HEALTH SERVICES AGENCY

Transcription

1 HEALTH SERVICES AGENCY PROPOSED BUDGET FY PROPOSED BUDGET All Funds FY FY Revenues 139,456, ,269, % General Fund 7,988,834 9,165, % Other Funds 276, , % Total Financing 147,722, ,646, % Expenditures 147,722, ,646, % ORGANIZATIONAL CHART Administration Director Giang T. Nguyen Total Staffing % Unfunded Staffing % Behavioral Health Clinic Services Public Health Environmental Health 5-YEAR TRENDS $160.0M Revenues vs. Expenditures 545 Funded Staffing $145.0M 530 $130.0M 515 $115.0M FY 14 FY 15 FY 16 FY 17 FY FY 14 FY 15 FY 16 FY 17 FY 18 Revenues Expenditures In the chart above, the gap between revenues and expenditures is financed by a combination of General Fund contributions and available other funds. In mid-year 16-17, a net of 2.0 budgeted positions were added and 1.0 position remained unfunded. The Proposed Budget recommends an increase of 1.95 budgeted positions and unfunding positions for a total of funded positions. 119

2 BUDGET SUMMARY OVERVIEW Actual Adopted Estimated Recommended Change from All Funds Revenues 118,366, ,456, ,099, ,269,316 (3,187,646) -2.3% General Fund 7,972,765 7,988,834 7,988,834 9,165,392 1,176, % Other Funds 158, , , ,958 (64,938) -23.5% Total Financing 126,497, ,722, ,214, ,646,666 (2,076,026) -1.4% Expenditures 140,129, ,234, ,672, ,966,021 (2,268,571) -1.4% IntraFund Transfers (13,631,935) (14,511,900) (14,458,511) (14,319,355) 192, % Total Expenditures 126,497, ,722, ,214, ,646,666 (2,076,026) -1.4% Total Staffing % Unfunded Staffing % MISSION The Health Services Agency s (HSA) mission is to protect and improve the health of the County of Santa Cruz residents. The Agency is composed of five operational divisions: Administration, Clinic Services, Public Health, Behavioral Health, and Environmental Health. ADMINISTRATION The Administration Division provides support to the divisions of HSA in the areas of general accounting, information technology support services, personnel, purchasing and contracts, facilities maintenance, repair, and leasing, capital projects oversight, and strategic planning of the Department. The division is also responsible for the oversight of the County s Medical Administrative Activities program throughout the community and payment processing for indigent care services provided through Medi-Cruz, the County s indigent health program. CLINIC SERVICES Clinic Services Division provides direct health care to the community through operation of three Federally Qualified Health Centers. Services include Primary Care, Specialty Care, Integrated Behavioral Health, and Dental Services. PUBLIC HEALTH The Public Health Division s core functions include: preventing epidemics; promoting healthy behaviors; monitoring the health status of the population; mobilizing community action for health; responding to disasters; providing outreach to link high-risk, disadvantaged residents to needed services; and to lead the recommendation for development of sound health policy and planning. BEHAVIORAL HEALTH The Behavioral Health Division has the direct oversight and management of Behavioral Health treatment. Services include adult and children s specialty mental health services, forensic mental health services, public guardian services, and substance use disorder services and programs. ENVIRONMENTAL HEALTH The Environmental Health Division is committed to the protection of public health and the environment within the County of Santa Cruz through oversight, inspection, monitoring, permitting, investigation, enforcement, information management, education, and collaboration, while providing excellent customer service. 120

3 HOW THE DEPARTMENT IS FINANCED FY Total Financing Other 11.8% General Fund 6.3% Other Funds 0.1% GENERAL FUND 6.3% of the Health Services Agency budget is covered by the General Fund. OTHER FUNDS Represents revenue from health and sanitation funds and special districts. Charges for Services 30.6% Federal & State 51.2% FEDERAL & STATE Transfers from a variety of federal and State funding sources represents 51.2% of HSA funding. CHARGES FOR SERVICES Charges for services are applied when appropriate to recover service provision costs. FINANCING BY DIVISION OTHER Includes licensing and permit fees. Federal & State Charges for Services FY Financing Other* General Fund Total Financing General Fund by Division Administration 8,149, ,101 3,378,438 2,191,672 14,578,347 Behavioral Health 54,341,744 7,215,771 2,718,142 3,527,300 67,802,957 Clinic Services 3,167,351 32,441, ,940 2,347,659 38,767,341 Public Health 8,327, ,239 6,263, ,315 15,638,144 Environmental Health 185,000 2,423,495 3,161, ,446 6,354,559 Total General Fund 74,170,253 43,472,997 16,332,706 9,165, ,141,348 Federal & State Charges for Services FY Financing Other* Other Funds Total Financing Other Funds by Division Environmental Health CSA ,000 2,000 83, ,284 CSA 12A 0 240,000 5,000 66, ,115 CSA 12 Capital 0 0 1, ,998 Zone 4 334, ,944 57,659 1,184,921 Fish and Game ,100 4,900 15,000 Total Other Funds 334,318 1,147, , ,573 2,505,318 Total All Funds 74,504,571 44,619,997 17,144,133 9,377, ,646,666 * Other - Includes revenue from other local governments, insurance proceeds, sale of property, and other Voter-Approved fees, miscellaneous 121

