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HomeMy WebLinkAboutM082108JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, August 21, 2008 2:30 PM — 4:30 PM Court House, First Floor Conference Room, 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 2:30 PM in the First Floor Conference Room of the Jefferson County Court House, Port Townsend, WA. Members Present: John Austin, Roberta Frissell, Phil Johnson, Chuck Russell, David Sullivan, Sheila Westerman Members Absent: Michelle Sandoval Staff Present: Jean Baldwin, Dr. Thomas Locke, Andrew Shogren A quorum was present. APPROVAL OF AGENDA Chair Austin added one item to the agenda under New Business, item 5: Approval of the appointment of Michael Blair to the Substance Abuse Advisory Board. Member Westerman moved and Member Frissell seconded for approval of the agenda, as amended. The motion to approve the agenda, as amended, was passed by unanimous vote. APPROVAL OF MINUTES July 17, 2008: Member Frissell moved to approve the minutes of July 17, 2008; the motion was seconded by Member Westerman. The minutes of July 17, 2008 were approved unanimously, as written. June 12, 2008: Approval of this set of minutes had been deferred in order to get clarification regarding the previous month's minutes regarding the total cost of onsite program in Clallam County. Dr. Locke said that the recording of the meeting had not included that information. The next step is to contact the speaker, Andy Brastad, when he returns from his vacation. Jefferson County Board of Health 1 August 21, 2008 PUBLIC COMMENT There were no public comments. OLD BUSINESS and INFORMATIONAL ITEMS Port Townsend Paper Air Quality Agreement Dr. Locke said that this item was a follow up to a presentation made to the BOH several months earlier regarding the air quality consultation. Port Townsend Paper and the State Department of Ecology (DOE) have reached an agreement, which Dr. Locke considered to be a very positive step. He said that information had been lacking about specific chemicals that might be released in the air, and where they might be dispersed within the community; this agreement is designed to determine that. He said much more accurate assessments of health threats would be possible with that information. Mental Health Consultation Outreach Access Line DSHS has targeted two regions in the State for a new program called PAL, Partnership Access Line, that will provide mental health consultation for children to any primary care provider. Jefferson County is part of Region 6, Southwest Washington. Jean Baldwin said that physicians and medical providers will be able to access mental health consults with Children's Hospital, including downloads through the interactive video systems. DSHS can be billed for phone consultation time and immediate mental health backup. Ms. Baldwin said this has been a continuing problem for families, which can possibly be alleviated by assisting medical providers in this way. The targeted areas are those with smaller counties and less well developed systems and infrastructure. Full funding for the staff at Children's Hospital will be provided by the State. Children are defined as those up to and including the age of 18 years of age. There was a brief discussion about the reimbursement amount, which is comparable to that of a short office visit for DSHS patients. Board of Health Letter re: City of Victoria Sewage Treatment Dr. Locke noted that there had been a request several months ago from an advocate in Canada that the BOH submit a letter of support to the Capital Regional District regarding a planned waste water treatment system for Victoria BC and surrounding areas. He said he had requested additional information and had not received a timely response. Recently, he was able to determine that the Capital Regional District and the BC Ministry of the Environment are still firmly behind the project, but that complications, including a well organized opposition group, have resulted in further delays. There was a brief discussion about the draft letter that Dr. Locke had included in the packet. He also described what he had learned about the opposition to the project. Several former health officers were among those opposed to the project. A major argument cited was the cost of the project, and other health needs that could be addressed with Jefferson County Board of Health 2 August 21, 2008 $1.2 billion dollars. Another is that the science is not rock solid and conclusive. However, proponents have provided a strong environmental case, and elected officials are apparently resolute in moving forward. Dr. Locke said that the cost projections are $500 per system user per year additional cost. Phil Johnson moved and Roberta Frissell seconded to approve the letter, as written. The draft letter to the Capital Regional District was approved unanimously, with agreement that each individual BOH member would sign it. NEW BUSINESS Nurse Family Partnership Annual Update Quen Zorrah pointed out the packet materials on. Family Support, Planned Performance Measures 2009, are also posted on the web site. Included for the first time is the new Mission statement for the Family Support Program. Improve Quality of Care giving — Ms. Zorrah noted that the mandate of offering services to all families with young children was renewed last year by the BOH. She said that in consideration of resource and financial restrictions, the Family Support group carefully triages their services, to continue to offer population based services, but not duplicating what is already out in the community. She said it is important to acknowledge the dwindling resources for the whole county, especially reduced access to housing and child healthcare. Preventing harm to mothers, infants and families at risk for maternal depression. There is now eight years of ongoing data collection showing a consistent 35-40% positive screening for