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JEFFERSON COUNTY HEALTH DEPARTMENT
802 SHER:OAN PORT TOWNSEND. WASH. 98368
(206) 385.0722
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Minutes:
December 19, 1984
Board Members:
B. G.. Brown, Ch<ti rman
John L . Pitts ,Member
Larry H. Dern}~l!>on, Member
Glen Ison, M~ml?er
Staff Members:
Randall M. Durant, R.S.
Gretchen Gephart, D.O.N.
Joseph Fischnaller, M.D.
Gael Stuart, Administrator
Aft;e~ introduction of the following people to the members of
the Health Bba~d, Chairman Brown called the meeting to order:
Dr. John Beare, Director; Hashington State Department of SOCilll
and Health Services; Division of Health
Lamont Carstens, Section Head; Washington State Department of
Social and Health Services; Division of Health.
Victor Dirksen, Administrator; Jefferson General Hospital
Pat Hogan, Director of Nursing; Jefferson General Hospital
Peter Simpson, Director; Clallam Jefferson Community Action
Council.
DiscQssion regarding the legality and advisability of the Hos-
pital District assuming the administration ot the Health Department:
Gael Stuart brought those present up to date on the discus9-ions that the
Health De'partment and Hospital District have had regarding the possibility
of a consolidation of health services in Jefferson County. It was felt
that it would be an advantage to have Dr. Beare and the County Prose:u!;ing
Attorney present to advise of the legalities and feasibility of such a
consolidation as well as any precedents that have been set in this area
by another County possibly, and the reaction of the State Division of
Health to such an arrangement. .
Dr. Beare began by advising that there are distinct differences between
providing primary medical care which is the function of a Hospital District
and providing the responsibilities of public health for the entire county
population as required by state law..
Health Board Minutes, December 19, 1984
Page 2:
There is a responsibility to assure that the county's citizens medical
care needs are taken care of and this is generally done through a variety
of sources: Private insurance, medical assistance and other kinds of
government payment programs, or a combination of public and private pro-
viders. The Hospital District such as the one here in Jefferson County,
provides services and has responsibilities that are outlined clearly
in the State Statutes governing them. Beyond those types of services
the Public Health responsibilities include the physical needs of the
people through the Environmental Health services which are unique and
not provided by any hospital district.
There have been instances in certain counties to relocate the Environmental
Health Services of the Health Department in an area in conjunction
with the county Planning Department for ease in the county's permiting
process. In a situation like this, it is the State position that the
reporting relationship between Environmental Health and the Health
Officer and Board of Health must remain in tact. There is a distinct
and singular responsibility for the Environmental Health services back
through the Health Officer and the Board of Health. In instances where
the County has tried to break that reporting relationship, the Attorney
General has been able to convince the County that until the law is
changed, there is a formal distinct relationship that must be maintained.
Dr. Beare continued by saying that he did not want to see fragmentation
of Public Health services in Jefferson County, because the Board of Health
has the entire responsibility for public health in this county. If
the Health Department contrac~for it's administration and services
with the Hospital District the Attorney General indicated that that
would be beyond the scope of what a Hospital District is set up to
do by law.
Hospital Districts have been set up, due to financial difficulties,
to provide funding ~n some areas. Some hospitals do market wellness
and health promotion programs, but these are items that are supplemental
to their responsibilities and are offered to make money. There will
always be a segment of the population, Dr. Beare feels, for which the
government will have the basic responsibility to provide preventative
health services for which those citizens will not be able to pay, and
he is not sure that the hospital can absorb the cost of providing that
free care.
Free care in a hospital is almost a thing of the past, while at the same
time most Health Departments have a sliding scale fee arrangement. With
basic funding provided by counties, the state and the federal government
and through user fees, the Health Department can provide the necessary
service to those in the community that can not afford to pay.
Another question Dr. Beare posed is, does the Health Department want to
get involved with delivery of primary care? Some Health Departments
are becoming involved in primary care basically for people with no other
resource for this care available to them, and the Health Department
being a port of last resort. The State is not opposed to this sort
of activity, but it means the Health Department would take on a whole
new set of responsibilities and legal obligations in terms of mal-prac-
tice and expertise.