4 WHERE DEPARTMENT EXPENDITURES GO FY Total Expenditures Other Charges 13% Other Financing 4% SALARIES & BENEFITS 46% of the expenditures provide for the staffing costs for programs and services. SERVICES & SUPPLIES Includes various costs such as professional and special services, data processing services, and office and medical supplies. Services & Supplies 37% Salaries & Benefits 46% OTHER CHARGES Includes County overhead and charges from other departments. OTHER FINANCING Financing of capital projects. *Expenditures do not include IntraFund Transfers. EXPENDITURES BY DIVISION FY Expenditures Salaries & Services & Other Other IntraFund Total General Fund by Division Benefits Supplies Charges Financing^ Transfers* Expenditures Administration 4,031,235 7,889,595 3,926,501 8,451,960 (9,720,944) 14,578,347 Behavioral Health 33,436,441 40,597,401 10,922,646 0 (17,480,882) 67,475,606 Clinic Services 17,406,230 5,638,247 2,552,629 35,000 13,135,235 38,767,341 Public Health 11,419,653 1,794,184 2,677, ,351 (252,764) 15,965,495 Environmental Health 5,282, , ,963 12, ,354,559 Total General Fund 71,576,550 56,454,032 20,603,810 8,826,311 (14,319,355) 143,141, Salaries & Benefits Services & Supplies FY Expenditures Other Other Charges Financing^ IntraFund Transfers* Total Expenditures Other Funds By Division Environmental Health CSA ,500 (4,216) ,284 CSA 12A 0 310, ,115 CSA 12 Capital Improve , ,998 Zone 4 0 1,178,314 6, ,184,922 Fish and Game , ,000 Total Other Funds 0 2,485,734 18, ,505,319 Total All Funds 71,576,550 58,939,766 20,622,780 8,826,926 (14,319,355) 145,646,667 ^Other Financing includes Fixed Assets. *IntraFund Transfers represent reimbursements to other departments.

5 BUDGET DETAIL Actual Adopted Estimated Recommended Change from All Funds Revenues Taxes 787, , , ,209 20, % Licenses & Permits 2,084,399 2,156,628 2,400,792 2,631, , % Fines & Assessments 325, , , ,985 92, % Use of Money 445, , , ,205 36, % Intergovernmental 73,736,328 86,747,219 83,718,197 74,504,571 (12,242,648) -14.1% Charges for Services 31,236,051 34,872,224 32,276,096 44,557,997 9,685, % Miscellaneous 1,899,886 6,092,563 13,168,369 4,821,943 (1,270,620) -20.9% Other Financing 7,851,591 8,100,414 8,097,800 8,116,258 15, % Total Revenues 118,366, ,456, ,099, ,269,316 (3,187,646) -2.3% General Fund 7,972,765 7,988,834 7,988,834 9,165,392 1,176, % Other Funds 158, , , ,958 (64,938) -23.5% Total Financing 126,497, ,722, ,214, ,646,666 (2,076,026) -1.4% Expenditures Salaries & Benefits 57,577,229 68,286,068 63,946,244 71,576,550 3,290, % Services & Supplies 52,158,854 58,888,190 56,530,191 58,939,765 51, % Other Charges 20,231,692 22,849,059 22,971,434 20,622,780 (2,226,279) -9.7% Fixed Assets 218,115 78, ,023 47,000 (31,571) -40.2% Other Financing 9,807,304 12,132,704 20,082,906 8,779,926 (3,352,778) -27.6% Contingency 136, Subtotal 140,129, ,234, ,672, ,966,021 (2,268,571) -1.4% IntraFund Transfers (13,631,935) (14,511,900) (14,458,511) (14,319,355) 192, % Total Expenditures 126,497, ,722, ,214, ,646,666 (2,076,026) -1.4% Total Staffing % Unfunded Staffing % DEPARTMENT STAFFING Division Adopted Mid-Year Total Recommended Change from Administration Behavioral Health (2.65) Clinic Services Public Health Environmental Health Total

6 EMERGING ISSUES The Health Services Agency budget will continue to be challenging for Fiscal Year The recommended budget reflects a strong commitment to protect and promote the health of the community, continuation of the legacy of collaboration with community partners, a highly leveraged budget of 93.6% percent federal and State funding and charges for services, promotion of strong support for staff development and training to embrace evidence-based and outcome -based practices, and exploring opportunities to align functions to ensure cost-effectiveness and quality improvement to better serve the public. All of these are being done while weathering another year of fiscal challenges. HSA will continue to operate its service delivery system under significant fiscal pressure due to the need to absorb staff salaries and benefits increases, substantial reductions in State Mental Health Realignment funds, and continued demand for primary care and behavioral health services, while experiencing competition for a limited physician supply pool statewide. There are a number of emerging issues of great concern as follows: 1) Potential Affordable Care Act (ACA) Repeal Impacts Approximately 35,000 residents could lose coverage and revert to uninsured status Episodic care could become the norm, negatively impacting health Escalation of health care costs Significant reimbursement reductions Disruption of provider care coordination Preventive, early intervention coordination and innovative care could be disincentivized 2) Impacts of Medicaid Structure Changes Affordable Care Act changes could have major implications for Medicaid $85 million is at risk in the County Proposed funding alternatives such as block grants or per-capita allocation could result in cost containment measures and potential eligibility changes at the State level Impacts are not reflected in FY budget at this time too many unknowns 3) Behavioral Health (BH) Funding Reductions FY 2017/18 budget begins to align spending with anticipated funding levels per priorities identified in County Mental Health Strategic Plan Loss of State Mental Health Realignment funding would require re-evaluation and reprioritization of the Behavioral Health service delivery system (including contract providers) Additional General Fund Contribution is requested to offset the loss of revenue for BH services and salaries and benefits increases 4) Drug Medi-Cal Expansion Impacts Approximately 20,000 residents have substance abuse disorders, of which County provides services to 1,500 individuals annually Expansion would allow County to double the number of individuals served and could potentially add new programs and services Expansion is subject to availability of federal funds and jeopardized by ACA repeal Staff currently modeling anticipated federal funding before contracting with the State 5) Alternatives to Assisting High Risk Individuals not Engaged in Behavioral Health (BH) Services Ensure that at risk individuals who are not engaged in BH services receive timely and appropriate treatment Laura s Law approach is extremely costprohibitive Need to use upstream approach and address longstanding service gaps Examine proposed alternative models and include prioritized options in the requested budget 124

