HomeMy WebLinkAboutAgenda 04-01-2004G °,,�vtY Hea�fh
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North Carolina Public Health
ORANGECOUNTY
HEALTH DEPARTMENT
Rosemary L Summers,
MPH, DrPH
Health Director
Richard E. Whitted Human
Services Center
300 West Tryon Street
Post Office Box 8181
Hillsborough, NC 27278
Phone: (919) 245 -2411
Fax: (919) 644 -3007
www. co. orange, nc. us /health
BOARD OF HEALTH
Alice White, MPH, PhD
Chair
Alan Rimer, PE
Vice Chair
doses Carey, Jr. Commissioner
Timothy Carey, MPH, MD
Christina Harlan, RN
essica Y. Lee, DDS, MPH, DrPH
Sharon E. Van Horn, MPH, MD
Matthew Vizithum, OD
Lee D. Werley, PharmD
Edith Kathryn Wilder, DVM
tv
To: Orange-County Board of Commissioners
From: Orange County Board of Health
Date: March 26, 2004
Re: Topics for Discussion at April 1 Dinner Meeting
The Board of Health appreciates very much the opportunity to meet with the
Board of Commissioners. The Board of Health identified many topics for joint
discussion, but has narrowed the field to the following topics:
• Primary Care
o Attachment 1: Business Plan and Financial Analysis
• Public Health Task Force 2004 Recommendations
o Attachment 2: Comments on Public Health Task Force 2004
Recommendations
o Attachment 3: Preliminary Report from the Public Health Task
Force 2004
• Community health assessment priority areas
o Attachment 4: Healthy Carolinians of Orange County
Community Priority Issues Plan
o Attachment 5: Executive Summary: Orange County Community
Assessment 2003
• Non - regulatory environmental education programs
The Board of Commissioners may also have topics not on this list that it wishes
to discuss.
The attached material is provided only for your reference and review. We are
very interested in your feedback on these topics that we believe are important
for services to all of our county's residents.
Again, thank you for the opportunity to meet with you to discuss these items.
Attachment 1: BOCC/BOH Joint Dinner Meeting 04/01/04
BUSINESS PLAN
Orange County Public Health Department
Primary Care Services
March 23, 2004
Business Description
The mission of the Orange County Health Department (OCHD) is "to enhance the quality of life, promote
the health, and preserve the environment for all people in the Orange County Community." Enhanced
quality of life and promotion of health are achieved through improved access to a continuum of services,
both preventive and primary healthcare services. As such, the OCHD is seeking to expand its current base
of preventive services to include primary care for its traditionally served populations. This new service
will be provided in the current VA -fitted clinical facility in Hillsborough to facilitate access for OCHD's
client base, as well as make use of existing staff, equipment, and supplies.
Industry Analysis
Primary care services are aimed at assuring that the basic health needs of patients are met. This includes
ongoing evaluation of the individual's health and early diagnosis and treatment of common illnesses. In
addition, the primary care clinician acts as an advocate and consultant to the patient, providing advice
regarding various diagnoses and therapies, referrals to specialized care physicians, and continuing care for
chronic conditions.
One of the primary goals of the OCHD is to provide quality health care services when they are not
otherwise available. In Orange County, several access -to -care barriers exist. Issues such as language and
cultural barriers (i.e. Latinos), uninsured, underinsured or Medicaid status, and workers earning wages
below the federal poverty line result in inadequate access to primary care services. Few medical providers
offer a sliding fee scale and those that do are often inaccessible due to a limited transportation system,
particularly in the northern part of the county. Orange County has a significant number of families living
in poverty, with 14.1 % of all individuals living below poverty level. More specifically, 3 8.5 % of female -
headed households with children under 5 years of age are living below the poverty level, of which many
are OCHD clients'. A 2002 Behavioral Risk Factor Surveillance Survey found that 8.4% of Orange
County residents usually went to a public health clinic for their healthcare, 23.5% said they did not have a
regular medical provider, 5.5% used the emergency room, and 2.8% went to urgent care. An income level
below $50,000 increased the likelihood of these occurrences from 4 times to as many as 25 times2.
Information from the University of North Carolina (UNC) Hospitals illustrates that 86.2% of Orange
County visits to the emergency room were made between the hours of 8am and 1 1pm. 49.6% of these
visits were for conditions with a low potential for complications or were unlikely to progress in severity,
and required minimal resource intensity. These conditions are of the type that can be handled more cost
effectively in a primary care setting.
'Scully, Aviva. Primary Care Needs Assessment for Orange County Health Department. October 2003.
'North Carolina Center for Health Statistics. Results from the N.C. Behavioral Risk Factor Survey (BRFSS).
hM?: / /www.ppi state nc us /SHSC/Healthstats/brfss /2002 loran /getcare.html.
Attachment 1: BOCC/BOH Joint Dinner Meeting 04/01/04
COMDetitive Analvsis
The Institute of Medicine's report on Core Public Health Functions stressed the importance of assessing
the needs of the community and assuring that quality health services are available and accessible to all
persons. A comprehensive Primary Care Needs Assessment was completed in October 2003. It revealed
that the Town of Hillsborough including the Northern Orange County unincorporated areas offer only
three primary care medical practices. These medical practices routinely require payment in advance and
limit the number of uninsured and Medicaid patients that they serve. Access to primary care services in
Northern Orange is substantially limited particularly for low - income, uninsured, vulnerable populations.
An OCHD client survey, as part of the Primary Care Needs Assessment, revealed that, of Whiffed clients,
36% indicated they did not have a place to go when sick, but of those, 73% considered OCHD to be their
medical provider. 56% of Whitted clients had used the Emergency Department in the past year one to
three times. 91 % of Whiffed clients surveyed said they would choose OCHD as their primary care
provider if primary care services were offered'.
The North Carolina Public Health Statutes state that the mission of the public health system is to promote
the availability of quality health care services through the private sector and to provide quality health care
services when they are not otherwise available. OCHD proposes to offer primary care services to
residents in the Hillsborough and Northern Orange county area who are currently enrolled in the
traditional services offered by the Health Department, namely the Family Planning, Child Health and
Maternal Health programs, and who do not have access to a primary care provider. In addition, women
who age out of or are otherwise no longer eligible for Family Planning Services will be offered continued
services. Through the provision of `preventive primary care' to women and children in
public health preventive programs on a sliding fee scale basis, OCHD seeks to improve the health status
of our clients by reducing fragmented care and increasing the continuity of care.
MarketinLy Strate
The marketing strategy will be aimed at women and their children who are participating in the Family
Planning, Child Health and Maternal Health programs who account for over 60% of all current clinical
encounters. The OCHD currently offers several preventive services for women and their newborns, such
as prenatal care, birth control counseling, well child care, and immunizations. The primary care services
will promote and build upon the relationships already established with these clients and offer early
detection and treatment of common illnesses.
Marketing will be focused in -house and to OCHD's traditional populations. Marketing strategies may
include one or more of the following approaches:
• Posters inside the OCHD waiting room
• Posters placed inside the exam rooms at the OCHD
• Brochures that can be given to clients during their clinical visits
• Brochures that can be mailed to current clients
• Featured information about primary care services on the OCHD's website
Cultural and language barriers are some of the impediments to receiving quality healthcare. To address
this issue, all marketing materials will be prepared in Spanish and English to reach all segments of the
population.
A minimum fee of $15 will be assessed in advance of services, with the balance payable based on the
sliding fee scale. This minimum fee was developed following a needs assessment, which asked current
2
Attachment 1: BOCC/BOH Joint Dinner Meeting 04/01/04
clients what they would be willing to pay for primary care services. According to the client survey, 72%
of clients stated that "a required small nominal fee would not be a financial barrier to seeking care." The
pricing strategy is different from private sector medical offices which may charge $100 or more per visit
and require the payment in advance, while limiting the number of uninsured and Medicaid patients that
are treated.
Fin ancial/Overational Analysis
The Orange County Health Department (OCHD) will operate the primary care services venture under its
Personal Health Services Division (PHSD). Startup and operating costs will be included as part of the
PHSD annual budget. The Health Department bills its services using a sliding scale, from which patients
are charged varying amounts depending on family income level. Patients will be billed anywhere from
0% to 100% of charges, with the majority of PHSD clients being Medicaid clients and 0% pay clients
(Appendix Q. [With the addition of a requested billing clerk position in the Central Administrative
Services Division, we anticipate improved recovery of receipts from clients in the 20 -100% sliding fee
scale range].
Current staff in the PHSD will be utilized to carry out primary care services. However, the Health
Department requests to increase a current Family Nurse Practitioner position from .5 FTE to 1.0 FTE.
With a decreasing yet substantial `no show' rate, we anticipate primary care services will be easily
integrated into our current open access scheduling format for preventive services. In addition, staff
schedules and hours of operation will be shifted so that some week night appointments will be available
to provide better access for working clients and teens.
The newly renovated Whitted building in Hillsborough (currently used for personal health preventive
services) will be utilized to provide primary care services. Clinical space will be tight and the pharmacy
will be crowded necessitating a new shelving system at some point, but this incremental change will be
achievable with current space.
There are approximately 1000 eligible clients currently seen within the Family Planning, Child Health,
and Maternal Health programs (primarily women and children). However, it is not expected that all
clients will seek primary care services. Projected primary care volume for the first year is anticipated to
be 50% of the total client base, which yields 500 patients. It is estimated that each client will make 1.5
visits per year, which yields 750 visits /year (Appendix A).
The minimum charge billable for a primary care visit will be $15. The average charge per visit is
estimated to be $90. The minimum charge for a dispensed stock medication will be $3.
Revenue Scenarios: (Appendix A)
Each figure includes patient service revenue, lab, and medication revenues
Worst Case (collecting only the minimum $15 fee) $115568
Best Case (collecting $90 from every client for every encounter) $73,375
Most Likely Case $49,364
OCHD will need minimal new equipment. The only projected major equipment needed for startup is 1
defibrillator and 1 EKG. In addition, other expenses will include DEA licenses for prescribing controlled
substances by FNPs, pharmaceuticals (which is expected to be one of the largest expenses), training costs,
and lab outsourcing fees (Appendix B).
3
Attachment 1: BOCC/BOH Joint Dinner Meeting 04/01/04
OCHD will use its current base of vendors for medical supplies, equipment, and drugs. To offset the
increased cost of pharmaceuticals that will ensue, OCHD will assist patients in completing applications to
receive drug assistance (free medications) from the major pharmaceutical companies and where
necessary, will dispense these medications according to company - specific guidelines.
First year expenses (which include start -up and operating costs) are expected to be
approximately $93,132 (Appendix B).
The following graph provides the most likely scenario for revenues, expenses, and net income for the first
five years of operations (Appendix E). Expenses in the first year are much higher than revenues,
primarily due to start -up costs. However, the gap between revenues and expenses subsides each year due
to higher patient volume (expected increase of 20% per year) and operational efficiencies. Nearly
breakeven is expected between year 5 and 6, if revenues and expenses continue as projected.
