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HomeMy WebLinkAboutM052010JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, May 20, 2010 2:30 PM — 4:30 PM Public Health Conference Room, 615 Sheridan Street, 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, County Commissioner, District #3 Julia Danskin, Nursing Services Director Kristen Nelson, Vice Chair, Port Townsend City Council Sheila Westerman, Chair, Citizen at large (City) Chuck Russell, Chair, Hospital Commissioner, District #2 Roberta Frissell, Citizen at large (County) Chair Chuck Russell called the meeting of the Jefferson County Board of Health to order at 2:37 PM. A quorum was present. Members Present: John Austin, Roberta Frissell, Phil Johnson, Kristen Nelson, Chuck Russell, David Sullivan, Sheila Westerman Staff Present: Dr. Thomas Locke, Julia Danskin, Veronica Shaw Guest: Frances Joswick, SAAB APPROVAL OF AGENDA Member Austin suggested the addition of an SAAB matter under New Business. Member Austin moved and Member Frissell seconded for approval of the agenda, as amended. The agenda was approved unanimously, as amended. APPROVAL OF MINUTES Member Sullivan moved for approval of the April 15, 2010 BOH meeting minutes; Member Austin seconded. The minutes of April 15, 2010 were approved unanimously. PUBLIC COMMENTS (None) Page 1 of 11 OLD BUSINESS and INFORMATIONAL ITEMS Annual Review of Jefferson County Shellfish Growing Areas Dr. Locke discussed the findings of the annual review from the State Department of Health, copies of which were included in the BOH meeting packet. This particular report is noteworthy in that there are two areas in Jefferson County threatened with a downgrade in classification. Dr. Locke noted that the accompanying letter from Maryanne Guichard, Office Director, could be misinterpreted. The two areas threatened with downgrades, Mystery Bay and Port Townsend, showed no evidence of current water contamination according to the report. For Mystery Bay, the classification is based on the number boats moored there; this has been the subject of a year long collaborative effort involving many parties. He pointed out the section of the report which mentions the work of the stakeholder group and the fact that a management plan has been developed to reduce the number of mooring buoys and boats. Dr. Locke pointed out that the water quality samples from these sites are fairly good; they meet all standards. The highest fecal coliform rates, although still meeting standards, occurred in areas where shellfish harvesting is prohibited such as industrial sites. Member Austin noted that there were some areas of concern listed, such as in Dabob Bay and Hood Canal, but that the sample/trend data and exact locations had not been shown in the report. He said these areas are presumably highlighted so that local jurisdictions can take corrective action, but the information is unclear. Dr. Locke said that he would research those issues further. Member Sullivan pointed out that the area referred to as Port Townsend, station 33, in the report is actually located at Port Hadlock/Oak Bay; that is, the first page is not consistent with the last page of the report. Dr. Locke noted that shellfish growing in the entire Puget Sound area could become a much greater issue. He noted that, due the oil spill aftermath, the Gulf Coast shellfish population could be unusable for the next decade, thereby placing additional pressure on other areas for shellfish production. Member Nelson inquired as to the content of prior reports and whether or not there has been any noticeable upward or downward trend. Dr. Locke recalled that the rates have been fairly stable over time, and said that he would verify that. It was also noted that once an area is identified as being "of concern", it will remain on the concern list for several years, even if there was only one problem sample. State Vaccine Program Update Dr. Locke referred to the May 5 News Release entitled "Childhood Vaccine Program to Continue after Previously Being Cut". He said that a funding process and program had been hastily developed through insurance companies to preserve this service. However, Page 2of11 there are now different information requirements that impose additional administrative costs on health providers. The previous programs run through I4ej&WHeaIth Department had been very streamlined and required minimal record keeping by the providers. He noted the importance of preserving the vaccine program. Member Austin inquired as to the rate of vaccination for HIN1 influenza. Julia Danskin said that the final tallies are still in progress; the total number of doses administered was over 6000. Only about 20% of very young children received vaccinations, which is low in comparison to the target levels for other vaccines. However, compared to other counties, the rates were good, especially for children age 5 and under. She noted that these vaccines are new and it is difficult to get parental consent for child vaccines that are not required by the schools, despite the fact that the flu is largely spread through the schools. Ms. Danskin noted that the seasonal flu vaccine becoming available in the fall of 2010 will have H1N1 vaccine in it. There is also plenty of unexpired HIN1 vaccine available. Dr. Locke said that there had been multiple logistical factors that affected the rollout of the HINT vaccine and contributed to the low levels of vaccinations. Up through the second week in December 2009, the vaccine was only available to children age 4 and under and those with chronic medical conditions. By the time that sufficient vaccine was on hand to open the program up to all ages, the peak of the flu epidemic had passed. He stated that to have significantly impacted the Fall