7 OVERVIEW $30.0M $20.0M $10.0M $0.0M ADMINISTRATION Revenues vs. Expenditures FY 14 FY 15 FY 16 FY 17 FY 18 Revenues Expenditures Funded Staffing The Administration division includes support to the operational divisions of the Health Services Agency in the areas of finance, accounting, contracts and purchasing, information technology, personnel, countywide health planning, and facilities maintenance, repair, and leasing. This division also has the responsibility for the oversight and management of the County s Medi-Cal Administrative Activities program, County s Benefits Program which includes the Medi-Cruz program, and financing and oversight for Capital projects to expand and enhance services provided through the Community. BENEFITS PROGRAM The Health Benefits budget unit primarily accounts for the County s Medi-Cruz program, which provides health care services to the indigent population of the County that are not eligible for other coverage. This budget unit also accounts for the contributions to the SB163 program, which provides funding for emergency medical physicians and hospitals for the under-insured. 30 CAPITAL PROJECTS 20 FY 14 FY 15 FY 16 FY 17 FY 18 HSA regularly oversees a number of capital projects funded through grants. Several large capital projects will be in process during FY including: a new Behavioral Health Office Building on the Freedom Campus in Watsonville, relocation and modernization of the Santa Cruz Clinical and Public Health Laboratory, and remodeling of the Santa Cruz Health Clinic and Watsonville Health Center to add service capacity. 125

8 ADMINISTRATION BUDGET DETAIL Actual Adopted Estimated Recommended Change from All Funds Revenues Fines & Assessments 4, % Use of Money 231, , , , % Intergovernmental 8,544,806 11,080,937 11,080,937 8,149,136 (2,931,801) -26.5% Charges for Services 535, , , , % Miscellaneous 116,599 2,795,507 9,545,499 1,398,551 (1,396,956) -50.0% Other Financing 1,800,000 1,800,000 1,800,000 1,800, % Total Revenues 11,232,794 16,715,432 23,501,118 12,386,675 (4,328,757) -25.9% General Fund 1,222,113 2,191, ,371 2,191, % Total Financing 12,454,907 18,907,095 24,104,489 14,578,347 (4,328,748) -22.9% Expenditures Salaries & Benefits 3,348,712 3,923,673 3,637,137 4,031, , % Services & Supplies 5,290,959 7,230,271 5,964,249 7,889, , % Other Charges 4,312,794 5,446,856 5,446,856 3,926,501 (1,520,355) -27.9% Fixed Assets 0 38,571 38,523 0 (38,571) % Other Financing 7,783,774 11,686,475 18,436,475 8,451,960 (3,234,515) -27.7% Subtotal 20,736,239 28,325,846 33,523,240 24,299,291 (4,026,555) -14.2% IntraFund Transfers (8,281,332) (9,418,751) (9,418,751) (9,720,944) (302,193) 3.2% Total Expenditures 12,454,907 18,907,095 24,104,489 14,578,347 (4,328,748) -22.9% Total Staffing % Unfunded Staffing (1.00) -50.0% ADMINISTRATION FINANCING CHANGES Financing Category Description Impact on Services Position Impact Increase/ (Decrease) Decrease to SB163 wraparound program None 0.00 (1,080,000) Elimination of grant award None. One-time capital project for one-time purchase fully funded in FY (1,126,828) Intergovernmental Increase in Medi-Cal Provides additional funding for Administrative Activities MAA services ,745 Federal Health Programs None. One-time capital project fully funded in FY (925,363) Federal Other None 0.00 (32,417) Various adjustments None 0.00 (11,938) Contributions from Other None. One time capital project Miscellaneous Funds fully funded in FY (1,476,540) Other Revenue None ,584 General Fund None Total 0.00 (4,328,748) 126

9 ADMINISTRATION EXPENDITURE CHANGES Expenditure Category Description Impact on Services Salaries & Benefits Services & Supplies Other Charges Fixed Assets Other Financing Position Impact Cost/ (Savings) Increases for existing staff and Enhanced admin support addition of 1.0 FTE to divisions ,562 Increased costs for Medi-Cruz program contracted medical None ,363 care Increased utilities costs None, cost offset by reduction in overhead ,000 Increased cost for data None, cost offset by processing charges reduction in overhead ,753 Increased costs associated with None, cost offset by custodial services reduction in overhead ,000 Increased cost for purchases of Improves staff efficiency computer equipment ,300 Reduction of contracted professional and personnel services None 0.00 (88,800) Various adjustments None ,708 Overhead reduction Reduction is primarily due to passed along to division decreased County Overhead 0.00 (667,704) to help offset salary through A-87 increases Reduction in match costs associated with SB163 None. Budget reduction based on program enrollment 0.00 (842,141) Reduction of internal HSA administrative cost allocations None 0.00 (11,409) Various adjustments None Reduction due to not budgeting for fixed assets for FY None 0.00 (38,571) for this division Decrease to support Capital None. Full capital projects costs financed through projects funding budget 0.00 (3,372,577) HSA in FY Support the costs of purchasing five (5) vehicles through Fleet Services Additional vehicles will enhance field-based services and reduce private car mileage ,000 Reduction in costs associated None 0.00 (11,938) with Realignment transfers IntraFund Transfers None 0.00 (302,193) Total 1.00 (4,328,748) 127

