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Home My WebLink About2014- December Jefferson County Public Health Agenda • & Minutes Extra Copy for Meeting • December 18, 2014 JEFFERSON COUNTY BOARD OF HEALTH December 18,2014 • Jefferson County Public Health 615 Sheridan St. Port Townsend, WA 2:30 —4:30 PM DRAFT AGENDA I. Approval of Agenda 1I. Approval of Minutes of October 16, 2014 Board of Health Meeting III. Public Comment IV. Old Business and Informational Items 1. Letter to Community Pharmacists re: Naloxone Dispensing 2. Girls Night Out Thank You Note 3. School Based Health Center Promotion 4. Commissioner Austin Farewell Party 5. Governing Magazine Article: Census Report on Poverty • V. New Business 1. Preliminary Briefing on Environmental Health Fee Revisions 2. Findings of the State Board of Health Re: Complaint Against Jefferson County Public Health 3. The New Blue H: Findings of the 2014 Rural Health Workgroup 4. Olympic Community of Health Update 5. 2014-15 Influenza Season Update 6. Ebola Preparedness Update VI. Activity Update : Community Health Improvement Plan Meeting January 8,2015 Northwest Maritime Center VII. Public Comment VIII. Agenda Planning Calendar IX. Next Scheduled Meeting: January 15, 2015 2:30—4:30 PM • Jefferson County Public Health 615 Sheridan St. Port Townsend, WA S JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, October 16, 2014 Jefferson County Public Health, 615 Sheridan Street, Port Townsend WA 98368 Board Members Staff Members Phil Johnson, County Commissioner District#1 Thomas Locke,MD,MPH Health Officer David Sullivan, Chair, County Commissioner,District#2 Jean Baldwin,Public Health Services Dir John Austin, County Commissioner,District#3 Julia Danskin,Public Health Manager Sally Aerts, Citizen at large Jared Keefer,Env.Health Services Dir Kris Nelson,Port Townsend City Council Veronica Shaw,Public Health Deputy Dir Sheila Westerman, Vice-Chair, Citizen at large Jill Buhler,Hospital Commissioner,District#2 Chair Sullivan called the October 16, 2014 meeting of the Jefferson County Board of Health to order at 2:30 p.m. A quorum was present. Members Present: David Sullivan, John Austin, Kris Nelson, Sheila Westerman, Members Excused: Sally Aerts, Phil Johnson, Jill Buhler Staff Present: Philip Morley, Thomas Locke, Jean Baldwin,Jared Keefer, Julia Danskin • APPROVAL OF AGENDA Chair Sullivan called for review and approval of the agenda for the 10/16/2014 meeting. Member Austin moved that the Substance Abuse Advisory Board Appointments be moved to item number one (1) in New Business. Jean Baldwin, Director, JCPH, suggested moving Strategies to Expand Access to Opiate Overdose Treatment in Jefferson County to item number two (2) in New Business. Dr. Thomas Locke, Health Officer, JCPH, will update the Board on a new item in New Business about the military's use of Electromagnetic Radiation on the Olympic Peninsula. Member Austin moved to approve the amended agenda; the motion was seconded by Member Nelson. The motion passed unanimously. APPROVAL OF MINUTES Chair Sullivan called for review and approval of the minutes of the 9/18/2014 meeting of the 4110 Board of Health. I Member Austin moved to approve the minutes; the motion was seconded by Member Nelson. No further discussion. The motion passed unanimously. PUBLIC COMMENT Gretchen Brewer stated she would like a status report on the financial assurance of the paper mill. Jared Keefer, Director of Environmental Health and Water Quality, JCPH,reported he does not have a formal response, but has received documents and is reviewing them. His initial overview is that everything is in line with expectations, but it will be a number of weeks before he can do a full review. Dr. Locke informed Ms. Brewer that the documents will be posted to the Jefferson County Public Health website as soon as it is reviewed and finalized. Catharine Robinson, Interim Chair for the Substance Abuse Advisory Board (SAAB), requested the Board give her direction on endeavors when it comes to substance abuse, alcohol and other . drugs, and youth and marijuana. OLD BUSINESS AND INFORMATIONAL ITEMS 1. Enterovirus D-68 Provider Bulletin Dr. Locke informed the Board that Enterovirus D-68 has been confirmed in Washington • State and is likely circulating in Jefferson County. Dr. Locke explained that it can cause severe illness in children, especially those with asthma and other chronic respiratory diseases. Enteroviruses are a common type of respiratory infections that typically circulates in summer and early fall. The Board was provided with a copy of the bulletin that went out to health care providers with clinical management recommendations. 2. Peninsula Accountable Community of Health (ACH)Update—Regional Meeting November 7,2014 Dr. Locke updated the Board on the regional effort to move from a 10-county ACH group to a three-county ACH group. The next step in the process is a meeting on November 7 at Fort Worden from 9:30 a.m. — 12:30 p.m. Jean Baldwin invited Catharine Robinson to attend. Member Austin asked Ms. Baldwin if Chair Sullivan should attend as a representative for the county commissioners. Ms. Baldwin will get back to Member Austin and Chair Sullivan with an answer after finding out if any other counties are going to have commissioner representation. 3. New England Journal of Medicine—Adverse Health Effects of Marijuana Use Dr. Locke provided the Board with a copy of the report, from the National Institute on Drug Abuse (NIDA). He explained that NIDA is under congressional mandate to only • • look at the harmful side of drugs, but a summary on page 2224 deals with medicinal effects, a first for a NIDA publication. The report presents evidence that marijuana use is harmful for children and adolescents and discusses potential adverse health effects for adults. NEW BUSINESS 1. Substance Abuse Board Appointments Catharine Robinson presented the Board with applications from Anthonie Cullen, Kenneth Frohning, and Eric Nygard. Member Austin, Ms. Robinson, and Julia Danskin, Public Health Manager, JCPH, interviewed all three applicants. Ms. Robinson informed the Board that all three are recommended for approval, and announced that SAAB is in need of additional Board members. If approved, a letter will be sent to each applicant, confirming their appointments, and copied to Safe Harbor and Fran Joswick. Member Austin moved to accept the SAAB nominations; the motion was seconded by Member Westerman. No further discussion. The motion passed unanimously. 2. Strategies to Expand Access to Opiate Overdose Treatment in Jefferson County Dr. Locke provided the Board with an information brief on the increase of heroin use in Washington State. With increasing use comes an increased risk of death by overdose, iwhich results from severe respiratory depression. The antidote, Narcan (naloxone), has been available for 40+years, and can be administered by non-health professionals either via nasal spray or auto-injector"epi-pen."Narcan has already been available to emergency aid workers who administer it by injection. Dr. Locke proposes that pharmacies make it available to the general public. Emergency use of Narcan would provide time for an overdosed user to be transported to a hospital. Washington State's Good Samaritan law has been amended to cover those who administer the medication in good faith. Dr. Locke's recommendation is to work with local pharmacies to make prescriptions available to anyone who would benefit from having Narcan on-hand (participants of the syringe exchange, family members of drug users, public safety officials, etc.)Ms. Baldwin will report back to the Board with information on the cost of the nasal spray and auto-injector and inform them if it is covered by insurance or Medicaid. Member Austin moved to have a document written in support of Dr. Locke's proposal, signed by the Chair, and sent to local pharmacies and primary care doctors. The motion was seconded by member Westerman. No further discussion. The motion passed. 3. Public Hearing: Adoption of Jefferson County Solid Waste Regulations Mr. Keefer presented the Board with the Solid Waste Regulations. Chair Sullivan opened the hearing to public comment: • Kevin Scott, Port Townsend Paper Mill, said that Mr. Keefer did a great job,that it is clearly written, and that it is in line with State codes. Gretchen Brewer asked where it is available for review and if it will be reviewed again. Ms. Baldwin informed Ms. Brewer it has been posted on the Jefferson County Public Health website and that the review period will conclude with this public hearing. Member Westerman moved that the changes to the Jefferson County Solid Waste Regulations be adopted and thanked the staff; Member Austin seconded the motion. No further discussion. The motion passed unanimously. 4. Washington State Board of Health Update Member Austin informed the Board that representatives from Asotin County, San Juan County, and Thurston County have applied to replace him on the WA State Board of Health. The Governor will choose one applicant. Member Austin and the director are also hoping Keith Grellner,Kitsap County Environmental Health Director will be chosen as the new chair. Member Austin also reported that the Spokane Board of Health gave an update to the WA State Board of Health and reported that they have programs where immigrants are picking up fruit and distributing it to food banks and co-ops and that they have a Nurse Family Partnership program. The WA State Board of Health also reviewed • several requests about adding a screening for newborn critical congenital heart disease. An advisory board will be formed within the Department of Health and will report back with a recommendation. 5. Electromagnetic Radiation on the Olympic Peninsula Dr. Locke was asked to give the Board an update on the military's plan to use electromagnetic radiation in the Olympic National Forest. Dr. Locke does not have any detailed information about what the military's specific plan and spoke to the issue of human health effects of electromagnetic radiation. Dr. Locke explained the three levels of radiation: Ionizing(ultraviolet, x-rays, gamma rays) which are clearly harmful and cause cancer;Non-Ionizing(microwave ovens) which can cause health effects if the radiation strength is strong enough that it heats your body; and Non-Thermal Radio Frequency (cell phones,wireless, etc.)which has been extensively studied without conclusive findings of adverse human health effects. It is established that the strength of the signal, the amplitude, is a key factor in terms of exposure. The intensity of radiation effects diminishes rapidly as the distance from the radiation source increases. 6. International Ebola Outbreak Update and Washington State Emergency Preparedness Efforts 41 I. • Dr. Locke provided the Board with a letter that went out to providers. He also informed the Board that he will be attending a meeting at the hospital to go over personal protective equipment later today. He told the Board that the CDC initially thought that all hospitals with blood-borne training could handle Ebola, but have modified that position after two nurses became infected in Dallas. Currently, only hospitals with Biosafety Level 4 training and facilities will handle Ebola cases. He reminded the Board that Ebola is not a threat to the general public, is not airborne, and that if any additional cases occur in the US, they will likely be healthcare workers returning from providing service in West Africa. 7. Jefferson County Paralytic Shellfish Poisoning Toxin Levels, Summer/Fall 2014 Michael Dawson, Environmental Health Specialist, JCPH, presented the Board with information about detected levels of Paralytic Shellfish Poisoning (PSP) in Quilcene Bay, Dabob Bay, and the Hood Canal. Mr. Dawson informed the Board that the biotoxins cannot be seen, smelled, or tasted; lab testing is the only way to detect them. PSP testing started in May with nothing detected. By September 23 the highest levels ever were detected. Mr. Dawson reported the following lethal levels detected: Pacific oyster: 3,24311g; Blue mussel: 12,688µg. The closure level is 80µg/100g tissue. 1,000µg can kill an adult. Mr. Dawson informed the Board that signs were posted on site,press releases were sent, and no known illness cases have been reported this year. Some individual PSP sample results have come back lower, but the closure is not lifted. It will need to be two weeks of below-levels before the closure can be lifted. 110 Mr. Dawson also informed the Board on the ways they are tracking biotoxins in Jefferson County, including modifying the Department of Health lab result spreadsheets to easily access local data, referring people to the clickable and mobile device-friendly shellfish safety map, working with volunteer reporters more effectively, creating easier access to data for press releases, posting danger signs in a timely manner, and utilizing a online new sign database with GPS coordinates. ACTIVITY UPDATE No meeting in November.Next meeting December 18, 2014. PUBLIC COMMENT No Public Comment. AGENDA PLANNING CALENDAR No Agenda Planning. NEXT SCHEDULED MEETING • The next Board of Health meeting will be held on Thursday, December 18, 2014 from 2:30— 4:30 p.m. at Jefferson County Public Health, 615 Sheridan Street, Port Townsend, WA. ADJOURNMENT Chair Sullivan adjourned the October 16, 2014 Jefferson County Board of Health meeting at 4:08 p.m. JEFFERSON COUNTY BOARD OF HEALTH Phil Johnson, Member Jill Buhler, Member Sally Aerts,Member David Sullivan, Chair Kris Nelson, Member John Austin, Member • Sheila Westerman,Vice Chair Respectfully Submitted: Natalie Crump • JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, October 16, 2014 Jefferson County Public Health, 615 Sheridan Street, Port Townsend WA 98368 Board Members Staff Members Phil Johnson, County Commissioner District#1 Thomas Locke,MD,MPH Health Officer David Sullivan, Chair, County Commissioner,District#2 Jean Baldwin,Public Health Services Dir John Austin, County Commissioner,District#3 Julia Danskin,Public Health Manager Sally Aerts, Citizen at large Jared Keefer,Env.Health Services Dir Kris Nelson,Port Townsend City Council Veronica Shaw,Public Health Deputy Dir Sheila Westerman, Vice-Chair, Citizen at large Jill Buhler,Hospital Commissioner,District#2 Chair Sullivan called the October 16, 2014 meeting of the Jefferson County Board of Health to order at 2:30 p.m. A quorum was present. Members Present: David Sullivan, John Austin, Kris Nelson, Sheila Westerman, Members Excused: Sally Aerts, Phil Johnson, Jill Buhler • Staff Present: Philip Morley, Thomas Locke, Jean Baldwin, Jared Keefer, Julia Danskin APPROVAL OF AGENDA Chair Sullivan called for review and approval of the agenda for the 10/16/2014 meeting. Member Austin moved that the Substance Abuse Advisory Board Appointments be moved to item number one (1) in New Business. Jean Baldwin, Director, JCPH, suggested moving Strategies to Expand Access to Opiate Overdose Treatment in Jefferson County to item number two (2) in New Business. Dr. Thomas Locke, Health Officer, JCPH, will update the Board on a new item in New Business about the military's use of Electromagnetic Radiation on the Olympic Peninsula. Member Austin moved to approve the amended agenda; the motion was seconded by Member Nelson. The motion passed unanimously. APPROVAL OF MINUTES Chair Sullivan called for review and approval of the minutes of the 9/18/2014 meeting of the • Board of Health. • Member Austin moved to approve the minutes; the motion was seconded by Member Nelson. No further discussion. The motion passed unanimously. PUBLIC COMMENT Gretchen Brewer stated she would like a status report on the financial assurance of the paper mill. Jared Keefer, Director of Environmental Health and Water Quality, JCPH, reported he does not have a formal response, but has received documents and is reviewing them. His initial overview is that everything is in line with expectations,but it will be a number of weeks before he can do a full review. Dr. Locke informed Ms. Brewer that the documents will be posted to the Jefferson County Public Health website as soon as it is reviewed and finalized. Catharine Robinson, Interim Chair for the Substance Abuse Advisory Board (SAAB), requested the Board give her direction on endeavors when it comes to substance abuse, alcohol and other drugs, and youth and marijuana. OLD BUSINESS AND INFORMATIONAL ITEMS 1. Enterovirus D-68 Provider Bulletin • Dr. Locke informed the Board that Enterovirus D-68 has been confirmed in Washington State and is likely circulating in Jefferson County. Dr. Locke explained that it can cause severe illness in children, especially those with asthma and other chronic respiratory diseases. Enteroviruses are a common type of respiratory infections that typically circulates in summer and early fall. The Board was provided with a copy of the bulletin that went out to health care providers with clinical management recommendations. 2. Peninsula Accountable Community of Health (ACH) Update—Regional Meeting November 7, 2014 Dr. Locke updated the Board on the regional effort to move from a 10-county ACH group to a three-county ACH group. The next step in the process is a meeting on November 7 at Fort Worden from 9:30 a.m.— 12:30 p.m. Jean Baldwin invited Catharine Robinson to attend. Member Austin asked Ms. Baldwin if Chair Sullivan should attend as a representative for the county commissioners. Ms.Baldwin will get back to Member Austin and Chair Sullivan with an answer after finding out if any other counties are going to have commissioner representation. 3. New England Journal of Medicine—Adverse Health Effects of Marijuana Use • Dr. Locke provided the Board with a copy of the report, from the National Institute on Drug Abuse (NIDA). He explained that NIDA is under congressional mandate to only look at the harmful side of drugs, but a summary on page 2224 deals with medicinal effects, a first for a NIDA publication. The report presents evidence that marijuana use is harmful for children and adolescents and discusses potential adverse health effects for adults. NEW BUSINESS 1. Substance Abuse Board Appointments Catharine Robinson presented the Board with applications from Anthonie Cullen, Kenneth Frohning, and Eric Nygard. Member Austin, Ms. Robinson, and Julia Danskin, Public Health Manager, JCPH, interviewed all three applicants. Ms. Robinson informed the Board that all three are recommended for approval, and announced that SAAB is in need of additional Board members. If approved, a letter will be sent to each applicant, confirming their appointments, and copied to Safe Harbor and Fran Joswick. Member Austin moved to accept the SAAB nominations; the motion was seconded by Member Westerman. No further discussion. The motion passed unanimously. 2. Strategies to Expand Access to Opiate Overdose Treatment in Jefferson County Dr. Locke provided the Board with an information brief on the increase of heroin use in • Washington State. With increasing use comes an increased risk of death by overdose, which results from severe respiratory depression. The antidote,Narcan (naloxone), has been available for 40+years, and can be administered by non-health professionals either via nasal spray or auto-injector"epi-pen."Narcan has already been available to emergency aid workers who administer it by injection. Dr. Locke proposes that pharmacies make it available to the general public.Emergency use of Narcan would provide time for an overdosed user to be transported to a hospital. Washington State's Good Samaritan law has been amended to cover those who administer the medication in good faith. Dr. Locke's recommendation is to work with local pharmacies to make prescriptions available to anyone who would benefit from having Narcan on-hand (participants of the syringe exchange, family members of drug users, public safety officials, etc.)Ms. Baldwin will report back to the Board with information on the cost of the nasal spray and auto-injector and inform them if it is covered by insurance or Medicaid. Member Austin moved to have a document written in support of Dr. Locke's proposal, signed by the Chair, and sent to local pharmacies and primary care doctors. The motion was seconded by member Westerman. No further discussion. The motion passed. 3. Public Hearing: Adoption of Jefferson County Solid Waste Regulations • Mr. Keefer presented the Board with the Solid Waste Regulations. Chair Sullivan opened the hearing to public comment: Kevin Scott, Port Townsend Paper Mill, said that Mr. Keefer did a great job, that it is clearly written, and that it is in line with State codes. Gretchen Brewer asked where it is available for review and if it will be reviewed again. Ms. Baldwin informed Ms. Brewer it has been posted on the Jefferson County Public Health website and that the review period will conclude with this public hearing. Member Westerman moved that the changes to the Jefferson County Solid Waste Regulations be adopted and thanked the staff; Member Austin seconded the motion. No further discussion. The motion passed unanimously. 4. Washington State Board of Health Update Member Austin infolined the Board that representatives from Asotin County, San Juan County, and Thurston County have applied to replace him on the WA State Board of Health. The Governor will choose one applicant. Member Austin and the director are also hoping Keith Grellner, Kitsap County Environmental Health Director will be chosen as the new chair. Member Austin also reported that the Spokane Board of Health gave an update to the WA State Board of Health and reported that they have programs where • immigrants are picking up fruit and distributing it to food banks and co-ops and that they have a Nurse Family Partnership program. The WA State Board of Health also reviewed several requests about adding a screening for newborn critical congenital heart disease. An advisory board will be formed within the Department of Health and will report back with a recommendation. 5. Electromagnetic Radiation on the Olympic Peninsula Dr. Locke was asked to give the Board an update on the military's plan to use electromagnetic radiation in the Olympic National Forest. Dr. Locke does not have any detailed information about what the military's specific plan and spoke to the issue of human health effects of electromagnetic radiation. Dr. Locke explained the three levels of radiation: Ionizing(ultraviolet, x-rays, gamma rays) which are clearly harmful and cause cancer;Non-Ionizing (microwave ovens) which can cause health effects if the radiation strength is strong enough that it heats your body; and Non-Thermal Radio Frequency (cell phones, wireless, etc.)which has been extensively studied without conclusive findings of adverse human health effects. It is established that the strength of the signal, the amplitude, is a key factor in terms of exposure. The intensity of radiation effects diminishes rapidly as the distance from the radiation source increases. 6. International Ebola Outbreak Update and Washington State Emergency • Preparedness Efforts • Dr. Locke provided the Board with a letter that went out to providers. He also informed the Board that he will be attending a meeting at the hospital to go over personal protective equipment later today. He told the Board that the CDC initially thought that all hospitals with blood-borne training could handle Ebola, but have modified that position after two nurses became infected in Dallas. Currently, only hospitals with Biosafety Level 4 training and facilities will handle Ebola cases. He reminded the Board that Ebola is not a threat to the general public, is not airborne, and that if any additional cases occur in the US, they will likely be healthcare workers returning from providing service in West Africa. 7. Jefferson County Paralytic Shellfish Poisoning Toxin Levels, Summer/Fall 2014 Michael Dawson, Environmental Health Specialist, JCPH, presented the Board with information about detected levels of Paralytic Shellfish Poisoning (PSP) in Quilcene Bay, Dabob Bay, and the Hood Canal. Mr. Dawson informed the Board that the biotoxins cannot be seen, smelled, or tasted; lab testing is the only way to detect them. PSP testing started in May with nothing detected. By September 23 the highest levels ever were detected. Mr. Dawson reported the following lethal levels detected: Pacific oyster: 3,243µg; Blue mussel: 12,688µg. The closure level is 80µg/100g tissue. 1,000µg can kill an adult. Mr. Dawson informed the Board that signs were posted on site,press releases were sent, and no known illness cases have been reported this year. Some individual PSP sample results have come back lower, but the closure is not lifted. It will need to be two • weeks of below-levels before the closure can be lifted. Mr. Dawson also informed the Board on the ways they are tracking biotoxins in Jefferson County, including modifying the Department of Health lab result spreadsheets to easily access local data, referring people to the clickable and mobile device-friendly shellfish safety map, working with volunteer reporters more effectively, creating easier access to data for press releases, posting danger signs in a timely manner, and utilizing a online new sign database with GPS coordinates. ACTIVITY UPDATE No meeting in November. Next meeting December 18, 2014. PUBLIC COMMENT No Public Comment. AGENDA PLANNING CALENDAR • No Agenda Planning. lk NEXT SCHEDULED MEETING The next Board of Health meeting will be held on Thursday, December 18, 2014 from 2:30- 4:30 p.m. at Jefferson County Public Health, 615 Sheridan Street,Port Townsend, WA. ADJOURNMENT Chair Sullivan adjourned the October 16,2014 Jefferson County Board of Health meeting at 4:08 p.m. JEFFERSO 1 COUNTY BOARD OF HEALTH 1 .04/ / , /Z1,76.7e,d(,- Phil ohnson, i ember ill Buhler, Member _,,/ z /91 ,,./ i e. ,C,)1J Sally Aerts ember David Sullivan, Chair • '-' \*\\\(Y) '''' . ill 1 Kris Nelson, Member 14 Austin, Member I/ S(UAL- IL)ie,A1 AA-0,---- Sheila Westerman, Vice Chair Respectfully Submitted: Natalie Crump Board of Health IV Old Business Item 1 Letter to Community Pharmacists Re: Naloxone Dispensing December 18, 2014 JF,FFERSOI\ COUNTY • BOARD OF HFALTH October 27,2014 Dear Local Jefferson County Pharmacist: Illicit opiate use is a serious public health problem in Jefferson County.Prescription narcotics like methadone, oxycodone,and hydrocodone have long been a problem with significant amounts stolen or diverted for non- therapeutic use. Most recently we have seen an alarming increase in heroin use in Jefferson County and across Washington State. Among the many harms that can be caused by these drugs is the potential for fatal overdose.As you are no doubt aware,there is an antidote for opiate overdose—naloxone,administered either as an intranasal spray or in the newer autoinjector form. Washington State has been a pioneer in promoting naloxone distribution for emergency treatment of opiate overdoses by"Good Samaritans". The Washington State Legislature has legalized this process and it is endorsed by the State Pharmacy Board and Washington State Medical Association.Jefferson County Public Health has run a syringe exchange program for over a decade. We would like to begin providing prescriptions for naloxone inhalers to heroin users as soon as possible. The Jefferson County Board of Health has recently reviewed this issue and at its October 16,2014 meeting, voted to send a request to all pharmacies in the County asking that you stock the naloxone and nasal atomizer kits.The Board also asks that you consider directly dispensing naloxone inhalers under a standing order from the Jefferson County Health Officer,Dr.Tom Locke. In addition,we are looking into the feasibility of equipping public • safety officers with naloxone kits to rapidly respond to opiate overdose cases in the field. Jefferson County Public Health staff will be contacting you in the near future to ask the following questions: 1) Is your pharmacy willing to stock naloxone plus nasal atomizers to be dispensed to patients who have a prescription for the medication? 2) Is your pharmacy interested in direct dispensing of naloxone inhalers under a standing order issued by the Jefferson County Health Officer? In both cases the patient would be financially responsible for the cost of the medication. On behalf of the Jefferson County Board of Health, I would like to thank you for considering this request and expanding access to a lifesaving emergency treatment to members of our community. If you have further questions,please don't hesitate to call Jefferson County Health Officer,Tom Locke,MD at 360- 385-9448 Sincerely, David Sullivan, Chair,Jefferson County Board of Health Board Members • David Sullivan(Chair),County Commissioner District#2;Sheila Westerman,Citizen(►ice-Chair); Phil Johnson,County Commissioner District#l;John Austin,Coumv Commissioner District#3; /iris Nelson,Port Townsend City Council;Sally Aeric,Citizen;Jill Buhler,Hospital Commissioner 615 Sheridan • Castle Hill Center• Port Townsend • WA • 98368 (360)385-9400 4, Board of Health IV Old Business II Item 2 Girls Night Out Thank You Note • • December 18, 2014 • ..,,,Crr-:,,,-. ,2-Aei .,,,,o Dear Friends of the Port Townsend Main Street Program: , 4444.44,0 , 0 ' ,,,, We were delighted to see how , ,4 successful Girls' Night Out was this '-::: 7 , year, and want to extend our warmest thanks for your generous donation to the Jefferson County Public Health Breast and Cervical Health Program. • We look forward to continuing to work with you in the years to come, and appreciate all that you do. i',... ., - , - ilk i 4,.