Loading...
HomeMy WebLinkAboutM101608JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, October 16, 2008 2:30 PM — 4:30 PM Pope Marine Building, Port Townsend Board Members Staff Members Phil Johnson, County Commissioner District #1 Thomas Locke, MD, Health Officer David Sullivan, County Commissioner, District #2 Jean Baldwin, Public Health Services Director John Austin, Chair, County Commissioner, District #3 Andrew Shogren, Environmental Health Director Chuck Russell, Hospital Commissioner, District #2 Julia Danskin, Nursing Services Director Michelle Sandoval, Port Townsend City Council Sheila Westerman, Vice Chair, Citizen at large (City) Roberta Frissell, Citizen at large (County) Chair John Austin called the meeting of the Jefferson County Board of Health to order at 2:35 PM in the Pope Marine Building, Port Townsend, WA. Members Present: John Austin, Roberta Frissell, Chuck Russell, Michelle Sandoval, David Sullivan, Sheila Westerman Members Excused: Phil Johnson Ad Hoc Member Present: Frances Joswick, Substance Abuse Advisory Board Staff Present: Jean Baldwin, Dr. Thomas Locke, Andrew Shogren, Julia Danskin A quorum was present. APPROVAL OF AGENDA Chair Austin stated that there had been a request from the public to move Public Comment to the end of the meeting. Member Sheila Westerman made a motion to that effect, which was seconded by Member Russell and approved unanimously. A typographical error was noted on page 3: 207 changed to 2007. A motion was made to approve the September 18, 2008 minutes, as amended. The motion was seconded and approved unanimously. Page 1 of 9 October 16, 2008 OLD BUSINESS Public Health Funding News Dr. Locke stated that there is an estimated $30 million shortfall in local health department budgets across the State and is concentrated in some of the largest counties. This reflects reductions in federal, state, and local funding and will impact core programs such as communicable disease control and maternal child health. The Washington Association of Counties (WSAC) and the Washington Association of Local Health Officials (WSALPHO) has asked the Legislature to revisit the issue of local public health funding. Dr. Locke referred to the WSAC/WSALPHO letter in the Board packet. He said that although the $100 million request may not be realistic in the face of an anticipated $3.2 billion state budget gap, the hope is to keep some of the critical programs pending continuing attempts to find a stable public health funding source. Jean Baldwin pointed out that larger health departments are subject to greater volatility than smaller ones, which have more diversified funding sources for services such as Family Planning. The larger counties have been urging legislative action that would allow them to become junior taxing districts. She said that even if that happens, it can not help them right now. Both Snohomish County and King County were directed to spend down their reserves in anticipation of increased state funding; now both are in serious financial difficulty. Dr. Locke discussed another development related to finding the right source of funding. He said that at the recent annual meeting of the Washington State Medical Association (WSMA), a resolution was introduced to reaffirm WSMA's longstanding support for increased public health funding. Amendments were offered from the floor to link the public health funding to the overall health system budget. This is a significant step in the direction of viewing public health as an essential part of the overall health care system. Dr. Locke said that many public health officials support this idea. Having only 1% of the state health care budget would be a major step forward. He said that most developed countries allocate 3 to 6 % of their health care budget to public health services. Member Westerman asked about current levels of health care funding in Washington State. Dr. Locke said that nationally, I% of health care funding is spent on public health and prevention. 96% is spent on personal medical care services and 3% is spent on research and training. In Washington State the proportions seem to be similar. He said that many public health proponents believe that public health is the key to cost containment and achievement of universal access to health care services. There must be a conscious plan for reducing demand for expensive services by effective illness and injury prevention programs. There is concern by some that funding public health as part of the larger health care system will created conflict with health care provides such as hospitals. Dr. Locke said that many believe that, at $2.2 trillion annually, there is sufficient existing funding to provide health care for everyone in the US and fund a world class public health system. Reprioritization and reallocation will be necessary and extremely difficult. Member Russell added that the system has been broken for many, many years. Member Austin asked if other programs such as Nurse Family Partnerships also have a wide variety of funding sources. Jean Baldwin said that that program is limited to first time mothers with low income. She said that DSHS and Maternal -Child Health allocations are first exhausted and then some funds come from General Fund or Child Protective Services contracts. The County General Fund is sprinkled throughout most of Maternal -Child Health and family support Page 2 of 9 October 16, 2008 programs/services. In response to a question about the overall General Fund contribution, she indicated that to be about $900,000, which includes Environmental Health. Letter re: Mental Health and Substance Abuse Treatment Funding Jean Baldwin noted that the text of the letter