Loading...
HomeMy WebLinkAboutM102110JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, October 21, 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, MPH 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 Roberta Frissell, citizen at large (County) Stuart Whitford, Environmental Health Services Director Kristen Nelson, Vice Chair, Port Townsend City Council Sheila Westerman, Citizen at large (City) Chuck Russell, Chair, Hospital Commissioner, District #2 Chair Chuck Russell called the meeting of the Jefferson County Board of Health to order at 2:30 PM. A quorum was present. Members Present: John Austin, Roberta Frissell, Chuck Russell, David Sullivan, Sheila Westerman, Phil Johnson Members Excused: Kristin Nelson Staff Present: Dr. Thomas Locke, Jean Baldwin, Julia Danskin, Stuart Whitford, Veronica Shaw Substance Abuse Board: Frances Joswick, SAAB APPROVAL OF AGENDA Member Austin moved and Member Frissell seconded for approval of the agenda. The agenda was approved unanimously, as written. APPROVAL OF MINUTES Member Austin moved for approval of the September 16, 2010 BOH meeting minutes, as written; Member Westerman seconded. The minutes of September 16, 2010 were approved unanimously, as written. PUBLIC COMMENTS Chair Russell, speaking as a member of the public, noted that Rotary Club raffle tickets are available for purchase. Page 1 of 10 Mr. Tom Brotherton said he wished to comment on tobacco use in Jefferson County; he distributed a handout. He referred to tobacco use information found on the Health Department's website. He said that, despite the stated objectives and list of priorities found there, the trends reported by the State for certain segments of the Jefferson County population were not good. He pointed out a number of statistics of particular concern and inquired what strategy would be followed to reverse the negative trends. Siri Kushner, epidemiologist, pointed out the overlapping confidence intervals on the Adult trend chart to which Mr. Brotherton had referred, noting that the 2007 to 2008 change is not statistically significant. Ms. Baldwin added that the Jefferson Health Department does not use these types of charts because they are easily misinterpreted. However, she and Ms. Danskin acknowledged the seriousness of the smoking problem and expressed their appreciation to Mr. Brotherton for bringing this to the attention of the Board of Health. They suggested that Ms. Kushner and the Tobacco Prevention Coordinator, Karen Obermeyer, be invited to a future meeting to address these issues in more detail. OLD BUSINESS and INFORMATIONAL ITEMS Region 2 Public Health Community Liaison Summary Dr. Locke noted that this regional project that had been operational for several years. A one page summary is included in the packet. This is a successful regional program in which public health nurses visit medical and veterinary clinics to provide up-to-date information about all notifiable conditions and public health programs, as well as answer any questions from practitioners. Feedback from clinicians has been very positive. SmileMobile coming to Chimacum, November 8-12, 2010 A copy of the informational flier is included in the packet. School Based Health Center Work Group Jean Baldwin referred to a series of articles in the September issue of the Journal of Public Health on school-based clinics disease prevention. A working group including Dr. Locke, Siri Kushner and practitioners are assessing data collection at the school based clinics to determine whether data collection and services are on the right track. She said that Jefferson Mental Health, instead of the Kitsap agency, is now providing services to adolescents in Chimacum, Quilcene and Port Townsend Schools; funding is from the 1/101h of 1 per cent source. Wendy White has retired and has been succeeded by a new nurse practitioner. The new team is up and running. Status reports will be given later in the school year. Copies of the journal articles are available. Page 2 of 10 NEW BUSINESS Nurse Family Partnership Reports: Local Data, Foundation of Lifelong Health Essential Findings Report, Washington State Adverse Childhood Experiences Report Quen Zorrah presented a report from the Family Health support team. In the 1990s the BOH directed that all pregnant women should be screened at least once in pregnancy for substance abuse and domestic violence. In 2009, they received a grant from Women Who Care to design a local assessment for pregnant women, which was expanded to include all care givers of young children. Nurse Family Partnership was started in the County in 1999 because of high rates of referrals for child abuse, i.e. 50% higher than the State rate. She said this was the beginning of basing JCPH services on evidence based practice or science. Also, since this time brain research has been growing exponentially. Much more is now understood about the impact of early development and how early experiences influence the expression of genetic material. Ms. Zorrah reviewed the Adverse Childhood Experiences (ACE) study done at Kaiser Permanente with a population of 16,000. A lengthy questionnaire dealt with 10 different categories of possible childhood adverse experiences. The study showed that the higher