Kenneth B. Cohen, Health Care Services Director 2011-12 2012-13 2013-14 2013-14 Increase/ General Fund Actual Approved Requested Recommended (Decrease) Expenditures Salaries & Benefits $17,755,051 $20,477,977 $22,465,808 $22,345,774 $1,867,797 Services & Supplies 3,540,891 4,319,151 4,711,227 4,711,227 392,076 Other Charges 67,574 33,000 33,000 33,000 0 Fixed Assets 81,361 175,000 199,250 199,250 24,250 Total Expenditures $21,444,877 $25,005,128 $27,409,285 $27,289,251 $2,284,123 Expenditure Reimbursements (465,164) (637,942) (1,493,942) (1,493,942) (856,000) Total Appropriations $20,979,713 $24,367,186 $25,915,343 $25,795,309 $1,428,123 Earned Revenues By Source Fines/F orfe itures/pena Ities $4,008 $4,000 $4,000 $4,000 $0 Aidfrom Other Governments 11,605,290 12,578,245 14,231,710 14,231,710 1,653,465 Charges for Services 1,671,768 810,355 908,000 908,000 97,645 Miscellaneous Revenues 239,840 60,000 60,000 60,000 0 Operating Transfers In 1,804,622 2,303,638 1,597,305 1,597,305 (706,333) Total Revenues $15,325,527 $15,756,238 $16,801,015 $16,801,015 $1,044,777 Net County Cost $5,654,186 $8,610,948 $9,114,328 $8,994,294 $383,346 Allocated Positions 177.0 195.0 199.0 198.0 3.0 Temporary (Full-Time Equivalent) 9.3 12.6 16.7 16.7 4.1 Total Staffing 186.3 207.6 215.7 214.7 7.1 Purpose The'mission of San Joaquin County Public (PHS) is: "PHS, in partnership with the community, promotes a healthy future for San Joaquin County." Its vision is: "San Joaquin County is a community where innovative, quality public health programs and services are available and accessible. San Joaquin County PHS promotes well being and prevents disease through community engagement and interaction, education, workforce development, leadership, and strategic planning. We serve everyone with respect by acknowledging and supporting diversity." Major Budget Changes ~ $373,210 Add five positions. ~ ($173,055) Delete two positions from sexuallytransmitted disease (STD) ~ $1,255,790 Full-year cost of 11 positions added midyear 2012-13. ~ $10,355 Increase in extra-help. ~ ($88,331) Decrease in overtime and holiday pay. Services ~ $432,478 & Supplies Increase in outside services for the Network for a Healthy California Salaries & Employee Benefits ~ $489,828 Negotiated salary and benefits adjustments. ~ $41,995 ~ ($103,704) Increase in Workers' Compensation and Casualty Insurance costs. Decrease in clinic medical supplies. F-15
Fixed Assets Expenditure Reimbursements ~ $196,700 ~ $2,550 Replacement computers, servers, and routers. Microscope. ~ $856,000 Increase in reimbursement for Cal-Learn Workload Data Health Promotion & Administration Actual Est./Act. Projected 2009-10 2010-11 2011-12 2012-13 2013-14 Births & Deaths Registered 13,501 13,216 13,191 13,200 13,500 Health Education Presentations 133 270 288 450 600 Disease Control & Prevention Communicable Disease Control Pres ent ations/c onsult ations 320 165 108 656 835 Surve illance/i nvestigations 2,000 1,510 1,389 692 1,200 AIDS Program HIV Tests & Counseling 654 470 348 500 600 Case Management for HIV Clients 205 204 182 200 200 HIV Public Education Contacts 1,190 1,092 632 800 800 Tuberculosis (TB) Control TB Clinic Visits 475 503 504 1,000 1,000 Case/Contact Investigation Visits 3,500 3,500 2,708 2,020 2,620 Observed TB Therapy Visits 7,000 5,200 5,084 5,951 6,057 Pres ent ations/c onsult ations 500 340 412 1,706 1,742 Public Health Clinic Patient Visits 14,694 17,860 18,003 14,208 14,500 Immunizations Administered 52,588 27,615 28,111 22,610 21,480 Public Health Laboratory Laboratory Procedures 169,000 168,340 161.497 120,000 125,000 Family Health Division WIC Caseload/Month 11,854 11,840 11,860 11,600 12,000 California Children s Services Average Monthly Referrals 292 295 298 205 225 New Cases Opened 1,625 1,508 1,476 1,404 1,450 Medical Therapy Treatment Units 23,506 13,670 12,041 21,000 21,000 Maternal Child & Adolescent Health Home Visits 1,951 648 432 1,150 1,150 F-16
Revenues >- $727,020 >- $274,645 >- $251,445 >- ($200,000) Program Discussion Increase in State funding for Network for a Healthy California Increase in laboratory revenue. Increase in State funding for California Children's Services (CCS) Decrease in clinic revenue. The recommended 2013-14 budget for PHS totals $27,289,251, which is an increase of$2,284,123 from 2012-13 primarily due to salary and benefits adjustments, full-year cost of II positions added midyear 2012-13 for Cal-Learn, Network for Healthy California, and MI Baby/ MI Bebe programs. The recommended budget includes the addition of five positions: >- A Public Health Nurse to comply with CCS minimum staffing standards. >- A Community Health Outreach Worker to provide support to the Network for Healthy California >- A Public Health Microbiologist to support increased laboratory testing. >- Two Women, Infants and Children (WI C) Nutrition Assistants for WIC eligibility services. 