinics. Its use is Flu vaccine available during limited to children without med- clinic hours: Monday-Friday 9 ical risk factors who are ages 3 a.m.-7 p.m., Saturday 9 a.m.-4 through 18.A small mist of vac- p.m. and Sunday 10 a.m.-2 p.m. cine in each nostril can protect Vaccine available for adults and against influenza. children age 4 years and older. Jefferson County Public Flu shots $25. Medicare billed. Health offers children's influ- All others cash. enza vaccines through walk- • Port Hadlock Medical in immunization clinics every Care, 121 Oak Bay Road, Tuesday and Thursday between Port Hadlock. No long lines; 1 and 4 p.m. No appointment call 379-6737 for appointment. is needed. Adult flu vaccines Bring insurance cards, as some are not offered at this time. For insurers might pay. Flu shots questions or more information, $25. Public welcome. call 385-9400. • Port Townsend Family Children's flu vaccine is Physicians, 934 Sheridan, Port • also provided through the three Townsend. Jefferson Healthcare clinics in Adult and children's vaccines Port Townsend; call your pro- available for patients of Port vider for an appointment: Townsend Family Physicians; • Jefferson Medical & call 85-3500 for an appoint- Pediatric Group, 834 Sheridan ment. St., 382-4848. • Safeway Pharmacy, 442 • Olympic Primary Care, Sims Way, Port Townsend. 1010 Sheridan St,379-8031. Walk-ins welcome for immu- • Port Townsend Family nizations from 10 a.m. to 2:30 Physicians, 934 Sheridan, 385- p.m.Monday through Friday.No 3500. appointment necessary.Medicare and Medicaid accepted. Many Adult clinics insurances billed. Bring your There are many local influ- insurance card. Flu shots $30. enza vaccine clinics remaining Pneumonia shots $45. Clients for adults. must be at least 11 years old. • Jefferson Medical & •SouthCountyMedicalClinic, Pediatric Group, 834 Sheridan 294843 Highway 101,Quilcene. i St., Port Townsend. Saturday, Flu clinics Wednesdays, 1:30- Dec. 6, 9 a.m.-noon. Medicare 4:30 p.m. Call 765-3111 for an patients bring your Medicare appointment. Medicare patients, cards; all others $25 cash or bring your Medicare cards. All check. Private insurance is not others$25 cash or check.Private billed.Medicaid clients call 385- insurance is not billed. • /<3' County hiring • Only 'mission critical' positions have priority By Allison Arthur reviewed by Morley first. nine-hour days weekly. In a memo to department Leader Staff Writer Mission-critical positions are Richards also said that there heads and elected officials Nov. defined in the commission's res- was no edict issued to depart- 3, Morley reminded people of A formal hiring freeze was olution as"those which must be ments to reduce hours, but he budget pressures facing local approved Monday by Jefferson filled due to contractual obliga- said some people in the health governments. County commissioners because tions, exposure to liability, spe- department voluntarily had "For the next few years of economic uncertainty. cific technical expertise neces- reduced their hours. all of us in Jefferson County "The housing slump and sary for the operation of internal Morley said there were seven government will need to work general economic slowdown systems or due to county ordi- or eight vacancies, including together to respond to these has affected county revenues nance or statutory provisions." Allen Sartin's position as cen- realities,"Morley wrote. from taxes and fees, while Commissioners approved tral services director, that had He noted that commission- increasing energy costs and Morley's request as part of not been filled. Morley said ers need to pass a 2009 budget general inflation are raising their consent agenda and only he had not yet made a recom- in December and that Jefferson expenses," concluded County briefly discussed the resolu- mendation to commissioners County was fortunate that com- Administrator Philip Morley in tion. regarding this position, which missioners have a general fund a written analysis. Commissioner David carries an annual salary of balance. Morley, who started the job Sullivan, D-Cape George, said $81,748,plus benefits. Morley expects to com- in September, said he still was the motion seemed to formalize The motion commissioners plete balancing the budget at working on the proposed 2009 what county department heads approved noted the national, month's end. county budget.A hearing on the and elected officials were prac- state and local housing and A proposed 2009 general budget is anticipated for Dec. 8, ticing already. economic slowdown likely will fund spending budget of $16 with adoption set for Dec. 15. In September, Interim hinder the county's revenues. million was out of kilter by In addition to a freeze on new County Administrator Dennis While revenues would be lower $1.5 million in early September. positions unless they are "mis- Richards said that some posi- than