10 $55.0M $40.0M CLINIC SERVICES Revenues vs. Expenditures OVERVIEW The County's Outpatient Medical Clinics protect the health of individuals and the community through a coordinated health care delivery network offering primary and specialty care, case management and ancillary support services such as laboratory and imaging. HSA operates three primary clinic sites in Santa Cruz and Watsonville that provide services to individuals and families who are among the poorest members of the community. Many of these individuals present highly complex medical issues as well as complex social issues due to mental disabilities, substance abuse addiction, and/or homelessness in addition to chronic conditions such as diabetes, HIV/AIDS, or hypertension. $25.0M $10.0M FY 14 FY 15 FY 16 FY 17 FY 18 Revenues Expenditures Funded Staffing INTEGRATED SERVICES HSA s clinics provide a wide variety of services including primary care, dental care, pediatrics, as well as specialty orthopedic services. Each of our clinics provide integrated behavioral health including psychiatry, therapy, social work case management and medication assisted treatment for addiction. The Homeless Persons Health Project (HPHP) provides a medical home, case management, and housing services for the homeless population throughout the County of Santa Cruz. HSA s two main clinics provide on-site laboratory and x-ray services FY 14 FY 15 FY 16 FY 17 FY 18 IMMUNIZATIONS HSA provides immunizations to the public at both the Watsonville and Santa Cruz clinics each afternoon without appointment. HOUSING SERVICES HPHP uses a Housing First approach to provide permanent supportive housing to over 100 chronically homeless and medically vulnerable individuals. Services include outreach, engagement, case management, and support services as well as housing navigation services including search, lease-up, move-in and housing retention to increase each individual s chances for success. 128

11 CLINIC SERVICES BUDGET DETAIL Actual Adopted CLINIC SERVICES FINANCING CHANGES Estimated Recommended Change from All Funds Revenues Licenses & Permits (113) % Intergovernmental 2,969,638 3,331,506 3,292,707 3,167,351 (164,155) -4.9% Charges for Services 20,209,533 28,907,912 23,583,636 32,441,391 3,533, % Miscellaneous 542,348 1,018, , ,940 (207,620) -20.4% Total Revenues 23,721,406 33,257,978 27,755,205 36,419,682 3,161, % General Fund 2,566,371 2,539,399 2,538,565 2,347,659 (191,740) -7.6% Total Financing 26,287,777 35,797,377 30,293,770 38,767,341 2,969, % Expenditures Salaries & Benefits 13,923,407 16,631,061 15,085,017 17,406, , % Services & Supplies 4,485,472 5,806,561 5,225,527 5,638,247 (168,314) -2.9% Other Charges 2,430,245 2,570,206 2,570,206 2,552,629 (17,577) -0.7% Fixed Assets 62,325 40,000 97,000 35,000 (5,000) -12.5% Subtotal 20,901,449 25,047,828 22,977,750 25,632, , % IntraFund Transfers 5,386,328 10,749,549 7,316,020 13,135,235 2,385, % Total Expenditures 26,287,777 35,797,377 30,293,770 38,767,341 2,969, % Total Staffing % Unfunded Staffing (0.00) 0.0% Financing Category Description Impact on Services Intergovernmental Charges for Services Reduction of Medi-Cal Administrative Activities revenue based on prior year actuals Increase in Federal Emergency Shelter Grant Expiration of Medication-Assisted Treatment grant funding Increase due to projected increase in patient demand for services and medical provider productivity standards Offset by Clinics redistribution of net county cost within Clinics budget to HPHP HUD funds available for rent subsidies for HPHP clients Potential reduction in substance use disorder services Position Impact Increase/ (Decrease) 0.00 (55,000) , (162,000) Increased services ,533,479 Miscellaneous Other Revenue primarily from Care Based Incentives Unknown 0.00 (207,620) General Fund None 0.00 (191,740) Total ,969,

12 CLINIC SERVICES EXPENDITURE CHANGES Expenditure Category Description Impact on Services Salaries & Benefits Increases for existing staff and addition of 1.10 FTE for provision HIV care and additional admin support Position Impact Cost/ (Savings) Increased services ,169 Medical materials and supplies Supports projected additional patient visits ,750 Services & Supplies Locumtenen physician services Supports projected additional patient visits Professional and Special Services. Reduction in projected None. Contract overbudgeted in FY contract expenditures for Dientes dental services based on prior year actuals , (517,508) Various adjustments None 0.00 (98,556) Other Charges Decrease in HSA Admin cost allocations None 0.00 (17,577) Fixed Assets $35k budget for exam room cabinetry in FY vs. $40k budgeted for radiology equipment in prior year None 0.00 (5,000) IntraFund Transfers None ,385,686 Total ,969,