to Lynn Kessler was included in the packet. Members made two corrections to the letter and Jean Baldwin suggested that the Chair sign on behalf of the BOH. David Sullivan moved for approval of the letter, which was seconded by Roberta Frissell. Sheila Westerman proposed a friendly amendment that the letter be signed by all members, which was accepted by Mr. Sullivan. The motion, with amendment, was approved unanimously. Public Health's "Ah -Ha" Moment Jean Baldwin called attention to an excerpt from a 1910 PT Leader article in the packet, and the persistence of certain fundamental issues facing the Health Department. Dr. Locke discussed the article "Public Health's A -ha! Moment and What it Means for the American People" by Dr. Risa Livizzo-Mourey. He called attention to the paradox: This is a moment of crisis, under -funding and potential collapse for public health just at the moment in history when increased investment in public health is being seen as a key strategy in resolving the broader health care access crisis. He noted that the methods and information technology used by public health are not applied as widely to our national health goals as they could and should be. John Austin cited an example involving a State Board of Health recommendation to the Legislature for school health and safety measures; he noted the challenge to provide funding and the repercussions when needs, regulations and funding are not in alignment. NEW BUSINESS 2008 Standards for Public Health Practice: Jefferson County Public Health Site Report Jean Baldwin acknowledged the challenge of explaining the Standards, which are performance management indicators for the Public Health system, both state and local. There are 12 standards and a variety of measures for each one. Every local health department or district is visited every three years to evaluate their performance with respect to the Standards. She said that Jefferson County Public Health documents much of its standards performance on its web site and in paper archives. Ms. Baldwin said that the standards have changed significantly since the last review in 2005 with the addition of 7 new categories for evaluation. She referred to "Standards for Public Health in Washington" slides, which list the 12 standards and summarizes the purpose, scope and process. The goal is for Public Health infrastructure to be consistent in all counties throughout the State, although the funding is very different across the state. The Standards review process evaluates progress towards this goal and allows comparison within peer groups of local health jurisdictions. Strengths and areas in need of improvement are indicated by the reviewers. Ms. Baldwin briefly reviewed key elements of the Fact Sheet and the Questions and Answers provided in the packet. Standards were developed to provide consistent health and safety standards across the State. For example, restaurant patrons are assured of proper food handling and preparation wherever they travel in Washington State. She explained that the survey is done by an independent firm, MCPP Healthcare Consulting, Inc., along with state and local reviewers; Page 3 of 9 October 16, 2008 the resulting report has been used by JLARC (Joint Legislative Audit and Review Committee) as a basis for evaluating the public health system. Each county receives its own scores and the overall State scores. She reviewed the list of 12 standards and a sampling of the measurements. With regard to "Address gaps in critical health services", she noted that Dr. Locke works with Jefferson Healthcare and several state and regional health access partnerships and the Health Department has stepped in to provide services as needed. She reminded that evaluators base their review on activities that have been documented. Jefferson County did very well in comparison to both its peer group (Small Town/Rural) and the combined LHJs (Local Health Jurisdictions) across the State. Ms. Baldwin said that one of the key strengths cited was the involvement of the BOH in health department activities and decisions, including the review of community health data. Jean reviewed the areas for improvement and discussed the next steps development of work plans. This particular audit looked at the Food program, the Maternal/Child Health program and the Communicable Disease program; Ms. Baldwin commended those teams for their achievements. She also noted that a large number of forms and policies/procedures will be listed as Exemplary Practices on the State DOH website. Member Westerman asked about the rationale for not sharing or publishing all county scores. She said this information would be of interest to businesses or individuals who are considering locating in a particular area and could be helpful if used in a collaborative spirit statewide. Staff noted that informal collaboration among jurisdictions does occur at the operational level. Dr. Locke said all of this information is publicly available and could be compiled and published in the media, if so desired. The argument for a less than totally open approach rests on the fact that these are "stretch standards", or optimal practices, not minimum standards that should be met. No county would wish to see itself at the bottom of a ranked list. Dr. Locke added that the more detailed report was in excess of 60 pages long; copies can be provided for those who would like to read the full report. Chair Austin suggested that a press release could be developed to share this positive news. Member Westerman agreed, noting the need to make it easily understood. Staff agreed to draft such a press release. Immunization Program Update: Immunization Program Review, 5930 Funding