the ACE scores, the more likely a person is to have a variety of chronic diseases as an adult. They looked at physical, mental and behavioral processes linked to the ACE score. For every rise in one's ACE score, there is a higher risk for having these issues. JCPH team is looking at health as the whole range of signs/conditions/behaviors, e.g. blood pressure, smoking, diabetes, drug use, depression, domestic violence etc. One's ACE score can reflect one's health throughout one's lifetime. A copy of the ACE short form was included in the packet. Ms. Zorrah said that since researchers had not previously collaborated in this way, her team used the valuable data on fostering better outcomes from Nurse Family Partnership and the ACE study to develop an assessment tool. The team has expanded the program so that its top priority is to prevent "ACEs". In addition to reducing the risk of chronic disease, it is a powerful clinical intervention to teach individuals about the ACE study and to help them understand their own ACE score. The assessment questionnaire is offered on intake and to the various Family support programs, meaning that the data is from a range of different people who are all caregivers of young children. Siri Kushner, epidemiologist, then presented some of the data derived from the questionnaire: • 67 persons seen in the Family Support Program at JCPH completed the questionnaire between September 2009 and June 2010. • The average age was age 26, ranging from 18 to 62. • 16% were male and 84% were female. • Almost half were unemployed or unable to work. • 63% reported household incomes of less than $10,000. • Average household size was 3 people. Ms. Zorrah noted that teen pregnancies are fortunately very low at this time. Jefferson County has seen a declining rate for the last ten years. Page 3of10 • About half of individuals under age 25 reported having less than a high school education; 46 % have completed high school or have earned a GED; 6% have completed an Associate degree or vocational training. • Of those over age 25, about half have some college and 19% have completed a 4 year college program. (The educational level of the mother greatly influences how well the child will do in learning and life.) • Just over half of the individuals (54%) reside in Port Townsend, and half elsewhere in the County. The questionnaire is rather lengthy (4 pages) and includes questions about substance use. • 80% reported ever using alcohol at least once or twice Ms. Zorrah said that since it is difficult to obtain accurate data about current substance use, questions/answers about history of use provide clues as to the family environment. Some of that data regarding alcohol and other drugs such as un -prescribed pain and sleeping pills are concerning. Ms. Zorrah said that although few people still smoke in their homes, they often smoke outside or in their cars. She said that the health risks of smoking, especially second hand smoke, are stressed, and that the Nurse Family Partnership has reduced tobacco use throughout the pregnancy by 33%. • 2/3 of people reported ever using tobacco at least once or twice. 31 % report current daily or almost daily use in the past three months • 41% reported a feeling of hopelessness some of the time within the last 30 days • Almost 30% reported feeling very irritable within the last 30 days • Almost 25% said they needed or had been told to get help with emotional problems • 21 % had spells or attacks of anxiety, fright or uneasiness • 18% reported nightmares or flashbacks • 17% reported being depressed, having lost interest or pleasure, trouble concentrating etc • 11 % reported they felt they were not the parent they wished to be • 5% reported having given into an aggressive urge or impulse Ms. Zorrah again stressed the seriousness of these findings given that these people are either pregnant women or caregivers of young children. She said these are frightening statistics considering what is known about the quadrupling of shaken baby syndrome and the increase of head trauma in our state. • About 2 in 5 report ever having received a diagnosis of mental illness • Of those, 81 % report a diagnosis of depression; about half, anxiety; and '/a bipolar diagnosis (Member Austin also noted that 8% reported borderline personalities) Ms. Zorrah added that it was also concerning that much of this population has never been able to access mental health services. She said the combination of diagnosis, history and current symptoms is a rather frightening picture. Page 4 of 10 • About 2 in 5 reported that they had ever lived with a step parent • 40% said they had ever lived with friends • Almost 30% reported they had lived with other family • About 25% had ever run away from home • Almost 1 in 5 had ever had interaction with CPS (Child Protective Services) • 12% had ever lived in foster care Ms. Baldwin said that one bright spot is that this population is getting services and that the department is serving the right people. • Of the clients who completed the ACE questionnaire, 15% reported no "ACEs"; Almost 30% reported "I"; the average score was "3"; the median was "2". (The highest possible score was "10". • If we compare the family history questions to the ACE