Future Financial Projections for Primary Care
$150,000 k i ,
_ e
+v.
MET
$100,000
$50 000 Re�nues
iq- §1v��,� �- Expenses
•-r "y' .rte` x -�rcd -.� a RE A-03
$0 Y ZSE z - Net Income
.�=-' �l
$50,000
f �''t3' -r „a...rt <= ti ':4 ^+• Sri -c �a
t
$100,000
Year
Success will be measured in several domains: Increased patient visits, decreased emergency room use,
and patient satisfaction with the service. OCHD has projected 750 patient visits for the first year; if this
goal is met or exceeded then the primary care services will be considered initially successful. Semi - annual
surveys of clients using OCHD's primary care services will be conducted. Emergency room usage and
patient satisfaction among other factors will be assessed. A decrease in emergency room usage from the
original survey and an overall 85% satisfaction rating by clients will be considered a success.
Detailed financial analysis follows.
* We acknowledge and thank UNC Students Allyson Banos, Victoria Huntley, and Moneica R. Kiser for
their work on developing the draft of this Business Plan.
2
Pro Forma Income Statement (YEAR 1)
Revenues*
ztEal
Expenses **
Z�,55,0 t
I. Start Up Costs
Large Equipment
6,900
Office Equipment
480
Books
386
IDEA License
630
START UP COSTS TOTAL
$8,396
11. Annual Operating Expenses
100
A. Personnel
$50,860
Labor
33,876
Personnel Total
Z�,55,0 t
B. Miscellaneous Operating Exp
Lab Fees
23,664
Pharmaceuticals
17,451
Supplies
3,985
Training
500
HealthLink Contract
5,160
Equipment Maintenance
100
MISC. OPERATING TOTAL
$50,860
START UP TOTAL $8,396
ANNUAL OPERATING TOTAL $84,736
2
6-1 . r� i{r ti.. may. ncorr�e r1 ar
Notes
* Appendix A
** Appendix B
Al
2
3
4
5
6
7
e
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
i3
Appendix A
Patient Revenues
C D E F G H i J K
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Total # of program clients
rounded up
1000
Family Planning
[Given]
532
STD
[Given]
201
Child Health
[Given]
323
Estimated % of clients that will use PC
[Given]
50%
Expected # of PC clientslyr
[D5'D9]
500
Expected # of encounters /client/yr
[Given]
1.5
,Expected # of PC encounters/ r
DI0*DI 11
750
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Given
_
Given
D12-D18
»
Given
Given
F -G
E "G
E "F
C'E'H +I
Self-Pay: Sliding Scale
0%
0%
28.8%
216
$ 90
$ 90
90
$ 15
$ 15
$ 15
$ 75
$ 75
$ 75
$ 3,240
$ 664
$ 360
$ 19,440
$ 3,983
$ 2,160
$ 3,240
$ 1,328
$ 1,080
20%
20%
5.9%
44.25
40%
60%
40%
60%1
3.2%
2.6%
24
19.5
$
$ 90
$ 15
1 $ 75
$ 293
$. 1,755
608
$ 1,170
$ 506
80%
100%
80%
100%
0.9%
8.2%
6.75
61.5
$ 90
$ 90
$ 15
$ 15
$ 75
$ 75
$ 101
$ 923
$
$ 5,535
$ 5,535
Medicaid
90%
49,4%
370.5
$ 90
$ 15
15
$ 75
$ 75
$ -
$ 56
$ 33,345
$ 338
$ 30,011
$ 309
Private insurance
90%
90%
0,5%
0.5%
3.75
3.75!'$
$ 90
90
$
$ 15
$ 75
$ 56
$ 338
$ 309
HeallhChoice
Total
100%
750
$ 5,693
$ 67,500
$ 43,489
Lab Outsourcing Fees
$3 fee for Stock Medications
Notes
* Appendix C
Conservative estimate is that 5% of Reference Lab costs sent to UNC will be paid on the sliding fee scale
Conservative estimate is determinded by multiplying total # of stock bottles /items X $3
Note: multiple prescriptions will be dispensed from some large bottles of stock medicines
$23,664 x 5% _ $1183 ; 1, 1 0J
1564 x$3 = $4692 $4,692
Total Anticipated Revenue $49,364
Appendix B
Detailed Start -Up and Annual Operating Expenses
Large Equipment
DC 200 Defibrillator
1 $
1,900 $
1,900
Eclipse 850 Electrocardiograph
1 $
5,000 $
5,000
RW
.. _ may' , 1. 1i �3t a ,y1R,{
Office Equipment
2 $
240 $
480
Books
Primary Care of Women, 2nd Edition; Carlson
1 $
gp $
80
Guide to Anti - Microbial Therapy, 2003; Gilbert
2 $
9 $
18
Patient Care Guidelines for Nurse Practitioners; Hoole
1 $
43 $
43
Disease Management for Nurse Practitioners; Springhouse
,1.1 $
50 $
$
50
125
Principles of Internal Medicine, 15th Edition; Branwo
125
$
70
70
Clinical Guidelines in _
A _ Fa m. i w Pracfrce, Uphold ''
Ri u �Fnj� •4 Ii
License
DEA License (3 year license)
_ - ._........_..3
2 10 $ 630
W1 $ 630
Supplies
Primary Care Medical Supplies 500 $ 7.55 $ 3,775
Printing of Lab Req ons _
a_ . � �� r � r
_.. -
_
4HealthLink* 400 $ 4,800
Contract Fee 12 $
Holiday Service 18 $ 20 $ 360
UNC LABS (outsourced)
Note
. Blank spaces in chart signify tests that will not be performed in prima
PROPOSED FORMULARY FOR PRIMARY C, 3/17/2004
Name
Strength
Size
Price /Unit
Price /Dose
Stock 1 yr.
Total Price
Infection
Infection
Amoxicillin f Cap
250 mg
1 DO
$5.00
$0.05
12
$60.00
Amoxicillin Cap
500 mg
100
$7.00
$0.07
25
$175.00
Amoxicillin
250/5 ml
100 ml
$2.27
20
$45.40
Azithromycin tab
250 mg
30
$172.41
$5.70
12
$2,068.92
Azithromycin Susp
100 mg /5 ml
15 ml
$18.86
10
$188.60
Azithromycin Susp
200mg /5 ml
30 ml
$24.32
10
$243.20
Cephalexin Monohydrate (Keflex) caps
500 mg
100
$7.65
$0.07
10
$76.50
Ceftriaxone
500mg /vial
10 vials
$72.37
3
$217.11
Dicloxacillin cap
500 mg
100
$12.00
$0.12
5
$60.00
Doxycycline tab
100 mg
100
$7.00
$0.07
20
$140.00
Metronidazole tab
500 mg
100
$3.00
$0.03
20
$60.00
Nitrofurantoin cap
100 mg
100
$24.00
$0.24
12
$288.00
TMP /SMX DS tab
800 & 60
100
$7.00
$0.07
12
$84.00
TMP /SMX susp
200 & 40/5ml
473
$22.15
15
$332.25
Ery-tab
333 mg
100
$8.06
$0.08
6
$48.36
Pen VK tab
500 mg
100
$10.00
$0.10
10
$100.00
Acyclovir tab
200 mg
100
$6.00
$0.06
12
$72.00
Cardiovascular
°
Atenolol
50 mg
100
$7.00
$0.07
20
$140.00
Clondidine
0.1 mg
100
$2.00
$0.02
40
$80.00
Cozaar
50 mg
100
$82.00
$0.82
4
$328.00
Enalapril tab
10 mg
100
$11.00
$0.11
15
$165.00
Furosemide
40 mg
10D
$2.00
$0.02
40
$80.00
Hydrochlorthiazide
25 mg
100
$3.00
$0.03
200
$6DO.00
Lovastatin
20 mg
60
$24.00
$0.40
30
$720.00
Metoprolol
50 mg
100
$6.00
$0.06
20
$120.00
Potassium Chloride
10 mEq
100
$4.00
$0.04
10
$40.00
Tdamterene /HCTZ
375 mg /25 mg
100
$4.00
$0.04
40
$160.00
Diabetes
Actos
15 mg
90
$62.10
-
$0.69
15
$931.50
Glipizide ( glucotrol)
5 mg
10D
$4.00
$0.04
20
$80.00
Glipizide (glucotrol)
10 mg
100
$6.00
$0.06
20
$120.00
Metformin Hcl (Glucophage)
500 mg
100
$15.79
$0.15
12
$189.48
CNS /Psych
Buproprion
75 mg
100
$32.00
$0.32
62
$1,984.00
Fluoxitene
10 mg
100
$13.00
$0.13
36
$468.00
Fluoxitene
20 mg
100
$14.00
$0.14
146
$2,044.00
Gastrointestinal
Dicyclomine tab
10 mg
100
$3.00
$0.03
100
$300.00
Respiratory
Albuterol inhaler
17 gms
il
$2.73
180
$491.40
Cromolyn inhaler
26 ml
$12.90
60
$774.00
Albuterol liquid
2mg /5ml
473 ml
$31.00
9
$279.00
Acne
Adapalene (Differen)
0.10%
15 gm
-
$37.19
5
$185.95
Azeloic acid (Azelex)
201%/.
30 gm
$48.52
1 5
$242.60
IX „anq;CnG�urlie[,iJn►a ::t.;.::_.,. _ _..:.... ............. .._.
Total Number of Full Charge Total Actual Charge Actual Paid Total
Responsible Party Encounters/Yr ($)
Total ($)
($)
0
Health Choice
0
519
0
43,496
0
42,765
41,128
Medicaid
Self Pay ( %)
56
2,901
0
0
0
20
10
553
111
0
40
3
125
50
0
60
11
654
393
0
80
3
168
135
0
100 77 4,006 4,006 0
9 at
�59-a- -� 903 4:4T�4 _, n17B
•$x. ._ �_..,.. -- .e_ .�.._ emu,., -
c:-:..:.+.
V�lViiu..r%�....• ._•a• _ - ctLt.v..�Gl=_.e�•.ry.
+ - t:crdva..-
....�ga:+ur�•
Health Choice
0
944
0
40,033
0
32,909
0
29,844
Medicaid
Self Pay ( %)
0
0
0
1906
81,158
20
398
16,585
3,327
0
40
228
9,689
3,885
0
60
142
5,808
3,488
0
80
50
1,974
1,582
0
100
194
7,891
7,891
0
e
Pnvate insuranc 15
""
15
0
-
Tots a..•Y f !ki Fr ! 5 S. Szf 5 [:� tf[ 'F , .4 Alf � Tr a p s5 �.'.i i. _ clY 12 �
f,rY
A, t, 51 .,.... .rt .. .:r
�
TtLl .i iaT rf '..•li, :i..ww, ..v. -.n- af......:. IV }. � {ta. >.e,.:ILt
..