anticipated, inflation has with real estate excise tax rev- sion critical," any vacant posi- tions weren't being filled and increased, and the largest item enue "dropping like a rock" tions — Morley said there were some departments had asked in the county's budget is sala- and sales tax revenue down as . seven or eight—will need to be employees to cut back to four ries and benefits. well. • ' * From: Public Health Nursing Directors [mailto:WS _ A • ALPHO-PHND@LISTSERV.WA.GOV] On Behalf Of McMaster, Diana A (DOH) Sent: Wednesday, November 05, 2008 12:05 PM To: WSALPHO-PHND@LISTSERV.WA.GOV Subject: FW: Not so good news... Importance: High FOR IMMEDIATE RELEASE CONTACT: Suzanne Pate, 425.339.8704 November 4, 2008 spateCa�shd.snohomish.wa.gov Public health cuts directed by Snohomish County Health Board Unanimous vote eliminates 36 positions, affects 11 local public health programs EVERETT, Wash. —At its monthly meeting on Nov. 4 the Snohomish County Health Board voted to eliminate 36 positions at the Snohomish Health District in early 2009. The cuts affect about 14 percent of the staff and 25 percent of the programs at the local public health agency. The Board expects the reductions will save the Health District $1 million in an effort to balance the 2009 budget. "A growing and more diverse population, years of level funding in the face of increasing 411 costs of doing business, and the current economic crisis created the perfect budget storm," said Dr. Gary Goldbaum, Health Officer and Director of Snohomish Health District. "With limited options to increase revenues, the Board had no choice but to cut services. "However, the consequences of these cuts are serious and will almost certainly impact the health of this community beyond 2009,"Dr. Goldbaum continued. "The Health District will not be able to respond to major public health challenges, such as the rise in chronic diseases, as we have in the past." The following programs will end as of Dec. 31, 2008: First Steps/Nurse Family Partnership Clearinghouse; Parent/Child Health; Healthy Communities; Injury Prevention; Water System Support; West Nile Virus. The following programs will lose staff: Tuberculosis Control; Vaccine Preventable Diseases; Child Care Health; Oral Health; Tobacco Prevention and Control. "Now that the Board has decided our immediate future, our challenge is to find creative, new approaches to getting public health done with fewer resources," said Dr. Goldbaum. "I will devote my energy to minimizing adverse effects on the community." • The Board also approved fee increases for clinical services, effective January, 2009. It approved raising Environmental Health fees at the October meeting, effective Nov. 1, 2008. Background. Over the past decade state and local funding for public health in Snohomish County has been flat, despite increased costs of business and living. Effectively, this has translated into annual cuts of 3 to 5 percent, or nearly 50 percent over 10 years. At the Board's direction in 2004,the Health District began using savings to offset the annual erosion. When revenues took an unexpected downturn in April of this year, the Health District froze positions and made other cuts to save $1 million in 2008. As the local and national economy lost traction,the Health Officer presented to the Board a proposal to reduce services supported by local and state funds(not supported by contracts and grants). The Health Board rejected the Health Officer's budget-reduction proposal in August. In September the Snohomish County Executive's budget proposal included a$134,000 increase in the County's contribution to public health. The Snohomish County Council rejected the Executive's budget. In October the Health Board warned the Health District not to expect an increase—but instead to prepare for a possible $300,000 reduction in local funding in the Council's revised budget. The Health Board appointed an ad hoc Budget Task Force from its members to examine all Health District programs and staff for possible cuts. The seven-member work group's recommendations to the full Board led to the reductions-in-force outlined above. Celebrating its 50th year of service to Snohomish County, the Snohomish Health District works for a safer and healthier community through disease prevention,health promotion, and protection from environmental threats. Find more information about local public health programs and services at www.snohd.org.