-4.1.. Sincerely, Ira*. : 41 , jean Baldwin Julia Danskin '±- ; -% / Director Public Health Manager / \ j 9efiretsort Public Health MOIN.....ea r • , ,""; Board of Health IV Old Business Item 3 School Based Health Center Promotion December 18, 2014 S 4:,v,tmt.u,,4o,,,t),,Aral. rytiebt, ni• 4 404,:eit r4. 4tit2To',Vv'tlsV'. 0-Ti'ottrAt't-! High School Parent Conference Student Fees Schedule is Set for November 20 Parent conferences at Port Townsend High School have been set for fhorsday.November 20 Here at PTHS. participate in arena style conferences.which means that all teachers are available at individual tables,which are set up in me gymnasium This formai allows parents an opportunity " to meet with multiple teachers in a short atillitAlt of time case, n c Conferences will bo nein in two separate sessions The heteritare rewing'I thcali,„t:net!rev wilt trkka afternoon session will be from 1•00-4•00 p rti (no Ont-abut mhha er.id itenitted into the gym atter 3:30 PM),and the evening session Win be inrliv held from 501) 1.00 p in (no entrance into the gym after . 510 peg The high school administrators and school Mmi,iiiitot we spfff'..clala lors will also be on site for conferences It you feel ihat need' an extended parent conference with one or be more teachers you may schedule that throughZi!joje#,,,,,t(„t„,,,,g,,000114„ tsffiCfy 4523 We look foiward to seeing you at Akvar„••Vv*",,,,,,,-„,,',,,,i, Arena Patent Conferences in November 104#4,t irpj4,4„ ,rjstojto„ ; lie— WS. 'at Evonts website is updated daily Firid iniportent and current . , , information regarding our school fat parents.ntorlerrts nod r.torrimunity Check it out, OPEN School Based Health Center Easy Access to Confidential and Affordable Healthcare • • for high school students! 50550 en Orion.Morse Proctar000r and an chic School bSred nit-sins Corer Illness and injury•Sports Physicals• immunizations IP Mental health services •and more No student is denied services due to inability to pop tthnei Bated Prams Crnnsn bmoghi loner 5y iette,00 County Public Stealth•letters?).HeAttlIcaip•Port TO•Merie School Mono Call JCPH for appointments:360-385-9400 • Board of Health lv Old Business Item 4 • Commissioner Austin Farewell Party • December 18, 2014 `mac ON c0 ,'' ; t4,.',6.„..4.9-.7,-:.:c,,.-,1' JEFFERSON COUNTY •41) L,..1-...,-}.-,-,,- r, BOARD OF COUNTY COMMISSIONERS .:` ''.7 I t ''SfrtNa'° tl't'4';A,,,t'' ',,4,r,A,:4, YOU ARE INVITED TO CHAIRMAN JOHN AUSTIN'S FAREWELL PARTY! .ak p l ,� � �:; Since 2007 John Austin has served.Jefferson County as °, 4 ; ( . County Commissioner for 0� Dstric 3..Please help us in eelebratingthe next phase`in _ . his life - RETIREMENT! r� r , EVENT L ETAILS s ° Monday, December 22, 2014 ', ''' f' 1:30 p.m. � ". Jefferson County Courthouse m Commissioner's Chambers '4, 1820 Jefferson Street Port Townsend, WA 98368 (360) 385-9100 7a� <ara �- 001. � ,.•'''' i.,,,,, ,, a ;ow a, 1 , \,..sti:,, , ast . i a; y iloil £. 44 ,, Photo of Murhut Falls, Bannon WA Board of Health IV Old Business Item 5 Governing Magazine Article: • Census Report on Poverty • December 18, 2014 Page 1 of 2 4 Takeaways from the Census Report on Poverty • If not for government assistance, millions more would be impoverished, according to the latest data. BY: J.B. Wogan October 28, 2014 About 2.9 million more Americans would be counted as poor if the federal government took a comprehensive snapshot of people's income and expenses. That's one of the key takeaways from a new report by the U.S. Census Bureau on the supplemental poverty measure (SPM). The measure is an attempt by Census researchers to improve its count of people living in poverty while keeping in place the official measure established in the 1960s and used for an array of federal safety net programs. The official federal poverty measure for 2013 counted slightly more than 45 million people as poor, roughly 14.6 percent of the population. The SPM shows that the poverty rate was actually higher-- 15.5 percent-- when researchers factored in some types of nondiscretionary spending, such as out-of-pocket medical costs, that aren't included in the official measure. Even more people would have been considered as living in poverty, the data shows, if not for tax credits and noncash benefits offered by the government. This appears in our free Human Services e-newsletter. Not already a subscriber? Click here. The bureau's latest accounting of poverty in America offers four insights: More people would be poor tomorrow if not for safety net programs. Florida Sen. Marco Rubio and Wisconsin Rep. Paul Ryan both used this year, the 50th anniversary of the federal "War on Poverty," to call for an overhaul of government safety net programs. They argued that the war has failed and that the programs need to be more efficient and effective. Reasonable people can debate whether any of the myriad programs work as well as they should, but the Census report does show that millions of Americans would fall below the poverty line if several of the major • assistance programs ended tomorrow. For example, the poverty rate would be 2.9 percentage points higher -- 9 million more people below the poverty line -- if not for refundable tax credits, such as the Child Care Tax Credit and the Earned Income Tax Credit. The chart below draws from data in the Census report showing how much higher the SPM poverty rate would be in the absence of specific public assistance programs. In every case, the denominator is the total number of Americans, roughly 313 million. The Census analysis does not take the additional step of trying to estimate the long-term ramifications of ending specific programs, which might still mean more people living in poverty, but also could result in other outcomes, such as people taking undesireable jobs or shifting to other types of assistance. The percent estimates are reported at the 90 percent confidence level.* Percent Margin of Estimate Error Social Security 24.1 0.4 Refundable Tax Credits 18.4 0.4 Supplemental Nutrition Assistance 17.1 0.3 Program (SNAP) Unemployment Insurance 16.2 0.3 Supplemental Security Insurance 16.8 0.3 (SSI) Housing Subsidies 16.5 0.3 Child Support Received 16.0 0.3 • School Lunch 16.0 0.3 15.8 0.3 http://www.governing.com/templates/gov_brint article?id=280549282 12/11/2014 Page 2 of 2 Temporary Assistance for Needy Families (TANF)/General Assistance • Special Supplemental Nutrition Program for Women, Infants and 15.7 0.3 Children (WIC) Low-Income Home Energy 15.6 0.3 Assistance Program (LIHEAP) Workers' Compensation 15.6 0.3 Some places are poorer than others. The 15.5 percent figure is the average SPM calculated for all people across the country, but the poverty rate is higher in the urban core of a metro area (20.1 percent). The neighborhoods outside the urban core -.- the suburbs -- had a lower poverty rate (13.4 percent). However, the suburbs also had slightly more people in poverty in absolute numbers (21.9 million vs. 20.5 million in cities). Researchers at the Brookings Institution have recorded persuasive evidence that poverty is growing faster in the suburbs than in central cities. While poverty remains a top priority for most big-city mayors, it's becoming a more important issue for suburban governments as well. Some groups of people are poorer than others. The Census data shows that poverty is concentrated in certain pockets of society. The poverty rates for blacks and Hispanics, for example, are well above the national average. Renters, as a group, are poorer than homeowners. Households with a single mother are poorer than ones with married couples. Poverty Margin of Rate Error • Single Adult Female 28.5 0.9 Householder Renter 27.1 0.7 Foreign-Born Noncitizen 29.2 1.3 Black 24.7 1.2 Hispanic 26.0 1.0 The poor haven't recovered from the recession. The latest Census report does indicate that the poverty rate declined by half a percentage point between 2012 and 2013. However, the official poverty rate is still several percentage points higher than in 2007, when the last economic recession took place. Researchers at the Brookings Institution predict a slow economic recovery, with the SPM not returning to its pre-recession level until 2020. This story has been updated with additional information to clarify what is being shown in the chart on SPM rates and public assistance programs. This article was printed from: http://www.governing.com/topics/health-human-services/gov- lessons-census-supplemental-poverty-measure-report.html • http://www.governing.com/templates/gov.print_article?id=280549282 12/11/2014 Board of Health V New Business Item 1 Preliminary Briefing on EH Fee Revision • • December 18, 2014 2014 On-Site Wastewater Activity and Fee Review • Introduction The last time On-Site Wastewater activities and fees were reviewed was in 2009. At that time, it was found that eight fees needed to be adjusted based upon the time study and work sampling data for those activities. Those were: All new septic system permits and new septic system permits done with a Site Plan Advanced Approval Determination (SPAAD) through the Department of Community Development. In 2012, we made substantial operational changes Public Health activities as they related to building permits in order to increase effectiveness; improve transparency and streamline processes. Given the time since the last activity review and the programmatic changes that have occurred since the last review, it is time to reexamine program activities and their resultant fees. Data on this review will be presented over the next two meetings with recommendations for action following at the subsequent meeting. Data for this activity review were gathered and analyzed in 3 ways: 1. Staff tracked their daily time associated with individual activities on Building cases were analyzed for the period 8/7/14 to 9/8/14. 2. Staff tracked their daily time associated with individual activities on septic cases from 8/6/14—9/22/14. 3. Beginning in September of 2011, staff tracked activities by septic case for the 'life' of the case, from receipt to final sign-off. This was using a randomized methodology and was • only a sample of all the case done from 9/11 to 9/14. Today's Takeaways • Activity on 86 Building cases were analyzed • Activity on 255 septic cases were analyzed • 38 septic systems were tracked from beginning to end • 496 specific work activities were analyzed Mean time spent per activity(directly Approx. 58 minutes(expenditure in today's attributable to a permit) n = 496 dollars of$82.17) Range of Minutes spent per activity 5—1190 (min -$7.08; max-$1685.83) Mean time spent per permit (includes all permit Approx. 546 minutes (expenditure in today's related activity, even those who do not obtain dollars of$765.85) permit) Range of Minutes spent per permit 85—1,730 min (min -$120.42; max-$2450.83) Outlier: • Repair on the Duckabush (still not complete yet) - 28.83 hours so far-$2,450.55, collected $245.00; *Expenditures are estimated at the current hourly rate-$85.00 Board of Health V New Business Item 2 State BOH Findings re: Complaint Against Jefferson • County Public Health � � December 18, 2014 St:�•rF. iu v At yfid"ss ,n h;t 19A° srA'FF.OF WASHINGTON DEPARTMENT OF HEALTH • Olympia, Washington 98504 November 18, 2014 Dr. Tom Locke Jefferson County Public Health 615 Sheridan Street Port Townsend, WA 98368 Dear Dr. Locke: The Washington State Board of Health has completed its preliminary investigation under RCW 70.05.120 in response a complaint against Jefferson County Public Health. The investigation involved a review of the complaint submitted; a review of RCW 64.44, Contaminated Properties, and Chapter 246-205 WAC—Decontamination of Illegal Drug Manufacturing or Storage Sites; and a review of records received as a result of public records requests to Jefferson County Public Health, Port Townsend Police Department, and Jefferson County Prosecuting Attorney concerning: • "1507 31st Street, Port Townsend, WA", "Public complaints and investigation reports for 1507 31st Street, Port Townsend, WA", and"records, inquiries, complaints, and other information requests or correspondence from Mr. Barry Ellis and Jefferson County Public Health, Port Townsend Police Department, and Jefferson County Prosecuting Attorney". In addition, three of the four witnesses identified in the complaint were interviewed. Based on the results of the preliminary investigation of your complaint, at its November 12 meeting, the Washington State Board of Health found that Jefferson County Public Health did not fail to enforce the rules and regulations concerning decontamination of illegal drug manufacturing or storage sites with respect to the property in question, and concluded that no further action under RCW 70.05.120 was warranted. You can review the findings of the investigation on our website at htt•://sboh.wa..ov/Portals/7/Doc/Meetin•s/2014/1 l-12/W SBOH-11-12-14-Tab09a.pdf Sincerely, p� GGC��! / Michelle Davis Executive Director • • • ?WASHINGTON STATE >! OARD OF HEALTH Working for a safer and healthier Washington since 1889 DATE: November 12, 2014 TO: Washington State Board of Health Members FROM: Keith Grellner, Vice Chair SUBJECT: RESULTS OF PRELIMINARY INVESTIGATION UNDER RCW 70.05.120 CONCERNING BARRY ELLIS COMPLAINT AGAINST JEFFERSON COUNTY PUBLIC HEALTH FOR FAILING TO POST A PROPERTY UNDER CHAPTER 64.44 RCW, CONTAMINATED PROPERTIES, AND 246-205 WAC, DECONTAMINATION OF ILLEGAL DRUG MANUFACTURING OR STORAGE SITES Introduction. On July 9, 2014, and August 13, 2014, Mr. Barry Ellis filed written complaints with the Washington State Board of Health pursuant to RCW 70.05.120. The complaints alleged that Jefferson County Public Health failed to carry out the State Board of Health's laws or rules and regulations concerning Contaminated Properties and Decontamination of Illegal Drug Manufacturing or Storage Sites, Chapter 64.44 RCW and Chapter 246-205 WAC, respectively. • Specifically, Mr. Ellis alleges that Jefferson County Public Health failed to post Mr. Ellis' former rental residence (1507 31St Street, Port Townsend, WA) as contaminated and unsafe due to illegal drug manufacturing activity, and to force the owner of this residence to clean up the illegal drug lab contamination. On August 13, 2014,the Board asked for a preliminary investigation of the complaint and allegations of Mr. Barry Ellis against Jefferson County Public Health. The purpose of this memo is to discuss the findings and conclusions of the preliminary investigation. Process. Board staff and I reviewed Mr. Ellis' complaint information; the relevant law, RCW 64.44 and WAC 246-205; and the results of public records requests to Jefferson County Public Health, Port Townsend Police Department, and Jefferson County Prosecuting Attorney concerning: "1507 31St Street, Port Townsend, WA", "Public complaints and investigation reports for 1507 31st Street, Port Townsend, WA", and "records, inquiries, complaints, and other information requests or correspondence from Mr. Barry Ellis and Jefferson County Public Health, Port Townsend Police Department, and Jefferson County Prosecuting Attorney"; I also interviewed three of the four witnesses that Mr. Ellis cited in his written complaints (Paula Martin, Christina Nelson, and Larry Stone). In addition, we reviewed a written statement • of response to the complaint from Thomas Locke,Jefferson County Health Officer. • • Findings and Discussion. The following points summarize the findings of the preliminary investigation: Intent and scope of the law, rules, and regulations: • RCW 64.44.005, Legislative finding, states, in part, that "The legislature finds that some properties are being contaminated by hazardous chemicals used in unsafe or illegal ways in the manufacture of illegal drugs. • RCW 64.44.010, Definitions, defines "Hazardous chemicals" in part as "...the following substances associated with the illegal manufacture of controlled substances..." WAC 246-205-001, Purpose and authority; -010, Definitions; -510, Local health officer responsibilities; -520, Posting property; and -530, Inspecting property; are authorized by, and mirror the language of, RCW 64.44. The law, rules, and regulations clearly state that the legislature's intent was to address hazardous chemicals used in the manufacture of illegal drugs, or associated with the illegal manufacture of controlled substances. 41, A. Local health officer responsibilities: • • RCW 64.44.020, Reporting—Warning—Notice—Duties of local health officer, states, in part, that, "Whenever a law enforcement agency becomes aware that property has been contaminated by hazardous chemicals, that agency shall report the contamination to the local health officer. The local health officer shall cause a posting of a written warning on the premises within one working day of notification of the contamination..." and "If a property owner believes that a tenant has contaminated the property that was being leased or rented, and the property is vacated or abandoned, then the property owner shall contact the local health officer about the possible contamination."This section of statute continues with, "A local health officer may enter, inspect, and survey at reasonable times any properties for which there are reasonable grounds to believe that the property has become contaminated." The local health officer is responsible to post a written warning on the property, and to inspect the property, when notified by a law enforcement agency or property owner that property has been contaminated by hazardous chemicals used in, or associated with, the manufacture of illegal drugs. Mr. Ellis cited Ms. Paula Martin, and her written statement concerning a conversation that she had with a woman alleged to be Ms. Joanne Meyer, co-owner of 1507 315t • Street, as further cause to confirm that illegal drug lab manufacturing activity occurred 2 • • at 1507 31st Street. I contacted Ms. Martin and interviewed her about her statement. • Ms. Martin confirmed that she had a conversation with a woman at this property and that she did provide Mr. Ellis with a written statement. However, Ms. Martin stated that she did not know who the woman was that she talked to; she had never been in the residence nor had ever seen or suspected any evidence of illegal drug manufacturing activity even though she was a neighbor to this property; and she never contacted any law enforcement agencies to report suspected drug manufacturing activity. Therefore, Ms. Martin's statement provides no reasonable grounds to suspect that this property had become contaminated, and her statement does not meet the intent of the law concerning notification of the local health officer. Attempts were also made to interview the owners of 1507 31St Street, Bent and Joanne Meyer, and Denyse Early, a neighbor to this residence whom Mr. Ellis cited as providing firsthand information to him that she was inside the home and saw meth manufacturing items.The Meyers did not return my messages asking for a callback. Ms. Early no longer works at the US Bank in Port Townsend, and the cell phone number Mr. Ellis listed does not belong to Ms. Early.There is no other phone listing or address for a Denyse Early in Port Townsend that I could locate. B. Sampling • • WAC 246-205-531, Sampling procedures, specifies, in part, that: • o Analytical results obtained through sampling may be used as a method to determine contamination; o Collection of samples shall be performed by department of ecology staff; department of health certified CDL supervisors; or the local health officer; o Samples shall be collected: using standards and protocols to ensure accuracy and the ability to produce similar results with repeated sampling; with proper care and prudent action to avoid contamination during sampling; and transported, stored, analyzed, and secured to assure an unbroken chain-of- custody as described in ASTM Standard D 4840. • The department of health has established and published Guidelines for Environmental Sampling at Illegal Drug Manufacturing Sites (September 2005). Mr. Ellis states in his written complaint to the State Board of Health that in April 2012, "before I was locked out of this residence, I removed items from the house and had them tested for meth residue..." In a previous written complaint that he also submitted to the State Board of Health, Mr. Ellis states that after speaking with Paula Martin in April 2012, that he bagged-up contaminated items for evidence, and sealed up the downstairs of the residence in plastic. Mr. Ellis also included a copy of the lab analyses of the items that he had sampled for meth residue. According to the laboratory correspondence between Mr. Ellis and A Best • 3 • • Environmental, LLC, Mr. Ellis personally dropped off the items he's alleged to have • removed from the residence at the laboratory on October 4, 2012. I also contacted and interviewed Mr. Larry Stone of A Best Environmental, LLC, and the technician that assisted Mr. Ellis with the sampling of the household items that Mr. Ellis allegedly removed from the residence. Based on Mr. Ellis' written complaint, the laboratory documentation submitted by Mr. Ellis, a review of the sampling regulations in WAC 246-205-531 and the department of health Guidelines for Environmental Sampling, and my interview with Mr. Stone, the sample results Mr. Ellis alleges are proof of contamination from illegal drug manufacturing are invalid for the following reasons: 1. Mr. Ellis was not qualified or authorized under the law to remove "contaminated" items and participate in the collection and sampling of these items under WAC 246- 205-531. 2. There is no unbroken chain-of-custody or valid documentation that the samples were collected, stored, and transported properly in accordance with the regulations. There is was a minimum of period of at least four months where the disposition of these sampled items is unaccounted for(May—October, 2012). Therefore the collection and sampling of these items violated WAC 246-205-531, and the results • are invalid. 3. Other than Mr. Ellis' claims, there is no proof or documentation that the items he • submitted for sampling were from the residence at 1507 31St Street, or that the items he submitted for sampling are related to an illegal drug manufacturing operation. 4. Mr. Stone, who is authorized and qualified to collect samples, stated that he offered to Mr. Ellis to come and collect proper and legal samples from the residence, but that Mr. Ellis declined. 5. Mr. Stone stated that he advised Mr. Ellis that the samples would not be valid for a legal case due to the sampling errors and omissions, but Mr. Ellis asked him to run the samples anyway. 6. According to Mr. Stone, the levels of meth contamination on the items submitted by Mr. Ellis are not consistent with those typically found at a drug lab manufacturing site---they are significantly lower than the values found with drug labs. C. Other allegations In Mr. Ellis' written complaints, he alleges that he was locked out of the house by the owner, and that Christina Nelson of Townsend Bay Property Management was a witness. He also states that Mr. Meyer was attempting to extort money from Mr. Ellis that was not owed to him. I contacted and interview Ms. Nelson about Mr. Ellis' allegations. In summary: • 4 • • • 1. Ms. Nelson stated that Mr. Meyer produced and showed to her written statements that showed that Mr. Ellis was behind in rent payments. 2. According to Ms. Nelson, when she and Mr. Meyer showed up in May 2012 to inspect the rental property, that Mr. Ellis had changed the locks. Ms. Nelson stated that it was actually Mr. Ellis who locked-out the owner, not Mr. Meyer who locked- out Mr. Ellis. 3. Ms. Nelson stated that after being informed by Mr. Ellis that the house was a former drug manufacturing lab, she checked with the Port Townsend Police Department to see if that was true, and that PTPD had no record of a drug lab at the residence at that time. 4. Ms. Nelson stated that despite being evicted by Mr. Meyer in May 2012, Mr. Ellis remained in the residence at 1507 31st Street through the better part of the summer without paying rent. She questioned why Mr. Ellis would continue to stay in a residence he claims was making him ill when he was evicted and not paying rent. 5. Ms. Nelson indicated that when she took over management of the property after Mr. Ellis finally left, that the house was in good shape and that no items were missing. Conclusion • There was no evidence found or presented that proves that hazardous chemicals were used to manufacture illegal drugs at 1507 31St Street, Port Townsend, WA. There was no evidence found or presented that shows that a law enforcement agency, or property owner, notified Jefferson County Public Health that 1507 31st Street, Port Townsend, WA, was contaminated by hazardous chemicals associated with the illegal manufacture of drugs. The sample results submitted by Mr. Ellis did not provide grounds for Jefferson County Public Health to post the property or conduct further inspections under RCW 64.44 and WAC 246-205. Public records requests to Jefferson County Public Health, Port Townsend Police Department, and Jefferson County Prosecuting Attorney's Office resulted in no findings or documentation that there was ever a drug lab at 1507 315t Street. • 5 • 11) Board of Health V New Business Item 3 The New Blue H: 2014 Rural Health Network Findings g December 18, 2014 SJ 18n8 • •STATE OF WASHINGTON DEPARTMENT OF HEALTH PO Box 47890.Olympia, Washington 98504-7890 Tel:360-236-4030• TDD Relay Service:800-8 s$ lCEIVED .� November 20, 2014 NOV 2 0 2014 Jefferson County Public Health Dear Rural Health Leaders: On National Rural Health Day 2014, it's my pleasure to thank the women and men who care for the residents of Washington's rural communities. It's a big job in a big part of the state. More than 1.75 million people live in rural Washington State. Thirty-one of our 39 counties are rural, and even more populous counties have rural areas. That brings big challenges.Emergency response agencies often rely on volunteers to cover large geographic areas. Many rural areas don't have enoughhealthcare practitioners, and plenty of the ones who are there are nearing retirement age. Caring for people in rural areas means caring for a • whole population, young and old,rich and poor,with a wide variety of health needs. 4110 Rural health work also offers big rewards. Professionals who practice in rural areas get to know the folks they treat. They rejoice with their patients—and yes,they cry with them,too. They're a crucial part of their communities because their neighbors trust them enough to put their lives in their hands. They must demonstrate many strengths, and they get to develop deep relationships with their colleagues and patients—relationships their urban counterparts may envy. Not only do I and many others in the Washington State Department of Health appreciate this effort,we're working to support and improve it. Our agency reaches out to assist rural practitioners and facilities,and is involved in recruiting a new generation of professionals. It's part of our mission to protect and improve the health of all people in Washington. On behalf of the department, I extend my deep gratitude for the work you do. Sincerely, o Wiesman, DrPH, MPH Secretary of Health • • • a�,rza Y STATE OF WASHINGTON DEPARTMENT OF HEALTH Olympia, Washington 98504 August 1, 2014 TO: John Wiesman DrPH, MPH, Secretary of Health Washington State Department of Health (DOH) C. Scott Bond, FACHE, President and CEO Washington State Hospital Association (WSHA) FROM: Rural Health Work Group "New Blue H" SUBJECT: The New Blue H: A Report on the Findings of the 2014 Rural Health Workgroup, a Partner Project Between the Washington State Department of 111 Health and the Washington State Hospital Association Attached is the final report of the Rural Health or"New Blue H"work group. As requested, staff from the Department of Health Office of Rural Health and the Washington State Hospital Association brought together a group of stakeholders to examine barriers and opportunities to maintaining and improving access to health care services in rural communities. The work group split into subgroups representing acute care, primary care and prevention, behavioral health, long term care, emergency medical services/transportation, and workforce to explore the opportunities in these service sectors more thoroughly. This report includes a summary of recommendations that emerged across all of the subgroups, and six appendices that include recommendations by service sector. As we discussed at the June 30, 2014 meeting staff will continue to move this work forward. Our next step will be to develop a work plan with our stakeholders to prioritize and pursue the recommendations in this document. • • The New Blue H: A Report on the Findings of the 2014 Rural Health Workgroup, a Partner Project Between the Washington State Department of Health and the Washington State Hospital Association • • New Blue H Report,August 2014 • The Rural Health Work Group was co-chaired by Karen Jensen, Director.of Partnerships, Planning, and Performance at the Department of Health, and Jeff Mero, Senior Vice President, Rural System Development at the Washington State Hospital Association. The advisory group for this report was the Washington State Rural Strategic Planning Committee. Participating organizations: Critical Access Hospital Network Dayton General Hospital Garfield County Public Hospital District Homecare Association of Washington Jefferson Healthcare Odessa Memorial Healthcare Center Olympic Area Agency on Aging Pend Oreille County Counseling Services • Rural Health Clinic Association of Washington Three Rivers Hospital Washington Association of Community and Migrant Health Centers Washington Dental Service Foundation Washington Health Care Access Alliance Washington Rural Health Collaborative Washington State Department of Health Washington State Health Care Authority Washington State Department of Social and Health Services Washington State Hospital Association Washington State Medical Association Wipfli For more information on this report, contact: Bonnie Burlingham, bonnie.burlingham(a)doh.wa.gov or Jacqueline Barton True, Jacquelineb(awsha.org. 410 New Blue H Report,August 2014 • Table of Contents Background 3 Summary Recommendations 4 New Facility Category 4 Joint Community Planning 5 Global Budget Pilot Program 7 Telehealth 7 • Workforce Assessment and Development 9 Appendices Transportation 11 Hospital and Acute Care 17 Workforce 20 Long Term Care 25 Mental and Behavioral Health 29 Primary Care and Prevention 36 • 2 New Blue H Report,August 2014 • Background Rural communities are unique from each other. They are also collectively different from urban communities in their population, health needs, assets, geography, and adaptability to health care reform. Rural health care systems mirror the nature of rural communities. Blanket policies in health care payment and regulation at the federal and state level have put rural health care systems in a tenuous situation where adapting to the change may limit access to health care for their communities. Some rural health care systems are in crisis. Federal health policy increasingly prioritizes population health and prevention, without a regulatory framework to promote these activities at the local level. Rural communities need support at state agencies and associations to transform to the care systems envisioned at the federal level. At the end of the day, it is critical to assure people living in rural communities still have access to essential services. During the Department of Health (DOH) and Washington State Hospital Association (WSHA) annual leadership team meeting in September 2013, the two agencies determined there was a strong need for a clear proposal for how health care in rural communities could change to better meet the needs of each community while responding to healthcare reform. In order to address the emerging concern over access to care for rural populations,this proposal would include new . models of care delivery. Though the focus was originally on hospitals, it was determined that this project should consider the continuum of care from prevention and wellness to acute and long term care,with a comprehensive look at how we organize and pay for care.New payment methods or facility models could be suggested. Secretary of Health John Wiesman and WSHA President and CEO Scott Bond charged staff in both organizations with convening a workgroup to develop the proposal. During the first few meetings, the working group expanded to include several state, federal, and local stakeholders and determined that the following objectives should be considered in this work: 1. Ensure access to integrated, flexible, quality health care services in rural communities, including prevention, 24 hour emergency medical services(pre-hospital and hospital), all primary care, behavioral health, oral health, long term care, home health, home care, hospice, social support services, and others based on community needs. 