13 CLINIC SERVICES GOALS & ACCOMPLISHMENTS GOALS The Health Service Agency Clinics Division (Clinics) primary goal is to provide high quality health care to our patient community. Clinics goals for FY include: Continue to increase primary care visits provided to County low-income patients. Continue to improve quality of patient care by developing formalized process improvement tools with defined measurable outcomes, coordinated under the advisement of HSA s Quality Management (QM) Committee and utilizing resources such as: Central California Alliance for Health (CCAH) Care-Based Incentives, Electronic Health Record Incentive Program, and Uniform Data System Measures. Begin expansion of the Emeline Campus Santa Cruz Health Center, adding thirteen exam rooms to improve health care access in the Santa Cruz area. Anticipated completion FY Add three exam rooms at the Watsonville Health Center by remodeling patient lobby areas in order to improve health care access in the Watsonville area. Anticipated completion FY Apply for federal Housing and Urban Development (HUD) Emergency Shelter Grant funding to provide rapid rehousing and case management services for chronically homeless, medically vulnerable individuals and families experiencing homelessness. Apply for additional HUD Continuum of Care funding to meet ongoing Homeless Persons Health Project goals of reducing chronic homelessness and providing medical care to this underserved, high-risk population. As a partner in Integrated Behavioral Health (IBH) services for patients with mild to moderate conditions, support IBH service expansion at our four clinic sites. Improve community access to substance abuse treatment by utilizing Drug Medi-Cal for referral to drug/alcohol services and coordinating outpatient care with IBH partners. ACCOMPLISHMENTS Provided approximately 39,000 primary care visits to 11,900 different patients. Received numerous competitive grant awards, including $3.4 million in capital funding for primary care and IBH service expansion, program support grants such as HRSA s Medication Assisted Treatment (MAT), and funding for essential medical equipment. Increased initial health assessments by 200 percent and behavioral health screenings by 20 percent through Quality Management coordination. Opened the Watsonville Health and Dental Center August 2016, providing dental and primary care in one location and increasing health care access in the Watsonville area. Launched a pilot telehealth program at Watsonville Health Center, allowing patients access to coordinated specialty care for endocrinology and pain management via information and communications technologies. Extended Santa Cruz Health Center hours, providing access to evening appointments. This site also increased pediatric care access and provides dedicated care to HIV-positive and other medically high-risk patients. Through the Homeless Persons Health Project: housed 13 chronically homeless, medically vulnerable individuals in permanent supportive housing; rendered ongoing supportive services to more than 100 formerly homeless individuals, improving quality of life and housing sustainability; provided medical care and case management services to 33 individuals with a history of high emergency care utilization and another 36 homeless individuals placed at the Recuperative Care Center following hospital discharge, reducing impacts on crisis services. Implemented MAT program to address substance use disorders through direct engagement and treatment, with more than 70 patients assisted to date. Introduced video interpretation services with medically trained interpreters for access to more than 50 languages. 131

14 OVERVIEW PUBLIC HEALTH The Public Health Division works with the community to: increase the years and quality of healthy life, promote healthy behaviors, prevent communicable diseases and preventable diseases, protect the community from health emergencies, assure access to health care, eliminate disparities in health status, ensure a healthy environment, and conduct surveillance and control of reportable diseases. $18.0M $16.0M $14.0M $12.0M Revenues vs. Expenditures FY 14 FY 15 FY 16 FY 17 FY 18 Revenues Expenditures Funded Staffing CHILDREN MEDICAL SERVICES Includes California Children Services (CCS), Health Care Program for Children in Foster Care (HCPCFC), and Child Health Disability Prevention (CHDP). Last year, CCS and CHDP programs served approximately 1,400 children under age 21 through a wide range of services. COMMUNICABLE DISEASES SERVICES Functions include identification, investigation, surveillance and evaluation of communicable, reportable, and emerging diseases and conditions to protect the health of the community. Over 2,000 communicable disease incidents were addressed last year. COMMUNITY HEALTH EDUCATION Staff provide health promotion services to address social determinants of health issues. Last year, the Supplemental Nutrition Assistance and Education Program (SNAP-Ed) provided evidence-based nutrition education to 3,354 residents and conducted health fairs to 494 residents FY 14 FY 15 FY 16 FY 17 FY 18 EMERGENCY MEDICAL SERVICES Staff work collaboratively with the stakeholders to ensure a coordinated countywide response to medical and health emergencies through planning, contract monitoring, training and incident response. MATERNAL, CHILD, AND FAMILY HEALTH SERVICES Dedicated to working with the community to promote health and to protect and support pregnant women, children, families and communities. Last year, public health nurses received 579 referrals and provided case management to 531 individuals in this program. The Nurse Family Partnership program will be implemented in April 2017 to serve 100 first-time pregnant low income mothers and their children up to the age of 2. VITAL STATISTICS AND RECORDS Office ensures compliance with the mandates of the California Health & Safety Code Sections This office registers all births, deaths, and fetal deaths in the County of Santa Cruz.

15 PUBLIC HEALTH BUDGET DETAIL All Funds Actual Adopted Estimated Recommended Change from Revenues Licenses & Permits 60,000 55,000 60,000 62,000 7, % Fines & Assessments 64, ,100 30, ,100 (3,000) -2.1% Intergovernmental 7,615,495 8,459,227 8,077,494 8,327,022 (132,205) -1.6% Charges for Services 424, , , , , % Miscellaneous 20, , , , , % Other Financing 5,129,848 5,657,748 5,657,748 5,676,455 18, % Total Revenues 13,314,475 14,824,808 14,571,079 15,123, , % General Fund 504, , , , % Total Financing 13,818,717 15,339,123 15,248,115 15,638, , % Expenditures Salaries & Benefits 9,271,246 10,752,090 10,415,665 11,419, , % Services & Supplies 1,853,839 2,067,846 2,182,721 1,794,184 (273,662) -13.2% Other Charges 2,946,568 2,925,108 3,002,261 2,677,071 (248,037) -8.5% Fixed Assets 2, % Contingencies 4, % Subtotal 14,078,967 15,745,044 15,600,647 15,890, , % IntraFund Transfers (260,250) (405,921) (352,532) (252,764) 153, % Total Expenditures 13,818,717 15,339,123 15,248,115 15,638, , % Total Staffing % Unfunded Staffing (7.10) % PUBLIC HEALTH FINANCING CHANGES Financing Category Description Impact on Services Licenses & Permits Increase in Emergency Medical Services (EMS) Ambulance Operators License revenue None. Allows EMS to support existing service level Position Impact Increase/ (Decrease) ,000 Fines & Assessments Various adjustments to Miscellaneous Fees and Fines revenue No significant impact 0.00 (3,000) Intergovernmental Net decrease of 1.7% due to various changes in grant Decrease in case revenues including management services for discontinuation of HIV care grant HIV patients funding ($226k) 0.00 (132,205) Continued on next page