score, the ACE score was 2 points higher among those who reported having ever lived in foster care, or with friends or other family's homes. • ACE scores for those ever diagnosed with mental illness are significantly higher than ACE scores for those without a mental illness diagnosis. Half of those ever diagnosed had a score of 4 or more. Ms. Kushner referred to the recently released Washington State Family Policy Council report. It reports on a state-wide BRFSS survey that included the ten ACE questions, comparing their data with the Kaiser Permanente 15 year ACE study. There are differences in the survey methods: the BRFSS study uses a telephone interview survey, and the Zorrah data is directly self- administered, with the client on site with the practitioner. The populations also differ in several ways including age, education and gender distribution. ACEs questions are a grouped into categories of abuse and household dysfunction. There are some notable differences between the Jefferson County group and other populations. Full details are available from the report. Fran Joswick inquired, of the ten issues, which had the highest reported incidence. Ms. Kushner responded: 75% reported that their parents were separated or divorced; 38% reported that they lived with someone who was a problem drinker, alcoholic, or used street drugs; 27% reported living with someone who often swore at them or insulted them. In response to another question, staff said that there are about 120 families served each year. Quen Zorrah said that staff is grateful for the funding that allowed this study. She introduced each of the nurses who participated in this study: Yuko Umeda, Mary Jo Mackenzie and Denis Langlois. Ms. Zorrah stressed that Nurse Family Partnership and ACEs fit extremely well together. Children who perceive their parents failed to take care of them and protect them; can develop coping strategies that are harmful to themselves or their children. Nurse Family Partnerships, which is based on relationships, is very powerful in this context. "We are using these therapeutic relationships to help heal and prevent health problems. And now that we are doing this assessment and asking people to do the ACE questionnaire, they are starting to understand for themselves the impact that their own ACEs have had on their lives." She said they are finding Page 5 of 10 that their lives now make sense to them and that this motivates them to prevent this from happening to their children. Ms. Zorrah said that there is great interest from the hospital and physicians to extend this study. She hopes that the ACE questions will become part of routine health histories and assessments used by health care providers. Member Austin inquired whether this information has been communicated to the State legislature and other funding bodies. Ms. Zorrah said that she had shared the process with other counties and agencies. There was a brief discussion about the dollars that can be saved with this program; Ms. Zorrah said research shows the minimum is about $5 for every dollar invested. Ms. Baldwin added that both the Rand Corporation and the Washington State Institute of Public Policy research named Nurse Family Partnership (NFP) as the most cost saving program. There was additional discussion about the Jefferson SAAB study of costs attributed to substance abuse, and the potential savings from NFP. Member Sullivan inquired what Proposition No. 1 and liquor tax elimination would mean to this program. Ms. Baldwin said that there would be a loss of $96,000 to Maternity Support. There are potential impacts over the next three to six months for which all details are not yet known. She said that the BOH would need to be involved in a series of related policy decisions. She mentioned other DSHS pharmaceutical cuts that would ripple through to other services, as well. Baldwin said a short version of this presentation was given to City Council last week, which was well-received and generated many questions. Ms. Westerman said that she believes it is important to communicate the proportion of services that are provided to City residents. Pre -adoption Briefing and Call for Public Hearing (12/16/10) on Board of Health Fee Schedule for 2011 Stuart Whitford referred to the proposed 2011 Fee Schedule in the packet. He noted that there was no COLA this year, and thus no across the board increases. He highlighted changes under Food Services. Fees are now broken out based on menu complexity, as well as seating, because there are greater inspection costs for greater complexity. Mobile units are also differentiated by menu complexity. He said that late fees have been eliminated; an establishment will be closed until renewal fees are paid. There is a new fee to cover the cost of pre -inspection for newly opening restaurants. There is also a re -opening fee to cover costs for those establishments previously closed for health or other reasons. He also introduced food inspectors, Dana Fickeisen and Mina Kwansa. Ms. Kwansa is a new inspector who holds a Masters degree in Public Health and has completed an internship at Benton County, Oregon. In response to a question about the Food Handler's card, Ms. Baldwin explained that the fee for a duplicate