2. Recognize the urgency of the financial challenges facing some critical access hospitals and rural health clinics and explore interim measures to address them. 3. Enable aging in place. 4. Address rural health disparities. • 3 New Blue H Report,August 2014 5pp Support rural economies and businesses through strong, local health care services. • 6. Achieve the objectives of the Triple Aim in rural communities: better care, better health, lower cost. 7. Ensure the recommendations are aligned with the Rural Health Strategic Plan and emergent proposals from the Public Health Improvement Partnership,the State Health Care Innovation Plan (SCHIP), Regional Accountable Collaboratives of Health, and other emerging initiatives and models for health care delivery in Washington. All recommendations are to be reviewed by the Rural Strategic Planning Committee,which serves in an advisory capacity to the group. A vision statement adapted from the 2012 Rural Health Strategic Plan and the Washington State Hospital Association Rural Hospital Committee was adopted: A strong, reliable, community-accountable health care system for rural Washington that ensures those who need care receive the right care,from the right person, at the right time and in the right place. The system provides personal and population health services shaped by the unique needs and resources of each community. The system provides planned access to the full continuum of care -- including physical, oral, and mental health services-- through regional systems that formally link primary and specialty services. The system produces high quality outcomes,promotes community health improvement, and merits the confidence of the community. The leadership to create and support our ideal rural health care system will come from communities and providers working together. • Summary Recommendations There is much work already happening throughout the state. This report identifies avenues for focusing DOH and WSHA efforts to expand and support existing initiatives while also identifying new proposals. The group identified several sub-groups (see appendices)to investigate more deeply the regulatory and system factors that shape health in rural communities. Through this process, clear themes emerged that threaded through all sub-group discussions. The following five summary recommendations invest the time of both organizations in supporting the development of a comprehensive rural health care system that prioritizes improving access to high quality and appropriate care while reducing health disparities. 1. Develop New Facility Category In 1989,the Rural Health Care Facility (RCW 70.175) statute was designed to create an alternative facility in rural communities that leveraged the existing facilities and services to better reflect individual community need. The statute was one outcome of the Washington Rural Health Care Commission Report of 1989. No associated payment model was provided. The work group proposes the modification of state licensing laws to allow for non-continuous care (i.e. 24 hour care) in a licensed hospital. This could lead to hospitals providing less than 24 hour/7 day a week service and hospitals without inpatient beds. Further review and expertise is • 4 New Blue H Report,August 2014 Sneeded to determine how to meet Medicare Conditions of Participation or to propose a new model to the CMS Innovations Center. Also, further review regarding Emergency Response and ties to tertiary facilities is needed. Lessons and findings from the Frontier Extended Stay Clinic model are a relevant foundation for the design of this new facility-type. Develo• New Facili Cate:o Short term actions DOH . WSHA Other agencies • Co-lead task force to determine • Co-lead task force to determine • Participate in task specifics of new facility category specifics of new facility category and force to assure that in order to propose rule-making on support DOH proposal for rule-making new facility category RCW 70.175 to modify licensing on RCW 70.175. does not have laws. • Determine funding stream for new unintended • Determine funding stream for new facility and request waivers and support consequences that facility and request waivers and from the Innovations Center where would negatively support from the Innovations appropriate(CMS and HCA). impact the service Center where appropriate(CMS • Work with other state hospital capability of other and HCA). associations to garner support for new community • Work with other State Offices of model. providers. Rural Health to garner support for • Work with hospitals to implement new new model. facility category when it is approved. • Commit staff time to regularly review facility license to measure its impact on rural communities and revise as needed. Long term action • Assure that the local community approach to finance and delivery ensures rural residents have access to services. • Utilize statute(RCW 70.175)to promulgate rules supporting a new facility type that will better meet the needs of the local delivery systems. 2. Promote Comprehensive Local Community Assessment,Planning, and System Development Local systems are dependent on the culture of their community and the strengths and resources of their local stakeholders. It is critical for the leadership of local health and social services systems including but not limited to, public health, health care providers, long term care, home health, community services, hospice, oral health, and behavioral health, to jointly assess and plan for the health of their community without the impediment of funding and regulatory silos. Additional planning partners to consider who have not been traditionally engaged in health care delivery are schools, employers, civic organizations and economic development agencies. Community engagement in the health care system can deter outmigration for services and support not only the local health care system, but the local economy. As a corollary, this engagement and dialogue will help promote a"Health In All Policies"approach at the local level, further impacting community health. The Department of Health and Washington State 1110 5 New Blue H Report,August 2014 Hospital Association can support the partnerships needed for comprehensive community health • planning. Promote Com I rehensive Local Communi Assessment,Plannin:,and S stem Develo i ment Short term actions DOH WSHA Other agencies • Appoint staff person to work with • Develop community engagement plan • Encourage local SCHIP to ensure rural perspective and tools for hospitals to conduct joint chapters/stakeholders in the implementation of the plan planning efforts. Provide technical to participate in and coordinate needs for rural assistance for the deployment of these community assessment, ACHs. tools. planning,and system • Provide staff time to support local • Provide advocacy and leadership in development. community meetings and public community development to rural areas • Incorporate patient education for health care reform that do not have the adequate navigator concepts into (meeting facilitation, infrastructure to implement SHCIP health care system to communication tools,find activities or benefit from ACH funding better support newly funding,public education opportunities. insured consumers in initiatives,etc). • Incorporate patient navigator concepts seeking care in • Continue to organize state into health care system to better appropriate settings. resources for communities by support newly insured consumers in aligning state initiatives and plans seeking care in appropriate settings. and connecting state level coalitions with local work;build resource clearinghouse for communities to use in planning and development. • Require joint assessment and planning for DOH-sponsored 1111 program and funding opportunities when appropriate. • Incorporate patient navigator concepts into health care system to better support newly insured consumers in seeking care in appropriate settings. Long term actions • Keep rural perspective in leadership conversations between statewide organizations. • Build community capacity to self-assess needs and implement needed changes. • Assure that the local community approach to finance and delivery ensures rural residents have access to services. 6 New Blue H Report,August 2014 • 3. Implement a Global Budget Pilot Program Consistent with the guiding principles of the State Health Care Innovation Plan (Appendix C, Section G), which supports providing stable, predictable funding to rural providers while they participate in work to redesign the health care delivery system,the state should solicit proposals from three to five communities to serve as demonstration areas for a "global budget"approach. The offer should be limited to communities where the lead applicant can demonstrate cohesive partnerships with members of the health care delivery system. This might involve identifying a list of essential services to be provided at the local level, with the expectation that the applicant would demonstrate its ability to meet those expectations either through direct service or through service agreements with other providers. To limit financial risk posed by clients to the service provider,this demonstration should feature state or federally based reinsurance for high cost claims. Additionally, this program would require each demonstration to align with their Regional Accountable Communities of Health funded by the SHCIP. Im,lenient a Global Bud let Pilot Pro l ram Short term actions DOH WSHA Other agencies • Rural Health Section to review • Identify and work with communities to • Encourage rural current federal funding streams implement pilot projects. stakeholders to (SORH,FLEX,PCO,SHIP)and • Support and lead where appropriate in support pilot other opportunities to determine new grant proposals to fund this work. approach. • where funds might be available for • Propose/support legislation for changes • Encourage broad pilot projects. in payment models for rural based leadership in • Provide infrastructure to contract communities based on evaluation of allocation of funds. with communities for pilot project pilot projects. • Provide letters of funds. support for new • Support and lead where appropriate grant proposals for in new federal grant proposals to this work. fund this work. • Support changes in • Propose/support legislation for payment models for changes in payment models for rural communities rural communities based on based on evaluation evaluation of pilot projects in of pilot projects. Global Bud:et Pilot Pro:ram. Long term actions • Assure sustainable funding for rural health care system. 4. Lead in the Development and Sustainability of Telemedicine and Telehealth Services and Remove Current Barriers for the Health Care System A multitude of barriers and opportunities surround the use of the rapidly advancing field of health information technology and its capabilities for the health care system. Telemedicine presents an opportunity to provide clinical services to remote clients that otherwise may not have access. Telehealth extends technology to support patient and employee distance learning. Because of the remote geography of rural areas, health information technologies can rapidly • 7 • • New Blue H Report,August 2014 advance access to care and educational services in rural communities. There are many • innovative uses for telehealth that can support the recommendations of this work group, such as aging in place, integration of care, and alignment with SHCIP. Unfortunately, both telemedicine and telehealth are underutilized assets because of challenges in policy, payment, equipment and broadband capacity, licensure, training resources, and actual implementation. The Department of Health and Washington State Hospital Association can position themselves to be leaders on this issue to support the advancement and innovation for which telehealth has the capacity. Lead in the Develo$ment and Sustainabili of Telemedicine and Telehealth Services Short term actions DOH _WSHA Other agencies • Designate staff member(s)to • Designate staff member(s)to coordinate • Continue coordinate the DOH efforts to with the Department of Health in implementing, support telehealth. supporting telehealth and act as a evaluating,and • Convene a work group to identify statewide convener on this topic. sharing innovative regulatory barriers to telehealth • Review the existing broadband uses of telehealth, implementation and create a infrastructure at the rural hospitals and such as telehomecare statewide rural telehealth plan. related clinics to create a priority list for and teleremote • Support the development and infrastructure improvements. monitoring for those implementation of flexible and • Improve telemedicine capabilities in who need assisted forward looking telemedicine rural hospitals to reduce the number of living services, practice guidelines by the inter-facility transports,keep patients in teledenistry, regulatory bodies. the rural hospital when appropriate,and telepharmacy,and • Develop capacity to support facilitate care management and post- telepsychiatry certification and continuing acute care in the local community. including diagnosis, education via telehealth for agency • Support ongoing net neutrality in treatment and 0 professional development Federal Communication Commission monitoring of offerings, regulations to allow for telehealth clients. • Consider supporting passage of an innovations. • Develop capacity to Interstate Medical Licensure • Evaluate the formation of a central hub support certification Compact.This would simplify to link rural hospitals to remote and continuing licensure of physicians in other specialists, education via states providing services via • Consider supporting passage of an telehealth for agency telehealth while maintaining clear Interstate Medical Licensure Compact. professional lines of disciplinary authority. • Support legislation to ensure payment development • Support legislation to ensure for telemedicine services, offerings. payment for telemedicine services. • Consider supporting passage of an Interstate Medical Licensure Compact. • Support legislation to ensure payment for telemedicine services. Long term actions • Robust technological infrastructure in place statewide to support telehealth advancement. • Payment parity in place for telehealth services. • Responsive licensure and regulatory policies that allow facilities to capitalize on emerging telehealth technologies to best meet community needs. — I 8 New Blue H Report,August 2014 • 5. Invest in a Comprehensive Statewide Evaluation of the Health Care Work Force and its Capacity While Supporting the Transition to a New System of Care Ensuring residents can access the right health care providers when needed is an important part of reducing health disparities experienced by rural communities. There are many aspects of the rural workforce that can support or limit access to care. Sometimes, one primary care provider leaving a small community is a significant impediment to care for the residents of that community. In the short term, extending existing rural providers and infrastructure can help maintain health care access. EMS is a vital resource in local communities, and a resource that can do more. Empowering EMS workers to engage in community health efforts through community para-medicine and allowing those professionals to augment hospital staff by continuing care once they enter the hospital setting, is just one example of how Washington can leverage current capacity to better meet local health needs. Investing in understanding the capacity of the health care work force,transitioning education programs to meet the shift toward population health, and ensuring proper alignment of state and federal incentives for rural practice can support access while the necessary infrastructure is built to provide for the health care needs of the changing population. Ongoing workforce gaps in rural areas are a consistent challenge. Some ideas below include transitional solutions to maintain access while an evaluation system is put in place to better understand access to health care providers in rural areas. Invest in a Comprehensive Statewide Evaluation of the Health Care Work Force and its Capacity to Su$ I ort the Transition to a New S stem of Care Short term actions DOH WSHA Other agencies • Commit staff time to regularly • Review and understand how • Review and understand how review and report on scope of hospitals are using community local chapters/stakeholders are practice across professions for health workers/ using community health opportunities to expand and meet promtores/navigators to workers/promatores/navigators the needs in rural areas. expand their capacity to meet to expand their capacity to meet Accommodate for remote areas. the needs of rural the various health needs of rural • Review use of Community Health communities. communities. Workers/Promatores/Navigators • Work with rural hospital • Work with local and look at ways to expand the systems and hospital districts chapters/stakeholders to provide work at DOH to meet the needs of to provide current data on the current data on the capacity of rural communities. capacity of their workforce to their workforce to better • Explore development of a direct better understand the staffing understand the staffing needs of incentive program,similar to that needs of rural health systems. rural health systems. of Alaska,to supplement the loan • Promote,where possible,new • Support education programs to repayment program to encourage and shared staffing models develop capacity to better train rural practice by mid and late- that better leverage existing the workforce for population career clinicians. workforce resources among health needs. • Support education programs to member hospitals. • Support legislation to reinstate develop capacity to better train the • Support legislation to reinstate and increase funds for the state workforce for population health and increase funds for the loan repayment program. needs. state loan repayment program. • Support legislation to reinstate and increase funds for the state loan repayment program. • 9 New Blue H Report,August 2014 • 0 Long term actions • Establish a sentinel workforce system using data gathered during the licensure process in order to have close to real time data about where health professional shortages exist and better understand the overall capacity of the rural health care workforce. • Use data gathered via sentinel system to better deploy state resources such as loan repayment funds and health professions education development. • Ensure providers are accessible to rural residents. Conclusion Through the work of the six subgroups, clear themes emerged that bridged traditional policy silos to provide a backbone for change to the rural health system. These priority recommendations reinforce the objectives of the work group charter. Through a flexible regulatory structure that prioritizes local needs,joint community planning, global payment options, and an expansion of telehealth services across the state,together with investments in the rural work force, the five priority recommendations support a cohesive and sustainable future for the rural health delivery system. In removing barriers to accessing care in rural communities and investing in systemic change that will lessen health disparities,rural communities will be well positioned to accomplish the vision of the Triple Aim -better health, better care, at a lower cost. Appendices Small changes at the policy level can have a big impact. The appendices of this work include 4111 specific recommendations in several policy areas, including transportation, hospital and acute care, workforce, long term care, mental and behavioral health care, and primary care and prevention. The solutions outlined in the appendices present a foundation for the summary recommendations, as well as specific steps to support and transition rural health providers to a more integrated prevention and delivery system. 10 1110 New Blue H Report,August 2014 • Appendices I. Transportation Background The transportation work group of the DOH and WSHA Rural Health Work Group presented its findings regarding the health care transportation system in rural Washington State. While a number of facets about health care transportation were discussed,the primary focus of this work is on the pre-hospital Emergency Medical Services(EMS) system. Non-emergent transportation resources, while somewhat limited, are present in rural communities. These resources are primarily provided through the Washington State Health Care Authority's non-emergency transportation brokerage system. Access to health care systems is a key factor in rural Washington State. Access to health care for rural communities requires the presence of a stable transportation system. This is particularly true for people who must travel long distances for health care resources. Health care transportation resources are separated between emergency health care and non-emergency health care. 41111 Local Emergency Medical Services (EMS)provides emergency health care transportation. EMS in rural communities is most often provided by volunteer workers. Rural communities lack sufficient funding to sustain a fully paid EMS workforce. Communities that do have paid EMS workers are more often supported by local EMS property taxes. The ability to maintain a paid workforce with a fee for service revenue stream is challenging. Therefore, rural communities must rely upon a volunteer workforce to sustain an emergency response system. Volunteer services continue to experience difficulty in maintaining adequate staffing. There are a number of reasons that contribute to the challenge, including: 1. An aging population. 2. Job opportunities moving from rural communities to more urban areas. 3. Increased training demands for EMS workers. 4. Family commitments and responsibilities. The decreasing number of volunteer EMS workers contributes to limited emergency response resources in a rural community. All rural EMS agencies have cooperative agreements with neighboring agencies that provide back-up when local resources are unavailable. While these agreements do address occasional gaps when local resources are unavailable, they result in longer response times. Adding to the strain on capacity, local ambulance services also provide • 11 New Blue H Report,August 2014 non-emergency ambulance transport in rural communities. These transports are typically from • the local hospital to a patient's residence, skilled nursing facility or a hospital in another city. The need to move patients between rural hospitals and urban health care centers poses a challenge for rural EMS systems. Washington's system of care for trauma, heart attack and stroke increases the demand on rural EMS resources. The clinical care provided to the acutely ill or injured patient frequently exceeds the level of training of local EMS resources. In such instances, rural health systems have two options available to them. They are: 1. Assigning a Registered Nurse (RN) from the local hospital to accompany the patient in the ambulance in order to continue advanced care; or 2. Using Helicopter EMS (HEMS) staffed with Critical Care RN's to move the patient to the urban center. Option 1 poses a staffing challenge for rural hospitals that already have limited staffing available. Replacing the RN who accompanies the patient results in additional unrecoverable cost for the hospital. RNs who do not regularly work on the ambulance are increasingly hesitant to ride on the ambulance from a safety perspective. Additionally, some rural hospitals lack sufficient staff to release a nurse to accompany the patient as this would leave the hospital without a nurse on duty. Using HEMS is an option for patients who are acutely injured or ill and require ongoing care by a specially trained RN. Washington State has a robust HEMS system in place. All HEMS providers have capable staff with access to the most current equipment and resources. HEMS' ability to respond to and transport patients is affected by weather and topography. During the winter months(October through March)weather conditions frequently hamper the ability of helicopters to respond and transport. Moreover,the Cascade Mountains represent a significant barrier for helicopters. However, most of the HEMS operators in the state also use fixed-wing aircraft. Moving a patient from the rural hospital to a suitable airport or landing strip creates a demand on local, volunteer ground EMS resources. Non-emergency transportation that does not require an ambulance can be provided by a number of resources. These include: • Local transit companies. • Transport services coordinated through the State Health Care Authority (HCA) transportation brokerage system. • Privately owned and operated wheelchair transport companies. • Local Taxi companies. • Public transit system. 