maternal depression. However, she said there are limited treatment options. Medicaid patients are still losing their medical coupon two months post partum, and now many babies are also losing their coupons. She said it is now necessary to have identification and verification for everyone is the household whether they are applying for benefits or not. Many people, especially the homeless or those in unstable situations, are not able to provide the needed documentation. She noted that more infants are losing their coverage than ever, but that it is extremely difficult to get statistical data from DSHS about this. She noted the $20 cost for a birth certificate copy. DSHS does not accept the hospital proof of birth certificate. There are also enforced federal requirements for providing proof of residency. There was a discussion as to whether the County could help provide/pay for the birth certificates for those who cannot afford them. Encourage and support breastfeeding for optimal nutrition and health — The Health Department has been holding a weekly group continually for fourteen years; this is the only community in the State that has been able to achieve that. This is the main outreach and response to all community women who are breastfeeding; the group tends to be mixed ages and income. She said this is a great resource for women who do not qualify for maternity support services or nurse family partnership. She said that the sessions include much more than breastfeeding, i.e. parenting, health education, nutrition, mental health, etc. It is advertised in the newspapers, brochures, childbirth classes and through the web. Jefferson County Board of Health 3 August 21, 2008 Improve birth outcomes — Ms. Zorrah pointed out that access to prenatal care is slipping and access to this care for women on Medicaid is below what it was in 1990. Although the 2010 goal is 90%, the current rate is only 70% for Medicaid and 88% for private insurance. The gap for those who get no prenatal care at all is quite significant for those on Medicaid. She said she is working with Jefferson Health Care to bring people in sooner. Healthcare access — Children in South County are particularly far behind in immunizations and well child care. Rises in fuel and other costs have exacerbated the situation since many families cannot afford to make the trip to the doctor, or even to afford cell phone minutes for making appointments. Board members expressed concern that there is currently no medical service for children in Quilcene. Member Russell said that he would check further on this issue. Nurse Family Partnership Program — Ms. Zorrah said that this is one of the most well researched programs. She pointed out the article from the Washington State Institute for Public Policy on costs and benefits related to children and the welfare system. She said that for this program the total benefits minus costs in keeping children out of the child welfare system is $18,054 per person. She noted that the cost of foster care was not factored into the cost/benefit analysis. There was a brief discussion about the methodology. Jean Baldwin pointed out that the methodology for the analysis is on the web page and appears in the report prior this one. She noted that foster care affects only a small number of children. What is known is that the number of cases referred to Public Health for prevention, intervention and possible neglect have quadrupled in the last few years. Concurrently, demands from Children's Administration on nursing service providers are increasing. Jefferson County has a high rate of grandparents raising grandchildren but there are no specific services for these cases. This remains a gap in services that should be addressed. Member Sullivan asked if O3A had resources for this segment. Ms. Zorrah said although there are general referrals for the grandparents, certain mental health grief/anger issues and complex family dynamics typical in this population are not addressed by any agency. She said that what is seen in general is that there is more economic stress, more mental illness, more violence and addiction in the community, which tend to lead to neglect. Infants are the fastest growing category entering into the child welfare system and the most expensive. Nationally, 43% of all fatalities attributed to abuse and neglect are infants under the age of one year. Other statistics show that 21 % of all children in foster care entered before age one. Infants stay in care longer and are more likely to be re -victimized. As adults, those who were in foster care in some part of their childhood had significantly higher rates of mental illness, PTSD, and rates of addiction higher than comparable young adults in the general population. They were also less likely to complete high school or be employed. There are two main strategies for working with this vulnerable population: prevention, through the Nurse — Family partnership and intervention, through the CPS contracts. Ms. Zorrah said that Public Health is also beginning to work with the Family Therapeutic Court, similar to the Drug Court. She said that there is interest in utilizing this Court for families at risk, i.e. preventative (rather than waiting until the child has entered the child welfare system), which would be more cost effective. There was a brief discussion about how this shift could be accomplished and consensus that the Court system would need to make this change. Member Westerman, who is also a member of a related funding advisory committee, suggested a meeting between the BOH and a representative of the Court. Pierce County was cited as the one jurisdiction that has Jefferson County Board of Health 4 August 21, 2008 already implemented a preventative Family Therapeutic Court and as a possible resource for protocols and other information. Member Sullivan advised that all the facts and implications, including