G
% of Encounters
°!o of Actual
'I Responsible Party Covered by Payor % of Full Charges Charges
% of Actual Paid
Health Choice
0.0%
0.0%
0.0%
90.1%
0.0%
100.0%
Medicaid
76.4%
83.8%
I' Self Pay ( %)
8.2 /o °
5.6%
0.0%
0.0%
0
20
1.5%
1.1%
0.2%
0.0%
40
0.4%
0.2%
0.1%
0.0%
60
0
1.6/0
1.3%
0.8%
0.3%
0.0%
0.0%
80
0.4%
0.3%
100
11.3%
7.7%
8.4%
0.0%
100.0% 100.0% 100.0% 100 0%
----
�..�ti.,.,_....
RE, Health Choice
0.0%
0.0%
0.0%
0.0%
�
Medicaid
24.4%
24.5%
62.0%
100.0%
Self Pay ( %)
49.3%
49.7%
0.0%
0.0%
20
10.3%
°
10.2 /o
6.3%
7.3%
0.0%
0.0%
40
5.9%
5.9%
60
3.7%
3.6%
6.6%
0.0%
80
1.3%
1.2%
3.0%
0.0%
100
5.0%
4.8%
0.0%
14.9%
0.0%
0.0%
0.0%
Private insurance
0.0%
100.0%
100.0%
100.0%
100.0%
Al
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2D
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
C D E F G
Appendix D
Five Year Financial Projections
Expected Increase in clients per
io,
4'
year
20%
xpectecd visits/Client[Yr
Expected ct
1.5
EV
io,
4'
77
$10ZW
$100,000 .-VL1
$5D , 000 n-' _q P gg� . . . . . . . . . . t
Revenues
[Given]
C1 1 +65
D10* 1 +C5
E10* 1 +C5
[FI0*(I+C5)]
Clients
50D
600
72D
864
1037
Net Income
[C6*C10J
fD10*C61
fE10*C61
fF10*C61-
rG10*C63
Office Equipment
750,
900,
10801
12961
1555.21
lEncounters
1
DEA License
630
EV
io,
4'
77
$10ZW
$100,000 .-VL1
$5D , 000 n-' _q P gg� . . . . . . . . . . t
Revenues
$49,364
$59,237
$71,084
$85,301
$102,361
Expenses
$93,132
$90'609
$97,005
$103,976
$111,978
Net Income
3 763
($4.)
($31,372)
($25,921)
($18,675)
($9,217)
EV
io,
4'
Revenue
9 04P, !W0011
$10ZW
$100,000 .-VL1
$5D , 000 n-' _q P gg� . . . . . . . . . . t
Revenues
Expenses
Expenses
s - Net Income
$50,000 -
I. Start Up Costs
$100,ODO
Year
Large Equipment
6,900
Office Equipment
480
Books
386
DEA License
630
0
0
0
START UP COSTS TOTAL
$8,396 0
II. Annual Operating Expenses
A. Personnel
Labor*
33,876 34,723
35,591
36,481
37,393
B. Miscellaneous Operating Exp
Lab Fees
23,664 26,03D
28,633
31,496
34,646
Pharmaceuticals*'*
17,451 19,196
21,116
23,227
25,550
Supplies"
3,985 4,384
4,822
5,304
5,834
Training
50D 500
500
500
500
HealthLink Contract"
5,160 5,676
6,244
6,8 * 68
7,555
Equipment Maintenance
100 100
100
100
100
MISC. OPERATING TOTAL
$50,860 $55,886
$61,414
$67,496
$74,185
START UP TOTAL
ANNUAL OPERATING TOTAL
$8,396
$114,736 $901609
$97,005
$103,976
$111,578
T 0 W J'E E � �ja 0 ;kUMW
Notes
*Labor expense increases by 2.5% per year
** Lab, pharmaceutical, supplies, and Healthl-ink contract expenses increase by 10% per year
Future Financial Projections for Primary Care
$150,ODD Zan
R1 NOW
.101-4-1-, -g.
$100,000 .-VL1
$5D , 000 n-' _q P gg� . . . . . . . . . . t
Revenues
Expenses
$0 IV42
s - Net Income
$50,000 -
$100,ODO
Year
Attachment 2: Joint BOWBOCC 04/01/04
Comments on the Public Health Task Force 2004 Recommendations
Orange County Board of Health
Orange County Health Department Management Team
March 2004
Accreditation Recommendations
Recommendation 2: Fund local health departments on a one -time basis in their year
of accreditation.
➢ Funding of $50,000 per county is welcome, but not adequate on a one -time basis.
The work of accreditation and more importantly a solid quality assurance /quality
improvement program, requires a continuous, not a one -time effort. We believe that
very few local departments have a department -wide, ongoing quality assurance
program developed and in place. In alternate, non - accreditation years, these funds
could be used for a position that would maintain an ongoing quality assurance
program and provide assistance to ongoing monitoring efforts key to a health
department's success in the community. Such a required quality improvement
program would go a long way towards assuring that the services offered by a local
health department are efficient AND effective.
There should be established measures of what is acceptable performance on all
activities within the ten essential services. The benchmarks should be specific,
reasonably tolerant (without being "soft "), and recognize that there is no perfect
system (i.e., no "all" or 100% standards as witnessed in some of the accreditation
instrument categories). Intolerance leads to manipulation of data and other
disingenuous actions on the part of those being assessed. An example might include
an acceptable rate of on -time restaurant inspections, is it 85 %, 95% or 100 %?
The accreditation instrument should be balanced on all division program areas. The
current one is heavy on clinical, community and Board of Health areas. There is little
emphasis on health education (other than in clinical and personal health community
settings), environmental health, and other programs that individual counties may offer
through the health department (animal control, waste control, etc.).
Recommendation 3: Accountability
Make sure all measures; whether Community Wellness Index or other, span all fields
of local health department programs.
There needs to be a direct link between the accreditation process and accountability
since capacity does not automatically indicate outcomes or proper performance as it
should not be axiomatic to assume one drives the other.
There are many unanswered questions regarding the funding surrounding the
allocation, potential uses and recurrence (if any).
Recommendation 4: Funding to improve capacity
➢ One task that has not yet been accomplished, or perhaps stated is to define what the
core SERVICES are that each local health department must provide. As an example,
will all local health departments be required to provide as specified in state law or
adopted standards:
Page 1
L:\ROSIE\130H\0404 Joint Boc -Boh mtg\Attach 2 0304 BOH Public Health Task Force 2004 Recommendations.doc
Attachment 2: Joint BOH/BOCC 04/01/04
• Birth and death certificate registration verification (in a five day time period) as
specified by general statute
• A communicable disease program that includes communicable disease
surveillance and follow -up, TB control, TB medical consultation, direct clinical
services for the diagnosis and treatment of STI, HIV counseling and testing, case
management services for HIV and chronic STI clients, and community outreach
and education services
• Immunization tracking services
• Restaurant and institutional inspection services
• On -site wastewater permitting and monitoring services
And so forth.
➢ Without the clarity around what services or program areas are REQUIRED, the
recommendations are not coherent and are subject to being individually "dropped" as
non - essential. A Public Health Improvement Plan may vary from one five or ten year
period to another depending on what health status data shows, but the CORE services
should remain the same to safeguard general public health.
Workforce Development
Recommendations 5 and 6: Workforce Development
The racial diversity of environmental health staff across NC is woeful.
An evaluation of pay scales is not mentioned specifically and it should be part of the
overall assessment in this area.
Recruitment is a much more complex issue than that detailed in this document. The
"lack of clarity about what public health does" statement may (or may not) be true but
offers little to the overall myriad of reasons for this problem.
Structure & Organization
Recommendation 7: Regional Incubators
The "incubators" initiative is interesting on the surface but hints of being someone's
pet project thrown into the mix for consideration. It is a huge leap of faith to expect
that they will self - sustain based on user fees.
This is a "hidden" drive for regionalization. There are a few core services that would
likely be able to be provided efficiently on a regional basis, especially in those areas
with sparse geographical populations.
Recommendation 8: Location of environmental health.
There is an inference in Recommendation 8 that service delivery at the local level is
impeded or otherwise poor because of where environmental health is housed at the
state level. This is erroneous and should be corrected before this document moves
forward. Environmental staff in the Orange County Health Department have worked
under both structural paradigms and have not realized any significant advantage or
disadvantage to either.
The structure illustrates the disconnect between health and environmental at all levels
(national, state and local), but in no way should environmental health services at the
Page 2
LAROSIMB014\0404 Joint Boc -Boh mtg\Attach 2 0304 BOH Public Health Task Force 2004 Recommendations.doc
Attaclunent 2: Joint BOH /BOCC 04/01/04
local level be maligned to argue for the move. A more salient move would be to
provide more financial support to EH programs at the local level regardless of the
state framework - this in and of itself would improve service availability and
coverage (not delivery) at the local level.
Financing Recommendations
Recommendation 416a: Financing environmental health programs.
Adding a local option to establish fees could potentially lead to confusion for restaurants,
especially for national chain franchises. There is also a real and substantial infrastructure
cost to establishing and collecting local fees that would also need to be included in a "fee
structure." EHS operate as AGENTS OF THE STATE in this program. Fees should
continue to be collected and dispersed by the state, although fees should be substantially
increased to defray the REAL costs of this program.
Recommendation #16b: Low wealth funding formula.
Currently no counties are adequately funded by the state or local governments to
provide core public health services. A base level of state funding that will enable core
services to be provided in each county should be the first step in funding public health
services. Other "supplemental" services could then be funded by an alternate funding
formula. The Department of Public Instruction provides for a per pupil funding level for
all school systems; there is no such baseline financing structure in place for local health
departments.
Recommendation #17: Medicaid relief for local governments.
We should not assume that local governments would willingly or consistently redirect
the local Medicaid match for public health infrastructure purposes. Again, it would be
LOCAL money rather than STATE funds being used to finance LOCAL public health
that is STATE mandated.
Recommendation # 18: Eliminate funding gaps in critical public health services.
Return to the comment on defusing "critical public health services" in Recommendation
4. The amount of money targeted to chronic disease prevention is very inadequate, even
in this recommendation. This model assumes a regional "lead health department" model
that has been popular in the state in the last five to seven years. The resources from this
regional approach are not visible to local health departments other than those to the lead
health department that was the initial grantee to "build capacity." Far more
PREVENTION resources should be devoted to this area as "core" funding.
Part II: Core Service Gaps:
All local health departments should have well siting and construction rules that they
administer. Protection of water supplies is basic to public health and the absence of
such rules reflects poorly on NC's system.
The issue of preemption needs immediate legislative attention as further delay will
paralyze the ability of field practitioners to enforce public health laws and regulations
as prescribed in Essential Service 6.
-See also the comment on core services under Recommendation 4.