is the same as for a new card, $10.00; previously, it was $5.00. Ms. Baldwin also pointed out the additional $73 per lot for Boundary line adjustment review, which had been inadvertently omitted in the 2010 schedule. In general, the intent was to make the schedule simple, clear and more readable for everyone. Page 6 of 10 Mr. Whitford also explained a recommended change under Water. For rain water catchment systems, now allowed by Ecology, a $65 per hour fee is proposed to cover time needed beyond the 1.5 hour base fee of $98 for Determination of Adequate Water Supply. To date, there have been few instances of these systems, although more are expected in the future. Member Johnson inquired about definitions for "limited menu" and "complex menu". Ms. Baldwin said that the Standard Operating Procedures contain definitions. She said that the categorization is also based on risk; the more complex a process the more risk and therefore the more points of review. Ms. Baldwin also noted that the fee schedule itself does not mention all conditions, such as off site uses of commercial restaurants. Member Sullivan moved that the Fee Schedule Hearing be set for December 16, 2010; Member Frissell seconded the motion, which was unanimously approved. National Health Care Reform: Orientation to the Affordable Care Act of 2010 Dr. Locke pointed out the Highlights of Community Benefit/Hospital Needs Assessment in the packet; he said this topic had been discussed with the new CEO of the hospital earlier in the day. One of the provisions of the Affordable Care Act is that all not-for-profit hospitals must do community needs assessments at three year intervals, at minimum. This document outlines the elements of needs assessments. Dr. Locke said this will overlap with activities that our health jurisdiction has been doing. Ms. Baldwin noted that, under Home visitation programs, Nurse Family Partnership has some national funding, but that the State must apply/qualify for it. Washington State has applied but funding is based on risk and size, so Jefferson County may not qualify. Member Sullivan suggested that various entities, including OlyCap, could collaborate on risk assessment. Member Russell noted that much remains to be defined with national health care reform, including "meaningful use". Data Steering Committee Update Ms. Baldwin referred to packet materials and noted that a list of attendees of the previous meeting had been included per Member Westerman's request. The next meeting is scheduled for Thursday, October 28 at 3:00 PM. State and County Budget Updates Jean Baldwin explained that the packet inserts are a just few of the letters and bulletins from the State regarding budget items. She said that the 6.3 % Health Care Authority decrease will be reflected in a variety of ways across many programs. Questions of timing and reduction amounts Page 7 of 10 are still uncertain. Maternity Support and Family Planning have already lost about 40% over two years. Veronica Shaw referred to the presentation on Nurse Family Partnership earlier in the meeting, noting past support from the BOH. She distributed a spreadsheet, County General Fund Trend, covering years 1994 through 2010, which summarizes transfers between the General Fund and Public Health. She also reviewed the BOH presentation she had made last year regarding the 2009 Public Health Department budget and recalling the County general fund (CGF) decrease of $157,000. In 2010, there was an additional CGF decrease of about $108,000 with another $50,000 more expected in the 2010 budget cycle. Ms. Baldwin said that these cash reserves are carry over funds that have been made possible by good management, by seeking out new funding sources, and by constraining staff salaries, etc. Ms. Shaw added that because of the uncertainties of State funds, she has built the reserves against the likelihood of more huge State cuts. She discussed the initiative taken to obtain the $175,000 in new grants, which has taken a toll due to the substantial added workload on existing staff. Ms. Westerman inquired whether other County departments are experiencing similar budget changes. It was explained that other departments had no cash and had different systems, but that departments have all contributed to the overall reductions but not fund balance returns. Ms. Baldwin and Ms. Shaw said they did not understand the rationale of why all departments were not being asked to make equally drastic adjustments or pay the same percent in overall costs to the county. Ms. Shaw said that Public Health is being asked to turn over their reserves and to participate in budget cuts, as well. She also recalled that previous across the board cuts had been temporary for most departments but had continued for the Health Department. There was further discussion about the fact that the Health Department "gives back" about half of their General Fund income for rent and IT. Member Sullivan suggested that it would be well to take the view that the citizen is the highest priority and to strive for the optimal set of services that can be provided with the money available; the focus should not be on departments but on total services. He said that Public Health should present its critical