16 PUBLIC HEALTH FINANCING CHANGES CONT D Financing Category Description Impact on Services Charges for Services Miscellaneous Other Financing Increase in projected Vital Statistics Revenue CA Prep Grant moved into Charges for Services from Miscellaneous Revenue Other Minor Revenue Increases Increase due to addition of Nurse Family Partnership (NFP) program Emergency Medical Services (EMS) Request for Proposals (RFP) Cost Recovery Transfer of CA Prep Grant to Charges for Services Increase in Public Health Realignment allocation Revenue increase due to projected increase services Position Impact Increase/ (Decrease) ,174 No net change in services ,000 Increase in Services Increase in Services ,545 None ,000 No net change in services (125,000) None ,707 Total ,021 PUBLIC HEALTH EXPENDITURE CHANGES 134 Expenditure Category Salaries & Benefits Services & Supplies Description Increases for existing staff and addition of 5.50 FTE Reduced expense for Syringe Services Program (SSP) due to supplies now State-purchased Reduction in Ecology Action contract due to expiration of SRTS grant Discontinuation of several Emergency Preparednessrelated purchase orders due to expiration of Ebola grant Impact on Services FTE increase to various positions. Minor increase in services No change in services. Partially offsets salary and benefits increases Discontinuation of SRTS classroom education services None. Grant deliverables completed Position Impact Cost/ (Savings) , (66,000) 0.00 (141,000) 0.00 (52,000) Various Other Changes None 0.00 (14,662) Other Charges No change in services. Decrease in HSA Admin cost Partially offsets salary and allocations benefits increases 0.00 (248,037) IntraFund Transfers None ,157 Total ,021

17 PUBLIC HEALTH GOALS & ACCOMPLISHMENTS GOALS Public Health continues to educate, plan and implement measures to control and reduce communicable and chronic diseases, prepare for emergencies and work toward a healthier the County of Santa Cruz. The goals for FY include: Completing a Community Health Improvement Plan and applying for Public Health Accreditation. The Communicable Disease Unit will address the increased rate of sexually transmitted diseases and will promote high immunization compliance in the community. The Emergency Medical Services will prepare for implementation of a new ambulance contract and system changes. The Emergency Preparedness Team will facilitate trainings in Hospital Incident Command System, Personal Protective Equipment, WEB EOC, and Start Triage. ACCOMPLISHMENTS Began implementation of the Nurse Family Partnership (NFP) program, a nationally recognized, evidence-based nurse home visiting program providing intensive home visiting services to low income first-time, atrisk mothers and their children. The Emergency Preparedness Team managed a statewide emergency exercise and trained community stakeholders in disaster response. The Emergency Medical Services program has completed forums to identify the strengths and weaknesses of the current system, and proposed efficiencies that would better serve the community and prepare for a new ambulance contract. There were eleven formal Community Dialogues on Healthy Communities done to gain feedback from residents for the Community Health Assessment needed to support the journey towards Public Health Accreditation. The California Children s Services program will collaborate with the Central California Alliance for Health in implementation of a Whole Child Model which will increase coordination of services. The Community Health Education s program will improve school crossing guard availability, decrease tobacco sales to minors, decrease childhood obesity, and improve bicycle/traffic safety. The syringe exchange program will transition to an intervention program with the goal to decrease the number of those who inject drugs, decrease the number of new HIV and hepatitis C cases, and move the majority of patients into medical care. The division has trained and distributed the drug overdose antidote Narcan to members of law enforcement and to patients who inject drugs. The Communicable Disease Unit responded to multiple early infectious disease outbreaks, multiple possible rabies exposures, and evaluation of elevated childhood blood lead levels. Children s Medical Services has begun inspection of clinics throughout the community in support of the Child Health and Disability Prevention (CHDP) standards. 135

18 OVERVIEW BEHAVIORAL HEALTH Revenues vs. Expenditures The Behavioral Health Division supports the individualized recovery goals of county residents in services through the provision of a full array of specialty mental health and substance use disorder services directly through County staff or through local provider organization contracts. Services are provided to children and families, adults and older adults through a system of care approach to most effectively leverage the community resources, with a strong emphasis on the use of Evidence Based and best practice models. $80.0M $70.0M $60.0M $50.0M FY 14 FY 15 FY 16 FY 17 FY 18 Revenues Expenditures Funded Staffing FY 14 FY 15 FY 16 FY 17 FY 18 ADULT MENTAL HEALTH SERVICES Adult Mental Health Services provides Specialty Mental Health outpatient services inclusive of psychiatry, psychotherapy, case management, occupational therapy and medication support to individuals with serious mental illness. Contract service providers offer intensive residential treatment, long term residential care, permanent supported housing and peer-run support services. CHILDREN S MENTAL HEALTH SERVICES Children s Mental Health provides a full array of mental health services to youths under age 21 who have full Medi- Cal benefits. Our interagency system of care provides specialty mental health services to youth and their families who are involved in Probation, Foster Care, Education, and in our community. SUBSTANCE USE DISORDER SERVICES The mission of the Alcohol and Drug Program is to provide opportunities for the education about, prevention of, intervention into, and the recovery from substance use related problems. Services include assessment and ongoing case management, contracted outpatient and residential treatment. Objectives include reduction of substance abuse while increasing employment, educational achievement and health, and promoting family well-being. CRISIS SERVICES The County s Behavioral Health Services provides a continuum of crisis services to the community at large. Services include Child and Adult walk-in crisis services, Mobile Emergency Response Team (MERT) services, an Adult Crisis Residential Program, an Adult Peer-Run Respite, the Santa Cruz County Behavioral Health Center that provide a Crisis Stabilization Program for children and adults, and an Adult Psychiatric Health Facility for inpatient care.