Activities, and Adult Vaccination Program Immunization Program Review — Jean Baldwin referred to the Site Visit Summary Report for the Immunization Program and CHILD profile. She noted the excellent results of this State review: The Jefferson County Health District Immunization Program is in full compliance, and no further follow up is required in 2008. According to the report, "This program has the highest standards of practice for immunization service delivery and program administration." Lisa McKenzie provided additional information on the program and the annual review, noting the limited State funding of $11,000/year for the program. She credited Jane Kurata for her huge contribution in ensuring the quality and effectiveness of this program. Page 4 of 9 October 16, 2008 Hepatitis Vaccines — Ms. McKenzie gave an overview of new hepatitis -related services. She said that in the past there have always been state subsidized vaccine programs for children, 18 and under, but there has been no subsidized vaccine or testing for adults. There are two new programs for high risk adults age 19 and over available. Free adult Hepatitis A & B combination vaccine (Twinrix) and free adult Hepatitis C testing are available. Outreach is being done to health care providers to encourage referral for these services. Member Austin asked if working in areas following floods and hurricanes is considered a risk factor for hepatitis. Ms. McKenzie said that medical workers should be vaccinated for Hepatitis B. Some public health experts recommended Hepatitis A vaccination for Hurricane Katrina responders although no outbreaks of Hepatitis A were documented. Dr. Locke noted that exposure to fecal material after a flood is a potential risk factor but Hepatitis A is quite rare in the US. It has been shown that sewage workers, who are routinely exposed to sewage, do not have increased risk of contracting Hepatitis A. However, there is a strong recommendation for vaccination when traveling in other parts of the world where Hepatitis A is more common. A third program is expected to provide free HPV vaccine (Gardasil) for low income, uninsured women age 19 — 26, and will be available later in the year through the State DOH and Merck Pharmaceuticals. The vaccine is expensive, $130 per dose, and three doses are required. Since this is a six month pilot program, extensive outreach efforts will be necessary. The Health Department has been collecting names of interested patients and providers who will be contacted when the program gets underway. Gardasil is effective against two cancer causing strains and two venereal warts strains of HPV. Dr. Locke said that another less expensive vaccine designed to be effective only against the two cancer causing strains of HPV will soon be marketed. 5930 Funding Activities — Ms. McKenzie called attention to the three Immunization Program BOH Updates. The first is about the HPV Vaccine program which started in May 2007. The Health Department administered the vaccine to girls of ages 11- 18 at a rate of about 5 to 13 doses per month. In March 2008, JCPH Family Planning Nurse Practitioners began administering the vaccines in Family Planning Clinics. The rate now is between 23and 30 doses per month. In response to a question about State Funding, Jean Baldwin said the 5930 money ($103,000) was appropriated by the Legislature in lieu of more comprehensive public health system funding and is being used statewide to improve immunizations and communicable disease control. If statewide progress is achieved, additional funds may follow. There are various sources for vaccine funding, including Vaccines for Children, a federal program for those meeting low income criteria. The State money comes from the State General Fund and is applicable for all children. Dr. Locke said that Washington is one of a dwindling number of states with what is known as "universal distribution" system for childhood immunizations — all childhood vaccines are paid for by either federal or state funding. Julia Danskin pointed out that Jefferson County has melded Family Planning with Communicable Disease and Immunization in a unique way allowing more effective use of resources. Lisa McKenzie briefly described how the department has also increased the use of Rotavirus vaccine since it became available from the State. The new South County Immunization Clinic was initiated and organized by Jane Kurata and local nurse Dyan Arnesen in response to the low immunization rates of children in the area. This Clinic is operating collaboratively with the Brinnon and Quilcene schools, as well as the JCPH Page 5 of 9 October 16, 2008 WIC and Family Planning clinic in Quilcene, who provide referrals for the State supplied vaccine program. Ms. McKenzie also discussed additional training to help school secretaries and others support the program by following up with parents and guardians. She also mentioned the efforts to reduce the number of immunization exemptions in the population. The school exemption rates for all schools, (not including home schools), is about 11-12%. The immunization rates for two-year olds, County -wide, is among the worst in the State. Jean Baldwin said that the department is moving more services to school age children, since parents are more open to immunization at this stage. There was further discussion about conflicting philosophical positions that can be taken by parents with regard to certain immunizations. Michelle Sandoval suggested that sensitivity to parents' fears and concerns would be advisable; she suggested that philosophical choices should not be labeled as problems or non-compliance. Dr. Locke said that, based on new state data, the