Page 3
LAROSIESOM0404 Joint Boc -Boh mtgWttach 2 0304 BOH Public Health Task Force 2004 Recommendations.doc
A �a (,k 06t 4 � 3
THE NORTH CAROLINA
PUBLIC HEALTH TASK FORCE 2004
PUBLIC HEALTH IMPROVEMENT PLAN
PRELIMINARY RECOMMENDATIONS
Strengthening public health infrastructure is important.
Either we are all protected or we are all at risk.
The Public Health Foundation
h!ortll► Gar�iins Pu��F F1eel�h
E n r1m Ea r• .ceder.
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
CHARGE TO THE TASK FORCE
x Improve the quality and accountability of the
state and local public health system.
Improve health outcomes.
Eliminate health disparities.
2
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
INTRODUCTION
North Carolina's public health system must respond to new and serious public health emergencies,
significant changes in population, unacceptable health disparities, decreasing funding and significant
variations in public health protection between counties and regions. A reinvestment in the state's
public health infrastructure is critical to providing the essential public health services that will assure
public health protections for all North Carolinians.
The recent terrorist events, along with outbreaks of new and often fatal infectious diseases, are a
wakeup call to North Carolina. The public health system must be strengthened in order to promote
and protect the public's health. New federal resources for bioterrorism preparedness have helped
build some additional capacity to detect and respond to certain public health emergencies. Now the
state must support these national preparedness efforts by reinvesting in core infrastructure that will
enable the system to respond to all public health emergencies and threats to the health and prosperity
of North Carolinians everywhere.
A reinvestment of resources in the state and local public health system by the North Carolina General
Assembly will coincide with an increase in public health accountability. This will be achieved
through an improved system for identifying the public health needs in each community, prioritizing
problems and solutions, and funding public health programs and services on the basis of performance
and achievement of desired outcomes. These new systems of accountability, accreditation, and data
collection will provide the tools necessary to measure success and allow the state to invest with
confidence.
The recommendations of this report are divided into two parts:
1. Core Infrastructure
2. Core Service Gaps
3
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
THE MISSION OF NORTH CAROLINA PUBLIC HEALTH
To promote and contribute
to the highest possible level of health
for the people of North Carolina.
3 PUBLIC HEALTH CORE FUNCTIONS AND 10 ESSENTIAL SERVICES
I. Assessment
1. Monitor health status to identify and solve community health problems (e.g., community
health profiles, vital statistics and health status).
2. Diagnose and investigate health problems and health hazards in the community (e.g.,
epidemiologic surveillance systems, laboratory support).
ll. Policy Development
3. Inform, educate, and empower people about health issues (e.g., health promotion and
social marketing).
4. Mobilize community partnerships and action to identify and solve health problems (e.g.,
convening and facilitating community groups to promote health).
5. Develop policies and plans that support individual and community health efforts (e.g.,
leadership development and health system planning).
III. Assurance
6. Enforce laws and regulations that protect health and ensure safety (e.g., enforcement of
sanitary codes to ensure the safety of the environment).
7. Link people to needed personal health services and ensure the provision of health care
when otherwise unavailable (e.g., services that increase access to health care).
8. Assure competent public and personal health care workforce (e.g., education and training
for health care providers).
9. Evaluate effectiveness, accessibility, and quality of personal and population -based health
services (e.g., continuous evaluation of public health programs).
10. Research for new insights and innovative solutions to health problems (e.g., links with
academic institutions and capacity for epidemiologic and economic analyses).
V.
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
EXECUTIVE SUMMARY
PART I: CORE INFRASTRUCTURE
Accreditation Committee
1. Establish state -level support for a mandatory system of accreditation and an Accreditation
Board. $ 989,000/Page 12
2. Fund local health departments on a one -time basis in their year of accreditation.
$ 1,100,000 annually for four (4) years /Page 12
Accountability Committee
3. Establish an Office of Public Health Accountability. $ 300,000/Page 14
4. Fund local health departments to improve their capacity to provide the Ten Essential Public
Health Services that will improve health outcomes and eliminate health disparities.
$15,000,000/Page 16
Workforce Development Committee
5. Assess the needs of the public health workforce by:
Conducting a short-tern workforce assessment study; and $ 150,000/Page 18
Identifying and disseminating core public health competencies. $ 10,000/Page 18
6. Assure an adequately trained public health workforce by: (Page 19, all)
Developing and implementing an outreach and recruitment plan to ensure an
adequate, capable, culturally competent and diverse public health workforce..
$10,000
=> Fully funding necessary maintenance and operational needs of the Public Health
Training & Information Network (PHT1I); $ 600,000
=> Creating public health internships at the state and local level; $ 150,000
=* Creating public health scholarships; and $ 200,000
=> Requiring training for Board of Health members and selected public health
management positions. $ 100,000
5
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
PART I: CORE INFRASTRUCTURE
Structure & Organization Committee
7. Create three (3) public health "incubators" to support regional collaboration by sharing
resources and developing economies of scale. $375,000 one time funding/Page 21
8. Reunite the Division of Environmental Health from the Department of Environment and
Natural Resources (DENR) with the Division of Public Health under the leadership of the
State Health Director in the Department of Health and Human Services. Page 22
9. Recommend that the position of State Health Director report directly to the Secretary of
the DHHS. Page 23
10. Drive collaboration of local health departments and any related structural changes at the
local and state level through the accreditation process. Page 24
11. Perform and distribute a Self Assessment of the Division of Public Health using National
Performance Standards. Page 25
Planning & Outcomes Committee
12. Improve the data and epidemiology to drive state and local decision- making and allocation
of resources. Page 27
=> Establish a common set of core health indicators.
=> Build capacity to conduct the Behavioral Risk Factor Surveillance Survey (BRFSS) to
provide county specific or county clusters data. $300,000
Enhance the opportunities to collect and report county or county cluster health
information on children (e.g. Youth Risk Behavior Survey).
=> Identification and analysis of existing state and local public health problems, health
disparities, and potential threats. $100,000
=t> Identify the best scientific and evidence -based strategies to address identified public
health problems at the local level. $200,000
Provide epidemiology training for local partners. $200,000
C
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
Planning & Outcomes Committee
13. Fund local health departments to assess and document community health needs through
community partnerships. Page 28
Establish a uniform statewide process for community health assessment to be conducted on a
four -year cycle (Comprehensive Community Health Assessment) and updated annually
(State of the County Report). $ 1,623,000
=> Establish a core set of questions to be used for primary data collection statewide. Local
partnerships (Healthy Carolinians, Community -based Organizations, and other health
agencies) may develop additional questions according to their needs.
=> Build the capacity of the state Office of Healthy Carolinians to support local
community assessment through local training, technical assistance, and report
generation. $ 441,000
14. Establish a process for comprehensive collaborative planning that integrates state and local
needs assessment, priorities, and strategic program objectives. Page 29
=> Develop and implement a collaborative State Public Health Plan to cover four years and
updated annually.
State Center for Health Statistics will provide county specific health data to local health
agencies for the purpose of local planning and priority setting.
The Office of Healthy Carolinians will compile and report information on local needs,
community priorities, and action plans to state level programs.
Establish an annual integrated planning cycle to inform state and local decision makers
regarding program priorities and funding allocations.
15. Fund increased information technology capacity at the local level to collect, compile,
analyze, and report essential public health data. Page 30
=> Build local capacity to collect, analyze, and report critical public health information
electronically. $5,160,000
=> Assure compliance with HIPAA guidelines.
Build the local interface with the Public Health Information Network to enhance the
ability of local health departments, hospitals, healthcare providers, and community
partners to communicate electronically in a secure environment. $ 860,000 (one time
equipment)
7
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
PART I: CORE INFRASTRUCTURE
Finance Committee
16. Consider the following as possible sources of support for the core infrastructure needs of
the public health system: Page 32
• Empower local health departments statutorily to charge fees commensurate with
the local costs of conducting the food and lodging program activity.
• Develop a Low Wealth Funding Formula to be used to distribute public health
program and administrative funds to local health departments.
• Seek private funding (philanthropic foundations, trusts and business partners) for
the enhancement of public health through creative partnerships.
• Secure state appropriations to implement the equipment replacement schedule for
the State Laboratory of Public Health.
• Assure that a significant percentage of any new health - related revenues as set by
the General Assembly be directed to support public health infrastructure and
services in keeping with a statewide Public Health Plan.
• Two essential core infrastructure needs not addressed in other Committee
recommendations are the following:
=> Dedicated, ongoing funding for replacement and ongoing maintenance of the
Health Information System, including local and state interface; and,
=> Ongoing state funding to share more equitably the costs of environmental
health services currently funded by local government.
17. The state should fund the local Medicaid share on a phased basis, and direct that a
significant percentage of freed up local revenue be appropriated for local public health core
infrastructure and service needs. The transition could begin by picking up any increase, and
then phase down county share percentage on an annual basis until state assumes total
amount. Page 39
N.
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
PART 2: CORE SERVICE GAPS
Planning & Outcomes Committee
18. Eliminate funding gaps in critical public health services:
=* School Nurse Services* $ 13,144,214/Page 42
=> AIDS Prevention/Control $ 3,341,656/Page 43
=> HIV/AIDS Drug Assistance Program (ADAP) $ 12,100,000/Page 44
=> Title VI Compliance $ 1,156,849/Page 45
=:> Chronic Disease Prevention $ 18,356,773/Page 46
=> Injury Prevention $1,075,000/Page 47
==> Immunizations (Prevnar) $ 13,113,249/Page 48
* Funding earmarked for local health departments and local educational agencies; provides for schools
nurses to be placed in counties at a rate of 263 /year over four years to achieve a statewide nurse -
student ratio of 1:750. Request is for a four year (2005 -2008) implementation schedule:
=> Year 1: $ 13,144,214
=> Year 2: $ 26,288,428
=> Year 3: $ 39,432,642
=> Year 4: $ 52,576,856/year ongoing
MINORITY REPORT
Structure & Organization Committee
The State Health Director and the reunited Divisions of Public
Health and Environmental Health should be located in the
Department of Environment, Health and Natural Resources
(DEHNR) with the state health director reporting directly to the
Secretary. Page 49
9
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
Part I:
Core Infrastructure
Recommendations
10
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
Committee on
Accreditation
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PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
1) Establish state -level support for a mandatory system
of accreditation and an Accreditation Board.
2) Fund local health departments on a one -time basis in
their year of accreditation.
Need Addressed /Rationale
Accreditation:
=> Demonstrates core capacity to respond to public health challenges in their communities;
=> Assures all citizens of North Carolina, regardless of county of residence, access to a standard of
quality in core functions and essential services of public health;
=> Improves efficiency and effectiveness of public health services as well as health outcomes
across the state;
=> Increases accountability for newly emerging communicable diseases; and
Recognizes that access to an agreed upon minimum standard of quality in delivery of core is
essential to public health services.