mandatory reporting requirements, should be investigated up front. Ms. Zorrah noted that the Court Coordinator had contacted Pierce County about their program. Ms. Zorrah then introduced two Family Support nurses, Yuko Umeda and Mary Jo Mackenzie, There are five nursing staff, about 3 full time equivalents, involved in Family Support services. Member Westerman and the Board commended this group for their dedicated services over many years. Port Townsend/Chimacum School Based Clinic Update Yuko Umeda presented a Power Point Presentation on the School Based Health program. Earlier this year, the Health Department received a planning grant from the State Department of Health to begin planning school based health centers. This includes seeking community support and building partnerships with other organizations to launch this program. School based health centers have been in existence throughout the U.S. Washington State currently has 17 centers, almost all in the Seattle area. There is also a center in Kingston. The original impetus was providing health care for teens because this age group often lacks access to various types of health care and this is a very efficient means to meet those needs. Ms. Umeda noted that typically school based heath care includes physical and mental health services provided by a team of providers specializing in adolescent health care, i.e. nurse practitioner and mental health counselors. The program for Jefferson County will begin with Port Townsend High School and Chimacum High School, with eventual inclusion of the middle schools. Broad community support is very important and there has been very positive interest and cooperation in both Port Townsend and Chimacum. Jefferson County Public Health, Jefferson Healthcare, and the two school districts are partners in this program. She said the first sports physicals had occurred, earlier in the week. The governance structure consists of a governance board represented by the Chimacum School District #49, Port Townsend School District #50, Jefferson County Public Health, and Jefferson Healthcare. The advisory group includes parents, teachers and community members. Services include acute health care, health education; oral health; chronic illness care, reproductive health, and mental health care. Currently, the Health Department serves more than 40% of 15-19 year old females for reproductive health. Ms. Umeda noted also the importance of mental health services, screening and counselor referrals to those specializing in adolescent mental health. This will include a contract with Kitsap Mental Health for a skilled adolescent counselor. The services of a team of intervention specialists (drugs and alcohol) were also mentioned. The funding for the mental health component will come from the 1/10th of 1 % sales tax for Mental Health services in Jefferson County. In the U.S., one in five children has some sort of mental health issue that impacts them. In Jefferson County, per a bi-annual survey of school children, 30% of 8 and 10th grade students reported feeling sad or hopeless every day. 11 % of 8th graders and 19% of 10th graders reported Jefferson County Board of Health 5 August 21, 2008 that they had seriously considered suicide. Ms. Umeda cited examples of the many health issues for adolescents, which can affect their academic performance as well as family and community interactions. Related statistics were cited: about 17% of children, ages 5-17, in Jefferson County live below the poverty line; over 50% qualify for the school lunch program. The plan provides for providers to be on site at each school center two days per week. One crucial aspect is the trust that can be established between providers and students. Member Johnson inquired as to the funding/payment structure after the planning grant has been expended. Jean Baldwin said that the original hope was that by taking family planning to the school districts, there would be an equal expenditure of Public Health dollars. However, it now appears that some elements will break even and some will not. The provider time, which is to be split with Jefferson HealthCare, is the most significant expense; school facilities and infrastructure costs are borne by the schools. She noted the impact of the weakened economy in recent months and lower certainty that all costs can be covered. This has led to the decision to implement only some services and delay the implementation on the provider side. Three grant applications are pending, which could cover up to three years. Medicaid reimbursement for children has increased and it is possible that with insurance billing the program could break even. Ms. Baldwin said that there has been a hugely positive response from the community and schools; contracts and facilities have been completed in very short order. There was a brief discussion about the school districts' related spending, Olympic Educational Service District (OESD), OSPI and the mechanisms through which substance abuse and other specialists had been placed in the schools. Jean Baldwin noted that the school districts are extremely interested in mental health services, having seen the benefits and results in past years, mainly through start up grants. They also do not wish to carry the supervision responsibilities. Therefore, they do not directly employ mental health professionals to do therapeutic work. He said that one important aspect was the ongoing presence of the counselors, the trust that developed, allowing earlier intervention and better outcomes. She noted that the various existing programs for children could be transitioned to the school based program umbrella and financing adjusted accordingly. Jean Baldwin also noted that many school based health programs do not charge for services at the outset, considering it as investment in prevention. She said that this is clearly not possible for Jefferson County, but that