H1N1 outbreak, vaccine would have had to have been available in August and administered to large numbers of people before the start of the school year. The first outbreaks were seen in September. There was a brief discussion about the fact that vaccinations are not mandatory and that schools do not collect the data. In general, the uptake of flu vaccine is low because parents do not perceive this illness as serious enough to warrant vaccination of their children. However, public health authorities consider the schools to be influenza virus factories. Dr. Locke said that there would be no seasonal flu outbreaks if influenza vaccinations of school age children were required. He mentioned that there has been consideration of adding flu vaccine to the mandatory panel. There is a multi-year type of vaccine under development that would require one dose with one or two boosters; this would be the ideal mandatory vaccine for school age children. There was mention that pending legislation would require parents to be counseled by a qualified health care provider if they seek to opt out of vaccinations for their children; the proposed bill has been passed by the House and stalled in the Senate. NEW BUSINESS Substance Abuse Advisory Board Nomination Member Austin reported that a subcommittee of the SAAB (Frances Joswick, Julia Danskin and John Austin) had met with Sam Marco, new Executive Director of the Jefferson County Mental Health Services, and determined his interest in serving on the Page 3 of 11 SAAB Board. Member Austin said that the subcommittee finds Mr. Marco to be well qualified and moved that the BOH approve his appointment to the SAAB. The motion was seconded by Member Westerman and approved unanimously. H1N1 Pandemic Response — After Action Report Julia Danskin reviewed the Jefferson County Health Department's and community's response to the H1N1 pandemic since it had first been declared in May 2009. A copy of the full written report submitted to the State Department of Health is included in the packet; it includes a month by month account of major events through April 2010, as well as key actions, observations and recommendations related to Epidemiology and surveillance; Communication; Vaccine Distribution and Tracking; Antiviral Distribution and Tracking; Health Care System Coordination; and Regional Coordination. The report also includes a set of conclusions and an Action Plan to address issues identified during the pandemic period. Ms. Danskin described the continuously changing conditions, vaccine supplies and information emanating from the CDC, state and other federal agencies, particularly early in the pandemic response period. She noted that locally there were many partners and that excellent working relationships had evolved. Over 6000 doses of HIN1 vaccine were administered. There were no reported deaths attributed to H IN 1 in Jefferson County. Dr. Locke noted that the HIN1 pandemic response had been an important test of our emergency response capabilities, and that there are always lessons to learn in the aftermath of this type of event. He said that he has been promoting the message that the H IN 1 pandemic was a trainer pandemic. He believes we were incredibly lucky in many ways. He said that the response plan that had been developed since 2005 worked well, but that it would be unwise to suspend efforts in preparedness activities. Dr. Locke said that statistics are still coming out and noted that the pediatric death rate, much of it in the 8 -12 year age range, was four times what is normally seen with seasonal influenza. Most of the children had medical conditions, such as asthma. Even in their mildest form, pandemics result in deaths. Future pandemics, such as one caused by H5N1 (Avian Flu), will likely be far more severe. Julia Danskin added that public health authorities have recognized that it is important to focus on the spread of all diseases, not just H1N1. She provided sample hand sanitation kits that are used to promote the importance of personal hygiene in preventing the spread of communicable diseases, especially influenza. Member Nelson said that she was impressed with the report, particularly the conclusions and the information showing what worked and what needed adjustments. She noted that e-mail communications had to be improved and that Jefferson Healthcare data had not been available for this report. Ms. Danskin explained that there had been a problem with the electronic identifier for Jefferson Healthcare which she believed had since been Page 4 of 11 resolved. Another problem with passing e-mail communication to the hospital EMR (electronic medical record) system was also being addressed. Chair Russell asked what the biggest problem had been in trying to respond to the HIN1 pandemic. Ms. Danskin said that the late arrival of H IN 1 vaccine had presented the biggest challenge. In addition, projected expectations about vaccine shipments were far off the mark on several occasions. In summary, the biggest problems were due to insufficient resources at the times when they were most needed; Ms. Danskin said that this was a nation-wide problem. In addition, there were multiple layers of information available through web sites, e-mail, bulletins, etc. that were not always perfectly synchronized. Locally, staff and community agencies cooperated very well under the circumstances. Ms. Danskin noted that staff did an excellent job of handling phone calls, listening to concerns, clarifying information and allaying fears of concerned citizens. In response to a question, Dr. Locke noted that the human mortality rate for Avian flu is about 65%. However, although H5N1 is endemic in birds, it is very hard to transmit to humans, except through airborne exposure to the