vaccination exemption trend in Jefferson County is going in the wrong direction. The exemption rates are climbing state-wide. As greater percentages of the population become susceptible to vaccine -preventable diseases, the risk of disease outbreaks like mumps and measles increases. He said there is a new initiative by the American Academy of Pediatrics and Academy of Family Practitioners to address this at a one- on-one encounter level. For those who have philosophical objections, it is important for health care providers to listen to these concerns and address them directly. Ultimately, parents are urged to base their decisions on the best available information regarding the benefits and risks of vaccines. He said the link between autism and the vaccine preservative has been conclusively disproven. With regard to exemptions, there are three categories allowed by state statute: medical (i.e. patient is allergic to the vaccine), religious, which are rare; and philosophical or personal, the most common type of exemptions. The third update concerns the state-wide web -based CHILD (Children's Health Immunizations Linkages and Development) Profile Immunization Registry. Ms. McKenzie said that this database has been in use in Jefferson County since 1991. Recently, there has been intensified training and follow up to ensure that all Jefferson Healthcare Clinics and the South County Clinic, in addition to the Health Department, use this system. The great advantage of this registry is that immunization records are available for children wherever they move within the State. Substance Abuse Advisory Board Presentation Frances Joswick, Chair of the Substance Abuse Advisory Board (SAAB), reported on the new relapse prevention program at the County Jail. She said the program design and implementation had been approved by the SAAB and had begun three weeks ago. A group of women meet with their Safe Harbor counselor weekly, and a separate group of men meet also weekly with their counselor. There is also a mid -week AA group for men with intentions to form a women's AA group as well. She said this program was requested by the jail inmates. Nurse Pat Wiggins assesses each new inmate for substance abuse and mental health issues, so is able to provide current and relevant data. According to Steve Richards, Supervisor at the jail, there are indications that the recidivism rate is 70%. He is currently verifying that the recidivism rate includes only those admissions that relate to drug and alcohol abuse, not assaults or other types of crimes. Housing following discharge has been a challenge. It is expected that the first "sober house" will be available in Quilcene within the next several months, to be provided by a nurse who is herself Page 6 of 9 October 16, 2008 in recovery. There will be accommodations for up to four women; establishment of a weekly 12 - step AA meeting is also planned. Ms. Joswick said that the SAAB is excited about being able to take tangible steps toward reducing the recidivism rate, and to increase outreach and education within the community about these issues. Jean Baldwin commented that there is a Board that oversees the administration of the one tenth of one percent tax authorized by the BOCC. The composition includes two people each from the SAAB (Ann Winegar and Catharine Robinson) and the BOH (Sheila Westerman and John Austin), two people from the law and justice community (Barbara Carr and Conner Daly) and one person from the City (Catharine Robinson). The jail nurse, Pat Wiggins, is paid through a portion of this funding. Member Westerman said she believes that this has been a very good use of the funds to focus on prevention, and agrees that Ms. Wiggins is absolutely perfect for this position. Ms. Joswick pointed out that although Ms. Wiggins is only paid for 20 hours per week, she is always available for day time meetings/hours and works many additional hours. Public Health Fees Discussion Jean Baldwin said that every two years, fees are updated based on review of actual costs. This was not done last year, as scheduled, for Environmental Health. Also, the State DOH required a cost analysis for Community Health Family Planning program using a specific proscribed method; a very in-depth analysis was done for Family Planning. When complete, the same process will be followed for Environmental Health. This consists of a comparison with other counties' current charges; a differential based on the cost of living index; and actual costs. She noted that the fees may not actually match the actual cost in today's market. Julia Danskin explained that in Community Health nursing, typically and historically, fees were based on what was reimbursable by Medical Assistance. Sixty percent of clients qualified for Medical Assistance. Since 2001, federal requirements have been that fees should be based on cost analysis. Last year, the State provided tools, i.e. formulas and templates, and required that cost analysis be done; Jefferson Public Health agreed to do so within about one year of October 2008. Jean Baldwin noted that moving to full actual costs likely needs to be done in a step -wise fashion over 2 or 3 years. Kitsap County also plans to phase in fee increases. The figures shown for Kitsap have been passed by their Board, but actual costs are higher. Julia Danskin said Gray's Harbor is involved in a similar process. Mason, Clallam and Island Counties do not have Family Planning programs or federal contracts in their health departments. Jean Baldwin noted that gaps on the draft sheets will be filled in; fees will also be developed for Immunizations and Environmental Health. Mr. Morley asked for clarification on the