Health Board Minutes, December 19, 1984
Page 3:
Generally public health, Dr. Beare concluded, is a well identified
speciality in its' own right. He feels it is best to maintain a
viable, separate, distinct and identified Health Department that will
look at the preventive and public health services required under the
state statutes which cannot be contracted successfully to a Hospital
District.
Gael Stuart advised Dr. Beare that the whole possibility of consolidation
of services is being discussed because it is evident that the hospital
will be having funding problems in the future and the Health Department
is continuingly seeing more indigents, so it is looking at possibly
providing a certain amount of primary care for these people which would
add to the funding difficulties that plague all Health Departments.
Consolidation could mean such things as cross use of nurses, since the
Health Department constantly finds itself in the situation of needing
another nurse part of the time, but cannot afford to hire a full time
nurse to cover this need.
There is quite a difference between providing acute nursing service and
community nursing service, Dr. Beare responded. Most nurses trained
today have had some public nursing training but that does not necessarily
mean that they are qualified to do it, especially on a basis where they
would be going back and forth between the two services. Dr. Beare is
not sure that economics should be the determining factor in deciding
on an option to increase nursing services to the hospital and the Health
Department. In both cases providing the best care possible is important.
Another option available to the Health Department in respect to primary
care would be to refer people from the Health Department that need primary
care to the Hospital in a cooperative program, since that's where the
primary care providers are located now.
Gael Stuart noted that that is what the Health Department does now for
people requiring primary care. If the attitude of the State Health
Department was favorable to a consolidation plan and the legality was
such to allow such a plan, then a feasibility study would have to be
done to determine if resources would be increased by such a plan.
The State is not saying absolutely "No" that this type of plan can not
be done, Dr. Beare informed, but from a review of the State Statutes
and the contracting mechanism there could be a problem of control. There
have been contrac~between County Health Departments and Health Departments
and Health Districts, but no contracts fo~ in essence, taking over of
Health Department or District functions by a Hospital District. The
State would need to see a clear picture of what it is that the county
is proposing to do and then the Attorney General would need to look at
the proposal to see if it was legal.
The Health Department cannot give up or farm out it's enforcement respon-
sibilities, Dr. Fischnaller pointed out.
Lamont
class
Public
of the
Carstens noted that if the concern of the County is for this new
of medical indigent, maybe the problem is being analyzed backwards.
Health is a governmental responsibility to preserve the health
people. The government also has the responsibility for public
Health Board, Minutes, December 19, 1984
Page 4:
welfare and public assistance. When you talk about the medical indigent
you are crossing into the public assistance role of government which
comes down to the question of how are you going to pay for indigent
care. Mr. Carstens wondered if the first analysis shouldn't be how do
we pay for indigent care and then where can this job best be done.
Commissioner Pitts then stated that he felt that the problem was being
simplified and that assumptions were being made that were far beyond
the question, and then he continued with his perception of this and his
involvment in the discussion.
Since serving as Chairman of the Uncompensated Care Committee for the
Puget Sound Health Systems Agency, Commissioner Pitts, reported that
he has some background on what will be coming down to local governments
in this regard and is concerned about that. His personal opinion in
regard to public health is that if any primary care is going to happen
on the local level in public health it is going to have to be 1) the
choice of the local health department to get involved and 2) it will
have to be funded by the State. Before primary care or uncompensated
care can be considered by a local Health Department that department will
have to talk about the ongoing programs that are traditionally provided
to the community and how they are going to be funded.
Commissioner Pitts'original question to Gretchen Gephart in March or
April was "What about combining the Health Department and the Hospital
to better provide service to the community?" After a variety of rumors,
questions, anger and alot of phone calls, Commissioner Pitts noted that
possibly the question, which is all that is being discussed at present,
should have been "What about considering the combination of certain as-
pects of the Health Department and the hospital in order to see if there
might be advantages, Q.e. economic, staffing and manpower, equipment and
facilities utilization) to allow us all to continue to provide the high
quality of health services to the community in the current economic climate."
There are a broad and wide range of things that we could do in this
community since there is a single hospital with a hospital district and
a small Health Department that is contained within the county.
In the future, Commissioner Pitts continued, the County will be faced
with having to replace the Health Department Administrator and the Health
Officer and it would be better to be prepared to deal with that situa-
tion when it occurs than to have to scramble around at the last minute.