droppings. Dr. Locke explained that such a lethal virus cannot spread widely because it rapidly kills its hosts. To become a serious pandemic threat, the virus would need to change significantly, becoming more contagious and less lethal. National Health Reform Legislation: Impact on Public Health and Prevention Activities Dr. Locke said that in preparing for a recent talk and panel discussion for the League of Women Voters he had done research and focused on the impact of health care legislation on public health and prevention activities. He noted that there are significant funds associated with the legislation, some of which has already been allocated and some which are potential sources. He referred to the summary in the packet prepared by Trust for America's Health, which he said is among the best references he has found. Dr. Locke described the major categories of changes/provisions. The bill expands clinical preventive services, access to wellness services, and personal prevention plans within the health care sector. It requires that private insurance plans, Medicare and Medicaid pay for these types of services. He pointed out the reason that insurers have been reluctant to cover prevention: the return on investment for preventive services may be years away and may not be realized by the same insurer who covers it today. He said that virtually the entire range of proven clinical preventive services will be eligible for mandatory coverage. There is also a system for determining which services should be funded, based on ratings of the US Preventive Services Task Force. The second category of changes involves the creation of a National Prevention, Health Promotion and Public Health Council within Health and Human Services headed by the US Surgeon General to provide coordination and leadership at the federal level. This council, with a twenty five member citizen advisory board, will have responsibilities for Page 5 of 11 developing national prevention strategies and policies, as well as for expanded access for chronic disease management and for looking at gaps in the public health system. The area that potentially affects the public health sector the most is the Prevention and Public Health Fund. As initially proposed, this would have been $10 billion per year nationally, or $200 million per year for Washington State. The funding has been scaled back to about $15 billion over ten years (page 3 of the summary). This is not subject to annual congressional decision and appropriation, but can be abolished by a subsequent congress. Among the many things that can be funded are demonstration projects such as: community transformation grants, "Healthy aging, Living well" projects for pre - Medicare age groups. Dr. Locke believes that Jefferson/Clallam Public Health, hospitals, Tribes and other community agencies are well positioned to take advantage of these grant opportunities collaboratively. He mentioned the Strategic Plan for Rural Health developed by a Washington State Hospital Association taskforce over the last few years would be an excellent model for a community grant. In addition, there are areas dealing with nutrition, labeling requirements for restaurants, and actions that aim at improving diets with respect to salt, sugar, and fat content. He said that this is a huge problem and these actions would hopefully have positive impact. Member Austin asked if making people aware of food content, particularly fat and sugar, has been effective in changing eating habits. Dr. Locke said he was unaware of any research on this subject. He noted that there is new evidence that dietary salt intake is a huge factor in high blood pressure and stroke risk. He said that reducing average salt intake by a gram a day would be a far more effective way to prevent strokes than investing in expensive new medical technologies. Another large planning issue is the health care work force, particularly for rural health care delivery and for public health. Dr. Locke noted the graying of public health work force and expected retirement of a substantial percentage in the next 5-10 years. He mentioned training programs, loan repayment programs, mid -career reeducation and pilot programs in this legislation. All of these programs/funds are part of the Patient Protection and Affordable Care Act (PPACA). Dr. Locke said that much of what Congress has directed is not yet specific and federal agencies are charged with designing appropriate programs and processes. He said that Public Heath has a huge amount of research data about what works, but has never been funded adequately to implement these ideas. There is a requirement in this new bill that non-profit hospitals conduct community needs assessments every three years and use this information to set planning priorities. He noted that there variations of interpretation with regard to community needs assessment versus community health assessment. The public hospital districts in this area are very interested and motivated in doing this function, and there is now actual authority for undertaking this responsibility. Page 6 of 11 There was a brief discussion regarding the portion of the legislative initiatives and provisions that have been funded. Dr. Locke said that in many cases a category of activity has been authorized, but there is not yet funding. Once proposals and grant requests are brought forward, there will be need to prioritize; Dr. Locke expects that Congress will need to revisit and refund areas that prove to have cost impacts. What is missing from the bill as a whole is an aggressive cost-containment focused approach. He cited the Public Health argument that the only way to afford universal access is to make people healthier. He believes this is possible, noting that