12 New Blue H Report,August 2014 • Current State of Health Care Related Transportation in Washington State Ground Ambulance Ground ambulance services in most rural communities are provided by volunteer EMS providers. The general characteristics of these services include: • Limited number of staff available to respond on EMS calls. • Limited number of ambulance vehicles. • Primarily use certified Emergency Medical Technicians (EMT) and Emergency Medical Responders (EMR). • The number of certified paramedics is limited in rural communities. In fact, there are eight counties (Adams, Columbia, Douglas, Ferry, Lincoln, Garfield, Stevens, and Wahkiakum) that do not have paramedics responding with the local ambulance service. • Core group of people who have a long-time association with the EMS agency. • Sporadic coverage. In some communities, staff is unavailable during normal working hours. Coverage improves after the work day and during the night and weekends. • Initial training of EMT's requires an average of about 175 hours of class and practice time. • Ongoing education requirements for EMT's average 12 hours per year. In order to meet this requirement, local EMS agencies hold one ongoing education session each month. There is also a concurrent hands-on session that is held with each didactic session. • • Difficulty in recruiting new volunteer EMS workers. • Reliance upon paramedic services in urban centers when a patient requires Advanced Life Support (ALS) care. Rural EMS ambulances frequently rendezvous with paramedic ambulances between the patient's location and the receiving hospital. • Sporadic cellular telephone coverage in some rural areas of the State. Air Ambulance HEMS is widely distributed throughout the state. Washington State is fortunate to have a committed group of air ambulance operators who have access to strategically placed helicopters across the state to provide coverage to both urban and rural communities. Weather and topography create the need to rely upon fixed wing aircraft when conditions prevent safe helicopter flight. Using fixed wing aircraft requires use of the rural ground ambulance service to move the patient from the hospital to the airfield. Non-Emergency Transport Non-emergency health care transport services span a broad range of service and are coordinated via Washington's Health Care Authority's non-emergent transportation service broker system. This system is a statewide system that has five brokers who provide service to 13 different regions in the state. • 13 New Blue H Report,August 2014 Resources that are made available to the user include: • • Bus passes; • Mileage reimbursement and fuel cards; • Sedans and vans; • Wheelchair accessible vehicles; • Volunteer networks; and • Lodging and meals. To qualify for these services, the individual must: • Have a current Services Card issued by the Health Care Authority. • Have no other way to reach their medical appointment. • Make sure the medical service is covered by the Medical Assistance Program. The transportation brokerage system provides an excellent resource for qualified individuals. For those people who do not qualify for the brokerage service,there are fewer resources. Private specialty transport services operate in some larger rural areas of the state. More often, these services are concentrated in urban areas where economies of scale allow more efficient operation of the service. In cases where the transportation brokerage system is not available for the individual and where private specialized transport companies do not operate, individuals rely upon family, friends or taxi service to obtain health care. • Recommendations Providing pre-hospital EMS in rural Washington State presents a number of challenges and opportunities. Rural EMS agencies rely upon volunteers to staff ambulance and aid vehicles. Rural hospitals rely upon these resources for delivering patients as well as transferring patients to urban centers. In some cases, rural hospitals actually operate the ambulance service. The transportation work group submits the following recommendations regarding health care transportation in rural systems. I. Improve recruitment strategies for volunteer EMS providers in rural areas through the development of a volunteer EMS workforce recruiting program. Included in this strategy should be improvements to the way that EMS training is delivered. DOH should provide EMS educators with additional resources and mentoring to increase student success in initial EMS training courses. Distributive learning methods for EMS education such as Web-based and telehealth technologies should be identified and expanded to mitigate time and travel barriers for students in rural areas. Requires time,technical support and resources from DOH. Distributive learning techniques permitted as/of 2011. • 14 New Blue H Report,August 2014 • 2. Implement a retirement program for volunteer EMS providers. A similar program exists for volunteer firefighters. Extending the opportunity to all volunteer EMS providers will serve as a recruiting incentive. Like their peers in the fire service, the non-fire EMS providers receive a small payment for service when engaged on an EMS response. This is not a full or part time paid position. This payment recognizes their volunteer activity with the EMS agency. Requires Statutory Change (RCW 41.24). 3. Conduct more Emergency Medical Responder (EMR) certification courses in order to build ambulance driver capacity. Requires recruitment of new Senior EMS Instructors (SEI). Achieving SEI status requires additional time and work. 4. Create county wide ambulance service through EMS taxing districts. This will generate funds to staff and deploy ambulances throughout the rural community. Requires new levies; taxpayer resistance is a barrier. 5. Create staffing models that utilize paid and volunteer EMS providers. This will address resource capacity through 24/7 staffing with paid personnel. Requires additional funding, potentially via new levies; taxpayer resistance is a barrier. 6. Establish paramedic "fly-car" program. Utilize paramedic in hospital E.D. when not engaged on an EMS response. A paramedic "fly-car" is a response unit that is staffed with one certified, paid paramedic who responds with the local Basic Life Support (BLS) ambulances. If the paramedic is needed in order to provide paramedic level care, the paramedic accompanies the patient in the ambulance. If the paramedic is not needed, they return in service and are available for the next response. The paramedic can be assigned to additional duties such as training and education when not engaged on an EMS response. Requires new/additional funding from DOH or local districts; taxpayer resistance is a barrier. 7. Create a messaging campaign that helps tell the story of rural EMS and the value that the EMS system contributes to the rural health care system and community. Increase connections between EMS and local providers to promote integration of services and generate new ideas for community services. Requires time, effort and technical assistance. 8. Improve cellular(cell) phone coverage in rural Washington State. There is significant variability in cell phone coverage throughout rural Washington. Improving cell phone coverage will improve access to EMS in rural communities. Requires cellular telephone carriers to agree with the expansion of existing service. 15 New Blue H Report,August 2014 9. Revise the reimbursement model for EMS service from a transport-only reimbursement • model to a service delivery model. Reimbursement for ambulance service is typically guided by the medical necessity for ambulance transport and the final patient destination. With the exception of medically necessary transports to skilled nursing facilities, the predominant destination is the hospital. Ambulance services are reimbursed only when they transport to one of these two health care facilities. Many national experts recognize that this is a reimbursement philosophy that has outlived its utility. The current reimbursement logic creates an incentive for all patients who are encountered in the outpatient part of hospital setting to be transported to an acute care hospital's emergency department. While the direct cost of transport represents less than 1 percent of Medicare expenditures,the expenses associated with the patient being transported to the E.D., E.D costs, tests, etc. represent a much larger expense. If the reimbursement methodology recognized alternative destinations (e.g., behavioral health treatment centers, clinics/urgent care, and sobering centers),the overall health care cost might be reduced and ambulance providers would recoup the cost of providing transports to facilities other than hospitals. This is only accomplished through revisions in the methodology established by the Centers for Medicare and Medicaid Services (CMS) and other health insurance providers. This will require federal and state legislative actions to accomplish. The benefit will most likely be a slow reduction in the overall health care costs by making sure only the acutely ill and injured patients are transported to hospital E.D.s. Requires rule and policy change at the federal (CMS) level. 10. Develop a procedure that allows alternative destinations for patients who do not require hospitalization (sub-acute behavioral patients, chronic inebriates, etc.). Requires change in Medical Program Director policies and EMS system policies and procedures. Efforts are currently underway. 11. Improve access within the rural health system to minimize the need for transport. Improve and enhance telemedicine capabilities in rural hospitals to reduce the number of inter-facility transports and keep patients in the rural hospital when appropriate. Conduct routine health care appointments via telemedicine to minimize the need for lengthy travel to physician and other health care provider appointments. Requires statutory change. • 16 New Blue H Report,August 2014 • II. Hospital and Acute Care Background The Hospital and Acute Care subgroup aims to address sustainable access to essential health services in rural Washington. The recommendations included in this report seek to provide greater value to both patients and payers through increased flexibility for local communities. Ultimately, Hospital and Acute Care services in Washington State should reflect a regulatory and policy framework with sufficient flexibility to allow a locally driven and sustainable approach to community health needs. Payment Fragmentation Current fragmentation in care delivery mirrors the fragmentation in payment. Hospital and acute care providers often struggle to provide needed community services because those services are insufficiently reimbursed. Payers (including the state) should be encouraged to treat rural health systems as systems. We propose the modification of regulations and payment mechanisms and support investments in key care management and business operations strategies including, but not limited to HIE, EHR, telemedicine, care coordination, and the development of regional systems and medical homes. In many communities the hospital and primary care base are both owned and operated by Public Hospital Districts(PHD). In other areas, the district may operate both the hospital and a nursing home, or the clinic and an ambulance service. Current practice is to break payment streams into component parts and to negotiate payment for the pieces separately(in some cases,there's no negotiation—SNF care, for example). The PHD is required to"own"multiple provider numbers to secure payment and comply with multiple payment systems and rules. This adds to administrative complexity and burdens for local hospitals so that they may maintain provision of core services. The current payment system is similarly plagued by misaligned incentives. Hospitals are paid for care delivered, not for the many preventative health programs that they undertake to prevent community members from needing care in the first place. Any savings from avoided admissions are realized by the payers alone, while the lost revenue threatens the financial viability of the hospital and, in turn, its ability to respond to community care needs. While rural hospitals across the state are engaged in innovative efforts to improve patient care community health and their financial efficiency,they do so at their own financial risk. For example, investments in care coordination activities hurts inpatient cost recapture for the hospital. New Facility Options Many remote communities could be well-served by a facility that offered primary care, urgent care, lab services, diagnostics(including radiology, ultrasound and CT), two or three 48-hour observation beds, behavioral health services(crisis and respite), respiratory therapy, physical therapy, occupational therapy, and transitional care and family support. A key question for • 17 New Blue H Report,August 2014 consideration then becomes: What's the difference between this "licensed hospital" and a clinic? • If a new facility is licensed as a clinic, services provided by this facility and any other clinic it operates won't be eligible for"provider-based"payment from Medicare. One answer might be in the range of services provided—for example, the facility might offer limited surgical care (a lightweight ambulatory surgery center), limited 48 hour monitoring and observation services, rehab therapies (respiratory, physical,transitional care) and Emergency/Urgent Care services. In offering this array of services that are more robust than a clinic but do not include inpatient beds, such a facility could retain the financial advantages of hospital licensure while being more responsive to the care needs of the local community. Recommendations 1. State licensing laws and/or regulations should be modified to allow for less than continuous care in a licensed hospital. This could lead to (1) hospitals providing less than 24 hour/7 day a week service; (2) hospitals without inpatients. Further review is needed to determine if(a)Medicare would recognize such a facility as meeting its Conditions of Participation; and (b) what expectations should the state have about Emergency Response in such a facility?This model would be limited to existing Critical Access Hospitals and could begin with a demonstration project with 3-5 facilities. Requires DOH to utilize RCW 70.175 to promulgate rules to support a new facility type.Would also require DOH review of Conditions of Participation and Emergency Response requirements. Would require advice from CMS certification team,and proposal to the Innovations • Center. Lessons from the Frontier Community Health Integration Program and the Federal Extended Stay Clinic may be relevant in this area. 2. The state should invite three to five communities to step forward to serve as demonstration areas for what would be a"global budget"approach.The offer should be limited to communities where the lead applicant can demonstrate cohesive partnerships with members of the health care delivery system, or where the principal applicant can meet expectations for service agreements to provide services beyond their current scope. This might involve the state identifying a list of essential services for which it requires local access with the expectation that the applicant would demonstrate its ability to meet those expectations either through direct service or through service agreements with other providers. To limit financial risk posed by clients to the service provider,this demonstration should feature state based reinsurance for high cost claims. Requires DOH and HCA cooperation to allow global payment for Medicaid services and CMS waiver or proposal to Innovations Center for Medicare payments. 3. WSHA should ask for the state's support to seek a modification to CAH Cost Allocation regulations to allow for a return on investment in integrated community services, including prevention,wellness, care coordination and school health. Current cost 18 • New Blue H Report,August 2014 • allocation rules prohibit investment in these activities (investing in care coordination hurts inpatient cost recapture). Requires CMS waiver or proposal to Innovations Center. 4. The state Medicaid Program should institute gain-sharing incentives to rural providers to reward efficiency gains and to recognize savings achieved through local delivery system improvements. Requires new or re-allocated funding within Medicaid. 5. Washington State should consider seeking authority from CMS to expand the PACE (Program for All-inclusive Care for the Elderly) to rural areas. This would require some re-insurance protection, and, again, could be tested in a handful of communities currently served by a CAH or clinic. Requires CMS approval and establishment of a reinsurance program. 6. Promote use of telemedicine to allow access to tertiary carewithin remote sites. Telemedicine not only ensures timely access to appropriate care, it reduces cost to the facility, health care system and patient through prevented travel and lost time. Requires investment and technical assistance on behalf of DOH and statutory change(such as HB 1448 which did not pass in 2014)to ensure telemedicine services are appropriately reimbursed. • 7. Promote expansion of the paramedic role beyond the pre-hospital setting. Allow paramedics to continue seeing incoming patients once they enter the Emergency Department, and in the community post-acute stay or otherwise to assist with care transitions and prevent unnecessary emergency department visits.The Washington Administrative Code(WAC)defines the environment in which certified EMS personnel can function. WAC 246-976-182 (1)(a) stipulates that a certified EMS provider may only work in the pre-hospital emergency setting or while transporting patients between health care facilities. This language restricts the activities of the EMS provider and prohibits functioning within the hospital, clinic, urgent care center, or community. This poses a challenge for rural hospitals that are already short staffed. Utilizing EMS personnel to augment hospital staff provides additional resources that can engage in patient care within the walls of a hospital or clinic,or in community settings.Requires rule change to WAC 246-976-182 (1)(a). Additionally,the scope is dependent upon,and allowed in part, by the EMS provider adhering to the oral or written patient care protocols of the MPD (RCW 18.71.205 (6)) 19 New Blue H Report,August 2014 III. Workforce • Background The workforce subgroup of the joint DOH/WSHA Rural Health Work Group project presented its findings regarding the healthcare workforce in rural Washington.The overall health of rural residents is determined by the interplay of biological, social and environmental factors. However, ensuring residents can have access to healthcare providers when needed is an important part of reducing health disparities experienced by rural communities. While the group discussed many aspects of the rural workforce,the primary focus was on extending existing rural providers and infrastructure. Ensuring proper alignment of state and federal incentives for rural practice also emerged as a theme. Recruitment and retention Rural healthcare facilities serving the main domains of primary care—medical, dental and mental health—experience difficulty recruiting and retaining clinical staff. Reasons for recruitment challenges include a lack of local training opportunities, perceptions of less pay than in urban communities, professional isolation and few providers interested in rural living. In both urban and rural areas, providers also leave the health care professions due to burnout and suicide. Rural areas are typically served by general practitioners such as family medicine physicians. Due to the skewed specialist to primary care physician ratio in the U.S.,these generalist physicians are in high demand and harder to recruit in both rural and urban areas.These staffing difficulties lead to many unideal outcomes including disrupted patient/provider relationships,the use of expensive temporary staff and long wait times for patients. Loan repayment and scholarship programs are two main mechanisms currently used to direct providers to practice in medically underserved communities. However these programs exclude mid and late-career providers who do not have educational debt. Often rural and frontier practice locations are better suited to experienced providers but loan repayment is only attractive to new graduates. Licensure The group's discussion of licensure challenges and opportunities exposed several issues, some specific to rural and some applicable to all providers regardless of practice location. Physician assistants(PA) practicing in remote sites are allowed to reduce their supervision time from 25 percent to 10 percent but must obtain special permission of the Medical Quality Assurance Commission or Board of Osteopathic Medicine and Surgery. PAs with interim licenses are not allowed to practice in remote sites. Anecdotally, Department of Health staff members have found rural sites prefer advanced registered nurse practitioners over PAs because ARNPs can practice without physician oversight. • 20 New Blue H Report,August 2014 Many rural communities use volunteer emergency medical technicians to staff their emergency services system. There are extensive training requirements for these volunteers. Overall, rural residents willing to be volunteer EMTs are becoming harder to find for many reasons, including the training commitment. Recent legislation and rule development affecting medical assistants has created confusion at some rural facilities about what tasks these providers are allowed to do. Before the changes MAs may have been performing tasks outside what was allowed by state law and rule. The setting of limits on certain types of licenses, especially pre-hospital providers, means there is wasted capacity in some communities. Paramedics,who are extensively trained in some areas of patient care, are not allowed to work inside a hospital. In a rural area this reduces staffing flexibility. Telehealth and telemedicine Telehealth and telemedicine applications are already starting to make inroads into rural areas, particularly in mental health and radiology.There is great potential in rural Washington to expand these services. There remain challenges with licensure, reimbursement and technology infrastructure that must be addressed through legislation. Current work • The Department of Health and other state agencies are currently working in these three areas. Recruitment and retention The Rural Health Section of the Department of Health is directly involved in the recruitment of primary care, dental and mental health providers for the state's rural employers. The recruitment staff person works mainly to fill physician, dentist, nurse practitioner and physician assistant openings. Section staff members also coordinate several incentive programs that operate in both rural and urban underserved areas. Current healthcare workforce programs include: • J-1 Visa Waiver Program • National Health Service Corps Loan Repayment and Scholarship Programs • Washington State Health Professional Loan Repayment Program The department participates in a healthcare workforce collaborative called the Washington Resources Group. Other participants include the Washington Association of Community and Migrant Health Centers,the Washington Student Achievement Council, the regional National Health Service Corps program staff and the Area Health Education Centers. The collaborative promotes rural/underserved practice and the loan repayment programs to eligible clinicians and health professions students. Workforce at free clinics in Washington is supported by the Volunteer and Retired Provider Malpractice Insurance Program. • 21 New Blue H Report,August 2014 Licensure • Allopathic and osteopathic physicians both have a full scope of practice; however they are separately licensed by the Medical Quality Assurance Commission and Board of Osteopathic Medicine and Surgery. This can cause issues for PAs who have an allopathic or osteopathic credential and need to work with a physician licensed by the opposite authority. The physician assistant rules are currently being revised with the intent to modernize PA licensure. These changes have the potential to allow for quick transfers by PAs between MD and DO supervisors. This will be an advantage to rural areas where flexibility in response to staff changes can be important in maintaining access to care. Telehealth and telemedicine The creation of a robust telehealth and telemedicine system that increases access to care in rural areas requires many foundational steps before significant progress can be made. Issues needing resolution include practitioner licensure, technological infrastructure and adequate reimbursement. Work in Washington is ongoing in several of these areas. Telemedicine physicians frequently treat patients located in states other than where the physician lives. Currently, a physician or his/her employer must ensure that the clinician is properly licensed in each state where practice occurs. This is a time-consuming and expensive process. Department of Health staff members have been actively working with others from across the United States to draft a potential solution.The proposed Interstate Medical Licensure Compact would simplify the licensure process for physicians who practice in multiple states via • telemedicine among other outcomes. If the legislature authorizes participation in the compact, it would allow both the Board of Osteopathic Medicine and Surgery and Medical Quality Assurance Commission to lower the licensure time and cost barriers to physician practice of telemedicine. In conjunction with other efforts to promote telemedicine,this could have the net effect of increasing access to care in rural Washington. Washington's rural counties have lower access to high quality Internet connections compared to the urban counties. These technological gaps will need to be addressed in some fashion before there can be strong use of telehealth.There are also federal threats to telehealth innovation in the Federal Communication Commission's proposed changes to net neutrality policies. Telehealth technologies are in the start-up phase when innovation is key. A non-neutral network could lead to the great potential of telehealth never being realized. Legislation to address the equal reimbursement of telemedicine services was considered during the 2014 session but did not pass. It is possible that the bill will be reintroduced during the next session. 22 New Blue H Report,August 2014 • Recommendations The workgroup recommends the following strategies to address the health care workforce needs of rural communities. Recruitment and retention I. Add I FTE to the DOH Rural Health Section recruitment and retention staff. This will allow the Department to broaden direct recruitment work to include behavioral health providers, physical and occupational therapists, registered nurses and other needed rural health professionals. This would also increase the ability of the staff to work on retention measures such as disseminating best practices and monitoring retention of providers participating in loan repayment programs. Requires resources from DOH. 2. Support the development of additional teaching health centers/family medicine residency programs in rural Washington. Requires participation of University of Washington School of Medicine and Pacific Northwest University of Health Sciences along with potential appropriation by the legislature or identification of alternative funding mechanisms. 3. Reinstitute funding at the pre-recession level for the Washington State Health • Professional Loan Repayment Program. Consider broadening types of health professions that can be eligible to include mental health providers. Requires legislation to reinstitute funds to this program. 4. Explore development of a direct incentive program to supplement the loan repayment program to encourage rural practice by mid and late-career clinicians. Alaska has implemented a possible model program. Requires DOH resources to develop a white paper regarding program development. Eventually would require legislation and an appropriation if the white paper finds the proposal justified. Licensu re 5. Examine the RCWs that control the health care professions to ensure that providers are able to practice at their highest level as according to the most recent evidence regarding safety and quality. Look for innovative ways of expanding scope of practice to maximize staffing flexibility in rural facilities while maintaining safety and quality. Requires potential legislation and subsequent rule changes. 6. Streamline the transition of military-trained health care professions to civilian licenses. Complete crosswalk between military training and civilian licensure requirements • 23 New Blue H Report,August 2014 and consider if some requirements can be waived or shortened in light of relevant 1111 military training. Changing licensure requirements would require legislation. 7. Promote Volunteer and Retired Provider Program to rural retiring healthcare professionals. Continue paying license fees and malpractice insurance for program participants. Request increased funding to this program to allow for increased license fee coverage and more staff time to manage the program. 8. Evaluate reasoning behind not allowing PAs who hold interim permits to work in remote sites. Look at research to determine whether the department should support legislation that would allow PAs with interim permits to work in remote sites. This would allow faster transition after graduation to practice in rural areas. Requires staff time from DOH. 9. Support the development of community or integrated paramedicine programs in rural areas. Could require statutory and rule changes to expand scope of practice address licensure, supervision, and liability issues. Telehealth and telemedicine • 10. Washington should pursue participation in the proposed Interstate Medical Licensure Compact. Participation will require the legislature to pass compact language,which could be sought in the 2015 session. 