Infrastructure /Capacity Improvement
The accreditation schedule in each county is linked to the timing of comprehensive community health
assessment. The system model being piloted is based on nationally recognized accreditation standards.
There is time provided in the initial round of accreditation for agencies to utilize corrective action
plans. A deadline will be established by which all local public health agencies must be accredited in
order to continue to receive state and federal funds. Major components would include:
=:> Four year "roll out" based on evaluation of pilot;
=> Process would include self - study, site visits and final Accreditation Board action;
Standards would address capacity to provide essential services, facilities and administration,
staff competencies and training, and Board of Health governance; and
Provisions for conditional accreditation and sanctions for failure to be accredited.
Budget FTEs:
$ 989,000 for staff to provide technical (11) State
assistance to local public health ( ) Local
agencies and support for an
Accreditation.Board.staff and operating
expenses (e.g., site visits)
• $1,100,00.0* for each of the first four
years of the accreditation process to
support local public health agency staff
during year of initial 'accreditation.
* Funding for local health departments /districts. Provides $5U,000 in support to each agency
(average of 22 /year) in the year they are seeking accreditation. This would be one -time money
for each local health department. Funding needed for 4 years (FY 05 — FY 08). Total amount
need over 4 years = $ 4,400,000
12
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
Committee on
Accountability
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PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
3) Establish an Office of Accountability in the Division of
Public Health that will implement a formal reporting
and accountability process for the state and local
public health agencies.
= Create a Community Wellness Index that will assess state and county - specific health
status —a state and county health report card.
=> Create a set of Best Practice Indicators that will provide county - specific data about
the effectiveness of efforts to promote population health.
Compile a set of the State Public Health Performance Measures that funders and
other stakeholders use to hold DPH accountable.
Implement an accountability process that will use accountability data to support and
evaluate the effectiveness of state /local efforts to improve the health of the residents of
NC.
Need Addressed /Rationale
North Carolina's public health system is complex, with organizational units at the state, regional and
local levels. Ensuring accountability in the areas of performance and fiscal management requires
capacity not only at the program and local agency level, but also at the state, where ultimate
responsibility for system accountability resides. There is currently no formal organizational structure
to manage a public health accountability plan or comprehensive quality improvement process. There is
a clear need to centralize accountability functions within the Division of Public Health.
Infrastructure /Capacity Improvement
Resources requested for this recommendation would support an organizational home for public health
accountability in the Division of Public Health in Raleigh. Professional staff employed in this office
will be responsible for managing the state's accountability plan, monitoring quality improvement
processes both locally and at the state level, analyzing accountability data and disseminating reports.
The public health accountability system recommended by the Accountability Committee aims to hold
state and local public health agencies accountable for the funding they have been given at the state and
federal level and the responsibilities with which they have been charged by state and federal
lawmakers.
For many health outcomes, the determinants of health status are deeply embedded in social factors that
the public health agency can only ameliorate, perhaps only marginally. In other instances, the
resources available to a local public health entity to address an important health outcome may be
relatively trivial. Recognizing these limitations with respect to measures of local accountability, a
public health accountability system should include only those measures which agencies either control
or can exert significant influence over.
The committee has proposed the creation of a Community Wellness Index (CWT), which will provide
state and county- specific "report cards" on health status. These will be broad measures, such as
Maternal and Infant health status, Heart Disease and Stroke morbidity and mortality, and Disparities in
Premature Death among different racial and ethnic groups. They will give a good sense of the overall
"wellness" of the residents of each county and the state as a whole.
14
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
3) Cont'd. Establish an Office of Accountability in the
Division of Public Health that will implement a formal
reporting and accountability process for the state and
local public health agencies.
The committee has also worked to identify a set of "Best Practice" indicators. These will be less
global than the CW1 measures and more specifically related to the charge of local health departments.
Examples may include: percent of children receiving appropriate immunizations by 24 months of age;
percent of women receiving adequate prenatal care; percent of restaurants appropriately inspected, etc.
The committee also proposed a system for state public health accountability based on the key measures
current stakeholders use to hold DPH accountable. Examples include: percent of infants receiving
mandated newborn metabolic screenings; percent of very low birthweight infants born at tertiary care
centers, birth rate for teens ages 15 -17, etc.
Budget FTEs
• $300,000 for Accountability Office staff, operating (3) State
costs, reporting and dissemination (0) Local
15
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
4) Fund local health departments to improve their capacity to
provide the ten essential public health services that form the
foundation of the accountability and accreditation systems.
Need Addressed /Rationale
The accountability system will help local public health agencies identify the health needs of their
communities. At the present time, however, resources are insufficient to allow local health
departments (LHD) to adequately protect the public's health. Funding is needed at the local level to
build LHD capacity.to protect and promote the health of the community by providing the ten essential
public health services. In providing these services, LHDs will focus on the core goals of the Task
Force: improving locally identified health outcomes and eliminating health disparities.
Infrastructure /Capacity Improvement
Each health department will use these resources to address different aspects of the ten essential services
as determined by local priorities and needs. The Task Force goals of improving outcomes and
eliminating disparities will be critical factors in allocating these resources.
The Ten Essential Public Health Services
1. Monitor health status to identify community health problems
2. Diagnose and investigate health problems and health hazards in the community
3. Enforce laws and regulations that protect health and ensure safety
4. Inform, educate and empower people about health issues
5. Mobilize community partnerships to identify and solve health problems
6. Link people to needed personal health services and assure the provision of health care when
otherwise unavailable
7. Evaluate effectiveness, accessibility, and quality of personal and population -based health
services
8. Assure a competent public health and personal health care workforce
9. Develop policies and plans that support individual and community health efforts
10. Research for new insights and innovative solutions to health problems
Budget FTEs
• $15,000,000 to local health departments to provide (0) State
elements of the ten essential public health services most Local staffing FTEs will vary, base on
needed in their communities. local need.
16
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
Committee on
Workforce Development
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17
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
5) Assess the needs of the public health workforce by:
=> Conducting a short -term workforce
assessment study; and
=> Identifying and disseminating core public
health competencies.
Need Addressed /Rationale
There has been no comprehensive analysis of the NCIPH workforce for sometime and specific
information is needed including an up -to -date count of public health work by;
=> Classification;
County and/or state; and
Diversity data.
Infrastructure /Capacity Improvement
The North Carolina Public Health Workforce Assessment Study would provide current data to inform
preparedness planning in the following areas:
=> Educational preparation by classification and county
=> Age range and average
=> Turnover
Productivity standard(s)
Programmatic training requirements
Resource directories of training resources
Budget
• $ 160,000.to conduct workforce
assessment study, develop and
disseminate core competencies.
FTEs
(0) State
(0) Local
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
6) Assure an adequately trained public health workforce
by:
Developing and implementing an outreach and
recruitment plan to ensure an adequate,
capable, culturally competent and diverse public
health workforce.
=> Fully funding necessary maintenance and
operational needs of the Public Health Training
& Information Network (PHTIN);
=> Creating public health internships at the state
and local level;
=> Creating public health scholarships; and
=t> Requiring training for Board of Health members
and selected public health management
positions.
Need Addressed /Rationale
The public health workforce is aging, and many are approaching retirement. The average age of the
workforce is ± 45 years of age. Recruitment is more difficult in public health because of a lack of
clarity about what public health does. Turnover in the public health workplace also is a major issue
that complicates workforce preparedness planning.
Currently there are 188 public health job titles in the state public health personnel system (DHHS) and
173 in local public health personnel systems. There are also public health classes within DENR for
which numbers are not available at this time. These numerous job titles in the public health personnel
system have created many difficulties in the preparation of the workforce. Often titles differ only in
level, not in function, and are simply designed to create a career ladder for public health workers.
Recent studies have shown that the current public health workforce is unevenly prepared to meet the
challenges in the practice of public health today. An estimated 80% of the workforce lacks formal
training in public health (CDC - ATSDR, 2001). Moreover, ongoing changes in technology, biomedical
science, informatics, and community expectations will continue to redefine the practice of public
health, requiring that current public health practitioners receive ongoing training and support to update
their existing skills (Pew Health Professions Commission, 1998).
Infrastructure /Capacity Improvement
This will ensure that all public health practitioners have a basic set of competencies involving general
knowledge and skills, and abilities that allow•them to effectively and efficiently function as part of their
public health organization or system (CDC - ATSDR, 2000; DHHS, 2000; CDC, 2001d).
Budget
• $ 10,000 Recruitment Plan
• $ PHTIN $ 600,000
• $ 150,000 Internships
• $ 200,000 Scholarships
• $ 100,000 Board of Health
FTEs
(0) State
(0) Local
19
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
Committee on
Structure &Organization
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PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
7) Create public health "incubators" to support regional
collaboration by sharing resources and developing
economies of scale
Need Addressed /Rationale
The Northeast Regional Partnership was formed in 1999 and is composed of 10 local health
departments covering an 18 county region. This Partnership, which is governed by a board composed
of the local health directors and state level representatives, is supported administratively by one of the
departments. The Northeast Partnership has secured federal grant funds to support the regional work of
an epidemiologist and a health disparities coordinator. This recommendation seeks to seed similar
regional collaborations on a one -time basis with ongoing support proposed to come from the
participating counties.
Infrastructure /Capacity Improvement
Implementation of this recommendation would result in the establishment of three regional resources to
assist county -level public health agencies develop cooperative approaches to service delivery,
organization and preparedness. It is expected that, once established, these regional incubators would
become self sustaining through user fees.
Budget FTEs
• $375,000 one -time funding to establish (0) State
three (3) .regional incubator pilots . at . (0) Local
$1255000 @. =
21
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
8) Reunite the Division of Environmental Health from the
Department of Environment and Natural Resources
(DENR) with the Division of Public Health under the
leadership of the State Health Director.
Need Addressed /Rationale
In 1997, the public health functions at the state level were divided when much of public health returned
to DHHS. The environmental health services (onsite water and waster water, pest management,
radiation protection and other services) remained behind in DENR. The result has been that the
delivery of public health services at the local level has required coordination of two state agencies. At
the state level, public health policy development and rule making have also become further
complicated by this separation of responsibilities which, again, has implications on the local level. It
was the clear consensus of the committee that local service delivery would be greatly enhanced by
reuniting the two divisions under one Department under the State Health Director.
Infrastructure /Capacity Improvement
Consolidation of environmental and public health services would greatly improve coordination of
service delivery, particularly at the local level.
Budget FTEs.'::.
No new funding required. (0) State.:,
(0) Local'
22
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
9) Recommend that the position of State Health Director
report directly to the Secretary of the DHHS.
Need Addressed /Rationale
The position of State Health Director has traditionally reported to the Secretary of the Department(s)
until recent years. Given the critical impact of many public health issues on potentially all residents of
North Carolina, this direct reporting relationship is significant.
Infrastructure /Capacity Improvement
Implementation of this recommendation would result in enhanced management of public health
services, resources and programs and improved integration of public health and related human services.