the US is 24`x' in the world with regard to population health. There was also discussion about the distortion caused by the current situation of 47 million uninsured. Dr. Locke noted that this could be the golden age of public health, i.e. massive investment in community health versus massive increases in the cost of treating illness. Ms. Danskin said that she is just becoming aware of certain complexities and implications of the bill. She cited an example of teen pregnancy prevention program funding that is limited to State agencies. She cited another example where States must develop Home Visit proposals and submit them to the federal government; local jurisdictions may join State agencies or regional groups in order to qualify for funds. In conclusion, the collective set of programs that have been set up are a compendium of things that have been proven to work — an encyclopedia of evidence based practice in all these areas, and thus are candidates for funding; many do not yet have allocated dollars. Draft Invitation Letter Dr. Locke recalled that the intention to embark on an updated community health assessment had been discussed at the previous BOH meeting. To date, there have been meetings with representatives of the Hospital and with Sam Marco from Mental Health. He pointed out that the work is being done in the context of the national health care reform effort, which touches on needs assessment and opportunities for improved chronic disease management and prevention. Dr. Locke referred to the draft letter in the packet as a work in progress. He said that it is evident that the BOH would be the best convener for the assessment effort and for inviting individuals to participate. He suggested a two stage process, with the first goal of convening a Data Steering Committee to identify available data, determine focus areas, and to prepare material for a larger group. He noted that Vic Dirksen had suggested that a process with good preparation and a relatively short time line of intensive effort would yield better results than a more drawn out process. It is uncertain whether it is feasible to get that level of commitment from participants. However, he said it may be feasible if linked to opportunities for community transformation grants, which could generate substantial amounts of money. Page 7 of 11 There was a discussion about the most appropriate time to convene the working groups. After consideration of delaying until the fall, there was agreement that the process would take time and should begin as soon as possible. Dr. Locke said that the focus should be on identifying the service gaps, where Public Health and other agencies could be doing more but have not been able to assign the resources. In addition, he said that the process should generate data that can be used for applying for community transformation grants within a very competitive process. There must also be new data systems such as electronic medical records that show whether or not practices and initiatives are working, as well as ways to address interoperability among existing systems. Member Westerman noted that including a good description of the group composition, timeline and collaborative process in any grant application would be beneficial. She also suggested adjustments to the draft letter that clearly identify the goal of positioning for federal funds. She said it is important to convey that we are preparing ourselves to compete for funding, and not only to update studies/assessments as in the past. In addition, it should be clear that what we will do with the funding is to address the gaps as well as support services already in place. She said that message would incentivize the community to provide more expertise and help with the whole process. Member Sullivan suggested a positively worded invitation to rise to the challenge. A member of the audience brought up the notion of `enlightened self-interest'. Dr. Locke said he would include those ideas and suggestions, as well as to mention specifically some of the items included in the new legislation. There was a brief discussion about possible approaches to developing a new draft and getting Board approval. It was agreed that Dr. Locke would place this topic on the agenda and include the next draft letter in the packet for the June 10 meeting. National Accreditation of State and Local Health Departments Dr. Locke and Julia Danskin described the performance evaluation process that the Health Department goes through every three years. There have been State standards for Public Health; five function areas have now grown to twelve function areas. Washington State was one of the first in the country to enact laws mandating this process. At the national level, an accreditation process has now been developed. This is a drive to establish standards for performance for local health departments. A team of evaluators visit local departments to determine whether they are meeting, exceeding or not meeting the standards. The last onsite visit was in May 2008. The outcome report from that audit was presented to the BOH in the fall of 2008; a copy is available online. The next scheduled evaluation will take place in the spring of 2011. Dr. Locke explained that, for the next round, counties may decide to also apply for national accreditation. In those cases, the auditors will perform the audit using the Page 8 of 11 combined state/national standards; there is about an 80% overlap. Federal accreditation includes additional standards. Kitsap and Clallam have decided to go for the full 100%; Dr. Locke said he recommends that for Jefferson County, as well. He said he supports the notion that critical evaluation of performance improves quality. Member Austin inquired about the resources