The traditional roles of the Health Department and the Hospital
are not sacred, Commissioner Pitts noted and the following quote from
Dr. Jonas Salk fi~our coming into a different era. "In order to survive
we need a new kind of thinking and a new kind of behavior. A new ethic
and a new morality, that will be the evolution of everyone rather than
the survival of the fittest. We must look into the emerging reality
to get the signals for what we ought to do now. We can each moment chose
to behave as natives on a new reality and co-creators in our evolution."
Commissioner Pitts concluded by noting that if the County is going to
look into the possibility of consolidation that it should be done in an up-
front and out in the open manner. He has no fixed agenda or time frame
but feels that the possibility should be looked into.
Health Board Minutes, December 19, 1984
Page 5:
Commissioner Pitts' question also produced a great deal of thought,
Dr. Fischnaller added, but in the discussions the staff had regarding
the possibility of consolidation, no good solutions were found.
Dr. Beare reminded those present that in his opinion there is a difference
between medical care and health care and advised that hospital services
and the whole delivery of medical care services is being looked at in
a different way. There may even be a revolution in how medical care and
health care in general is going to be delivered. There has been a
House and Senate Select Committee set up by the State Legislature to
look at public health in this state i.e. it's organization, it's delivery,
it's responsibility and it's funding. This could well impact the current
laws. Dr. Beare advised that his comments are related to what the current
law says, and maybe the suggestion from Jefferson County is for an on-
going study group to really look at this and perhaps be creative in this
community, which could possibly serve as a model throughout the State
for looking at a better way to deliver what is necessary from both a
public and a private side. His office would be happy to participate
in such a study group. The State Health office is a strong supporter
of cooperative working relationships between the Health Department and
the hospitals in areas such as utilization of space, facilities and maybe
even equipment. There is alot of room for cooperative planning to provide
better services.
Dr. Beare cautioned that
and a committment, but at
and that staff can not be
well.
doing a study such as this will take time
the same time service has to be maintained
expected to do both things and do them both
Vie Dirksen advised that the interest of the Hospital District and it's
commissioners is focusing on the community and improving the service
to that community.
In response to Commissioner Pitts query as to what form of help the
State would be willing to give, Dr. Beare advised that when a study
group was formed the State could provide someone to sit with that group
so that they could work with the group and possibly provide research
of legal questions through the Attorney General's Office.
Approval of Minutes: The minutes of the November 21, 1984
meeting of the Health Board were approved on the motion of Commissioner
Pitts, seconded by Commissioner Dennison.
Appeal of permit denial: Gerald D. Piper: Gael Stuart read
a letter from Mr. Piper requesting the variance since he could not be
present at the meeting. The Board became aware of Mr. Piper's request
at their Commissioner's meeting on Monday and decided at that time to
hold off on any action until they could discuss it as the Health Board
at this meeting, the Chairman advised.
After discussion of the type of repair that Mr. Piper is proposing for
this summer cabin near Brinnon, Dr. Fischnaller noted that the septic
tank repair was approved because it was a repair of an existing system
even though that system is within 30 feet of the Canal, and he suggested
Health Board Minutes, December 19, 1984
Page 6:
that the variance allowing the approval of the building permit be
allowed even though the water system is not up to State standards.
Commissioner Pitts moved to grant the variance and at the same
to Mr. Piper the need for the development of a community water
that meets State standards within a reasonable period of time.
Dennison seconded the motion.
time stress
system
Commissioner
NURSING DIRECTOR REPORT: Nursing Director, Gretchen Gephart
noted that the following services were provided to an increased number
of people during the month of November: Foot care was up 18%, Immun-
izations were up 19% (701 flu shots were given) WIC clinics were up
30% and newborn services were up markedly.
The following community services were provided in the Health Department's
continuing effort to reach out and make services accessible to as many
county residents as possible:
*Hepatitus B vaccine education for the staff of three group homes.
*Toothbrushing demonstrations for Head Start children in Port Townsend
and Kindergarten to Grade Three children in Brinnon.
*Educational session for sixth, seventh and eighth graders on tobacco and
alcohol in Brinnon.
*Breast self examination training session for doctor's office nurses and
staff at the Kai Tai Nursing Homes.
*Flu shot clinics at the Quilcene School.