Budget
No new funding required.
FTEs
(0) State
(0) Local
23
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
10) Drive collaboration of local health departments and
any related structural changes at the local and state
level through the accreditation process.
Need Addressed /Rationale
For the past 30 years various efforts have been made to consolidate local health departments into a
fewer number. North Carolina's strong tradition of local control has constantly resulted in the decision
to maintain county health departments with the exception of a few, well established district health
departments. After thorough discussion it was the unanimous decision of the Committee that the drive
for efficiency, effectiveness and possible structural change should rest on the shoulders of
accreditation. Committee members voiced strongly the need for maintaining autonomous, individual
departments in counties so desiring, unless a structured accreditation and competent follow -up proves
that the individual agency cannot provide quality essential services for the county's residents.
Infrastructure /Capacity Improvement
This recommendation is a new approach which, through increased accountability and the
implementation of an accreditation system, would allow locally determined collaborations to evolve to
include the creation of new district health departments.
Budget FTEs
No new funding required. (0) State
(0) Local
24
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
11) Perform and distribute a Self Assessment of the
Division of Public Health using National
Performance Standards.
Need Addressed /Rationale
No national accrediting body exists for state level public health agencies. However, CDC has
developed a set of National Performance Standards that the state can use as a benchmark for evaluating
the Division of Public Health's ability to fulfill its role in providing effective public health services.
Infrastructure/Capacity Improvement
Implementation of this recommendation would link quality improvement efforts at the state level with
national standards, and align the state's quality improvement process with local efforts.
Budget FTEs
No new funding required. (0) State
(0) Local
25
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
Committee on
Planning &Outcomes
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10.iT Eve. pa: EbeeyDa►!.
26
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
12) Improve the data and epidemiology to drive state
and local decision- making and. allocation of
resources.
Need Addressed
Public health covers many fronts and is challenged in many ways. This breadth of responsibilities
often makes public health difficult to define to the public and state /local leaders. Additionally,
without a common set of indicators, it is difficult to monitor the State's health, identify gaps and
priorities, develop and implement statewide plans, and adequately correlate resources to high priority
issues. Establishing a common set of indicators will provide a clear statement for public health
business and can be used to monitor the health of the state and manage state /local resources.
Infrastructure /Capacity Improvement
Implementation of this recommendation would:
=:> Establish a common set of core health indicators.
=> Build capacity to conduct the Behavioral Risk Factor Surveillance Survey (BRFSS) to
provide county- specific or county cluster data.
Enhance the opportunities to collect and report county or county cluster health
information on children (e.g. Youth Risk Behavior Survey).
Identify and analyze existing state and local public health problems, health disparities, and
potential threats.
Identify the best scientific and evidence -based strategies to address identified public
health problems at the local level.
=> Provide Epidemiology training for local partners.
Budget FTEs
$300,000 BRFSS . (7) State
• $100, 000 PH problem and threat assessment (0) Local
•. $200,000 Best Practices
$200,000 Epidemiology training
27
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
13) Fund local health departments to assess and
document community health needs through
community partnerships.
Need Addressed /Rationale
Integral to pubic health is community health assessment (CHA) -a public health core function. CHA is
also a critical part of Accreditation of health agencies. Local health agencies are mandated to conduct a
collaborative, comprehensive CHA every four years that must include a review and analysis of
secondary and primary data and development of community action plans. Primary data collection is
key in engaging community members in the discussion and planning for community health
improvement.
However, there are NO state funds to support this critical function at either the state or local level.
Public Health in NC needs CHA to be funded that will support the CHA process at the local level. This
critical system will inform each county of its health status, provide information for planning both at the
local and state levels, support accountability and continuous quality improvement in public health, and
enable the local health agency to be accredited. Providing a uniform set of core questions for primary
data collection enables data to be compared across the state.
Infrastructure /Capacity Improvement
Implementation of this recommendation would:
=> Establish a uniform statewide process for community health assessment to be conducted on
a four -year cycle (Comprehensive Community Health Assessment) and updated annually
(State of the County Report).
=> Establish a core set of questions to be used for primary data collection statewide. Local
partnerships (Healthy Carolinians, Community -based Organizations and other health
agencies) may develop additional questions according to their needs.
=> Build the capacity of the state Office of Healthy Carolinians to support local community
assessment through local training, technical assistance, and report generation.
Budget:: FT Es
3
$ 1,623,000 Community Health Assessment
State
. $ 75,000 state O Local:
• $ 1,548,000 local
• $ 441,000 Healthy Carolinians
• $ 225,000 state
• $ 216,000 local
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
14) Establish a process for comprehensive collaborative
planning that integrates state and local need
assessment, priorities, and strategic program
objectives.
Need Addressed /Rationale
NC Public Health System needs a comprehensive, collaborative process for planning that includes
valuable input from local public health agencies and Healthy Carolinians Partnerships as well as a
wide - variety of state agencies, and public health programs. This collaborative process will foster good
communication among the pubic health community, coordination of programs and services, and
cooperation toward health improvement outcomes. A collective process will support good fiscal
management and avoid duplication of services and careful articulation of gaps and emerging issues.
Infrastructure /Capacity Improvement
The recommendation, if implemented, would provide for the following improvements:
=> Develop and implement a collaborative State Public Health Plan to cover four years and
updated annually.
State Center for Health Statistics will provide county specific health data to local health
agencies for the purpose of local planning and priority setting.
The Office of Healthy Carolinians will compile and report information on local needs,
community priorities, and action plans to state level programs.
Establish an annual integrated planning cycle to inform state and local decision makers
regarding program priorities and funding allocations.
Budget
No ' new funding required.
FTEs
O State
O Local
29
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
15) Fund increased information technology capacity at
the local level to collect, compile, analyze, and
report essential public health data.
Need Addressed /Rationale
Technology capacity is critical for all phases of public health practice, especially community health
assessment. The need to collect, compile, analyze, report data is key to fully providing the essential
services required by public health. Because technology capacity has been left to community
resources, it is not uniform across the state. With accreditation, required community assessment, and
other reporting requirements, it is critical to assure that all local public health agencies have a
minimum standard of technology capacity.
Infrastructure /Capacity Improvement
• Build local capacity to collect, analyze, and report critical public health information
electronically.
• Assure compliance with HIPAA guidelines
• Build the local interface with the Public Health Information Network to enhance the
ability of local health departments, hospitals, healthcare providers, and community
partners to communicate electronically in a secure environment.
Budget FTEs
• $ 5,160,000. local information management: (0) State
• $ 860,000 local IT technology, onetime funding (0) Local
30
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
Committee on
Finance
North Carolina PubIlc H�aitb
E' wyY IMM EvW100Y. E. -
31
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
16) Consider the following as possible sources of
support for the core infrastructure needs of the
public health system (Note: Individual
summaries follow):
Empower local health departments statutorily to charge fees
commensurate with the local costs of conducting the food and lodging
program activity.
=> Develop a Low Wealth Funding Formula to be used to distribute public
health program and administrative funds to local health departments.
=> Seek private funding (philanthropic foundations, trusts and business
partners) for the enhancement of public health through creative
partnerships.
=> Secure state appropriations to implement the equipment replacement
schedule for the State Laboratory of Public Health.
Assure that a significant percentage of any new health - related
revenues as set by the General Assembly be directed to support public
health infrastructure and services in keeping with a statewide Public
Health Plan.
➢ Two essential core infrastructure needs not addressed in other
committee recommendations are:
- Dedicated, ongoing funding for equipment replacement and
maintenance of the Health Services Information System
including local and state interface; and
- Dedicated, ongoing state funding to share more equitably
the costs of environmental health services currently funded
by local government.
32
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
16a) Empower local health departments to charge. fees
for food and lodging program activities at local
level to cover operational costs.
Need Addressed /Rationale
Local health directors and county commissioners on the finance committee highlighted the tremendous
local burden that environmental health services/ programs in general put on county governments.
Additionally, it was evident from several of the documents that we have reviewed, as well as the
review of DPH funding, that the amount of funding that the state provides to local health departments
to support environmental health is extremely small.
Currently, local health departments are allowed to charge a fee to support the on -site sewage program
(septic tank permitting) in their counties. This fee is set by the Board of Health and varies by health
department. However, it is the local option to determine how much fee base they choose to have and
how much local appropriations they use to support this activity.
In contrast, local public health agencies are currently prohibited by state statute to charge a fee to
support the Food and Lodging Program Currently, a fee of $50.00 is charged each food establishment
once per year at the state level. The funds generated come to the state and are redistributed to locals
according to a base of $5,500 with an additional amount provided if 100% of the county's restaurants
are inspected the appropriate number of times. The total amount that any health department receives is
significantly below the cost of the program (ranging from .07 to .66 per capita).
Infrastructure /Capacity Improvement
Will require legislative action to remove the prohibition from the current statute. Could eliminate the
state fee based on the new local fee option.
Budget FTEs
No new funding required: (0) State :
(0) Local
33
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
16b) Develop a methodology for distribution of funds to
local health departments that takes into account
Low Wealth areas of the state and obtain additional
funding to address these needs
Need Addressed /Rationale
North Carolina counties vary greatly in their ability to pay for essential public services. This concept
has been recognized in the public school funding to enable students across the state to have a more equal
educational opportunity
All residents from Murphy to Manteo deserve consistent high quality public health services. In some
areas, it clearly costs more to provide the same services well. It is also true that some counties have
more funding available for essential and optional services.
To provide for consistent public health services, additional targeted funding must be obtained and a
distribution methodology must be identified and implemented to account for these low wealth
differences.
Infrastructure /Capacity Improvement
Models exist, as mentioned above, for public schools that could be used as a basis for developing
appropriate public health funding models for disadvantaged areas where health disparities are often the
greatest. This study should to be done in concert with local public health, county commissioners and
state officials.
Budget:
FTEs
Yet to be determined: (0) State
(0) Local
34
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
16c) Seek private funding for the enhancement of public
health services from private foundations, trusts,
and business partners.
Need Addressed /Rationale
Public health at the local and state level cannot exist and accomplish its goals in a vacuum. The future
success of improving the health and well being of our citizens will only be accomplished through
partnerships built between local and state government, private non -profit organizations, hospitals,
community based organizations, the faith based community and the public. The local and state public
health community must reach out and partner in new and creative ways with our traditional health care
providers as well as other organizations. Resources exist in these segments of the private sector that
could be tapped if the need and the benefit are clearly articulated and ownership of the solution for the
future public health condition is appropriately shared (public and private).
Infrastructure /Capacity Improvement
Appropriate non - governmental trusts and foundations must be developed to enable private industry and
community partners to contribute to benefit public health while retaining appropriate fiscal and policy
control of the uses and expected outcomes of these contributions.
Budget
Minimal expense involved if any.
FTEs
(0) State
(0) Local
35
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
16d) Secure State Appropriations to implement the
equipment replacement schedule for the State
Public Health Laboratory of Public Health.