2012-13 Activities Communicable Diseases San Joaquin County and other California jurisdictions continue to experience an increase in syphilis cases. Expertise has been retained on a part-time basis to manage investigation and control activities. This position will continue into 2013-14. The State implemented a new system called CalREDIE for required disease reporting. In 2012-13, PHS began utilizing CaIREDIE, and it is anticipated that community health care providers will be able to begin reporting through the system in the near future. In 2013-14, the State will add an Electronic Lab Reporting component to CaIREDIE. Health Accreditation Board. Although PHS is a few years from meeting all of the standards and measures necessary for accreditation, a Senior Deputy Director position was filled to assist with guiding PHS through the development. Since the mid 1990's, PHS has participated in a community health needs assessment required every three years to meet nonprofit hospitals' community benefit requirements. Also, the San Joaquin Valley Public Health Consortium, a collaborative of the eight health departments and other university and health care systems in the region, are working together on regional apprqaches to develop the capacities to meet accreditation standards. Adolescent Programs In the 2011-12 State budget, the Cal-Learn program, which provides mandatory case management for pregnant and parenting teens receiving public assistance, was suspended. In 2012-13, the program and positions were restored late in the fiscal year. The 2013-14 budget includes full-year cost of the Public Health Facilities In 2012-13, the acquisition and installation of the Biosafety Level (BSL) 3 laboratory was completed. The unit has enhanced capacity of the entire PHS Laboratory, and will allow for more frequent tests and improved turnaround times. Staff continue to prepare for certification by the Centers for Disease Control and Prevention so that the BSL 3 can be used for select agent testing. In 2012-13, PHS began utilizing a new laboratory management and billing software. 2013-14 Considerations State Budget & Other External Funding The Governor's proposed 2013-14 budget does not include any material reductions to public health programs; however, federal "sequestration" could result in a number of funding reductions. Nutrition Education and Obesity Prevention, WIC, Immunizations, Adolescent Family Life, Maternal and Child Health, Tuberculosis Control, and Emergency Preparedness programs may be affected. The recommended budget includes known funding levels for multiyear agreements and otherwise assumes no increases in State funds. Should the final adopted State budget have any direct impacts, PHS will return to the Board with recommendations. Affordable Care Act (ACA) Public Health Accreditation In 2012-13, the first State and local health departments the country achieved accreditation through the Public in The impact of ACA on PHS is not known. Core public health functions will continue, such as communicable disease surveillance and control, tuberculosis and sexually transmitted disease control, health promotion and chronic F-17
disease (cardiovascular, stroke, obesity, diabetes, and asthma) prevention, and maternal, child and adolescent health. The ACA includes provisions for clinical preventive health services and incentives for health care providers to manage chronic conditions. These are areas in which there will be opportunities for PHS to work more closely with the medical community; however, these activities are not the same as community-level prevention, and PHS will continue to work with partners across all sectors of the community on efforts to prevent chronic diseases. Women, Infants and Children (WIC) Supplemental Food Program Statewide, the WIC case load has been falling, even though the program is not serving all of the eligible women and children. WIC agencies must serve at least 97% of its assigned caseloads or risk a reduction in funding. In 2012-13, the PHS WIC program received a cut in funding and continues to operate below the 97% threshold, which may result in an additional case load reduction in 20 13-14. Children in Healthy Families who transition to Medi-Cal will be deemed eligible for WIC, and PHS is partnering with the Health Plan of San Joaquin and other WIC agencies in the County to make eligible families aware of this benefit and encourage enrollment. Clinical Services In 2008-09, PHS became an approved provider in the Family Planning Access, Care, and Treatment (FPACT) program, which allows PHS to bill the State for sexually-transmitted disease (STD) services. Providers may no longer bill FPACT if the primary service sought is STD. Combined with an overall drop in total caseload, the clinic will receive less revenue in 2013-14 than the prior fiscal year. The recommended budget deletes two positions to partially offset the revenue reduction. Emergency Preparedness PHS administers Public Health Emergency Preparedness (PHEP) federal funds to develop emergency response plans, train staff, and conduct exercises and drills. Emergency Medical Services (EMS) similarly administers the federal Hospital Preparedness Program (HPP) grant, which provides funds to plan for hospital surge capacity, mass fatality management, emergency communications, advanced registration of medical volunteers, and other areas. PHS and EMS coordinate and cooperate with the Office of Emergency Services and other first responder agencies for emergency planning and response. Emergency preparedness is now considered an essential public health function. Although federal resources are declining, the program is ongoing. In 2012-13, a Public Health Emergency Preparedness Coordinator position was established to manage this function. Health Information Exchange (HIE) The development of a HIE, is a cooperative effort of Health Care Services, San Joaquin General Hospital, the Health Plan of San Joaquin, and Community Medical Centers. The HIE