19 BEHAVIORAL HEALTH BUDGET DETAIL Actual Adopted Estimated Recommended Change from All Funds Revenues Fines & Assessments 219, , , ,500 83, % Use of Money 201, , , ,100 36, % Intergovernmental 53,456,098 62,297,793 59,918,162 54,341,744 (7,956,049) -12.8% Charges for Services 6,314,928 1,267,211 4,234,333 7,215,771 5,948, % Miscellaneous 1,229,007 1,514,768 1,771,820 1,604,354 89, % Other Financing 885, , , , % Total Revenues 62,306,197 66,073,755 66,924,671 64,275,657 (1,798,098) -2.7% General Fund 3,121,820 2,159,011 3,794,074 3,527,300 1,368, % Total Financing 65,428,017 68,232,766 70,718,745 67,802,957 (429,809) -0.6% Expenditures Salaries & Benefits 26,520,393 31,971,105 29,957,177 33,436,441 1,465, % Services & Supplies 37,585,563 40,641,307 40,460,903 40,597,401 (43,906) -0.1% Other Charges 9,646,024 10,614,380 10,658,346 10,922, , % Fixed Assets 3, % Other Financing 2,017, ,751 1,645, ,351 (115,400) -26.1% Contingencies 131, % Subtotal 75,904,698 83,669,543 82,721,993 85,283,839 1,614, % IntraFund Transfers (10,476,681) (15,436,777) (12,003,248) (17,480,882) (2,044,105) 13.2% Total Expenditures 65,428,017 68,232,766 70,718,745 67,802,957 (429,809) -0.6% Total Staffing (2.65) -1.0% Unfunded Staffing N/A BEHAVIORAL HEALTH FINANCING CHANGES Financing Category Description Impact on Services Position Impact Increase/ (Decrease) Fines & Assessments Increased Drinking Driver Fines- AB 2086 None. Projections based on current fines being collected ,805 Increased SB920 revenue None. Maintains current service levels ,000 Use of Money Increased Telecare Corp. Behavioral Health Center rent None ,000 Continued on next page

20 BEHAVIORAL HEALTH FINANCING CHANGES CONT D Financing Category Description Impact on Services Position Impact Short Doyle revenue decrease No impact to BHC ($7.852M) due to moving revenues to operations. Loss in be recognized as patient revenues to FFP related to 13 account for patient revenue collected unfunded positions, by Telecare in operation of the decreased MHSA Intergovernmental County's Behavioral Health Center funding resulting in ($6.2m), loss related to decreased reduction of some projected revenue from Federal direct services, Financial Participation for Mental reduction of Drug Health Services ($1.5m), and other Medi-Cal services reductions ($104k) BEHAVIORAL HEALTH EXPENDITURE CHANGES 138 Increase/ (Decrease) 0.00 (7,956,049) Charges for Services Increased patient revenue Increased Services ,948,560 Miscellaneous Other Revenue None ,586 General Fund None ,368,289 Expenditure Category Description Impact on Services Salaries & Benefits Services & Supplies Other Charges Other Financing IntraFund Transfers Total 0.00 (429,809) Position Impact Cost/ (Savings) Increases for existing staff less the net reduction of 2.65 FTE and unfunding of 13.0 FTE None (2.65) 1,465,336 Minor reduction in contracted services from Reduction in Medical Services community MH 0.00 (426,863) providers Increase in In-County Providers Contracts Increase in hospital expenses Various Other Changes Increase in housing services funded by MHSA In Home Supported Housing None. Increase to CSP/ PHF expenses Minor reduction in direct services , , (139,840) Increased projected expenses None ,266 for MH residential care Reduction in State Hospital offset Increase in MH FQ revenue Reduction in CHFFA Grant Funding for onetime purchase of cars Reduction in HSD ADP funding, reduction in parole reentry program, reduction in SIP/ Sobering beds funded by MHSA PEI 0.00 (115,400) 0.00 (2,044,105) *Other includes all changes under $5,000 Total (2.65) (429,809)

21 BEHAVIORAL HEALTH GOALS & ACCOMPLISHMENTS GOALS ACCOMPLISHMENTS Behavioral Health goals for FY include: Complete the new the County of Santa Cruz Behavioral Health Office Building in Watsonville, and begin providing services in the new facility as of January 1, Continued Avatar Electronic Health Record training for staff, and implementation of system modifications as necessary. Continue making the changes necessary, including the publishing of an RFP and selection of vendors, in response to changes due to children s Continuum of Care Reform (CCR), which makes significant changes in how services are delivered to children served by both HSD and HSA. Continued expansion of Integrated Behavioral Health Services, with a focus on the development of a robust program in Watsonville at the new Behavioral Health Office Building and Clinic program there. Implementation of expanded substance use disorder treatment through the Drug Medi-Cal waiver with the State of California to double the clients served from approximately 1,600 people per year to 3,000 people per year. Continued collaboration with key partners in the County to expand the Behavioral Health Court, Maintaining Ongoing Stability through Treatment (MOST Team), Mobile Emergency Response Team, and the County s new Rapid Connect Program to reach greater numbers of residents in the County who have not been previously engaged in treatment. Expansion of Evidence Based Supported Housing in the community for individuals with co-occurring mental health and other health conditions through an Innovations grant from the State. Successful award of grant funding from the Central Coast Alliance for Health to build a mobile workforce, enhance data analytics capacity, fund training in evidence-based practices, and fund the construction of a new Behavioral Health Office Building in Watsonville. Wide training in trauma-informed care across County agencies and in the community through a collaborative grant program in the Bay Area, in which Santa Cruz is actively participating. Implementation of a new Rapid Connect program, linking individuals seen in the crisis stabilization program with services within 24- hours of evaluation in order to engage more clients and families in treatment. Implementation of the Countywide Avatar Electronic Health Record which covers all services provided by the County and mental health and substance use disorder contractors to more effectively coordinate care, and facilitate access to a data set for future outcomes tracking. Expansion of outreach to individuals with severe mental health conditions through the use of peer and family partners embedded in programs throughout the County. 139