11. Evaluate broadband internet capacity across Washington or identify previously done evaluations in order to identify gap areas and promote building the infrastructure necessary for telehealth/telemedicine implementation. Requires staff time. 12. Increase uptake of telehealth and telemedicine technology in rural Washington. Create a joint workgroup between DOH/HCA/DSHS to define telehealth, create standards, and address reimbursement and licensure. Consider innovative use of telehealth such as using rural EMS providers to conduct in-home telehealth visits connecting home-bound patients with distant providers. • 24 New Blue H Report,August 2014 • IV. Long Term Care Background For the purposes of this report, long term care includes institutional care, residential, and in- home care. Institutional care refers to nursing homes, residential care to assisted living and adult family homes, and in-home care means home health services and home care services. Home health services are provided by licensed home health agencies and are medically-oriented. They must be prescribed by a physician, and require a need for skilled care from a nurse or a physical or speech therapist. Home care is primarily non-medical assistance with activities of daily living, such as bathing, dressing, feeding, medication reminders, and transportation. Social work, case management, care coordination, durable medical equipment and other services may be part of home health or home care depending on the payer and patient's needs. Providing long term care services in rural areas is challenging for many of the same reasons identified in other sectors: workforce shortages, limited access to required training, travel distances and costs, inadequate reimbursement, and regulatory barriers. Additionally identified were lack of coordination between different types of providers, and lack of knowledge about the resources available due to our traditional siloed approach to planning and service delivery. Work group members identified adult family homes and assisted living as particularly lacking in rural areas, especially for people on Medicaid. Nursing home options continue to shrink as • critical access hospitals (CAHs) close their nursing homes. Today, only six of the 39 CAHs have nursing homes, and most of them operate at a significant loss (annually over $300,000 for one CAH and $1 million for another). However, the impact of these closures on communities is somewhat mitigated by CAHs using swing beds for long term care and the state's commitment to providing long term care in home and community settings like adult family homes and assisted living. Home health services are also not readily available in rural areas, nor are they used to their full capacity. Reasons for this include: • Regulatory barriers in Medicare, Medicaid, and state certificate of need requirements. • Lack of knowledge about home health services and eligibility in communities, particularly for care coordination. • inadequate reimbursement, particularly in rural areas where longer travel times and costs are not taken into account in reimbursement rates. Medicaid reimbursement rates have been stagnant for 10 years, while Medicare rates are continually subject to cuts. At the same time, the cost of care continues to increase including the cost of medical supplies, travel, and technology upgrades. These services are different from health homes which are settings for coordinated primary and behavioral • health/substance use services,usually for patients with one or more chronic health conditions and on Medicaid. 25 New Blue H Report,August 2014 The Long Term Care subgroup developed their recommendations with two primary intentions: • • Preserve access to long term nursing home, residential care, home health services, and home care services in rural areas, and increase resources for these services where needed; • Support aging in place by providing long term care for people in their own communities, at home where possible, and in coordination with other health and social services. Recommendations 1. Expand care coordination and transitional care services to all people who need them. Develop policy and use local planning processes to ensure services are provided efficiently and not duplicated by multiple entities. Providers could be rural health clinics, hospitals, home health services, Medicaid health homes, area agencies on aging, or others based on the resources in the community. Care coordination and transitional care services must include non-clinical services, such as assistance with transportation, meals, caregiver support, and other psychosocial factors impacting health and use of services. Requires: • Policy changes and additional funding to pay for care coordination for public and private payers who don't already pay for it or where payment is inadequate,or the service is inadequate to achieve the goals of care coordination. • Local/regional planning and coordination to identify or develop the most . effective and efficient, non-duplicative care coordination providers based on local/regional resources. • Development of standardized definition of care coordination services and training to avoid perpetuating disparities in rural/urban services and health outcomes. • Explore state or other certification to support consistent and quality services across rural and urban areas. Note: Work in some of these areas is already underway, but not necessarily from a rural perspective or in rural areas, or for all payers or people. DOH needs a better understanding of what's already happening with care coordination in rural areas in Washington and other states, as well as at other state agencies and organizations, such as DSHS Aging and Long Term Support Administration (ALTSA), Health Care Authority, WSHA Partnership for Patients, Qualis, etc. 2. Include long term care providers, area agencies on aging, and ALTSA regional representatives and resource developers in local and regional health care systems planning along with public health, hospitals, primary care, and behavioral health. Ensure rural and long term care providers and policy makers are included in regional planning 26 S New Blue H Report,August 2014 • for the State Health Care Innovation Plan's (SHCIP) Accountable Communities of Health. Requires dedicated staff time and specific initiatives for partnership- building between these organizations at the state and local level,with particular attention to the latter, and rural-specific representation on SHCIP planning and implementation teams. 3. Increase understanding and utilization of services provided through ALTSA Home and Community Services and home health services in rural communities. Requires technical assistance and a communication plan from DOH staff in partnership with ALTSA and the Home Care Association of Washington, and culture change among local providers. 4. Support the development of tele-home care services, including tele-monitoring, possibly reimbursed on a per patient/per month basis. Requires further exploration of tele-home care services, a payment mechanism and associated statutory changes,and coordination with ALTSA and CMS and other regulators and providers of home care and home health services. The telemedicine bill,HB 1448, does not cover tele- home care services. 5. Maintain long term care beds as needed in communities. Explore sustainable 1111 reimbursement through changes to or waivers of regulations and cost allocation policies that increase costs or decrease reimbursements unnecessarily. Suggestions include a unified cost report for CAHs with skilled nursing facilities (SNFs) and other services, expanding CAH cost-reimbursement to CAH SNFs, maintain swing beds as an option. Requires further study to identify potential statutory and regulatory changes, and coordination with CMS,Aging and Long-Term Support Administration (ALTSA), DOH Facilities and Certificate of Need. 6. Increase availability of adult family homes and assisted living in rural areas. Requires identification of gaps in this level of care in rural areas and work with ALTSA resource developers. 7. Use home health care coordination and management to the full extent, including long term care management. Provide services in the home where feasible. Requires changes to the federal and state statute and regulations and possibly the Medicaid waiver: • Address home health reimbursement issues, including an add-on for mileage/travel costs. • A waiver from federal regulations such as "face to face" and "homebound" for home health care eligibility. • 27 New Blue H Report,August 2014 • Addition to home health services of a one-time nursing visit benefit to help • with medications reconciliation and transition from hospital to home. • Review certificate of need requirements for home health services for opportunities to expand home health services in rural areas. Certificate of Need RCW 70.38.015,WAC 246-310. 8. Work with DSHS, ALTSA and SEIU and other workforce development and training programs to increase access to long term care worker training in rural areas, via telehealth and more on-line training. Address workforce shortages by cross-training therapists and nurses from hospitals for home health care as hospital census decreases and more health care is provided in the home. Requires additional resources and technical assistance from DOH, licensure changes. This relates to work force and telehealth recommendations. 9. Build upon exemptions granted to professions such as RNs and medical assistants for long term care worker certification. This model could serve as the basis for other multi- purpose certifications/licenses to address the multiple and duplicative training requirements. Requires DOH licensure review and changes to requirements. Relates to work force recommendations. 10. Address gaps in physical and occupational therapy workforce. Medicare requires nursing, • PT, or speech before they can authorize OT or social services. Medicare home health benefit doesn't include a one-time nursing visit, e.g., to help with med reconciliation, set up at home for transitional care. Requires changes at CMS. 11. Develop/provide/replicate training for specialty care where needed, e.g., Yakima obesity coalition, dementia care, etc. Requires additional funding and technical assistance, work with ALTSA. • 28 New Blue H Report,August 2014 • V. Mental and Behavioral Health Background Washington's current publicly-funded behavioral health system is complicated and contains many barriers to accessing services. Some of the barriers center on limitations for eligibility for services(only Medicaid-eligible individuals can receive services through the publicly-funded system) and limitations based on severity of condition. Other limitations are based on state and federal law; for instance, at what point can an individual be involuntarily detained due to concerns about a mental illness concern. In rural areas, these problems are exacerbated due to lack of personnel, especially specialists like psychiatrists. Access to adequate mental health services for children was recently the subject of a lawsuit that resulted in an out-of-court settlement that calls for the reorganization of children's mental health in the state. Access to mental health services from private sources is also restricted in Washington State based on insurance coverage, access to qualified providers, and acuteness of conditions. Lack of Mental Health Providers in Rural Areas Services in the publicly-funded system are coordinated through 11 (eleven) Regional Support Networks(RSNs). The RSNs contract with service providers to deliver mental health services. The services can vary between RSNs based on the amount of funding available and the • qualifications of individuals providing services. Four principal factors contribute to the challenge of caring for persons with mental illness in rural settings: (I) limited access to mental health providers, particularly psychiatrists; (2) lack of coordination and information sharing among continuum of providers often due to lack of information technology/data systems, regulations/statutes, or trust among providers; (3) a shift to increased public financing of treatment, accompanied by declining private coverage, budgetary constraints in publicly funded systems, managed care policies and practices, and the large number of uninsured individuals; and (4) limited utilization of available mental health services because of stigma or limited awareness of mental disorders. Additional workforce challenges: 1. Difficulties in recruiting and retaining staff often due to concerns over compensation and difficulty in recruiting to rural areas; moreover,the significant demands and stress related to crisis work leads to turnover and burnout. 2. Rural agencies are challenged by clinicians who complete their training/licensing in rural areas and then move to urban areas to practice. 3. Limited access to relevant and effective training;trainings in Evidence Based Practices (EBP)are often offered infrequently and only in one location. 4. Financing systems that place enormous burdens on the workforce to meet high levels of demand with inadequate resources. 5. Lack of familiarity with resilience- and recovery-oriented practices. 1110 29 New Blue H Report,August 2014 6. Insufficient numbers in the behavioral health workforce to respond adequately to the • changing needs of the rural population; moreover, rural communities lack the population needed to sustain specialists, requiring local providers to train for a wide variety conditions and patient populations. 7. Insufficient array of skills needed to assess and treat persons with co-occurring or co- morbid conditions. Inpatient Treatment Bed Capacity • Limited availability of beds to meet the current need, Washington has 8.3 hospital psychiatric-care beds for every 100,000 people—ranking the state 49th in the country'; access to facilities that can accept patients with co-morbidities is severely limited; • Rural patients are required to travel long distances to nearest beds creating a burden for support systems and both patient and caregiver/family; • Hospitals are dis-incentivized from adding capacity by the insufficient reimbursements associated with psychiatric beds;there are numerous challenges to creating a sustainable line of service for these providers; • Evaluation and Treatment bed certification creates significant staffing challenges; • Burdensome CMS clinical record requirements. Outpatient Treatment Capacity • Limited or no access to outpatient mental health care due to provider shortage, particularly psychiatrists; • • Limited availability of affordable housing options, including transitional, living, supportive living and"halfway houses"to support recovery in a safe environment; • Many clinics must subsidize poorly reimbursed crisis services through outpatient services, reducing available resources for additional staff,training, etc.; • Treatment of mental illness shifted to primary care practitioners which can result in a number of practice and professional constraints such as: insufficient mental health training in medical school or residency; limited time for additional education required for managing challenging cases; insufficient skills in mental health; failure to detect a mental disorder, heavy patient case load; lack of time for counseling and related therapies; and lack of specialized backup. Transportation Concerns • Patients often have limited or no transportation. And in rural areas, this is exacerbated by the frequent lack of public transportation options; • Patients are required to travel outside of their community to access services. Burden can result in need to take time off work, arrange childcare, or seek transportation from friends and family; • Provider shortages can result in increased travel burden for providers serving multiple counties or larger rural service areas. S 30 New Blue H Report,August 2014 • Crisis Intervention/Triage Services/Substance Abuse Services • Workforce and treatment capacity insufficient to meet demand. • Need for better integration between behavioral health and local public safety. • A changing profile of the people in need of services,which includes increased co- occurring mental illnesses and substance use disorders, medical comorbidity, rapidly evolving patterns of licit and illicit drug use, and involvement in the criminal justice system. Limited or no integration between mental health,chemical dependency and primary health care • Historical fragmentation that has divided the mental health system from the physical health system has meant that collaboration between primary care and specialty mental health care and/or chemical dependency is a challenge. • Lack of integration remains a barrier to improving quality, outcomes, and efficiency of the delivery of care. • Having three separate delivery systems and four separate funding streams to take care of patients' medical, mental and substance abuse needs can result in high costs, low satisfaction, reduced access and poor outcomes, including premature mortality. • A continual escalation of demands on the workforce to change their practices, including the adoption of best practices and evidence-based interventions. • Ineffective payment structure • Increased public financing of treatment due to Medicaid expansion, accompanied by declining private coverage/managed care policies and practices, and the large number of uninsured individuals results in scarce resources for local providers. • Fragmentation and silos between physical health, mental health and chemical dependency in clinical practice are mirrored in the fragmentation of funding streams. • Budget constraints, cuts and realignments in publicly funded systems—economic challenges like never before. • No system in place to move to scale innovative practices and systems change efforts that promote recovery. Lack of medication management • Limited access by primary care providers to consultation regarding types and dosage of medications used for treatment of mental illness conditions. • An increase in the use of medications in treatment has not been accompanied by appropriate practice supports, with the resultant demand that the workforce be knowledgeable and skilled in managing medications. • Decisions about psychotropic medications to be driven by cost rather than effectiveness. • 31 New Blue H Report,August 2014 Data/Information sharing obstacles • • Providers and care teams do not have access to stable data systems for sharing patient health information and for monitoring quality and performance measures that support the goals of whole-person care and accountability for health outcomes. • Rural behavioral health providers lack health information technology and do not fit easily into the CMS requirements for electronic health record meaningful use support. • An expansion of requirements to implement performance measures and to demonstrate patient outcomes through data. Obstacles for rural primary care providers and patients when specialized mental health professionals are available • Lack of expertise of when to refer patients to a mental health specialist. • Stigma and concerns about the patients' acceptance of the diagnoses and future impact on insurability. • Patient reluctance to use mental health providers due to concerns of confidentiality or lack of anonymity in rural communities. • Rural patients suffering from mental disorders may be less likely to perceive a need for mental health care. Overall complexity, contradictory nature of the regulatory framework Senate Bill 6312, is a first step to integrating state Medicaid contracting for physical and • behavioral health services, a move that will help the state provide better care to more people at a lower cost over time. Passed by the legislature during the 2014 session, SB 6312 creates "behavioral health organizations" (BHO)to replace current Regional Support Networks(RSNs). It also expands the Adult Behavioral Health Systems Task Force (task force), which was created last year. The task force is directed to provide recommendations on substantially reforming and integrating the funding of the adult behavioral health system in a preliminary report by December 15, 2014, and a final report by December 15, 2015. The task force recommendations include: 1. The means by which services are purchased and delivered for adults with mental illness and chemical dependency. 2. Guidance to the Health Care Authority (HCA) and the Department of Health and Human Services (DSHS) on creating common regional service areas for state purchasing of behavioral and physical health services. 3. Key issues for accomplishing integration of chemical dependency into managed care contracts by April 1, 2016. 4. Strategies and key issues to address to move toward full integration of medical and behavioral health services by January 1, 2020. 5. Review of Department of Social and Health Services (DSHS) and Health Care Authority (HCA) performance measures and outcomes. 32 • New Blue H Report,August 2014 • 6. Review of criteria for reviewing applications to become a BHO and applications for BHOs to become early integration adopters. 7. Recommendations on the creation of a statewide behavioral health ombuds office. 8. Scope of the services offered by the state chemical dependency program. 9. Obstacles to sharing health care information. 10. The extent to which there are variations in commitment rates in different jurisdictions. 11. Availability of effective means to address recovery and prevention in behavioral health. 12. Availability of crisis services, including behavioral health boarding outside licensed treatment beds. 13. Best practices for cross-system collaboration among stakeholders. 14. Public safety practices regarding persons with behavioral health needs with forensic involvement. Based on recommendations from the task force and Washington counties,the Health Care Authority and the Department of Health and Human Services will establish joint regional service areas and contract for mental health and substance abuse services in these areas by April 1,2016. The bill retains the current regional support networks' right of first refusal to serve the newly established regional service areas.The entities serving the new regional service areas will be called"behavioral health organizations." In the long term,the bill requires that mental health, chemical dependency, and medical services • for Medicaid clients be fully integrated in a managed care health system by January 1, 2020. This means the five managed health care organizations serving Medicaid clients will be newly responsible for enrollee services for chemical dependency and chronic mental health. The regional support networks' role will significantly change. Finally,the bill includes a provision to encourage expansion of inpatient mental health capacity. Under SB 6312, Certificate of Need requirements are suspended in fiscal year 2015 for hospitals that convert existing licensed hospital beds to provide psychiatric services, including involuntary treatment services.This waiver does not apply to hospitals adding new psychiatric beds. Recommendations I. Assure that the Adult Behavioral Health Systems Task Force's recommendations address rural disparities, specifically access barriers such as provider shortage and high rates of medical comorbidity and rapidly evolving patterns of licit and illicit drug use in the rural setting. Rural providers must be given a voice in the task force. This incudes but is not limited to input regarding the actuarial study, the development of a single information system, and flexibility in program guidelines to reflect the needs of rural communities. Requires rural participation in task force activities and coordinated input in the stakeholder feedback process by rural counties and providers. 41 33 New Blue H Report,August 2014 2. The legislature's recent funding of three additional Evaluation and Treatment facilities is • an important first step, however it will not be enough to fully address capacity issues. The state should continue to expand E&T capacity and work to raise the number of inpatient psych beds available. Raising capacity alone will be insufficient if done without sufficient reimbursements to ensure a sustainable line of service. Requires additional funding. The process of raising capacity in rural hospitals will be eased by waivers or changes to CMS staffing regulations. 3. Revise privacy laws to allow mental health and primary care providers to collaborate on care and communicate patient information more effectively. Integrated communication could increase the quality of care, reduce adverse prescription drug interactions, and lead to other beneficial outcomes.Requires statutory change and review of federal law. 4. Allow flexible funding streams for treatments covered by Medicare and Medicaid. Flexible funding streams, or global payments for the total cost of care for a patient, remove funding limits for the treatment of individuals in order to provide a full range of medical and nonmedical services. Such a structure is designed to eliminate the cycle of patients receiving limited, incomplete treatment, which leads to the need for additional care for the same issue.This cycle of care is not only more costly in the long-run than flexible funding streams, but it can contribute to adverse patient outcomes. Clinical fragmentation will persist as long as funding for physical health, mental health and chemical dependency services remains siloed. Requires policy change by HCA/Medicaid and possible CMS waiver. 5. Work withP roviders and academic institutions to develop more evidence-based practices • (EBPS) specific to rural areas, or to adapt current EDPs to the rural delivery system. This includes increasing awareness and training specific to rural culture.Requires additional time and resources from DOH. 6. Increase reimbursements to providers. Current rates are too low; increases in reimbursements could attract and retain quality providers. In particular, higher compensation is needed for DMHPs and crisis workers who face unique challenges, stress and high turnover. Low reimbursement rates for chemical dependency make recruitment and retention difficult. As Washington moves forward with integrated care models, increased reimbursements will help to ensure rural communities can staff all needed members of a care team. Requires additional state funding. 7. Increase the number of providers able to care for clients with mental health needs by allowing for expanded roles for current providers and expanding training and educational opportunities. Specifically: a) Develop and expand training opportunities for primary care providers to recognize and respond to behavioral health issues that present in primary care. b) Develop an expedited mechanism for clinicians already practicing to obtain co- occurring training and credentialing. 34 New Blue H Report,August 2014 • c) Develop an outreach system for education on evidence-based practice and continuing education. Requires time and technical assistance from DOH and WSHA and may result in policy changes. 8. Washington State should continue its efforts to enact telehealth legislation to ensure services delivered via telehealth technology receive reimbursement. Requires additional resources and support from DOH; statutory change to guarantee reimbursement. 9. Address significant discrepancy between the funds allocated to assist mental and behavioral health care providers in accessing health information technology (HIT), as compared to other health providers. This lack of equality leads to fragmented and incomplete care. The Health Information Technology for Economic and Clinical Health (HITECH) Act(P.L. 111-5)was passed in 2009 and is intended to increase the adoption of HIT and support electronic sharing of clinical data among health care stakeholders primarily through electronic health records (EHRs).The HITECH Act provides financial incentives for health care providers to use HIT. It was asserted that mental and behavioral health providers were less able to benefit from these incentives than their"traditional medicine"counterparts. Requires additional funding. 