Need Addressed /Rationale
The State Public Health Lab has developed a 5 -year equipment replacement schedule. Funding has
never been provided for this purpose and the lab does not currently have the necessary resources to
provide for needed equipment replacement. Due to the state's severe financial crisis, there has been
inadequate continuation funding and no expansion funds to equip the State Lab.
As the state's only public health laboratory, the State Lab must serve in time of emergencies such as
BT threats, SARS, West Nile Virus, Avian Flu, as well as provide ongoing testing support for public
health services, hospitals and physicians across North Carolina. Due to the fast pace of improvements
in lab diagnostics and their integration with automation, the lab must upgrade its lab diagnostic
equipment, computer hardware and related software to take advantage of the new technologies. In
addition, it must have resources available to purchase upgrades as they occur. Since many mandated
services, especially services required during natural disasters, terrorist attacks or communicable disease
outbreaks, are required regardless of the costs,-the State Lab must have a dependable source of state
fiinding to maintain required levels of expertise and laboratory equipment. While some activities, such
as services during a natural disaster, may later earn federal revenues to reimburse the state, the lab must
first be equipped to answer emergencies to protect the public safety. This requires ongoing and upfront
state funding.
Infrastructure /Capacity Improvement
Will require legislative action to provide additional funds.
Budget FTEs
Funding in attached schedule by year. (0) State
(0) Local
36
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
16e) Assure that a significant percentage of any new
health related revenues as generated by the
General Assembly be directed to support public
health infrastructure and services in keeping with
the Task Force 2004 Public Health Improvement
Plan and subsequent statewide health plans.
Need Addressed /Rationale
Almost unanimous support was achieved from the Finance Committee that products whose consumption
negatively impacts health should be taxed significantly to generate revenue, which could be directed to
counteract the economic impact and improve the health of North Carolina's people. If such user fees
are passed by the General Assembly, a significant percentage of the revenue should be designated for
the support of essential public health services and critical service gaps.
Two essential core infrastructure needs not specifically addressed in other Committee
Recommendations are the following:
Dedicated, ongoing funding for replacement and ongoing maintenance of the Health Services
Information System (HSIS), including local and state interface; and
Dedicated, ongoing state funding to share more equitability the costs of environmental health
services currently funded by local government.
Funding for a new Health Information System: The state's current Health Services Information System
(HSIS) is totally outdated, it does not meet state needs, and certainly it does not meet the local health
department needs.
Approximately 65 county departments are "on line counties with HSIS ", and are totally dependent on
HSIS today for all of their reporting and billing activities. These departments provide one third (1/3) of
the total services reported/ billed to the state from local public health. The remaining 20 departments
(larger and better funded) have purchased propriety software applications that provide them a much
more robust management information system; however, they still must send their statistics to the state
DPH through an interface with HSIS, the only system that DPH has for this activity
The 7 individual vendor applications of these health departments must interface with HSIS and are
essential for the state and local health departments. However, it is becoming more and more difficult to
get the HSIS state system to appropriately interface with these newer systems. If Failed transmissions
of data occur for whatever reason it impacts county cash flow with Medicaid and requires a tremendous
amount staff time to resolve and resend information.
Equitable State /County fundingLof Environmental Health Services: County Commissioners and Local
Health Directors on the Finance Committee repeatedly stressed the environmental health services
financial burden carried by county government in NC. The Committee recommends that an equitable
sharing of costs between the state and counties be developed to support state and federal environmental
mandates at local health departments' service level. (A prior recommendation stated that local health
departments should be allowed to charge fees for the Food and Lodging Program, and this current
recommendation.emphasizes that even if counties are allowed to increase fees; the counties will still
bear an inequitable share of the total environmental health services costs requiring additional state
funding to correct.) 3
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
16e Cont'd.) Assure that a significant percentage of any
new health related revenues as generated by the
General Assembly be directed to support public
health infrastructure and services in keeping with
the Task Force 2004 Public Health Improvement Plan
and subsequent statewide health plans.
Infrastructure /Capacity Improvement
Revenues would be directed to priorities of the State Health Plan and this Task Force. Providing
ongoing funding for information technology requirements will ensure that both state and county
governments can document performance and accountability for public funds. Equitable state /county
funding for environmental health services will ensure consistent, reliable funding to protect the state's
environment for all citizens. Note: Legislative action required.
Budget'
No new funding required.
FTEs
(0) State
(0) Local
W
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
17) The state should fund the local Medicaid share on a
phased basis, and direct that a significant
percentage of freed up local revenue be
appropriated for local public health core
infrastructure and service needs. Transition could
begin picking up any increase, and then phase down
county share percentage on an annual basis until
state assumes total amount.
Need Addressed /Rationale
County Commissioners and Local Health Directors on the Finance Committee repeatedly stressed the
burden that the local Medicaid match inflicts on county government in NC, preventing them from
having adequate funding to support many of the other critical services needed by local residents.
The majority of committee members agreed that this burden needed to be relieved by the state. There
was no consensus on whether a percentage of the resulting county funds should be designated by the
state for public health purposes. Or, if a percentage were to be designated, there was no consensus on
what percentage should be designated.
Final consensus was that all agencies of county government would benefit from a more economically
sound condition created by this relief including public health, and that this Task Force must recommend
that a significant percentage of the local revenue freed up be directed to local public health for
infrastructure and core service gaps.
Infrastructure /Capacity Improvement
This issue is not new with multiple approaches being discussed in the General Assembly. State
assumption of the local Medicaid match is the #1 goal of the NC Association of County Commissioners.
Public Health would benefit greatly from local government's improved fiscal conditions.
Note: Legislative action required.
Budget..... FTEs
Not placed in funding scheme of this (0) State
committee's budget given the broad (0) Local
benefits described.
39
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
Part II:
Core Service Gap
Recommendations
t�to-�Gnrolf�n P�IIa Nna►m
E Iwno Ear• �Y` 40
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
PLANNING & OUTCOMES COMMITTEE
18) Eliminate funding gaps in critical public health services:
• School Nurse Services
• HIV Prevention /Control
• AIDS /ADAP
• Title VI Compliance
• Chronic Disease Prevention
• Injury Prevention
• Immunizations (Prevnar)
Need Addressed /Rationale
See individual service gap need statements that follow.
Infrastructure /Capacity Improvement
See individual service gap improvements in proposals that follow.
Public Health Service Gaps
• School Nurse Services:
• HIV Prevention/Control
• AIDS /ADA.P
• Title VI Compliance
• Chronic Disease Prevention
• Injury Prevention
• Immunizations (Prevnar)
Budget
$ 3,341,656
$ 12,100,000 at 200% Federal Poverty Level..'
$ 1,156,849
$ 18,356,773
$ 1,075;000
$ 135113,249
*Year 1: Request is for a four year (2005 -2008) implementation schedule:
• Year 1: $ 13,144,214
• Year 2: $ 26,288,428
• Year 3: $ 39,432,642
• Year 4: $ 52,576,856/year ongoing
41
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
SCHOOL NURSE SERVICES
Need Addressed /Rationale
The health needs of students have changed dramatically in the past ten years creating increased
demands for appropriate care from school nurses. Yet the ratio of school nurses to students in North
Carolina remains far below national recommendations.
The North Carolina Annual Survey for Public Schools for 2003 reported 10 percent of students present
with chronic illnesses or special health care needs. More than 12,000 students needed one or more
invasive procedure performed during the school day and six percent of students receive medication
while at school. School nurses are often responsible for supervising the care of children whose illnesses
(e.g. acute asthma and diabetes) were managed in a hospital setting prior to the restructuring of the
health care system that reduced hospitalizations and/or length of stay.
In addition to the growing numbers of children with complex health problems, the prevalence of high -
risk behaviors in schools continues to be elevated. The new "social morbidities" include substance
abuse, homicide, suicide, child abuse and neglect, and developmental problems. Preventive health
programs have become a greater focus in schools as the obesity epidemic is affecting children and
youth at earlier and earlier ages. One in four North Carolina teens and one in five children, 5 to 11
years, are now overweight.
School nurses play important roles in meeting all these needs. Yet the North Carolina statewide school
nurse to student ratio averages 1:1918. Ratios range from 1:473 in one county, to 1:7082 in another,
based on full -time equivalencies. Four local school systems do not have any school nursing services.
Infrastructure /Capacity Improvement
Set a state - funding ratio for school nurse positions to meet the national recommendation of 1:750. In
FY 2002 -03 there were 667 school nurses in North Carolina, 323 of which were from State
expenditures. It is estimated that additional 1,052 nurses will be needed to meet the 1:750 ratio. This
program proposes that State funding be provided through the Division of Public Health.
Budget
Funding earmarked for local health departments'and local educational $13,144,214*
agencies; provides for: schools nurses to be placed in counties at a rate of
263 /year over four, years to achieve a statewide nurse- student ratio of
1:7.50:
*Year l Request is for' a four year (2005 -2008) implementation schedule:
•
.:'Year l : $ 13,144,214
• , Year 2: $ 26,288,428
• Year 3: $ 39;432,642
• Year 4:.$ 52,576,856/year ongoing
42
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT.PLAN
HIV /AIDS PREVENTION AND CONTROL
Need Addressed /Rationale
The number of new HIV and AIDS cases reported in North Carolina has increased annually since 2000
and although great strides have been made towards eliminating syphilis, much remains to be done.
HIV /STDs disproportionately affect minority populations and local health departments, community-
based organizations, Historically Black Colleges and Universities and HIV Care Consortia provide the
most direct, appropriate and effective links to the communities and populations at highest risk. These
organizations and agencies are not adequately funded, equipped or staffed to provide the variety and
magnitude of services required to effectively slow the spread of the disease in the affected communities
and populations. African Americans currently comprise 72% of the persons living with HIV/AIDS in
NC; the rate of HIV infection among Hispanics has increased from 4.1 per 100,000 in 1998 to 15.0 per
100,000 in 2002.
Infrastructure /Capacity Improvement
This multi - faceted initiative will increase the capacity of Local Health Departments, Community Based
Organizations, including HIV Care Consortia and Historically Black Colleges & Universities, and the
state agency charged with HIV and STD prevention and care. Existing Community Based
Organizations will receive funding to increase their outreach, case management, counseling, staffing
and infrastructure. Additional Community Based Organizations and NTSs in underserved high -
incidence areas and serving high -risk population will receive financial support for the first time. Local
Health Departments in high - impact areas will receive funding to provide enhanced outreach,
counseling and case management services and to support the hiring of eight additional Disease
Intervention Specialists. These Specialists will work at the local level in local health departments
providing direct field follow -up to persons with HIV /STD, and their partners, as well as to support
additional clinical, educational and management staff to provide training, consultation and
monitoring /quality assurance for the new and existing prevention- focused agencies and programs. The
HIV /STD Prevention and Care Branch will hire a Behavioral Epidemiologist to track, analyze and
disseminate relevant data and a Public Health Program Consultant II to perform evaluation activities
for the prevention program.