it should be possible to operate at about the same financial profit as current clinic services. In response to a question about school nurses, Ms. Baldwin said that all the schools contract with Public Health for school nursing. Currently, Chimacum and Port Townsend each get 8 hours per week, while Quilcene and Brinnon each get 4 hours per week. With the implementation of the school based program, the school nurse would not do medical exams, etc., but would do screening and referrals. Jefferson County Board of Health 6 August 21, 2008 In summary, Ms. Baldwin said that her intention is to proceed slowly, with no additional staff, and monitor the finances very carefully. Member Austin asked if there is any possibility for additional State funding, and/or if any encouragement or advocacy from the BOH would be of help. Ms. Baldwin said that she plans to apply for a Department of Health grant due in October. At minimum, this would allow for the designation to do DHSH billing; she also mentioned applications for Legacy and Rural Health grants. However, she believes that the BOH could be an advocacy group for ongoing funding. She said that this program is directed at 1400 students in the County. It is not expected to have the same dramatic family change as the best practice Nurse Family Partnership. However, she said it is a good way to provide services. Final arrangements with Jefferson Health Care are still in negotiation. A new start up date for the program, originally scheduled to begin in October, has not been set. Cyanobacteria (Blue Green Algae) in Jefferson County Status Report Neil Harrington reported on the status of this water quality problem. There are four lakes in Jefferson County that are currently at a Warning state: Anderson, Leland, Gibbs, and Crocker. Tarboo Lake is at Cautionary status. Teal Lake is a drive by lake; if no surface algae are observed, it is not sampled every week. In general, a Warning is triggered by over 100,000 cells/mL and Caution at 30,000 cells/mL. Mr. Harrington referred to web site handouts and discussed the multiple types of cyanobacteria found in Lake Leland. He said that the latest sample showed both microcystin and anatoxin -a. Anderson Lake was posted with a warning in late April based on its history and cell density. The lake was closed in late May after high cell density and scums formed, subsequently in early June anatoxin -a was detected in the lake. There is little swimming in Anderson Lake, but there is recreational fishing and boat use, so there is concern about exposure if a boat capsizes. Two dogs had died there in 2006 after exposure to lake water. The park has not been closed completely, but the lake has been closed and dogs are required to be leashed. After an algal bloom in April, the bloom subsided and spiked again in early June, which is consistent with timing during the previous two years. In late June, there was an extremely high reading of 172,640 µg/l (ppb) for anatoxin -a, which is among the highest in the literature according to Joan Hardy, State DOH cyanobacteria specialist. Lake Leland has had a strong microcystis bloom during the summer. On August 11, the reading was 191 µg/l of microcystin and about 100,000 cells/mL of microcystic. The recreational guidance is 6 µg/l for swimming. With the observed presence of microcystin in early July, staff phoned everyone in the Lake Leland shoreline to ensure that they were not drinking water around the lake. He noted that there are residents with surface water rights and wells in the area. With regard to Gibbs Lake, there have been various types of cyanobacteria blooming throughout the summer. In order to downgrade from Warning to Cautionary, the staff needs to see at least two consecutive weeks under 100,000 cells/mL and a decreasing trend. However, that has not happened as yet. In response to a question about the process by which the toxicity decreases, Mr. Harrington said that is toxin dependent. Microcystin is fairly stable, and anatoxin -a tends to degrade rapidly. Organisms that are stressed by depletion of nutrients tend to produce more Jefferson County Board of Health 7 August 21, 2008 toxin. This has implications for lake treatment regimens. He mentioned an instance where aeration was attempted at Anderson Lake, which resulted in lower levels of dissolved oxygen, possibly as a result of stirring up the bottom of the lake. Mr. Harrington noted that bottom sediments, such as phosphorous, can also have a negative impact when stirred up. One treatment being considered here is alum treatment, which both clarifies the water and binds the phosphorous and sediments for about five years. However, this requires further research. Regarding the budget status, $28,300 has been spent so far this year, with some about $4,000 coming from the State Parks. A grant from the Department of Ecology for $40,000 is expected to reduce the need for General Fund monies next year. Mr. Harrington said that having staff take over monitoring and cell counts, in an effort to cut cost, is under consideration. Expenses not reimbursed amount to about $19,000, mostly for lab and staff costs. Member Sullivan said that one option is to close the lake, and not monitor unless the State provides the funds to do so. Mr. Harrington responded to a question about long term aeration, stating that he had not seen research indicating that as a possible solution. He noted that the characteristics and conditions of each lake are fairly unique. There was a brief discussion about phosphates and a new law in Washington State requiring reduction of phosphates in laundry detergent. There was acknowledgement that the long term conditions of Lake Anderson have not been fully monitored and documented. There can be short term shifts in variables such as wind, sun and temperature associated with large shifts in algae blooms. Dr. Locke said that this situation is characteristic of an