can transmit required information to CaIREDIE, provide real-time exchange of immunization information with the local immunization registry, and furnish patient medical information for PHS case management. Information will be available that may assist PHS in its role of monitoring the health of the community such as incidence of disease and certain laboratory test results. The data may also be helpful for "syndromic surveillance," or identifying illness clusters early, before diagnoses are confirmed and reported to public health agencies, which would assist PHS to mobilize a rapid response. Health in All Policies (HiAP) In February 20 I0, the Governor signed an Executive Order establishing the HiAP Task Force. A HiAP approach recognizes that health and prevention are impacted by policies managed by non-health government and non-government entities. Many strategies that improve health will also help to meet the policy objectives of other agencies. The HiAP Task Force recommendations addressed two strategic directions: >- Building healthy and safe communities with opportunities for active transportation (such as walking and bicycling); safe, healthy, affordable housing; places to be active, including parks, green space, and healthy tree canopy; the ability to be active without fear of violence or crime; and access to healthy, affordable foods. >- Finding opportunities to add a health lens in public policy and program development and increase collaboration across agencies and with communities. PHS has engaged in activities that support a HiAP approach. In 2007, PHS provided written policy recommendations to the City of Stockton General Plan Update. Similar comments will be submitted for the County General Plan Update. PHS is engaged with the San Joaquin Council of Governments process to develop a Sustainable Communities Strategy for its Regional Transportation Plan. Network for a Healthy California Program In 2012-13, additional funding was received from the California Department of Public Health's Network for a F-18
Healthy California to expand comprehensive local nutrition education and obesity prevention programs. The recommended budget adds a Community Health Outreach Worker for this The State requires 30-50% of the funds be directed to local organizations to conduct some of the initiatives. California Children's Services (CCS) Program The CCS is a State-mandated program, which provides diagnosis, treatment, and therapy services to financially and residentially eligible children under age 21 who have severe handicapped conditions. Diagnostic and Treatment Claims CCS funding is derived from a State/County cost-sharing formula. In any given fiscal year, the program may receive excessive referrals of children with CCS eligible conditions for which there are no funds available for diagnosis, treatment, and therapy. In such instances, program options could include: ~ Appropriate additional County funds to meet increased program needs. ~ Cease to authorize services for children who are not covered by Medi-Cal or Healthy Families; therefore, are 100% the responsibility of the State and local ~ Continue to authorize services, but when the County has depleted appropriated funds, delay payment to health providers and facilities until the next fiscal year. ~ Prioritize those conditions for which authorizations are issued and cease authorizing those that do not meet priority criteria. Through April 2013, the caseload has included few participants requiring large expenditures and the program has remained within budget. The administrative decision continues not to pay the State for the County share of diagnostic and treatment claims for children with Healthy Families coverage. The County has already met its statutory Maintenance-of-Effort (MOE) requirements, and PHS asserts that payment for local share of Healthy Families claims cannot be compelled once the MOE is met. Administration & Case Management In 2008-09, the State began to allocate a capped allotment to counties for program administration. Previously, local jurisdictions were reimbursed, in accordance with various matching formulas, program administration costs necessary to meet a set of defined staffing standards. As a result of the capped allocation, local health departments can no longer support the number of employees necessary to comply with the State staffing standards. While State staffing standards dictated a standard of 400 cases per nurse, the CCS program now assigns 800 cases. Medical Therapy Program (MTP) Statute requires that CCS provide physical and occupational therapy in public schools to children for which such therapy is included in their individualized education plans. There are not enough allocated therapy positions in CCS to provide the number of therapy hours prescribed for all of the children in the Statute allows schools to provide therapy for the students who do not receive therapy through CCS, and PHS would be obligated to pay those expenses. Supplemental Request The Health Care Services Director submitted a supplemental request totaling $120,034 to add one Public Health Educator to provide support for chronic diseases primarily dealing with obesity. This position would assist in collaborating with community and faith-based organizations, local government agencies and policy makers, schools, and the business community. Funding for this request has not been included in the recommended 2013-14 budget. F-19