10. Enhance workforce development and recruitment e.g.: Focus on outreach to high school students and college students regarding their interest in the psychology field. Tie in with current programs reaching youth, such as the Youth Health Service Corps, and Project Hope. Requires additional time and resources for DOH/AHECs. • • 35 New Blue H Report,August 2014 VI. Primary Care and Prevention Recommendations • Background The primary care work group of the joint DOH/WSHA Rural Health Workgroup presents its findings regarding the prevention and primary care system in rural Washington State. While a number of issues were discussed,the focus of this work is on a larger vision that communities have access to the full continuum of prevention and primary care. Services are driven by patient and community outcomes, and it is critical to maintain access to high quality care for all residents of rural Washington. Provider and payer incentives must reward the most cost effective and high quality delivery of care. Challenges and Opportunities The work group identified the following challenges and opportunities facing rural communities. They include: Prevention Challenges • Local public health is underfunded • Lack of alignment between public health and clinical care • Patient Access Challenges • Office of the Insurance Commissioner's network adequacy rules may reduce access to the full continuum of care for rural residents. Rural primary care providers may not have anywhere to refer patients needing specialty services. • Currently only some preventive services are paid for by insurance plans, and all insurances subject patients to deductibles for primary care"sickness" services. This is an access issue for those with limited resources seeking primary care. Primary care services for both"sickness" and "wellness" should not be subject to deductibles. • Patients need more support for decision making in a time of significant health care culture change. Patients who have not had insurance or access to primary care in the past may not know how the system works and where to access appropriate care. In- person-assister funding ends in December 2014. Navigator funding subject to approval for 2015. • Some patients will continue to be left out of the traditional health care system, despite wide improvements in access to care, including Medicaid expansion. In particular, those between 139 and 200 percent of the federal poverty line and undocumented immigrants need to know about the free clinic resources available to them. • 36 New Blue H Report,August 2014 SAdministrative & Payment Challenges There is not a sustainable payment model for Rural Primary Care. There have been many past challenges to payment: • Because of the specific program finance models, there is no room for cost shifting for FQHCs and RHCs, so they must get paid costs to provide care for the Medicaid population; • RHC and FQHC Medicaid Recoupment and Reconciliation processes contribute to this lack of sustainability; • Current Medicaid reconciliation and recoupment process has a four year delay. This presents challenges of budgeting and overall stability. Process needs to be more timely. • Enhanced capitation payment rates need to be updated to reflect current rates and transparency of what rates are based on. • Health care payment system is based on face-to-face visits rather than Patient Centered Medical Home Principles. o Some chronic care patients would benefit from additional provision of care management. o RHC payments only allow face-to-face visits with a provider(no nurses or care coordinators, no email or phone care). • • Primary care organizations and providers know how to be creative, but are working in current regulations with limited grant funding available for creative solutions. There needs to be more sustainable funding support for piloting programs. Health Information Technology Challenges • Small primary care practices struggle to afford an EMR, keep track of updates and training and it only provides an upper level look at data. Even those clinics that afford an electronic health record may lack the expertise to pull meaningful population measures due to the vendor's product limitations or staff skill levels or both. The EMR falls short as a tool to support patient management. • The administrative burden of"meaningful use" doesn't support outcome-based care and ends up being an extra task with no incentive to look at outcomes. Oral Health Specific Challenges Oral health is an essential component to overall health. For example, diabetes and periodontal (gum) disease are chronic conditions that commonly occur together and exacerbate each other. There is a growing body of evidence that periodontal disease adversely affects blood sugar control which can lead to diabetic complications. Additionally, untreated tooth decay impacts children's development and ability to pay attention in school. 4110 37 New Blue H Report,August 2014 These challenges are exacerbated in rural communities in which access to oral health care is 1111 limited. • Oral health care access is limited in rural communities in general; • Oral health is essential and linked to physical health and mental health, however, oral health is frequently not included in systems aimed at improving whole-person health; • Missed opportunities to prevent oral disease can lead to unnecessary healthcare expenditures. The Washington State Hospital Association found that dental complaints were the number one reason uninsured patients sought care in emergency rooms, resulting in over $36 million in charges over an 18-month period. Provider Sustainability Challenges • There are not enough primary care providers in the nation to fit the needs of the current system.There are not enough medical education family practice training options and debt loads are too high for students who want to practice in primary care. • The state loan repayment program, which is crucial for recruitment and retention for providers who want to take lower paid positions,has taken many cuts and needs to be made whole again. Recommendations 1. Communicate and support implementation of the Washington State Plan for Healthy • Communities with rural community leaders.Requires improved communication between groups and technical assistance from DOH. 2. Support the work of those around the state in better aligning the work, knowledge, and resources of public health and clinical care. (State Health Innovation Plan, Agenda for Change, Rural Strategic Plan, Public Health Improvement Partnership etc). Requires increased time and coordination between stakeholder groups. 3. Adopt the federally established essential health benefits into state regulated plans on the exchange to further align Washington State's reform efforts with federal efforts under the Affordable Care Act. DOH should pursue increased partnership with the Washington Health Benefit Exchange Board.Requires work with the Exchange Board and policy change going forward. 4. Stay educated on implementation of network adequacy rules. Assure implementation of rules supports rural communities.Requires point person and coordinated plan. 5. Continue to promote enrollment in the expanded Medicaid program & enrollment in the marketplace to make sure all patients are covered. Continue patient education on • 38 New Blue H Report,August 2014 Sinsurance options and appropriate sources of care. Continue state investment in positions that assist patients in making health care insurance and access to services decisions. Work with Health Benefit Exchange leadership to support in-person assister training for Navigators and to prioritize funding for these Navigators for 2015. Align with the efforts of HCA on Medicaid expansion. 6. All primary care services in all facility types paid for by health insurance plans approved by the exchange should not be subject to deductibles. Requires statutory changes or waiver options. 7. Continue to invest in programs that support primary care service delivery, including interpreter service. Provide funding at a level commensurate with the demand for those services. Medicaid expansion has increased demand for these services. Evaluate the expansion of alternatives to in-person interpretative services, such as telephonic interpretation, or interpretation through audio-visual links as telehealth services are provided. Requires staff time for review of the current process to determine if it is meeting current needs and how it could be improved to meet the increased demand (WAC 388-271- LEP services; WAC 388-03 qualification of interpreters). Improvements to telehealth infrastructure may be required to facilitate alternative delivery methods. • 8. Promote systemic linkages between the traditional health care system and the free clinic network, in order to expand access to care for individuals not eligible for Medicaid or able to afford subsidized health care coverage. Requires staff time from DOH and WSHA. 9. Review new designs for payment for the reconciliation process. An enhanced capitation model provides predictable payments, without the instability of recoupment. A streamlined, timely reconciliation process will ensure compliance with federal requirements that RHCs and FQHCs are paid at least the federally required minimum. (Social Security Act, Section 1902, bb(6)(B); See FQHC/RHC Alternate Payment Methodology Report. Requires review and potential adoption of FQHC/RHC Alternate Payment Methodology Proposal 4 and change to Health Care Authority interpretation of Federal Regulations. Look at other state models for refinement of reconciliation process. 10. Preserve access to primary care by allocating state funds to cover a permanent "bump" in Medicaid payment (same as first half of year 2014 Federal Medicaid expansion payment bump)for the future for certain primary care services. While this does not directly impact Rural Health Clinics and FQHCs, it helps independent primary care providers in rural 4110 39 New Blue H Report,August 2014 Washington and stabilizes the whole system, increasing access to care. Requires 2015 110 legislative approval for permanent funding. Also requires time and effort to evaluate initial 2014 payment increase to understand impact. (There was not an official bill for this,just a budget request for 2014 session). 11. Broaden the workforce of providers to the care team utilizing appropriate connection modalities (telephone, email, etc.). Require state health insurance and health insurance plans approved by the exchange to pay for telehealth services. Requires statutory change. Reintroduce legislation in 2015 session. OR Admin. R. 410-130-0610 passed in 2009 for comparison.. 12. Implement a per-member, per-month enhancement payment system not based on visits. Through per member per month payment system, reimburse for patient centered medical home team based delivery of care. a. Require state health insurance and health insurance plans that are approved by the Exchange to have an insurance code to pay for care management services, following Medicare's lead (newly paid starting Jan 2015) for top level medical home certification. Requires statutory change. 13. Align with priorities of State Health Innovation Plan (Appendix C). Set aside funds for pilot projects that reward providers/organizations for high quality, cost-effective outcome • based care. This could occur through the reinstatement of HSR Grant Program through Office of Rural Health; Support from RCW 70.175.130; SHCIP. 14. Support development and transformation of the medical home so that patients develop a relationship with the entire medical home team not just physician. Increase use of Community Health Workers to assist with implementation of the medical home. Additionally, train Community Health Workers to address oral health, encourage people whose oral health may be impacting their overall health to talk with their primary care team, and link those in need of oral health care to dental providers. Support/maintain Community Health Workers program at DOH. Increase funding to allow for broader work in this area. 15. Statewide, support incentives in the SHCIP to improve population level reporting. Nationally, tie meaningful use requirements to NCQA medical home requirements to give them more meaning for population level reporting and streamline data entry requirements. Requires alignment with SHCIP and staff time for examination of HITECH/ARRA. Review other states' legislation around meaningful use requirements. 4111 40 New Blue H Report,August 2014 11/ 16. Engage primary care teams to address oral health during medical visits in the same manner in which they address other components of health: assess risk, deliver preventive messages, and refer those in need to treatment resources. Requires increased engagement with oral health providers and primary care workforce; technical assistance and staff time. 17. Provide oral health training resources and tools to primary care providers through the regional health extension program. Requires staff time and resources. 18. Utilize the training and coaching support of the Washington Dental Service Foundation. Encourage providers, health systems, and other organizations interested in engaging in oral disease prevention. Requires increased coordination and communication. 19. Support and increase capacity of programs that incentivize providers to work in rural and underserved areas and to provide volunteer care for patients not served by the traditional health care system. Requires secure funding and staff time for regular program evaluation: a. Reinstate funding for State Loan Repayment Program (WAC 250-25) b. Evaluate and increase capacity of Volunteer Retired Provider Program (WAC 256-564) c. Increase capacity of health care pipeline programs for students who want to pursue health care careers. • 41 Board of Health V New Business Item 4 Olympic Community of Health Update December 18, 2014 Board of Health V New Business Item 5 2014-2015 Influenza Season Update • • December 18, 2014 Board of Health V New Business Item 6 • Ebola Preparedness Update � December 18, 2014 0 Media Report • Jefferson County Public Health October/November 2014 NEWS ARTICLES 1. "Talk includes parents, their teens Monday," Peninsula Daily News, October 12th, 2014. 2. "Peninsula prepared for Ebola, but flu's a bigger threat, health officer says," Peninsula Daily News, October 23rd, 2014. 3. "Shellfish harvesting reopens as toxins recede in Discovery Bay, part of Hood Canal," Peninsula Daily News, October 29th, 2014. 4. "Discovery Bay, Hood Canal beaches reopen to the recreational harvest of shellfish," Port Townsend Leader, October 29th, 2014. 5. "Jefferson County Public lauds businesses for `eliminating barriers' for those with developmental disabilities," Peninsula Daily News, November 4th, 2014. 6. "Marquis new head of JMHS," Port Townsend Leader, November 4th, 2014. 7. "Jefferson, Clallam and Kitsap counties discuss team approach to health care with Olympic Community of Health," Peninsula Daily News, November 10th, 2014. 8. "Jefferson Healthcare offers help with insurance enrollment," Port Townsend Leader, November 12th, 2014. 9. "Local employers honored for inclusiveness," Port Townsend Leader, November 12th, 2014. 10. "Scabies alert issued at PTHS," Port Townsend Leader, November 19th, 2014. • 11. State Seek Immunity from SCOTUS Ruing on Health Subsidies," www.governing.com/topics/health-humanservices/gov-supreme-court-obamacare- subsidies.html, November 18th, 2014. 12. "North Olympic Peninsula health officials ask pharmacies to stock heroin overdose antidote," Peninsula Daily News, November 21st, 2014. 13. "Girls Night Out a success," Port Townsend Leader, November 26th, 2014. 14. "Good Works: Staying healthy," Port Townsend Leader, November 26th, 2014. 15. "Take charge of your health to plan for your pregnancies," Port Townsend Leader, November 26th, 2014. 16. "PT meth lab complaint rejected," Port Townsend Leader, November 26th, 2014. 17. "Health advisory issued after sewage spills in stream flowing into Port Ludlow Bay," Peninsula Daily News, November 26th, 2014. 18. "SmileMobile to arrive in Chimacum in December," Peninsula Daily News, November 30th, 2014. 19. "Dabob Bay beaches reopen for partial shellfish harvest," Port Townsend Leader, December 2nd, 2014. 20. "Dabob Bay beaches reopen for partial shellfish harvest," Port Townsend Leader, December 3rd. 2014. 21. "Jefferson's Dabob Bay opens for harvesting of some shellfish species," Peninsula Daily News, December 3rd, 2014. 22. "Healthy Children, Thriving Families," Port Townsend Leader, December 3rd, 2014. 23. "Brinnon open house sees debate on benefits, impacts of proposed Pleasant HarborResort," Peninsula Daily News, December4 4th, 2014. • • Talk includes Keynote speaker Clay recognize perceptions Roberts will present. regarding student drug and parents, their Roberts has been fea- alcohol use and to shift the tured on NBC's"Today focus toward healthier teens Monday Show"as a prevention choices. expert and is an adult past Refreshments will be pro- CITMACUM—A meet- board member president vided. ing on communication and supporter of the Bain- For more information, between teens and parents bridge Island Teen Center. contact Sue Hay at 360-379- will be held in the Chima- The Chimacurn High 5610 or sue.hay@wsu.edu. cum High School library, School Prevention Club will 91 West Valley Road,from present its Social Norms 7 p.m.to 9 p.m.Monday Campaign to help people • • • 1a i°2-//,/ Peninsula prepared for Ebola, but flu's a bigger threat, health officer says .By Rob 011ikainen, Peninsula Daily News, October 231d, 2014 PORT ANGELES—In the unlikely event that the Ebola virus reaches the North Olympic Peninsula, the regional health care system would be ready to respond, a public health expert said. "We are prepared to deal with this if we have to deal with it," Dr. Tom Locke, public health officer for Clallam and Jefferson counties, said Tuesday. Ebola has killed more than 4,500 people in West Africa, mostly in Liberia, Sierra Leone and Guinea. But influenza is a bigger threat to the North Olympic Peninsula, Locke says. Infection control at U.S. hospitals, including full-body, fluid-resistant protective suits for health care workers, should prevent an outbreak from occurring here, Locke said. "We have the technology; we have the knowledge to prevent it," Locke told the Clallam County Board of Health. Two American nurses remain hospitalized after catching the virus from a Liberian man who traveled to the U.S. before showing symptoms and dying at a hospital in Dallas. "We have two very unfortunate nurses who were exposed to that individual while providing care who became infected, which is something that really should not happen," Locke said. "We know how to prevent that from happening in this country. And for some reason, it didn't get done." In the wake of the Ebola transmissions in Texas, the Centers for Disease Control and Prevention issued more- stringent safety guidelines. "The head of the CDC got a lot of grief by calling it a breach in protocol, but it had to be a breach in protocol," Locke said. "Protocol is to not contaminate. You cannot get infected unless you're exposed to the virus. So something went wrong." Locke predicted that the two American nurses would survive. "They are getting state-of-the-art treatment," he said. "Unfortunately, it's not feasible to import that kind of technology to West Africa. "What's essential for West Africa is having treatment facilities so people who are severely ill can be isolated from their families and other people, and then safe burial of remains." Ebola is spread through contact with body fluids. Olympic Medical Center, Jefferson Healthcare and Forks Community Hospital have infection-control procedures that would help rein in a virus like Ebola, Locke said. "We have very dangerous infections that we see in hospitals that we need to contain all the time," he added. "We treat some of these antibiotic-resistant infections a lot like we treat Ebola." Health care workers nationwide are being retrained on donning and doffing full-body suits to prevent contamination. • As Locke sees it, Ebola presents two main problems: the outbreak itself and the "Ebola scare." "It's dominating the news cycle, and it's getting a lot of political attention," he said. "This is a real problem, too, but the problem is not that we have an Ebola outbreak in the United States." To put it into perspective, the U.S. death toll from influenza ranges from 4,000 to as many as 40,000 per year, Locke said. • "The death toll of Ebola in the United States is one," he said. Anyone traveling into the U.S. from Ebola-stricken nations is being monitored for symptoms for 21 days. The virus is not contagious before early symptoms of fever, weakness and nausea and vomiting develop. "It rapidly progresses, and the multiplication of the virus in your system is logarithmic," Locke said. "The level goes up to extraordinarily high levels." U.S. Rep. Derek Kilmer of the 6th Congressional District, which includes the North Olympic Peninsula, held a Tuesday conference call with officials from OMC, Jefferson Healthcare, Forks Community Hospital and other regional hospitals on ongoing planning and preparations to handle any possible Ebola case. Hospital officials reported they are providing training exercises on isolation techniques, screening patients and the proper use of personal protective equipment. "Ebola is both a public health concern and an international security threat," Kilmer said in a news release. "In Washington state and across the country, it's important we take the proper preventive measures to ensure the health of every American." Locke said the real danger from Ebola comes from people "taking care of people who are severely ill with Ebola and then disposal of human remains if a person should not survive. "That's where we see most of the transmission," he said. • Although Ebola is"very controllable" in the U.S. and other developed nations, the mortality rate in West Africa is 50 percent to 70 percent, Locke said. "But that's in an area that has virtually no health care infrastructure," he said. "In western settings, especially with the kind of treatments and supportive services we have available, this is a very survivable infection." Health officials believe the international outbreak would "snuff itself out" if 70 percent of Ebola patients are treated in a hospital setting and 70 percent of the bodies of Ebola victims are properly disposed of, Locke said. Beyond the lack of health care infrastructure, efforts to control the outbreak in West Africa are further impeded by dysfunctional and corrupt governments, Locke said. "The only solution to this is a very aggressive international response to stop the outbreak," he said. "A world where there's chronic Ebola is not something anyone wants to imagine." Reporter Rob 011ikainen can be reached at 360-452-2345, ext. 5072, or at rollikainen(a peninsuladailynews.com. i Shellfish harvesting reopens as toxins recede in Discovery Bay, part of Hood Canal Peninsula Daily News, October 29th, 2014 IlkPORT TOWNSEND — Declining biotoxin levels have allowed Discovery Bay and parts of Hood Canal to be reopened to recreational harvesting of most species of shellfish. Discovery Bay shellfishing areas have been reopened to all species except butter and varnish clams, which can retain biotoxins longer, Michael Dawson, water quality lead for Jefferson County Environmental Health, said Tuesday. Hood Canal beaches from Seal Rock south to the Mason County line have been reopened for all species, he said. Quilcene and Dabob bays remain closed to the harvest of all species of shellfish because of high levels of the biotoxins that cause the potentially deadly paralytic shellfish poisoning (PSP). Shellfish harvested commercially are tested for toxin prior to distribution and should be safe to eat. Earlier this month, a portion of Hood Canal shoreline never before closed to recreational shellfish harvesting was placed off limits because of high levels of the PSP toxins. The state Department of Health had closed Hood Canal beaches from Dabob Bay south to the Jefferson County-Mason County line. Discovery Bay had been closed July 24 when state shellfish testing found high levels of biotoxins that produce diarrhetic shellfish poisoning (DSP) caused by a bloom of marine algae. The bloom lasted until October, when biotoxin amounts in most species returned to safe levels, Dawson said. Starting in early September, Hood Canal, Quilcene and Dabob area beaches were impacted by a heavy bloom producing the potent nerve toxins that cause PSP, he said. PSP biotoxins are still high in Quilcene and Dabob Bays, but levels declined enough south of Seal Rock to allow a reopening in that area. Elsewhere in Jefferson County, Discovery Bay, Kilisut Harbor including Mystery Bay and Port Ludlow including Mats Mats Bay are closed for butter and varnish clams only. In Clallam County, the recreational harvest of butter clams is closed from Cape Flattery to Dungeness Spit. Varnish clams are closed along the entire North Olympic Peninsula. Sequim Bay is closed to all species of shellfish. Seasonal closures are in effect for all Pacific Ocean beaches. Closures do not apply to shrimp. Crabmeat is not known to contain the biotoxin, but the guts can contain unsafe levels. To be safe, clean crab thoroughly and discard the guts, health officials say. • Symptoms of PSP can appear within minutes or hours and usually begin with tingling lips and tongue, moving to the hands and feet, followed by difficulty breathing and possible death. Anyone experiencing such symptoms should contact a health care provider immediately and call 9-1-1 in extreme cases. DSP is less serious but can cause illness such as can cause diarrhea, nausea, vomiting, abdominal cramps and chills. Toxins in shellfish are not destroyed by freezing or cooking. Recreational shellfish harvesters can get the latest information before they leave for the beach by visiting www.doh.wa.gov or phoning 800-562-5632. Recreational shellfishers also should consult state Fish and Wildlife at www.wdfw.wa.gov • • Discovery Bay, Hood Canal beaches reopen to the recreational harvest of shellfish Port Townsend Leader, Wednesday, October 29, 2014 Declining biotoxin levels have allowed certain areas in Jefferson County to reopen to recreational shellfishing. Discovery Bay beaches have reopened to all species except butter and varnish clams, which can retain biotoxins longer. Hood Canal beaches from Seal Rock south to the Mason County line have reopened for all species. Quilcene Bay and Dabob Bay as well as West Jefferson County ocean beaches remain closed for sport harvest of all species. Discovery Bay closed on July 24, 2014 when testing by Washington State Department of Health revealed high levels of biotoxins that produce Diarrhetic Shellfish Poisoning caused by a bloom of marine algae. The bloom lasted until October, when biotoxin amounts in most species returned to safe levels. Starting in early September, Hood Canal, Quilcene and Dabob area beaches have been impacted by a heavy bloom producing the potent nerve toxins that cause • PSP. PSP biotoxins are still high in Quilcene and Dabob Bays, but levels declined enough south of Seal Rock to allow a reopening in that area. People can become ill from eating shellfish contaminated with marine biotoxins, which are not destroyed by cooking or freezing. In most cases the algae that contain the toxins cannot be seen and must be detected using laboratory testing. Therefore, recreational shellfish harvesters should check the DOH map at doh.wa.gov/ShellfishSafety.htm or call the Biotoxin Hotline at 800-562-5632 before harvesting shellfish anywhere in Washington State. Recreational harvesters should also check Fish and Wildlife regulations and seasons at wdfw.wa.gov/fishing/shellfish/ or the Shellfish Rule Change Hotline 866-880-5431. • Jefferson County Public Health lauds businesses for `eliminating barriers' for those with developmental disabilities Peninsula Daily News,November 4th,2014 � 2 r- a .2„,..„,„m ,„4„ ,‘? The Developmental Disabilities Program at Jefferson County Public Health recognized National Disability Employment Month by honoring several employers recently. From left are program board chairs Carl Hanson and Lesly Sheinbaum; Bob Giesler of Safeway; Rich Stewart of Chimacum School District; Kelly Anthony of Bayview Restaurant; and Jefferson County Commissioners David Sullivan and John Austin. PORT TOWNSEND —The Developmental Disabilities program at Jefferson County Public • Health, in partnership with program's advisory board, Skookum and Concerned Citizens, celebrated October as National Disability Employment Awareness Month by honoring 13 Jefferson County employers. They are Subway, Pizza Factory, Pane d'Amore, Enclume Design Products, Port Townsend Business Guides, Pippa's Real Tea, Glow Natural Skin Care, Goodwill Industries, Homer Smith Insurance, Uptown Nutrition, Safeway, Chimacum School District and Bayview Restaurant. Those businesses lead efforts to employ local people with developmental disabilities, according to the advisory board, and "leading by example when it comes to eliminating barriers to work." Members of the advisory board and the three Jefferson County commissioners presented three of the businesses — Bayview Restaurant, Safeway and Chimacum School District—with certificates of appreciation. Last modified: November 03.2014 7:02PM • Marquis new head of JMHS . By Allison Arthur of the Port Townsend Leader, November 4, 2014 11:15 pm:77. _ Adam Marquis recently took the helm as executive director of the = private nonprofit Jefferson Mental Health Services. Sam Markow „,, - retired as executive director but has been retained as a consultant. Adam Marquis turned down three other job offers to move to the Olympic Peninsula and take the helm as executive director of the private non-for-profit Jefferson Mental Health Services (JMHS). • h x °/ °�•� : €!