22 $12.0M $9.0M $6.0M $3.0M ENVIRONMENTAL HEALTH Revenues vs. Expenditures FY 14 FY 15 FY 16 FY 17 FY 18 Revenues Funded Staffing Expenditures OVERVIEW Environmental Health delivers services over a broad spectrum of responsibilities directed primarily at the protection of public health and the environment. Many of the programs are regulatory in nature and are based on State and federal mandates and local ordinances. Environmental Health program activities are primarily funded by permit and service fees, the County of Santa Cruz Service Area (CSA) 12 fees, grants for beach water quality monitoring and Prop 84 for integrated regional water resources management and funding from Zone 4 of the Santa Cruz County Flood Control and Water Conservation District. CONSUMER PROTECTION Over 5,000 inspections per year are conducted providing regulatory oversight of 1,687 retail food facilities, 315 public pools and spas, 27 organized camps, employee/farm labor housing (8 camps-189 workers), waste collection/storage/ disposal from 416 medical facilities, and 30 body art facilities. They also reviewed 78 plans for new construction/ upgrades to regulated facilities. Furthermore, Consumer Protection staff investigated 335 citizen s complaints of food poisoning, substandard housing, trash dumping, & disease vectors (rodents & roaches). HAZARDOUS MATERIALS FY 14 FY 15 FY 16 FY 17 FY 18 1,070 facilities that receive, store, use, create and dispose of hazardous materials are inspected annually, including 365 underground and above-ground storage tanks. Environmental Health staff are on-call every day of the year to responded to incidents involving hazardous materials releases, restaurant fires, sewage spills, and other risks to public health and the environment. This program is the certified unified program agency for the County. Members of this team provide oversight of the clean-up of 83 previously contaminated sites in the County of Santa Cruz. LAND USE This section permits small water systems, well construction, and individual sewage disposal systems. They regulate septic pumper trucks, & respond to over 50 complaints annually of waste water discharges. WATER RESOURCES This section provides water quality surveillance and protection through monitoring, testing and advisory postings, watershed management, fisheries protection and coordinating regional water management with other local water agencies and organizations. 140

23 ENVIRONMENTAL HEALTH BUDGET DETAIL Actual Adopted Estimated Recommended Change from All Funds Revenues Taxes 787, , , ,209 20, % Licenses & Permits 2,024,512 2,101,628 2,340,792 2,569, , % Fines & Assessments 37,348 30,678 28,913 42,385 11, % Use of Money 12,337 9,440 10,379 10, % Intergovernmental 1,150,291 1,577,756 1,348, ,318 (1,058,438) -67.1% Charges for Services 3,751,579 3,512,735 3,247,267 3,570,495 57, % Miscellaneous (8,330) 578, , ,085 (18,175) -3.1% Other Financing 36,463 3, (2,863) -82.3% Total Revenues 7,791,908 8,584,989 8,347,027 8,063,473 (521,516) -6.1% General Fund 558, , , , % Other Funds 158, , , ,958 (64,938) -23.5% Total Financing 8,508,207 9,446,331 8,847,991 8,859,877 (586,454) -6.2% Expenditures Salaries & Benefits 4,513,471 5,008,139 4,850,071 5,282, , % Services & Supplies 2,943,021 3,142,205 2,696,791 3,020,338 (121,867) -3.9% Other Charges 896,061 1,292,509 1,293, ,933 (748,576) -57.9% Fixed Assets 149, ,500 12,000 12, % Other Financing 6,463 3, (2,863) -82.3% Total Expenditures 8,508,207 9,446,331 8,847,991 8,859,877 (586,454) -6.2% Total Staffing % ENVIRONMENTAL HEALTH FINANCING CHANGES Financing Category Description Impact on Services Position Impact Taxes Licenses & Permits Fines & Assessments Use of Money Increased property tax revenue will increase Zone 4 Flood Control Maintains service Water Conversation District levels revenue Proposed increase in most types of license and permit fees Proposed increase in most types of fines and assessments Increase is due to small miscellaneous changes Maintains service levels Maintains service levels Increase/ (Decrease) , , ,707 None Continued on next page

24 ENVIRONMENTAL HEALTH FINANCING CHANGES CONT D Financing Category Description Impact on Services Position Impact Reduction is primarily due to None. Grant Intergovernmental expiration of Prop 84 Stormwater projects completed. grant program Maintains service Charges for Services Increased license and permit fees. levels Increase/ (Decrease) 0.00 (1,058,438) ,760 Miscellaneous Decrease in HSA Zone 4 revenue None 0.00 (18,175) Other Financing None 0.00 (2,863) Other Funds None 0.00 (64,938) Total 0.00 (586,454) ENVIRONMENTAL HEALTH EXPENDITURE CHANGES Expenditure Category Description Impact on Services Position Impact Cost/ (Savings) Salaries & Benefits Increases for existing staff None ,852 Services & Supplies Other Charges Fixed Assets Other Financing Increase due to planned purchase Improves staff of tablets for field-based staff efficiency Reduction in Zone 4 services and None. Project supplies due to expiration of Prop complete 84 Stormwater grant program Decrease in HSA Admin cost allocations None. Offsets salary and benefit increases and reduces fee increases Increase due to planned purchase Improves staff of large format scanner efficiency Reduction is due to small miscellaneous changes , (211,867) 0.00 (748,576) ,000 None 0.00 (2,863) Total 0.00 (586,454) 142