fees shown in column 2 versus the number of years expected for phase-in. Veronica Shaw said she had assumed 3 years, although the calculations must take into account annual CPI allowances and other factors, as well. Additionally, the economy has shifted dramatically during the period of analysis. Jean Baldwin added that the time period of three years would need to be approved by the BOH. Member Sullivan suggested adding a column showing the actual cost on the spreadsheet. Member Russell asked how often this fee is actually paid. Julia Danskin noted that in 2007 Family Planning had 2012 visits. Of those visits, 66% were Medical Assistance patients. There was a brief discussion about the Page 7 of 9 October 16, 2008 remaining 34% and sliding scale fees. Member Westerman asked if a phased in approach is possible for different categories of patients. She asked if the full cost can be charged to those with private insurance and the Medical Assistance related charges can be phased in. Jean Baldwin pointed out that if insurance denies a charge, the Health Department then rebills on a sliding scale, based on federal poverty guidelines. Staff does not anticipate increases in reimbursement from Medical Assistance. Jean Baldwin said that the Health Department is permitted to raise its fees monthly or quarterly to remain in synch with increases in Medical Assistance allowances. Staff indicated that they would follow up on Michelle Sandoval's inquiry about the "Other" category, i.e. she wished to know if this was a Paid category. Member Russell noted that the Hospital's sliding scale goes up to 400% of federal poverty guidelines, per the recommendations from the State Hospital Association. Member Austin asked if staff believed that patients may be scared away by the size of the full fees. Veronica Shaw said that staff routinely explains the sliding scale fees, which usually allays any concerns on the part of the patients. Medicare patients are referred to other providers who have Medicare contracts, but encouraged to come back if they cannot obtain medical services elsewhere. Jean Baldwin noted that travelers have complained about paying the $60 nurse visit fee. However, she said this is an expensive visit, actually not fully covered by the fee. Other counties generally charge more. One accommodation is to charge less for the second person, when two people are traveling together. There was acknowledgement that even these visits are subsidized by taking advantage of State supplied vaccines. Staff also mentioned that reviewers have been impressed by the insurance billing infrastructure; over 30 insurers are accepted and billed. Jean Baldwin said that the department saves money by maximizing this process. There was further discussion regarding the plan for phasing in the full fee and consideration of whether or not to do this all at once or over a three year period. Member Westerman was concerned that the existence of the Family Planning program would be threatened by under funding. She urged that there be further discussion about the strategy and projections. Veronica Shaw noted that there would be better information by the next meeting after all the line item costs and fees have been determined. Member Westerman said she agreed with Member Sullivan that actual costs would be helpful, and that the comparison with other counties was very useful. As possible, staff will gather comparison data from other counties with Family Planning services or Planned Parenthood. They will also show impacts on patients paying partial fees and data about percent of paid, etc. If possible, staff will set up the modeling software tools so that various parameters can be changed and viewed dynamically during the meeting. Chair Austin suggested postponement of the Environmental Health data discussion until the following meeting. BOH members were asked to retain their copies of the most recent versions of the packet sheets. Jean Baldwin said that the intention is to provide better information on real costs, especially Environmental Health whose fees have not been based on actual costs in the past. Page 8 of 9 October 16, 2008 Several members recalled that a similar cost analysis had been done by a task force six years ago. Member Westerman said it is important to acknowledge that work and for the public to understand the policy basis for fees and fee increases. She said that group had represented a cross section of the community and, by the end of that process, had come to agreement that fees should be based on costs. Jean Baldwin added information about timing. She said that usually fee changes are made only once per year in January. She said it would be well to link the fee discussions to the budget process and complete the determination of new fees by December. Agenda item, Expedited Partner Therapy program, was postponed until the next meeting. Staff also called attention to Flu vaccine and tire recycling event fliers. PUBLIC COMMENTS Norman MacLeod referred to an earlier mention of mental health parity. He said that the recent financial bailout provisions had been tacked on as an amendment to an existing Senate bill, i.e. the Mental Health Parity bill. Mr. MacLeod said he was pleased to hear that certain government officials within the County and the State recognize the existence of a serious economic problem. ADJOURNMENT Roberta Frissell moved to adjourn and David Sullivan seconded. Chair Austin adjourned the meeting at 4:44 PM. JEFFERSON..COUNTY BOARD OF HEALTH John' Austin, Chair S eila We a , Vi hair Roberta Frissell, Member Excused Phil Johnson, Member Michelle Sandoval, Member Chuck Rus 11, Member David Sullivan, Member Page 9 of 9 October 16, 2008