�°� "I think there's a lot of good work to be done here," Marquis said of q why he picked the Port Townsend job with the only licensed community mental health system in Jefferson County. He said his family likes the peninsula because of its beauty and the fact that the area feels family friendly. On the job for only 10 days as of Oct. 31, Marquis said he is excited about the job and looks forward to building bridges between agencies to deliver services in Jefferson County. "Stewardship. Relationship. Leadership. Those are the guiding forces. How do we get better not bitter? How do we build on the positives?" he said. "I understand my role as a servant-leader, manager-steward, and scholar-practitioner using my • experience, education and expertise as a healthcare administrator. Marquis is working toward a fellowship in the American College of Healthcare Executives, which would make him board certified for almost any healthcare leadership position. Chuck Henry, president of the JMHS board that hired Marquis, said Marquis had done his homework, knew the lay of the land and the challenges of the organization when the board interviewed him. "He had experience working with union contracts, which affects us, and extensive experience in community collaborative projects and innovative thinking, and he's very knowledgable about electronic records," Henry said. Marquis was one of 27 people from around the country to apply for the $89,000-a-year-position last month after the retirement of executive director Sam Markow, who will remain a consultant. Markow has been with the agency since 2010. Markow said in August that the agency is not in crisis, but that the overall healthcare system is in transition, in part because of the Affordable Healthcare Act, better known as Obamacare, that has made more people eligible for healthcare at a time when there are fewer providers. JMHS lost both of its psychiatrists in the last year, one who left because she wanted to move back to her home state; the other because of expanding caseload, Markow said. Marquis said a solution to that has yet to be determined, but he noted that a psychiatrist or an ARNP (Advanced Registered Nurse Practitioner) can prescribe medications and an ARNP may be able to do that long-term. He has already reached out to Jefferson Healthcare CEO Mike Glenn to discuss the issue of boarding; parking people with mental health issues in hospitals instead of licensed mental-health facilities. • Marquis plans to "spend a lot of time with internal teams and outside stakeholders and constituencies," including Glenn, to get the lay of the land and then start building bridges between the agencies that care for patients. "A primary focus is bridge building and improving ways to deliver mental-health services in our community," Marquis said, adding he has experience in both designing new programs and deploying them. Marquis currently is reading, "Patients Come Second: Leading Change by Changing the Way You Lead," by Paul Spiegelman and Britt Berrett, a book on the best-seller lists of The New York Times, USA Today, and The Wall Street Journal. The book is about changes in how healthcare services are delivered and it zeroes in on not just the patient's experience but how businesses "can't take care of customers if you don't take care of employees," according to a synopsis of the book. "Every person at every level is important to get the job done," Marquis said of what he is learning from the book and what he sees as an emerging trend in healthcare. Another issue for Marquis is that of what he calls "shared responsibility." He notes that patients aren't just seen by one agency. Most patients are seen by a number of providers, from Jefferson Healthcare to Jefferson County Public Health, the school systems, and even Jefferson County Jail, as well as JMHS. "I'm getting more familiar with the forces and constraints of what's impacting community mental health • service delivery in this area," Marquis said. JMHS employs roughly 40 people, Henry said. BACKGROUND Marquis is originally from Maine. He lists his most recent job as CEO for a community mental-health organization in Chesapeake, Virginia, where he was a leader, fundraiser and worked to expand new business. He's also been an executive for several organizations in Bangor, Maine. Marquis has a master's in business administration, healthcare management and resource management from Walden University in Minneapolis, a bachelor's in communication and psychology from the University of Maine and is a certified behavior specialist, who can work with children and adults with mental health, substance abuse and intellectual disabilities. His resume also includes numerous community volunteer activities. He describes himself as "a driven innovator, and intrapreneurial strategist with years of public and private sector healthcare multi-side administration and management, as well as someone who inspires enthusiasm and maintains a positive bottom line." FAMILY Marquis is renting a home for a year while he becomes familiar with the area. He is joined by his wife, Hannah, 3-year-old daughter Zoe, and son Joshua, who was born Sept. 16, 2014. He said both he and • his wife enjoy hiking as well as being near the ocean. "The combination of the Olympic mountains and ocean closer together has truly made this area one of the most beautiful in the country we have seen," Marquis said. Jefferson, Clallam and Kitsap counties discuss team approach to health care with • Olympic Community of Health By Charlie Bermant, Peninsula Daily News, November 10th,2014 PORT TOWNSEND — Health services officials from Jefferson, Clallam and Kitsap counties are discussing building a regional coalition to increase health care efficiency. "We want to bring together all the people and agencies involved in medical care, mental health and substance-abuse treatment," said Dr. Tom Locke, the medical officer for Jefferson and Clallam Counties, after a meeting Friday. "This will be accomplished by bringing together all of the stakeholders —the different people who do the same thing —so they can work with each other," he added. About 40 people, including health officers from the three counties, attended the meeting at Fort Worden State Park as the first step to forming the coalition that is to be called the Olympic Community of Health. A lot of the details are yet to be determined, such as cost of services and what can be streamlined, but opening a dialogue is the first step toward building a partnership, according to Locke. Locke said the impetus for the coalition comes from the state, which has mandated the creation of Accountable Community of Health districts as a resource-sharing measure. Locke said that the state's initial plan was to create 10-county districts, a move that he said would be • counter-productive. "In order for this to work, it will take coordination between many different agencies that aren't used to working together, like the police and the schools," Locke said. "To attempt this over a 10-county area would be too complicated." Bringing Kitsap, Clallam and Jefferson counties together makes sense, he said, since the three are already working together to some extent. "It didn't make sense for us to be grouped with Olympia, because no one up here goes to Olympia for health care," Locke said. Seattle health care consultant Dale Jarvis, who facilitated the four-hour meeting, said he was energized by the group's reaction —which isn't always the case. "The idea of these alliances is to move from an isolated impact to a collective impact," Jarvis said. "In an isolated situation, a funder gives money to one agency to do one thing and to another to do something else. "In a collective impact situation, the funder creates a more complete system of care that better meets • people's needs." As an example, Jarvis referred to a health care system in Bend, Ore., that analyzed treatment patterns. "There were people who were visiting the emergency room every week, so they looked for ways to prevent those frequent visits," he said. Change will be difficult, participants said. • "The system will be hard to change because we are on a fee-for-service trajectory," said Jean Baldwin, Jefferson County Public Health Department director. Locke agreed, saying that "we are trying to change the system so it is focused more toward wellness. "Right now, it's all about how many services you can sell." A certain amount of coordination and leverage of services already exists among counties, according to Iva Burks, Clallam County Health and Human Services director. "We all work together, and our jobs aren't the same," Burks said. "Each of the public health departments have different services," she added. "Jefferson County does a lot with family planning which we don't offer while we are bigger in human services. "We already draw from each other." Creating the Olympic Community of Health will require creating an additional level of bureaucracy to secure funding and connect services, but supporters of the idea say that existing staff can perform many • of those functions within their current jobs. It will cost money, but Locke expects some funds to be available for that purpose through a $94 million federal grant to the state to administer the programs. While Burks expects that it will take some time, "more than six months" to coordinate the programs, Jarvis thinks that success will come from a more seat-of-the-pants process. "You can get started right away," he said. "All an agency needs to do is pick a project, secure the funding and do it on their own. "You don't need to spend three years planning this." Jefferson County Editor Charlie Bermant can be reached at 360-385-2335 or cbermant(c�peninsuladailynews.com. • Jefferson Healthcare offers help with insurance enrollment Port Townsend Leader, November 12th, 2014 The open enrollment period for signing up for medical insurance through the Affordable Healthcare Act— better known as Obamacare — is Nov. 15 through Dec. 23 for coverage starting Jan. 1, 2015. Jefferson Healthcare, the largest healthcare system in Jefferson County, is offering help to those interested in obtaining insurance. There are four insurance carriers to choose from in 2015, instead of two carriers available this year. Starting Nov. 15 people can check to see for what kinds of insurance they are eligible either in person or online. So long as a payment for insurance is received as of Dec. 23, coverage starts Jan. 1, 2015. People have until Feb. 15, 2015 to enroll in a qualified health plan. Those who don't enroll face a possible penalty on their income taxes. Jefferson Healthcare's financial service office has extended its regular business hours to Saturdays for added convenience and accessibility during the open enrollment. In-person assisters are available by appointment Monday through Friday during regular office hours, 9 a.m.-4:30 p.m., or for drop-in (no appointment necessary) from 10 a.m. to 2 p.m. on the following Saturdays: Nov. 15, Nov. 29, Dec. 13: Jefferson Healthcare Financial Services, 834 Sheridan St. 4110 Nov. 22, Dec. 6 and 20, Jefferson County Library, 620 Cedar Ave., Port Hadlock. Extended hours have been scheduled for 9 a.m.-6 p.m. Dec. 22 at Jefferson Healthcare. Call 360-385-2200, ext. 2267 to make an appointment. In 2014, there were only two issuers of plans in Jefferson County. For 2015, there are four issuers: Coordinated Care, Lifewise, Moda Health Plan, and Premera. Also new this year, people do not have to choose a personal navigator to enroll. Starting Nov. 15, Washington Healthplanfinder customers who signed up for a qualified health plan last year are eligible to renew their health coverage for 2015 plans. Most customers may be eligible to automatically renew their current health plan, but customers also have the option to update their application and shop for new plan options. Approximately 80 percent of qualified health plans offered in 2014 is to be offered again during the next open enrollment period. "The great news is that most customers won't need to take further action if they like the health plan they had last year," said Richard Onizuka, CEO for the Washington Health Benefit Exchange. "With twice as many health plan options this year, they may also decide to shop for a new plan that may better suit their needs and budget." RENEWAL NOTICES Current customers should be on the lookout for "Open Enrollment Renewal" notices from Washington Healthplanfinder as early as this week. It provides more information about 2015 coverage and the renewal process, changes to eligibility, whether they still qualify for financial help, including an updated tax credit amount, and if they need to update their online account. Customers may also receive notices from their health insurance company detailing any changes to their coverage next year. • "It's critical that customers take the time to shop for their health plan and submit their applications and payment by Dec. 23 if they are seeking coverage that starts in the new year," said Onizuka. "Whatever, you do, don't wait until the last minute to make this important decision for you and your family." Customers are eligible for auto-renewal if their current plan is still available in 2015, if they provided the Exchange with permission to check their eligibility for tax credits for the next year, and if they still qualify for coverage based on their income level and household size, residency and citizenship status. APPLE HEALTH, HELP Those who are enrolled in Washington Apple Health (Medicaid) should receive a notice 60 days before the month they enrolled in or renewed their coverage last year. Washington Apple Health enrollment is year-round. To apply for Medicaid/Apple Health for the first time, visit wahealthplanfinder.orq. To request assistance for completing a new application from Jefferson Healthcare, call 385-2200, ext. 2267 or Jefferson County Public Health at 385-9400 for an appointment. Olympic Area Agency on Aging offers assistance 8:30 a.m.-5:00 p.m. Monday-Friday at the Tri-Area Community Center, 10 W. Valley Rd., Chimacum. They can be reached at 360-732-0094. • i • Local employers honored for inclusiveness Port Townsend Leader, November 12, 2014 ''''' MA 44 i+ .,7r. l',..7,7\747., ''': <4..„ eta w$ —Nit. N.- jilt, .f,, i T E *Sk.4*vitt ' Local employers honored for inclusiveness Attendees at the presentation of honors included (from left) Carl Hanson and Lesly Sheinbaum, co-chairs of Developmental Disabilities Board; Bob Giesler of Safeway; Rich Stewart of Chimacum School District; Kelly Anthony of the Bayview restaurant; and Jefferson County Commissioners David Sullivan and John Austin. Submitted photo The Developmental Disabilities (DD) program at Jefferson County Public Health, • in partnership with the DD advisory board, Skookum and Concerned Citizens, is celebrating National Disability Employment Month by honoring the following employers: Subway, Pizza Factory, Pane d'Amore, Enclume, Port Townsend Business Guides, Pippa's Real Tea, Glow, Goodwill, Homer Smith Insurance, Uptown Nutrition, Safeway, Chimacum School District, Bayview Restaurant and the Jefferson County Chamber of Commerce Visitor Center. These businesses are leading efforts to employ local people with developmental disabilities, and leading by example when it comes to eliminating barriers to work. By allowing local people with developmental disabilities to fully participate in the community workforce, everyone wins. Members of the DD advisory board and Jefferson County Board of Commissioners presented three of the honored businesses with certificates of appreciation. III Scabies alert issued at PTHS Port Townsend Leader, November 19, 2014 • An outbreak of scabies, a contagious skin condition, has prompted a health alert at Port Townsend High School. The school's Facebook page was used on Friday, Nov. 14 to inform families of what high school authorities learned through various contacts from parents. As of Nov. 14, there were at least 10 confirmed cases of students with scabies at PTHS. Because scabies is a contagious skin condition, authorities at the high school wish to inform families so they can evaluate their teenagers; then seek medical treatment as soon as possible if visible symptoms of the disease are present. Scabies is an itchy skin condition caused by tiny mites that burrow into the skin. The itching is caused by an allergic reaction to the mites. Not everyone reacts the same but itching is present for sure; most likely small red bumps on the skin as well. According to the Facebook release from PTHS, individuals with scabies often report unusual rashes on various parts of their bodies. Scabies spreads easily from person to person, is transmitted through skin to skin contact, clothing, and/or bedding. It affects people of all ages in all living situations. Clothing and bedding of infected households should be washed in hot water. PTHS has taken extra precautions by having the classrooms in the school sanitized. For more information on scabies visit tinyurl.com/ndmga6x. As per the Mayo Clinic website (tinyurl.com/nyedt55), symptoms of scabies include but aren't limited to: - Itching, often severe and usually worse at night. -Thin, irregular burrow tracks made up of tiny blisters or bumps on the skin. - The burrows or tracks typically appear between skin folds. • - In children, common sites of infestation include the scalp, face, neck, palms of hands and soles of feet. In adults, the symptoms are often present between fingers, in armpits, around the waist, insides of wrists, inner elbow, soles of feet, breasts, genital areas, buttocks, knees and shoulder blades. Note that many skin conditions, such as dermatitis or eczema, are associated with itching and small bumps on the skin. A family physician may determine the exact cause and indicate proper treatment. Scabies spreads quickly through close physical contact in a family, child care group, school class or nursing home. Because of the contagious nature of scabies, doctors often recommend treatment for entire families or contact groups to eliminate the mites. Scabies is readily treated and it must be treated as the condition doesn't improve by itself; bathing and over-the-counter preparations don't eliminate scabies. Medication is required to kill the mites and to keep them from spreading to other people. Medications applied to skin kill mites that cause the rash and their eggs, although people afflicted with the condition may still experience itching for several weeks after treatment. For further questions, contact the local health department at 385-9400 or your medical provider. • • States Seek Immunity from SCOTUS Ruling on Health Subsidies BY: Chris Kardish I November 18, 2014 The U.S. Supreme Court took many by surprise when it announced earlier this month that it will review a case that has the potential to make health insurance significantly less affordable in the states that rely on the federal exchange. With a decision expected in June, a number of states are likely to consider action to avert a worst-case scenario. The case, King v. Burwell, is one of four suits brought by opponents of the Affordable Care Act's requirement that everyone has health insurance. Inspired by the libertarian Cato Institute, the plaintiffs argue that, as written, the health law restricts the federal subsidies to only states that host their own exchange. By the U.S. Department of Health and Human Services' count, 18 states operate their own exchanges. The rest, if the court sides with Obamacare's critics, would see premiums soar in the absence of federal subsidies. The consulting firm Avalere Health estimates that nearly 5 million people would see their premiums spike 76 percent, on average, if the Supreme Court strikes down subsidies in states that don't operate their own exchange. That estimate assumes a greater number of exchanges are considered federal, not state-based, but the question of what exactly constitutes a "state-based" health exchange is murky. This appears in the free e-Health newsletter. Click to subscribe. • Exchanges are online marketplaces where consumers can shop for health insurance plans, but they're far more than just websites because they also make determinations about eligibility and subsidy levels and manage many other aspects of insurance coverage. States have the option of running their own exchange completely (a state-based exchange), managing aspects of plan design or consumer outreach (a partnership exchange) or leaving everything to the federal government (a federally facilitated exchange). Of the 18 states and the District of Columbia that HHS considers to have state-based exchanges, several use the federal website, HealthCare.gov, but still maintain control over aspects such as plan approval, data collection and quality reporting. Those include Nevada and Oregon -- both of which abandoned their own failed technology platforms -- as well as New Mexico. Utah and Mississippi are both considered state-based exchanges by HHS because they host their own small-business exchange but let the federal government host their sites for individuals. Along with the 25 states considered federally facilitated exchanges, the seven partnership exchanges would also lose subsidies if the Supreme Court sides with the plaintiff, according to Tim Jost, an expert on health law at Washington and Lee University who supports the ACA. The states in the partnership category are Arkansas, Delaware, Illinois, Iowa, Michigan, New Hampshire and West Virginia. Those seven states are where lawmakers and/or governors will most likely advocate to develop full state-based exchanges in the coming months. But there could also be pushes in more politically moderate federal-exchange states such as Pennsylvania. To be ready for the next open enrollment period, states have until June of next year to apply for state exchange status. That would require 11111 completing or updating an application spelling out responsibilities. Before doing that, though, states need the legal authority to apply. In some states, such as Kentucky, the governor can create an . exchange via executive order; in others, such as Illinois, the legislature has to pass a bill. HHS won't say exactly what a state needs to do to qualify as running a state-based exchange, but the federal government handles some of the duties listed on the application for state-based exchanges in New Mexico, Nevada and Oregon. There's ample precedent for states to apply to HHS, which has broad authority on how it defines exchanges, for full state-based status along similar lines, said Joel Ario, a health consultant who previously worked as the director of HHS' Office of Health Insurance Exchanges. "Their classification shouldn't depend on their IT decision," he said. "It should depend on plan management and consumer assistance." According to Justin Giovannelli, a Georgetown University health policy researcher, "many of the states, even those that are not state-based exchanges, are doing the things [state-based exchanges] already do. They just don't have the legal status." Jost emphasizes that it's far from an easy lift, pointing out that, for example, partnership states still don't have governing boards for their exchanges or make eligibility determinations for themselves, and state-based exchanges are also expected to handle consumer assistance. But Delaware, for one, says it's already actively certifying the plans offered on the exchange and doing most of the things a traditional state exchange does-- it just needs formal status. Delaware will apply for state-based status after getting authorization by executive order or through the legislature, said Jill Fredel, the director of communications for the state's Department of Health and Social Services. Fredel argues the state simply doesn't have the resources to run the necessary IT, but it's doing just about everything else a state exchange does. Illinois' outgoing governor, Democrat Pat Quinn, said he's pushing his legislature to authorize a state-based exchange before Republican Bruce Rauner starts the job in January. But it won't be easy because the legislation may need a supermajority in a short veto session, according to state Rep. Greg Harris, who holds leadership posts on the insurance and human services appropriation committees. • "You have an awfully heavy lift to get the votes and you have essentially four days to do it," he said. "Every single thing would have to fall into place perfectly just to meet the deadlines mechanically of getting a bill through the legislature." The effort could be even tougher in Iowa, where Democrats narrowly control the Senate and Republicans control the House and the governor's mansion. State Sen. Pam Jochum, the majority leader, said her party will try to pass an authorizing bill this session. But past efforts failed due to Republican opposition and a recent statement from Gov. Terry Branstad's communications director won't likely raise hopes for supporters: "Gov. Branstad has always worked to make health care insurance more predictable and affordable for Iowa families and businesses, and a hastily built exchange, which some states are considering, would not support either of those goals," said Jimmy Centers. In Arkansas, which has worked to fit aspects of the law to a more conservative worldview, lawmakers might wait until after the Supreme Court decision, if at all. State Sen. David Sanders, a • key supporter of the state's privatized Medicaid expansion, said he'd rather wait until after the ruling because it could force HHS to grant even greater flexibility. f "We have been operating under the assumption that at some point we'll have the flexibility we want," he said. "My directive is to see how we can continue to get more of that." This article was printed from: http://www.governing.com/topicslhealth-human-services/gov- supreme-court-obamacare-subsidies.html • S North Olympic Peninsula health officials ask pharmacies to stock heroin overdose 40 antidote By Rob 011ikainen, Peninsula Daily News, November 21,2014 yai Dr.Tom Locke, public health officer for Clallam and Jefferson counties PORT ANGELES — Public health officials in Clallam and Jefferson counties have joined a national push to make a life-saving heroin overdose antidote more available to the public. The Clallam County Board of Health voted Tuesday to ask area pharmacies to stock and dispense naloxone, a non-narcotic antidote to opiates that can be administered in the form of a nasal spray. "This is a legitimate prescription drug," said Dr. Tom Locke, public health officer for Clallam and Jefferson counties. "It's present on every emergency crash cart at every hospital and clinic," he added. "But this is a different idea. This is to trying to get it out in the public, just based on the chance that it might be used in a life-saving way." In a letter signed by Locke and health board Chairman John Beitzel, Clallam County pharmacies were asked if they would stock naloxone with nasal atomizers for patients with a prescription and whether they would consider dispensing the antidote under a standing order from the health officer. Only one pharmacy in Clallam County stocks naloxone now, Locke said. "We would like to begin providing prescriptions for naloxone inhalers to heroin users as soon as possible," the letter says. The Jefferson County Board of Health recently approved a similar letter, Locke said. Naloxone, also known by its brand name Narcan, is administered intravenously by emergency medical technicians and health care providers after an opiate user loses consciousness. "If you take a higher dose [of heroin] than your body's used to, you stop breathing, and you've got about four minutes for someone to do something about that," Locke told the Clallam County Board of Health. "But there is an antidote. 411 "The question is how to make this more available to those who might have the opportunity to save a life / with it." Naloxone has had a surge of national visibility since the heroin overdose death of actor Philip Seymour Hoffman in February, Locke said. Washington state has been ahead of the curve in the distribution of the antidote because of its high opiate-related death rate. • The state medical association and pharmacy boards have removed barriers to naloxone access, and the state Legislature has expanded good Samaritan laws to protect people who administer the antidote to intravenous drug users from legal liability. "Washington state has had one of the highest opiate-related mortality rates in the country," Locke said. "Several years ago, Clallam County had the very unwelcome distinction of having the highest rate in the state of Washington," Locke said. "Those numbers have actually been coming down over the last several years. They peaked in 2009, and they're dropping. "But the type of opiate misuse is changing in Clallam County." In 2009, the most common opiates being used on the North Olympic Peninsula were prescription methadone pills. The state has since cracked down on people filling multiple prescriptions, and heroin is "moving into the vacuum," Locke said. Based on survey data from a syringe exchange program run by Clallam County Health and Human Services, heroin and methamphetamine are now "running about 50-50," Locke said. "Heroin has some unique dangers," Locke added. • "With heroin, you never really know what the dose of the drug is that you're taking. You're procuring it from a completely illegal supply chain. At least with a prescription opiate, you generally know what the dose is that you're taking." Naloxone is routinely provided to heroin-addicted jail inmates upon their release. "We know that if you're a heroin addict and you're released from jail, you have a significant chance of overdosing in the next four weeks," Locke said. "People almost always go back to resume heroin use, and because their tolerance for heroin has gone down, you're at an increased risk for overdose once you resume it." Although some needle exchanges and most treatment centers discourage naloxone, the antidote has become "much less controversial in the last six months as there's a national push to make it available," Locke said. Seattle-area pharmacies are dispensing the antidote to people close to heroin addicts. "If you find someone who has lost consciousness from a heroin dose, they're no longer able to administer naloxone themselves," Locke said. "But if there's someone with them and the drug is available, it's simple to squirt it in the nose." 40 Reporter Rob 011ikainen can be reached at 360-452-2345, ext. 5072, or at rollikainen(a.peninsuladailynews.com. Girls' Night Out a success Port Townsend Leader, November 26th, 2014 The Port Townsend Main Street's 2014 Girls' Night Out event Thursday, Oct. 2, was a glitzy success. Forty participating businesses offered special events, in- store promotions and refreshments. Goodie bags and raffle tickets sales raised $6,160 to benefit Jefferson County Public Health Breast and Cervical Cancer Program and the Port Townsend Main Street Program, a nonprofit organization. Since its inception, Girls' Night Out has raised more than $29,900 to help local women in need receive cancer screenings through the Jefferson County Public Health Department. This event is sponsored by the Port Townsend Main Street Program, Jefferson Healthcare, Ozone Socks and participating businesses. Nearly all 500 goodie bags were sold by the evening of the event and more than 80 people attended the wrap up party at The Belmont. The event takes place each October during Breast Cancer Awareness Month and women are encouraged to get their cancer screenings. The winner of the "Gatsby Glitz" raffle valued at $580 was Carla Main of Port • Townsend and she purchased her winning ticket at The Clothes Horse. S Good Works: Staying healthy • Local options for low-cost medical care Port Townsend Leader, November 26, Medical care on a budget may not seem possible, but there are options here in Port Townsend and Jefferson County. Consider these sources: JC MASH Jefferson County Medical Advocacy and Services headquarters (JC MASH) has been providing medical attention to local folks for two decades. The 501(c)(3) nonprofit organization aims to help individuals get access to comprehensive care within the larger medical community by validating their medical needs and acting as their advocates. Paid staff includes a medical clinic manager and two state-licensed mental health counselors. Volunteers include two medical doctors, a youth mental health RN clinic manager, intake personnel and the JC MASH Board. The medical clinic is open 7-8:30 p.m. every Tuesday except national holidays at 1136 Water St., suite 109. Call the clinic at 385-4268. No one is turned away because of a lack of ability to pay. The Youth Mental Health clinic is open in the same location every Thursday, 4-7 p.m., except national holidays. As with the previous clinic, no one is turned away because of a lack of ability to pay. For more • information, call 379-2630. Another JC MASH medical clinic is open 5-6:30 p.m. Thursdays at Kively Center, 121 Oak Bay Road, Port Hadlock. Patients are seen on a first-come, first-served basis. Again, no one is turned away because of a lack of ability to pay. On the JC MASH board of directors are Karen Clemens, Steve Rafoth, Karen Ciccarone, Dan Youra, Kim Rotchford, Ken Brown and Amber Benner. HEALTH DEPT The Jefferson County Health Department's Take Charge Program offers free birth control and family planning services for women, men and teens. The program covers one annual exam for women and free birth control, including tubal ligation for women and vasectomy for men. The Take Charge clinic offers sliding-scale fees. Cash, medical coupons and insurance are accepted. It's open 9 a.m.