emerging health problem where basic scientific information is lacking. Officials are then forced to make decisions with high degrees of uncertainty, including recommending against healthy behaviors such as swimming and fishing. He said there are also concerns about longer term exposure. He pointed out the need to respond to citizens' questions and concerns, and noted the educational materials that had been prepared. He said that Lake Leland residents have been informed about detoxification and disinfection methods, but which are complicated and expensive. He noted that pets and livestock are more at risk because of the possibility of drinking untreated lake water. There have been no observations of this problem or of scum layers in any Clallam County lakes. This is likely attributable to the fact that these lakes tend to be deeper, colder and spring fed. Lake Southerland, which is surrounded by heavy development and is likely experiencing nutrient loading, is very deep and has a fast recharge. In a follow up comment regarding the budget, Veronica Shaw said that funding for lake monitoring had been requested during the preparation of the 2008 budget. At that time, $5,000 was granted from the General Fund, with a directive to request additional money if necessary. In consideration of the tight budget situation, staff had then sought grant funding from DOE. For 2009, this will cover most of the 2009 expenses, but a small portion will still be needed from the General Fund. Jefferson County Board of Health 8 August 21, 2008 Approval of Appointment of Michael Blair to Substance Abuse Advisory Board Chair Austin stated that he and Jean Baldwin had interviewed Mr. Blair, and heartily recommended him for appointment to the Substance Abuse Advisory Board. Mike Blair, Superintendent of Chimacum Schools, had indicated his interest in serving on the advisory board. Member Sullivan moved to appoint Mr. Blair to the advisory board and member Johnson seconded. Member Westerman suggested that the BOH send Mr. Blair a letter of thanks, noting that she had sought to involve the school districts in this endeavor for many years. Member Russell added his support for Mr. Blair. The BOH voted unanimously to approve the motion to appoint Michael Blair to the Substance Abuse Advisory Board and to send him a letter of thanks. Jefferson County Public Health 2009 Budget Planning Budget packet materials were supplemented by several charts and graphs. Veronica Shaw briefly reviewed the budget materials. She noted that Environmental Health permit fees for drinking water and programs are down about 50% at this time, with little expectation that they will rise in the near future. This amounts to a loss of about $300,000 over two years. On the other hand, the budget must accommodate wage and benefit cost increases. The approach is to analyze Environmental Health programs and to consider possible steps to balance the budget and continue to monitor it. Last week there was staff reduction and the decision not to fill two vacancies. Reduction in hours (4 days, 9 hours per day) was offered to all Environmental Health and Water Quality staff. Jean Baldwin noted that the union has no objection to this arrangement since it is voluntary. Additionally, the department requests that the County continue to fund the match for the Discovery Bay and Hood Canal grants for next year. Ms. Shaw and Ms. Baldwin explained that the increases for wages and benefits would amount to over $177,000 in 2009. Considering the overall picture for the County, Public Health developed a formula allowing for the full increases to be applied only in those areas where there is no opportunity for recovery. For example, in Administration, only 50% (of the increase) is requested from the General Fund. For Community Health, the budget shows 75%, with the rest coming from grants. Public Health Emergency Preparedness and Response funds are being decreased. There is also a slight decrease in Family Planning funding from state and federal grants. Several other changes were mentioned. Bill 5930 Blue Ribbon funding did come in, but has additional deliverables. Ms. Westerman commended staff on the budget documents, noting they were very clear and understandable. The department will return with the fee analysis work in November. She said they were looking at service costs in surrounding counties, what we are charging and actual costs. JCPH has not restructured fees for five years. She suggested that everyone retain their copies of reports/charts for future discussion. Jefferson County Board of Health 9 August 21, 2008 Activity Update Chair Austin reminded that the State Board of Health would be meeting in Jefferson County on Wednesday, November 12, at the Inn at Port Hadlock from 9:00 AM to 3:30 PM. The BOH is invited to attend. An agenda will be distributed about two weeks prior to the meeting via e-mail. Commissioners Austin said he is otherwise scheduled on that day, so will be unable to attend. Agenda Planning Member Frissell raised the question of whether the BOH would be meeting with legislators this year. After a brief discussion, there was agreement that it would be well to set up a meeting including the Clallam BOH. Member Westerman restated her request that staff follow up with Pierce County on the Preventative Therapeutic Court issues mentioned earlier, and provide an update at the next meeting. The next BOH meeting is scheduled for September 18 in the Court House First Floor Conference Room, unless otherwise announced. Adjournment Member Westerman moved to adjourn the meeting, which was seconded by Member Johnson. Chair Austin adjourned the meeting at 4:39 PM. JEFFERSON COUNTY BOARD OF HEALTH John Austin, Chair Roberta Frissell, Member Phil Johnson, Member Absent Michelle Sandoval, Member Sheila Westerman, Vice Chair Chuck Russell, Member David Sullivan, Member Jefferson County Board of Health 10 August 21, 2008