A letter was received from the Department of Social and Health
Services that the Health Department postpone administration of the booster
DPT vaccine doses that are gien at 18 months and 4 to 6 years because
of a vaccine shortage. A tickler file will be kept on the children that
have missed this booster and when the vaccine becomes available again
they will be called in for that shot. '
Commissioner Pitts and Commissioner Brown both thanked Gretchen for her
hard work in the community and noted that they have received many oral
compliments from people as well as the written letter of appreciation.
Fee schedule hearing and Food Service Ordinance hearing:
The Board advised that these hearings will be held in January, since
there isn't sufficient time for proper publication left in December.
Suggestions for way to reduce need for overtime and comp time
accrued by Health Department staff: Gael Stuart presented a list of
suggestions that the Health Department staff had made to reduce the
amount of overtime and/or comptime accrued due to the amount of work
and the possibility that there will not be funds available for additional
staff.
Pros and cons for each item are:
Health Board Minutes, December 19, 1984
Page 7:
Item 1: Could reduce the time the Health Department is open to the
public by a half hour or an hour to allow time for doing paper
work, but none of the staff like this idea.
Item 2: Call back period for staff members sounded reasonable but have
always wanted to be accessible to the public.
Item 3: There are certain meetin~ that staff are required to attend
as a condition of a grant or regulation, etc., but all others
would be eliminated. This does not lead to professionalism
and people do need to keep abreast of what is happening in
their profession.
Item 4: Having all clinic at the Health Department office would be
terrible because this would deny people without transportation
and funds the services of the Health Department.
Item 5: Eliminating the foot care program could provide a $2,000 saving
that would be questionable in the long run. This is a preventa-
tive program that helps many people who could develop a more serious
problem if they did not attend such a clinic.
Item 6: Seeing people outside of regular office hours is a convenience
to them.
Item 7: Limiting community meetings would not help the public relations
of the department but could reduce comptime.
Commissioner Pitts commented that he would not object to item number
1 or 2. Scheduling would have to be developed, but this may be a way
to maintain more important services even though it may inconvenience some
individuals. Items 3,4, and 5 would be foolish and item 6 may need to
be looked at closer if it's just purely a convenience to some people.
The Health Department gains alot of Public Relations from Item 7, as
Gael Stuart pointed out.
After discussion of the options and possibilities available for improving
the way telephone calls are returned by the staff, it was noted by
Chairman Brown that this would have to be worked out with the secretaries.
Suggestions for increasing revenue: Gael Stuart advised that there were
suggestions made such as requiring medical coupons for services performed
for indigent patients (people on Medicaid). This would only transfer
money from one governmental program to another.
Gretchen Gephart noted that less than 5% of the people who use the
Well Child Clinic are on Medicaid , and there are alot of poor people
who are not covered by Welfare.
Full charges for medical services performed was also discussed. Glen
Ison noted that the $3.00 charge for the flu shot seemed as if it should
be higher to cover the actual cost. The $3.00, he was advised, only
covers the cost of the vaccine and the syringe. Commissioner Pitts
noted that a sign advising the flu shot recipients of the actual cost
of the shot may encourage people who can afford more to donate money
Health Board Minutes, December 19, 1984
Page 8:
toward the cost of the shot.
Gael Stuart added that if the Environmental Health, Nursing and Secretarial
staff time could be increased then none of the reduction in service
suggestions would be necessary.
The Board will have a meeting with the Planning/Building Department,
and the Environmental Health staff to discuss ways that the Planning/
Building Department staff could be used to supplement the Environmental
Health Department in such areas as final checks on septic tanks and
water sample delivery.
Gael Stuart asked for permission to increase the following areas of
the 1985 Health Department budget for the following: $7,000 for contract
nursing services and $3,000 for clerk hire secretarial services, and
also whatever is necessary to cover a contract with the County Building
Department if those services are used.
ENVIRONMENTAL HEALTH DIRECTOR REPORT: Due to the length of
the meeting, Randy Durant did not make any comments on his November
activities report.
ADMINISTRATORS REPORT: The financial report for November 30,
1984 is at the bottom of the agenda.
MEETING ADJOURNED
JEFFERSON COUNTY
BOARD OF HEALTH
B.G. Brown, Chairman
John L. Pitts, Member
ATTEST:
Larry W. Dennison, Member
Lorna Delaney,
Secretary