###END### Suzanne M. Pate, Public Information Officer Snohomish Health District 3020 Rucker Avenue, Suite 306 Everett, WA 98201-3900 425.339.8704 Public health—always working for a safer&healthier Snohomish County • JEFFERSON COUNTY BOARD OF H[F;ALTH • November 21, 2008 Mari Mullen Executive Director Port Townsend Main Street Program 211 Taylor St., Suite 1 Port Townsend, WA 98368 Dear Mari, Once again we extend our heartfelt thanks to you and the Main Street Program for all you did to make Girls' Night Out another huge success this year! The $3,140 raised during the event will insure that women have access to Health screenings in our county. October is Breast Cancer Awareness Month and it's a good reminder that early • detection is the best protection. It is wonderful to work with such a caring community. Thank you for all the time and effort devoted to this life-saving cause. We look forward to working together again in the future. Sincerely, ),,, Jo n Austin, Chairman Je erson County Board of Health • 615 Sheridan• Castle Hill Center•Port Townsend • WA • 98368 (360)385-9400 • \*1••‘... k ,:,41;14` NitV,49. 14 Tay •.s.:••5744;,),•-••• j'ATT 2104•141M:;(1.1::••',111 ; '1. ,•••-•-•.t• -'?(1. November 19, 2008 Cullen Stephensen Puget Sound Partnership P.O. Box 40900 Olympia, Washington 98504-0900 RE: Puget Sound Partnership Action Agenda Dear Mr. Stephensen: This letter is written on behalf of the 12 Puget Sound County Environmental Health Directors. We would like to share with you a number comments and concerns we have about the draft Action Agenda. First, we applaud the Partnership in developing a very comprehensive approach to cleaning up • Puget Sound by 2020. Most if not all of our recommendations set forth in our September 9,2008 letter to the Partnership, were addressed in one fashion or another in the Action Agenda. We also very much agree with your basic strategy to: Protect— Restore— Prevent—Work together- and Build a new system to adaptively manage all aspects of Action Agenda implementation. As you have identified, one of the biggest challenges we face is how to protect and restore Puget Sound while welcoming the estimated one million additional people coming to live in the Puget Sound region. The depth and breadth of this undertaking will mean extensive work for local health jurisdictions (LR.ls). Most people identify environmental health as the folks who permit septic systems. However, our programs run the gamut of: • everything related to septic systems • hazardous and solid waste management and local source control programs • water quality monitoring, TMDL plan implementation addressing and non-point pollution impacting, ground water, freshwater, and marine environments • monitoring water quality for water recreation and shellfish growing areas • drinking water programs (including individual and public water systems) • instream flow rule implementation • education and outreach activities regarding environmental public health and environmental resource issues Have no doubt that the LHJs have been and will continue to be heavily involved in the work of protecting, cleaning up and restoring the Sound. Ji As stated,we support the Action Agenda but have called out some specific items to comment on: A.1.1 • We support better land use planning and focusing growth in the areas best suited for that purpose. Many LHJs in urban areas promote"the built environment" concepts which by design promote healthy living habits. We would hope that any regional planning groups include people with expertise in this subject. A.3.1 As instream flow rules are enacted more LHJs may be.Involved in developing and enforcing local ordinances to implement, at the local level, the programs that support instream flow rules. At this point, Skagit and Clallam County LHJs are in that process. Just as the Action Agenda identified the need to build capacity at the local level for assisting local governments in completing and implementing GMA, Critical Areas Ordinances, and Shoreline Master Programs, we also need assistance and funding with instream flow rule implementation at the local level. A.3.2 Many LHJs make the determination regarding water availability for building permit issuance. Many of us believe that Washington State's water law is at best complicated, vague, and conflicting, and at its worst: is an impediment to wise land use planning, growth management, and ecosystem recovery and sustainability, and is in need of reform. A3.3 We support the further development of the water reuse concept. The Washington State Department of Health needs to have the capacity to develop rules that implement safely the use of reuse water and gray water as a resource and not a waste product. . C.1.1 There is compelling evidence that pharmaceuticals are making their way into surface water, ground water, and the marine environment. A very positive step for the Puget Sound area would be a prescription drug take-back program. We also need to further investigate the impact to the environment, particularly drinking water sources,from pharmaceuticals and personal care products not only from sewer treatment plant effluent but also onsite septic discharges. C.4.1 LHJs in the 12 Puget Sound Counties have already begun implementation of SHB1458 (codified as RCW 70.118A) (On-site sewage disposal systems—marine recovery areas). We meet on a