-4 p.m. weekdays at 615 Sheridan St. (next to QFC in the Castle Hill Center). Call 385-9400 for an appointment. The health department offers the same services at the Quilcene Clinic, on Roger Street next to the South County Clinic. It's open 10 a.m.-2 p.m. Wednesdays. Call 765-3014 for an appointment. Jefferson County Public Health offers education and support for pregnant women and parenting families, childbirth education classes, newborn follow-up and home visitation, and a breastfeeding consultation. A support group for pregnant women and breastfeeding mothers is 11 a.m.-12:30 p.m. Wednesdays at the • Health Department, 615 Sheridan St. Nursing infants and children are welcome. For families whose food budget needs a boost, the Women, Infant, Children (WIC) program offers nutritious foods and information for eligible pregnant or breastfeeding women and kids under age 5. The PT WIC office is open 9 a.m.-4:30 p.m., Monday and Wednesday and 9 a.m.-noon on Tuesdays and Thursdays. In Chimacum, the clinic is open 9 a.m.-2 p.m. on the first and third Tuesday of each month; call 385-9432 for an appointment. The Quilcene walk-in clinic is 10 a.m.-2 p.m. Wednesdays. • The sexually transmitted disease clinic offers confidential diagnosis and treatment and a sliding fee scale. Call 385-9400 for an appointment. A syringe exchange program has anonymous and confidential walk-in services 1:30-2:30 p.m. Mondays and Wednesdays at 615 Sheridan St. Call 385-9400 to arrange for other times. Jefferson County Public Health also has a Foot Care program. For appointments in Port Townsend, call 385-9007; in the Tri-Area, call 732-4822; for homebound seniors, call 385-9400. HOSPITAL Jefferson Healthcare Hospital's walk-in clinic hours are 10 a.m.-7 p.m. daily, except major holidays. The walk-in clinic is located at 934 Sheridan St., corner with 10th street. Jefferson Healthcare's South County Clinic is open 8:30 a.m.-5:30 p.m. Monday-Thursday at 294843 Hwy. 101 in Quilcene. Call 765-3111 for an appointment. Jefferson Healthcare's Port Ludlow Clinic is open 9 a.m.-5 p.m. Monday-Friday at 9481 Oak Bay Road. Call 437-5067 for an appointment. SCHOOL CLINICS Port Townsend and Chimacum high schools each have a Health Center, offering comprehensive health • care to all students during the school year. Health care providers are available to help with illness and injury, immunizations, family or relationship issues, stress management, birth control, nutrition and sports physicals. In PT, call 379-4609; in Chimacum, call 732-4090, ext. 241, ext. 82206. • Take charge of your health to : plan for your `` pregnancies. Talk to a caring and confidential family planning professional . about the best method for you. k^: Available at little or no cost. We accept many insurance plans including: Apple Health•Sliding scale Same week appointments Choose from many methods including long-acting contraceptives:IUD&implants. (360) 385-9400 615 Sheridan•Port Townsend • • (1/32-6V// PT meth lab complaint rejected By Allison Arthur, Port Townsend Leader, November 26, 2014 A former Port Townsend resident who rented a 31st Street house in 2011 - and then concluded he had become sick because the place was infused with chemicals from earlier methamphetamine manufacturing - has encountered a setback in his effort for relief. That former renter, Barry Ellis, at first sought help from the Jefferson County Board of Health, which has the power to publicly post a hazard warning on property proven to have had meth activity, and to require landlords to do a thorough cleanup. The County Board of Health turned him down, citing a lack of clear evidence. He then appealed that decision to the Washington State Board of Health. That board, on Nov. 12, denied his appeal, endorsing the earlier decision of the county board to place no restrictions on the property. Coincidentally (or not, according to Ellis), Jefferson County Commissioner John Austin is both a member of the County Board of Health and the chair of the Washington State Board of Health, to which the appeal was made. Austin, however, recused himself from voting on the matter as a state board member. In addition, Dr. Tom Locke, public health officer for Jefferson and Clallam counties, has been a state leader in drafting a law related to drug-infused housing, and argues that standards are too strict and should be reduced. • "I was expecting this," said Ellis of the state board's rejection of his appeal. Ellis says he is likely to appeal to a higher power, federal court. He's not giving up, he said, because he thinks that the health of unsuspecting renters like himself is on the line. "They can't admit liability. I'm already talking with attorneys. You never win against the state in the state court. I have a three-year clock," noting a three-year statute of limitations to sue the state Board of Health. Ellis said he could draw a lesson from the state board's ruling. "I think that what happened is this is a good of boy network, and I think they covered their ass with Locke," he said. STARTED WITH 2011 RENTAL The case is based on Ellis' complaint about a house at 1507 31st St. in Port Townsend. In his written complaint to the Jefferson County Board of Health, Ellis stated that he and his girlfriend rented that house in April 2011 .. During the 14 months he was there, "I experienced internal bleeding, two emergency surgeries, numerous medical procedures." He said his former girlfriend had tried to commit suicide and required medical attention right after moving in. In his formal complaint to the county, Ellis wrote that a neighbor told Ellis that the house had been used to "cook" methamphetamine. In April 2012, Ellis went to Marjorie Boyd of Jefferson County Public Health to inquire about possible drug use or chemical infusion at the house. He also started submitting open public records requests to the Port Townsend Police Department (PTPD) to find out if there were any incidents at the house investigated by police. In his testimony before the county health board in March of this year, Ellis said he had contacted the owner of the house, Bent Meyer. Meyer "refused to address the situation, but did tell me to move out immediately," Ellis said. When Ellis responded that he wanted permission to have the property tested for meth, "I was locked out of the residence without a court order," he said, so that he could not have the residence tested. Before being locked out, Ellis said, he removed some items and later had those tested for meth residue. He forwarded the results to Boyd of the county health department. Ellis said the test results showed chemical levels "between two and 26 times the legal limit." Boyd told him there was nothing she could do to help him, according to Ellis, a conclusion repeated by other county health department staff. Ellis said he took the matter to the PTPD, where Sgt. Joe Kaare created a case file. However, the PTPD apparently could not confirm prior drug activity at the house. Without that finding, the county health department again declined to take action. Ellis did not let it drop. Instead, he said, he pursued the matter by contacting local police, the state Department of Ecology and the Jefferson County Prosecutor's Office. Ellis' history shows he is persistent. He said he has been involved in more than 30 lawsuits involving the Kitsap County Sheriffs Office, and added that he's won a number of those. STATE INVESTIGATION Ellis appealed to the state Board of Health, calling on that panel to overturn Jefferson County Public Health's decision against taking action on the house. In a Nov. 12, 2014 memo on the case prepared by state board vice chair Keith Grellner, Grellner said that Ellis' complaint was reviewed and that three of the four witnesses Ellis cited in his written complaint were interviewed. Neither the state board investigator nor the Leader was able to get landlord Bent Meyer to return calls. "There was no evidence found or presented that proves that hazardous chemicals were used to manufacture illegal drugs at 1507 31st St., Port Townsend, Wa.," Grellner wrote in a conclusion. "There was no evidence found or presented that a law enforcement agency or property owner notified Jefferson County Public Health" that the property was contaminated, he continued. "The sample results submitted by Mr. Ellis did not provide grounds for Jefferson County Public Health to post the property or conduct further inspections under RCW 64.44 and WAC 246.205," he added. And finally, he said that public records requests resulted in no findings or documentation that there was ever a meth lab on the property. 4111 LOCKE: LAWS TOO STRICT • Locke said he is pushing to relax state cleanup laws related to buildings used as drug labs, laws that he helped to write. Locke said the cleanup threshold is so low today that it impacts the supply of public housing. When traces of meth are found in housing projects, Locke said, cleanup crews are "charging tens of thousands of dollars" to do "very destructive cleanups" of homes "when there is no evidence that the amount of meth detected is dangerous." It is not a new subject for Locke. "I felt especially strong about this code because I helped write it," Locke said last week. In the late 1990s, Locke said, clandestine drug labs were a real problem. "We had several in Jefferson County and hundreds around the state," he said. But today, Locke said, meth labs are a much smaller problem, because the market is flooded with cheap meth made in Mexican superlabs. "There's a very small amount of shake-and-bake," he said of meth that is made in 2-liter soda bottles. "Meth labs have virtually disappeared, and those that do exist, exist on a very small scale." But those strict cleanup laws from a decade ago are still on the books, he said. What is happening now is that any tiny amount of meth - even from smoking it - can trigger a massive cleanup that involves practically tearing the house apart. "The point is, the cleanup standard is so low, we've been urging the state to raise the • cleanup standard," he said. Locke is proposing the state raise its cleanup standards from 0.1 micrograms to 1 .5 micrograms per 100 square centimeters, which is the level the state of California recommends based on a 2007 study, according to public health department minutes from April 17, 2014. "Current cleanup protocols call for all drywall, carpeting, appliances and personal possessions to be removed," state the minutes. "This is expensive and has limited the availability of public housing because units are closed and/or demolished rather than cleaned." "The law was not written to compel cleanup of residences where the only thing that has happened is the smoking of meth," Locke said. He said tiny amounts of meth on surfaces of things, such as floors, aren't dangerous unless you do something like prepare food on them. Locke said that at a recent state hearing, even the Peninsula Housing Authority testified that the law, as written, is having an impact on public housing because of the high cost of cleanup. He noted that public housing is already in short supply. • PROTECTING RENTERS Again, Ellis isn't buying it. • "By asking to relax these standards, it sets up landlords to be able to move people into contaminated houses without legal recourse," Ellis said in August. "It sets up renters as second-class citizens." "I'm going to sue them over what they have done. It's discrimination," he said. Ellis said he still suffers from his days in that Port Townsend rental home, but he's moved out to the country and is starting to feel better. He asserts that Locke and county officials are trying to protect their tax base. "Anyone who owns property here, they give protection to. But some child goes and gets in that house and gets sick, there's no protection," Ellis said. "There was no evidence found or presented that proves that hazardous chemicals were used to manufacture illegal drugs at 1507 31st St., Port Townsend, Wa." Keith Grellner vice chair, Washington State Board of Health "I was expecting this. They can't admit liability. I'm already talking with attorneys." Barry Ellis complainant, former renter Jefferson County "The point is, the cleanup standard is so low, we've been urging the state to raise the cleanup standard." Dr. Tom Locke public health officer, Jefferson and Clallam counties • • Health advisory issued after sewage spills in stream flowing into Port Ludlow Bay Peninsula Daily News, November 26th,2014 • PORT LUDLOW—The Jefferson County Health Department is warning people to stay out of Port Ludlow Bay and a stream that flows through the Port Ludlow golf course after a sewage spill several days ago. The department announced a "no contact" health advisory Wednesday after finding high levels of Escherichia coli, known as E. coli, in the unnamed stream flowing through the golf course into Port Ludlow Bay. Warning signs have been posted near the stream. The idea is to warn people to stay out of the water, said Michael Dawson, water quality lead for the environmental health division. "Keep children and dogs out of the stream if you are walking in the area," he said. The public also is advised to avoid contact with the water in Port Ludlow Bay. Shellfish harvesting is always closed at Port Ludlow because of the proximity of the sewage treatment plant outfall and marina, he added. 1,000 gallons About 1,000 gallons of sewage spilled Sunday from a manhole at the intersection of Muir Court and • Highlands Drive in Port Ludlow because of a blockage in the pipe, Dawson said. Olympic Water and Sewer immediately fixed the pipe and stopped the spill, he added. "As soon as they cleared the blockage" Sunday afternoon, "they corrected the problem," Dawson said. Sewage flowed down the road, into a roadside ditch and into the small unnamed stream. The health department found between 400 and 500 colonies of E. coli per 100 milliliters in samples taken this week from the ditch and the stream, Dawson said. Guidelines specify that colonies should be below 100 colonies per 100 milliliters. Testing will be done next week, with results announced by the end of the week, Dawson said. "We expect this to go down," he added. If so, the advisory will be lifted. For more information, phone Jefferson County Public Health's water quality program at 360-385-9444 or visit www.jeffersoncountypublichealth.org. Last modified: November 26.2014 8:57PM • SmileMobile to arrive in Chimacum in December . . . and other items • Peninsula Daily News, November 30th,2014 CHIMACUM —The Washington Dental Service Foundation SmileMobile is coming to the Tri- Area Community Center, 10 West Valley Road, to care for children with dental needs. The SmileMobile will provide examinations from 9 a.m. to 4 p.m. Monday, Dec. 8, and from 9 a.m. to noon Tuesday, Dec. 9. Follow-up treatments are through Friday, Dec. 12. The SmileMobile travels the state to offer dental services to children who might not otherwise have access to dental care. Children birth through high school with limited access to dental care can be scheduled by calling the Washington Dental Service Foundation at 888-286-9105. The SmileMobile is staffed by a clinic manager, dentist and dental assistant, and local volunteer dental professionals in each community it visits. Medicaid (Apple Health) and a sliding-scale fee are accepted as reimbursement for services. • • Dabob Bay beaches reopen for partial shellfish harvest Port Townsend Leader, December 2, 2014 Declining biotoxin levels in mussels, oysters and Manila clams have allowed a partial reopening for recreational shellfishing in Dabob Bay, according to a press release from Jefferson County Public Health. The harvest of Butter and Varnish clams remains closed due to biotoxins that cause Paralytic Shellfish Poisoning (PSP). The Dabob Bay zone includes the following areas: Tarboo Bay, the western shore of the Toandos Peninsula south to Zelatched Point, the eastern shore of the Bolton Peninsula to its southern tip near Red Bluff and the shoreline from just south of Point Whitney to Seal Rock. Signs have been posted to reflect these changes. Quilcene Bay, including Point Whitney, remains closed for all species. Dabob Bay closed on Sept. 11 when shellfish testing by Washington State Department of Health revealed high levels of PSP toxins caused by a bloom of marine algae. Toxin levels in oysters from nearby Quilcene Bay were the highest • in Washington State history. Toxins in Dabob Bay mussels, oysters and clams also reached lethal levels and toxins spread south to Hood Canal. The bloom has persisted, but levels have declined enough in Hood Canal and Dabob Bay to allow limited reopenings. Testing continues weekly and updates will be posted. People can become ill from eating shellfish contaminated with marine biotoxins, which are not destroyed by cooking or freezing. In most cases the algae that contain the toxins cannot be seen and must be detected using laboratory testing. Therefore, recreational shellfish harvesters should check the DOH Shellfish Safety map at doh.wa.gov/ShellfishSafety. htm or call the Biotoxin Hotline at 800- 562-5632 before harvesting shellfish anywhere in Washington State. Recreational harvesters should also check Fish and Wildlife regulations and seasons at wdfw.wa.gov/fishing/shell-fish/or the Shellfish Rule Change Hotline 866-880-5431 . Dabob Bay beaches reopen for partial shellfish harvest • Port Townsend Leader, December 3, 2014 3:00 am Declining biotoxin levels in mussels, oysters and Manila clams have allowed a partial reopening for recreational shellfishing in Dabob Bay, according to a press release from Jefferson County Public Health. The harvest of Butter and Varnish clams remains closed due to biotoxins that cause Paralytic Shellfish Poisoning (PSP). The Dabob Bay zone includes the following areas: Tarboo Bay, the western shore of the Toandos Peninsula south to Zelatched Point, the eastern shore of the Bolton Peninsula to its southern tip near Red Bluff and the shoreline from just south of Point Whitney to Seal Rock. . Jefferson's Dabob Bay opens for harvesting of some shellfish species Peninsula Daily News, December 3rd, 2014 • PORT TOWNSEND — Dabob Bay has partially reopened to recreational shellfishing, although butter and varnish clamming remains closed because of the danger of potentially deadly paralytic shellfish poisoning (PSP), Jefferson County Public Health said Tuesday. The closure zone includes Tarboo Bay, the western shore of the Toandos Peninsula south to Zelatched Point and the eastern shore of the Bolton Peninsula to its southern tip near Red Bluff. Quilcene Bay, including Point Whitney, remains closed for all species. The county health department closed Dabob Bay on Sept. 11 when shellfish testing revealed high levels of PSP toxins from a bloom of marine algae. Lethal levels in Dabob Bay mussels, oysters and clams spread south to Hood Canal. In both Jefferson and Clallam counties, Pacific Ocean beaches remain closed to all species, including clams, geoduck, scallops, mussels, oysters, snails and other invertebrates. In Clallam County, public beaches on the Strait of Juan de Fuca remain closed for varnish clams east of Cline Spit. Sequim Bay is closed to all species. West of Cline Spit, the Strait is closed for both butter and varnish clams. Possibly fatal PSP can sicken and possibly kill people with marine toxins that are not destroyed by cooking or freezing. In most cases, the algae that contains the poisons cannot be seen and must be detected by laboratory testing. Symptoms of PSP can appear within minutes or hours and usually begin with tingling lips and tongue, moving to the hands and feet, followed by difficulty breathing and possible death. Anyone experiencing such symptoms should contact a health care provider immediately and call 9-1-1 in extreme cases. Recreational closures do not apply to shrimp. Crabmeat is safe, but crab innards, also known as butter, may contain harmful levels of toxins. Clean crabmeat thoroughly and discard the guts. Commercially harvested shellfish are tested before sale for safety. Recreational shellfishers should check the state Department of Health shellfish safety map at www.doh.wa.gov/ShellfishSafety.htm or call the Biotoxin Hotline at 800-562-5632 before harvesting shellfish anywhere in Washington. Recreational shellfishers also should check the state Fish and Wildlife regulations at http://wdfw.wa.gov/fishing/shellfish. Healthy Children, a ' Ihrivin Families ; g Pregnant? Have kids under rn� 5 years old? Jefferson County Public Health is partnering with you to meet the challenges of parenting young families. tip;41 ; Health and safety,breastfeeding,nutrition and food budget boost, sleep issues,health goals,and more. Collaborative office or home visits. WIC:Maternity Support Service:Nurse Family Partnership: Breastfeeding Tea The kind of support that you are looking fir. •t6j` {,.t (360) 385-9400 Public Health 615 Sheridan•Port Townsend • • //' e2'. - /'2/2//Y I - - Brinnon open house sees debate on benefits, impacts of proposed Pleasant Harbor Resort By Charlie Bermant, Peninsula Daily News, December 4th, 2014 X a a , aux I r it 1 MI a4 mss,PR ',. " P� -2:4.':- 1. -..., -t ''',„. 'AI....:'tss-P C.:;:,M .,1,-.::::-.,,t1' -4 - 4144 i. $ $' x sg a Consultant Craig Peck answers questions from Dan Herrin, right, about the Pleasant Harbor Resort project at an open house Wednesday afternoon at the Brinnon Community Center. —Charlie Bermant/Peninsula Daily News BRINNON —The proposed Pleasant Harbor Resort would provide an economic boost to this small town Ali in southern Jefferson County, according to several people who attended an open house Wednesday. Others brought up questions about the environmental impact of the 252-acre resort proposed in 2006 for Black Point, about 2 miles south of Brinnon, while still others said they had misgivings but did not want to speak about them in detail. "This community doesn't have any industry leftexcept for tourism and shellfish. Forestry is gone," said Joy Baisch, a Brinnon small-business owner who favors the project. "What troubles me is that it has taken so long. We don't have any family-wage jobs, our school enrollment is down and our food bank use is up. "We have become a destitute community." Said Christy Vliet of Brinnon: "It's a beautiful project. I know it will change things here." She added it could drive some people away. "My mother-in-law has lived here for years and said as soon as she can smell french fries, she's moving out," Vliet said. Don Herrin, who manages the water system for the nearby Pleasant Tides area, said he has concerns about the resort's impact on his wells but trusts that the county Department of Health and the state Department of Ecology would not allow the project to proceed if it does not meet safe ecological 0 standards. The open house, which drew about 40 people over a 2'/-hour period, focused on a draft supplemental environmental impact statement that Jefferson County released Nov. 19 on the proposed development by Statesman Corp. of Calgary, Alberta, which is seeking a county permit for the resort. • David Wayne Johnson, DCD associate planner, who is managing the project, has said "ways to have a less significant environmental impact" have been developed during the extended approval process. The proposal had sparked controversy over the years, especially from The Brinnon Group, which said the development was too large for the area. The draft supplemental environmental impact statement was slated for discussion at a Jefferson County Planning Commission meeting Wednesday night. Nicole Black, a Brinnon Parks and Recreation commissioner, questioned the timing of the open house since many summer residents could not attend. "A lot of our property owners are snowbirds and aren't here in the winter," Black said. "It would be nice to hear from them about this issue and give them a chance to ask questions." Public comment will be taken on the draft document until 4:30 p.m. Jan. 5. A final supplemental environmental impact statement is expected to be released by the end of March, with a public hearing set in April or May. Statesman was represented at the open house by employee Diane Coleman and consultant Craig Peck. Peck, who has worked with the project for six years, said he expects it to move at a rapid pace now. . "We've had some major challenges when the county proposed a larger setback at the shoreline, as the original development had more development at the marina," Peck said. "The original proposal called for 2 million cubic yards of dirt being moved. We are now down to 1 million." Peck said his mission is to make the project more environmentally friendly by making use of the natural topography and maximizing the use of impervious surfaces. While the facility would be gated, several areas would be publicly accessible, such as retail space along U.S. Highway 101 and an 1,100-foot zipline. The resort would not be visible from the highway. The long-standing cost projection for the complete project of$300 million will be modified, according to Statesman CEO Garth Mann in an email sent last week. He did not say how it would be modified. Phase one of the resort would include a "maritime village" located adjacent to U.S. Highway 101, Mann said, with three phases, each with a 30-month duration, to follow. Mann said the resort complex would eventually create more than 300 new permanent jobs. Peck said many of these jobs would be seasonal and the resort would fill them locally if possible. He said the resort will not compete with existing businesses. i "We aren't building a gas station, so it will bring people to Brinnon who will buy gas," he said. The two-part report, 269 pages of narrative plus 992 pages of appendices, is available along with other project information at http://tinyurl.com/PDN-Pleasant-Harbor. • Hard copies can be viewed at the county office; the Jefferson County Library at 620 Cedar Ave., Port Hadlock; and the Brinnon Fire Department at 272 Schoolhouse Road. Comments can be emailed to dwjohnsonco.jefferson.wa.us or mailed to Pleasant Harbor DSEIS c/o Jefferson County DCD, 621 Sheridan St., Port Townsend, WA 98368. Jefferson County Editor Charlie Bermant can be reached at 360-385-2335 or cbermant@peninsuladailynews.com. S S �asENfl k, Ad ID: 135601 %, Pre-Bill (,The+Cett&r) 026 Adams Street • Port Townsend, WA 98368 • 360-385-2900 • Bill to: Sold to: Account ID: 15829 Jefferson County Board of Commissioners Denise Banker BOCC/Non-Departmental Jefferson County Board of Commissioners PO Box 1220 BOCC/Non-Departmental Port Townsend, WA 98368 PO Box 1220 Port Townsend, WA 98368 Please pay from this Pre-Bill. Return stub with payment Rep ID: DR Terms: Net 30 Description Classification of Ad: 460—County Notices Zone: A PO: Public Hearing Clean Water District Fee Text: JEFFERSON COUNTY BOARD OF COMMISSIONERS NOTICE OF PUBLI... Charges from 11/12/2014 to 11/12/2014 Date Pub Type Description Price Discount Applied Due 11/12/14 PTL ad LEGALS: JEFFERSON COUNTY- $46.00 $46.00 w • $46.00 $46.00 Please return this portion with your payment. Pre—Bill Remit Payment to: Port Townsend Leader Amount Due $46.00 226 Adams Street Port Townsend,WA 98368 Phone: 360-385-2900 Fax: 360-385-3422 Amount Enclosed Issue Date: 11/12/2014 Jefferson County Board of Commissioners Prebill Date: 11/12/2014 BOCC/Non-Departmental • PO Box 1220 Ad # 1356011111 Port Townsend, WA 98368 Account# 15829