required to prepare for the audit. Dr. Locke and Julia Danskin said that the process is very data intensive and requires the assemblage of many forms of records. It was noted that the BOH meeting minutes and documents are important components of that collection. Ms. Danskin indicated that this effort would require only her time, with some medical records and administrative support to gather existing records. It was noted that federal accreditation is still somewhat controversial at the State level. There are some who believe that the additional effort is not warranted or that ratings do not truly reflect quality and high performance. Staff believes that the process does verify what is already being done, and does help to identify gaps and improvement opportunities. In addition, with the advent of health reform legislation, accreditation may be of benefit in acquiring federal funds. BOH members agreed that Jefferson County should be evaluated for federal accreditation in the 2011 round of performance evaluations. Interlocal Contracting for Environmental Health Director Services Dr. Locke provided information on the search for an Environmental Health Director. He said that an excellent candidate had been found, a person who is currently with the Kitsap Health Department. However, a counter proposal was made by Kitsap County whereby the person would have part-time responsibilities in both counties, under an interlocal agreement. Dr. Locke cited experience with such arrangements, as for his own position of Health Officer for both Jefferson and Clallam counties. Although the negotiations are still in progress, Dr. Locke said the individual would likely spend about 40% of his time working for Jefferson County; he would continue to live in Poulsbo. He explained that help is needed with high level administrative work and to carry out grant commitments, as well as to move forward with onsite septic code revisions and the homeowner inspection program. He noted that formal standards for homeowner inspection have not yet adopted at the State or local level, although there is broad support for the concept. There was a brief discussion about the status of this issue in Clallam and the fact that there are now models for Jefferson County to evaluate and/or customize for its own use. There was discussion about whether or not this position would be adequately served by a part-time Director. Member Nelson noted that the alternative of hiring a full time person who would also be part of the community may be preferable; she noted that under a Page 9 of 11 commuting arrangement, Jefferson County may receive even less than 40% of the person's energy and time. Veronica Shaw cited the commonalities shared by Jefferson and Kitsap counties and the specific experience of the candidate with multiple important programs. She said that she believes this arrangement would work and would be beneficial for Jefferson. It was noted that, because of the qualifications, this position has been fairly difficult to fill and that it may be better to have an expert part-time than someone who is less qualified full- time. A member of the audience, Tom Brotherton, suggested that one obstacle may be a "conflict of interest" in attempting to serve two different counties. Mr. Brotherton went on to introduce himself as an attorney working for the Jefferson County Prosecuting Attorney's staff and a "legal advisor" to the Board of Health. Veronica Shaw said that the contract had been be reviewed by David Alvarez, the Health Department's legal advisor and the final agreement will also be reviewed with him. In response to a question from Member Sullivan, Mr. Brotherton confirmed that he had not been assigned to be an advisor to the Board of Health by the County Prosecuting Attorney. ACTIVITY UPDATE Frances Joswick, SAAB, reported that the preparation of a second Department of Justice grant application focusing on substance abuse and mental illness is in progress. Member Austin informed the BOH of a scheduled press interview on Monday June 7, 12:30 PM, at Mountain View. The purpose is to release the results of SAAB research on the amount of money spent in this County as a result of substance abuse. It is an estimate, based on a template developed by Columbia University that includes costs for: hospitals, jail, law and justice, mental health, Child Protective Services, lost work and other components. Member Austin said that the preliminary results indicate at least $15 million per year, which is equivalent to the entire Jefferson County General Fund. He invited others to attend. Member Johnson requested clarification on the processes available to the BOH for review, editing and approval of a document, such as the draft letter discussed earlier, particularly when it is impractical to do within a meeting. Mr. Brotherton advised that any official actions should be taken during a public meeting; any action considered by a quorum must be done within a meeting. Dr. Locke stated that for routine letters, the BOH decides in advance which person is authorized to review and sign on behalf of the BOH. In special cases, a higher level of participation by BOH members may be desirable and that should be done during meetings of the Board. AGENDA PLANNING CALENDAR Page 10 of 11 The next BOH meeting is scheduled for June 10, 2010 (second Thursday instead of third Thursday) in the Health Department Conference Room. Roberta Frissell indicated she would be unable to attend due to travel arrangements. ADJOURNMENT Chair Russell adjourned the meeting at 4:32 PM. JEFFEjt$ON, CO TY B%)kD OF HEALTH 6�"'144 zRus 11, Chair W1 l � Kristen Nelson, Vice -Chair Roberta Frissell, Member �" 0 *V Sheila Westerman Page 11 of 11 Phil Johnson, mber J Au s 'n, Member David Sullivan, Member