regular basis with the Department of Health to "compare notes"and coordinate activities where we are able. We need stable funding to continue this work. C.4.1.1 SHB 1458 (RCW 70.118A)uses the term Marine Recovery Areas, not Marine Managed Areas, as the designation for areas where onsite septic system may be impacting marine water quality. C.4.2. An impediment to identification and timely repair of failing on-site sewage systems occurs when LHJ's cannot survey properties of uncooperative property owners. This issue should be considered as part of the septic system regulation revision process. C.4.3. Providing a method for homeowners to pay for needed on-site septic system repairs, replacements, or connecting to a municipal sewer system is paramount to successfully • 2 implementing our local on-site management plans.We have identified that using the ShoreBank model appears to work very well and we believe that this type of program needs to be available to all of the 12 Puget Sound counties that wish to use such a program. We consider this a priority action for the Puget Sound region. C.5 The public health risk and environmental protection basis for toxic clean up standards need to be confirmed. This information needs to be made available to the public in plain English so they can understand whether contamination levels at a site warrant clean up and if proposed remediation activities are sufficient. Unfortunately low levels of contamination are ubiquitous in our environment and we cannot achieve "0"contamination through clean up actions. The public struggles when clean Up is achieved yet low levels of highly toxic chemicals remain. C.6.2 We support and in many cases are the local implementers of the BEACH, algae blooms in lakes (cyanobacteria), and shellfish monitoring programs. We concur that these important programs have been very much under funded and in need of funding to continue the work at a local level. D.5.1 Many of the environmental permits cited in this section may be "touched" by LHJs during development of the permit. We suggest that LHJ representatives be included in the process to develop an ideal compliance assistance program (see D.5 Near Term Action#1). Priority E Performance Management System We support this concept with the caveat that whatever is put in place must be efficient, effective, reasonable, and are not duplicative of other reporting systems we already are required to use. Sufficient stable funding This is also a priority action for LHJs. In most cases, we have no mechanism that is politically palatable at the local level to fund much of the work called out in the Action Agenda. Stable funding is one of the basic supporting beams of the Action Agenda structure. Without it, the Action Agenda will collapse on itself. Communication, Outreach, and Education This is another priority action of LHJs. We believe that this activity needs to be done on a regional scale, address the critical issues in the Agenda, and educate and assign responsibility to the residents of Puget Sound to do their share. Our last comments are that although we highly support the Partnership and the Action Agenda we also have some trepidation about how implementation will proceed. At this juncture, we are saying that we need to be involved, at the table, in developing some of the processes to be used and coordinating with other stakeholders, knowing full well that in 2009 we are losing capacity and funding within our ranks due to the economic downturn. How we will stay engaged, at the level the Partnership expects and needs in these formative years of Agenda Implementation, will be a struggle. We are mindful that the Partnership will ask us to"use our new method"of reporting progress and show certainty of success even if the "old" method was easier and less costly. We are nervous about loss of local control because we have spent years developing programs, building a rapport with local residents, and building constituencies to get work done. We do not want to see that existing work damaged. In closing, we wish to thank the Partnership for its extensive effort to collect input on the Action • Agenda and in giving us this opportunity to once again provide comments. We anticipate being 3 actively engaged with the Partnership as you move into the priority-setting and implementation stage of the Agenda. Sincerely, • 6i/ Z1.1 462- Andy Brasted R.S., Director, Ciallam County Environmental Health on behalf of the 12 Puget Sound county environmental health directors Clallani, Island, Kitsap, Jefferson,Mason, San Juan, Seattle-king, Skagit, Snohomish, Tacoma- Pierce,Thurston and Whatconi cc: Gregg Grunenfelder, Washington State Department of Health Aaron J. Henderson, Environmental Health Director, Island County Public Health Art Starry, R.S., Director, Thurston County Environmental Health Division, 2000 Lakeridge Drive SW, Olympia, WA 98502 • 41111 4