services, of which there are many, and show how why these programs/services deserve priority. Ms. Westerman expressed her concern that employees who are asked to give more and more over the years will burn out and believes that impact can be detrimental to the citizenry. She said she hears the concern that some people are stepping up to the challenge of doing more with less, while others have not. She said that the BOCC is in a unique position to evaluate and respond to that effectively, while other BOH members do not have all necessary information or authority to do so. She added that the health of this community can be seen as a foundation for all other departments/services. Page 8 of 10 There was further discussion about the work and accomplishments of the Health Department during increasingly difficult circumstances. Ms. Baldwin expressed her disagreement with placing emphasis on 2015, and planning for surplus, in face of the current economic realities of citizens and unknowns of 2010-11. Member Sullivan explained that any consideration of future years out to 2015 is with the goal of maintaining services as long and as well as possible, not creating surplus. Member Sullivan advised Health Department administrators to provide their best information on the impact of planned cuts, noting that the final decisions had not yet been made. In closing, Ms. Baldwin drew an analogy with the Nurse Family Partnership program and its structure built on relationships. She said that departmental administrators and field staff need to know there is support from County authorities, just as mothersibabies must feel support from nurses, who in turn are supported by their supervisor. She added that she and Dr. Locke are trying to redesign Public Health in the face of the ongoing recession, and doing everything possible to prepare for a very different future. Member Sullivan said that there are ways in which the BOCC is showing its support for the Health Department. Member Russell said that he appreciated the difficulty of managing the County budget and noted that there are many other municipalities and counties going bankrupt during this economic crisis. Member Johnson noted that other departments are also feeling the pressure, and acknowledged the difficulty of the whole situation. Member Frissell said that it appears that there are some problems with the process and suggested that needs to be improvement in the system. She asked the BOH be made aware of County Budget processes in a timely manner. Member Sullivan described the current process in which the BOCC, County Administrators and department heads strive for consensus. Member Austin noted that there is considerable misunderstanding about actual control over funding for services, about the discretion government officials have with regard to public monies, and also about how much is being asked of its government employees. He said he believes the hard work and commitment of County employees should be recognized and publicized. There was further discussion about the general economic climate and the difficulty of balancing all interests fairly. Dr. Locke expressed his concern about the "multiplier effect" and its impact on many health programs. For example, what are called Medicaid savings in the General Fund are only the State share of service; the federal dollars are 54% in addition to that; the State will be saving $8 million for adult dental care but will be giving up $17 million in services. He agreed that the most important consideration in budgeting is the impact on community health and the wellbeing of community members. Ms. Baldwin called attention to the fact that the existing staff is well trained and experienced. She said she is very concerned that small counties like Jefferson as they shrink, will not be able to maintain the total expertise required. She said she believes that there is a critical mass of expertise that must be maintained, even if that means "buying" it from neighboring counties. She said it is necessary to maintain a certain level of infrastructure. There was agreement that there is a tipping point that should not be crossed. Page 9 of 10 Substance Abuse Advisory Board Nominations Member Austin briefly described three SAAB nominees who had been interviewed by Fran Joswick, Julia Danskin and himself: Colman Riddle is a high school student who is expected to be helpful to the SAAB in understanding and communicating with the youth of the community. Member Austin moved that the BOH appoint Arnie Danberg, Coleman Riddle and Michael Phimister to the Substance Abuse Advisory Board. The motion was seconded by Member Sullivan and approved unanimously. SAAB Chair Frances Joswick confirmed that the SAAB is now at full complement with 14 members. There were no updates. ACTIVITY UPDATE AGENDA PLANNING CALENDAR The next scheduled BOH meeting will be held December 16, 2010 from 2:30 to 4:30 PM at the Department of Public Health, 615 Sheridan Street, Port Townsend, WA. ADJOURNMENT Chair Russell adjourned the BOH meeting at 4:25 PM. JEFFE N COUN BOAR OF HEALTH Chuck Russell, Chair Excused Kristen Nelson, Vice -Chair / i ?I � W� —1 7154- 4 �' Roberta Frissell, Member �W L., lj &I °k*" --L-- Sheila Westerman Page 10 of 10 Jo Au: Member