Budget
Total funds required for SFY. 2005 to meet HIV Prevention requirements that are $3,341,,656.-. Of that
total, $2_,000,000 is designated for community -based organizations, especially those targeting and
serving minority populations and Historically Black Colleges & Universities. An additional.
$1,232,064 is designated to go to local health departments. The remaining $109,592 would go to the
HIV /STD Prevention and Care Branch to support two (2) Full Time Equivalents —a Behavioral
Epidemiologist and a Program Consultant/Evaluation Specialist - including travel and °other operating
expenses reauired to swiport the new prevention initiative.
43
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
HIV /AIDS DRUG ASSISTANCE PROGRAM (ADAP)
Need Addressed /Rationale
The NC AIDS Drug Assistance Program (ADAP) had been closed to new enrollees for the majority
of time from December 15, 2001 through March 1, 2003, due to a shortage of funds. The Program
opened to new applicants briefly, and then was forced to re- implement a Waiting List as of September
15, 2003. About 120 individuals were moved from the Waiting List to the Program on November 30,
2003, and the Waiting List`was re- established — and remains in effect — as of December 1, 2003. As of
January 22, 2004, there are 163 individuals on the ADAP Waiting List. With an average of about 65
new individuals applying to and qualifying for the Program each month, more than 300 individuals will
likely be placed on the Waiting List by June 30, 2004. An estimated 750 additional individuals will
apply and qualify for the ADAP Program next year. Serving these individuals will not be possible
without significant additional funds.
North Carolina's ADAP financial eligibility criterion, atibelow 125% of the federal poverty level, is the
lowest in the nation. It is essential that this eligibility level be raised to 200% of the federal poverty
level in order to provide essential, life sustaining medications to individuals that are still very low
income and do not have any other means of accessing these medication. It is also worth noting that, in
FY 2003, almost 64% of North Carolinians served by ADAP were persons of color, who as a group are
disproportionately affected by HIV disease. Without additional funds to enable the ADAP Program to
remain open and serve all HIV+ North Carolinians at or below 200% of the federal poverty'level, the
results may well include (1) an increase in the need for more costly health care services by these
individuals in the future, and (2) an increase in the likelihood of further transmission of HIV disease.
Individuals that do not receive coverage through ADAP may wind up being served, both for
medications and more costly medical care, by Medicaid and/or other public state and/or local
institutions and programs, as well as by private institutions. Additional social services targeted to
families where HIV disease is present, as well as mental health/substance abuse services, may also be
required and need to be provided by public sources /programs. HIV prevention efforts are also hindered
by a lack of access to appropriate and required treatments (i.e., medications), contributing to the
continuing and further spread of HIV disease within the State. Those without access to these
medications are often unable to maintain a reasonable health status and thus unable to remain at and/or
return to work. This may increase their dependence on unemployment insurance and/or other public
agency /program support.
Infrastructure /Capacity Improvement
Increased funding is required in order for the state to serve all low — income (below 200% of the Federal
Poverty Level) HIV+ individuals, and to assure ongoing and permanent access to medications to those
individuals that are most seriously affected and most in need.
Budget
$12.1 million in State appropriations is required; no local funding is requested and no Full Time
Eauivalents are required
..
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
TITLE VI COMPLIANCE - LANGUAGE SERVICES
Need Addressed /Rationale
On August 11, 2000, the President signed Executive Order 13166, "Improving Access to Services for
Persons with Limited English Proficiency." The Executive Order requires Federal agencies to examine
the services they provide, identify any need for services to those with Limited English Proficiency
(LEP), and develop and implement a system to provide those services so LEP Persons can have
meaningful access to them. , The Executive Order also requires that the Federal agencies work to ensure
that recipients of Federal financial assistance provide meaningful access to their LEP applicants and
beneficiaries. Title VI and its implementing regulations provide that no person shall be subjected to
discrimination on the basis of race, color or national origin under any program or activity that receives
Federal financial assistance. The courts have held that Title VI prohibits recipients of Federal financial
assistance from denying LEP persons access to programs, on the basis of their national origin.
North Carolina has a diverse population consisting of 21.4% African Americans, 1.4% Asian 1.2%
American Indians and 4.7% Hispanic /Latinos. According to 2000 U.S. Census figures,
the Latino
population in North Carolina is estimated to be 387,963 residents. North Carolina's Latino population
grew by 394% between 1990 and 2000, the largest increase of any state in the country. The demand for
providers in the health and human service fields who are culturally and linguistically qualified has
increased accordingly. The growing numbers of Latino residents in North Carolina has presented new
challenges to the State's health and human service providers. They have overwhelmingly reported that
language is the most significant barrier to providing adequate care for Latino clients. In a December
2003 assessment of local health departments and community based organizations, the need for cultural
diversity training and interpreters were identified as resources needed to support their efforts to provide
effective services to clients.
Infrastructure /Capacity Improvement
Since 1998, the Office of Minority Health and Health Disparities in the NC Department of Health and
Human Services has collaborated with NC Area Health Education Centers Program, the University of
North Carolina at Chapel Hill School of Public Health, and the AHEC Office at Duke University
implement the Spanish Language and Cultural Training Initiative (SLCTI). The initiative's ultimate
goal is to increase the availability of culturally based and linguistically appropriate programs and
services for North Carolina's increasingly diverse population. Training and resources have been
offered across the state of North Carolina to front -line health practitioners and interpreters. The CTI
will help local health departments and human service agencies reduce the potential for liability and
assure compliance to Title VI.
Budget
Interpreter Ttaining '
• Spanish Language Training for Health Professionals
• Cultural Competency Training
Spanish Language and Cultural Training Website
• Mental Health and Substance Abuse Training
• : Staffing and Logistical Fees
45
$-,273,551::*.
:.
.$
.29", 000
$
181,298.
$
2000
$
18,000
$
372,000
45
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
CHRONIC DISEASE — PREVENTION & CONTROL
Need Addressed /Rationale
Tobacco use, physical inactivity and unhealthy eating habits are the big three leading preventable
causes of death in both North Carolina and the United States. Together, they are responsible for the
deaths of 15,000 North Carolinians each year. This represents 35% of the all deaths in the state.
Tobacco use continues to be the leading preventable cause of mortality in NC resulting in more than
14,000 deaths annually (NC SCHS, 2002). Tobacco use is highly addictive, and most tobacco users
start at age 12 -14. North Carolina has the 11 th highest smoking rate in the nation (MMWR., 2004).
Regular physical activity reduces the risk of developing coronary heart disease, colon cancer, diabetes
and helps to control weight and strengthen bones, muscles and joints. Only 18% of adults in North
Carolina reported engaging in regular and sustained physical activity in 2000, and only 5 states in the
nation have a lower prevalence of regular and sustained physical activity. Unhealthy food choices are
recognized as a-major risk factor for cardiovascular disease. An estimated 35% of cancer deaths can be
attributed to poor diet alone. Low fruit and vegetable intake is associated with various cancers; yet in
2000, only 22% of North Carolina's adults reported eating at least 5 servings of fruit and vegetables;
the 17`h lowest prevalence in the nation.
The combined annual cost of these preventable risk factors to the state of North Carolina exceeds $14
billion each year in direct medical care costs, and lost productivity. When combined, direct medical
and productivity losses cost NC $4.8 billion annually (Centers for Disease Control and Prevention State
Highlights 2002). The costs of poor nutrition, overweight, and obesity in North Carolina are of $4.9
billion each year. In terms of health disparities, the death rate for stroke among African Americans is
30% - 40% higher than for whites. In addition, African Americans and American Indians are two times
more likely to die from diabetes than whites in North Carolina.
Infrastructure /Capacity Improvement
The state currently provides very limited funding to address the leading causes of preventable deaths:
tobacco use, physical inactivity, poor nutrition and obesity. This new approach for 2004 -2010 will
address the leading preventable causes of deaths and containing health care costs by implementing new
sound science and best practices interventions in NC communities. Local health promotion
coordinators and their community partners will plan and implement evidence -based programs
promoting policy and environmental change interventions that reduce the risk of cardiovascular
disease, diabetes, cancer and other chronic diseases attributable to tobacco use, physical inactivity and
unhealthy eating.
Budget
• Community. cooperative agreements
• Paid media interventions
• 12.5 Full Time Equivalents
Program Planning and Evaluation
Onerating and Equipment. Costs
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
INJURY PREVENTION
Need Addressed /Rationale
Injury is the leading cause of death in NC for persons aged 1 -44 and the fourth leading cause of death
for all ages. In 2001, there were 5,071 deaths an NC from injuries with half of these deaths occurring
people 1 -44 years of age. Between the ages of 10 -24, there was an average of 127 suicide deaths per
Y ear ( 1997 - 2001). Injuries result in more years of productive life lost than any other cause of death.
team from the State and Territorial Injury Prevention Directors Association conducted an assessment
of NC's injury and prevention program in 2003 and concluded that there is a clear need for the
development of injury prevention infrastructure at the state and local level.
In 1999, an Institute of Medicine report called for significantly increased funding to strengthen the
public health infrastructure in injury prevention by developing core injury prevention programs ins each
state (i.e. ability to perform the core functions /essential services of public health). Little funding
available to strengthen NC's capacity for unintentional injuries. The ability to perform the core
functions of assurance and policy development is greatly compromised. Local public health
infrastructure is non - existent and there is no state support to local health departments for core injury
and violence prevention programs. Suicide and homicide rates underscore health disparities in this area.
Homicide rates are especially high among minority populations, with African Americans and American
Indians being four times more likely to die of homicide than whites.
Infrastructure /Capacity Improvement
• Develop and apply- health communication strategies (including social marketing) for informing and
influencing individual/community decision - making to prevent injuries and violence.
• Build state capacity to supply the leadership, financial and technical assistance needed at the ocal
level to conduct core elements of injury programs: needs assessment, program development/
evaluation, staff training, local data surveillance, and other technical assistance as recommended by
the Institute of Medicine (1999).
• Build infrastructure /capacity at the local level to perform core functions by establishing and
supporting a lead Local Health Department within 6 regions in NC (similar to Cardiovascular
or
Health), and two Local Health Departments to provide leadership and capacity building
minority /special populations.
State Local
Budget .
4 Full Time $ 275,000
Fun g
din for salaries/benefits ($182,9.46) for
Equivalents (Health Communication Specialist, Program
Coordviator,,, Pro gram Evaluator, and Office Assistant): Funding
($92,054) for program development/evaluation support,
e ui ment, and o erational cost. $ 800,000
Funding of $100.,000 for each lead LHD within 6 regions in NC,
and $100,000 for each of the two minority /special population
focused Local Health 'Departments
47
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
CHILDHOOD IMMUNIZATIONS: PNEUMOCOCCAL CONJUGATE VACCINE (PREVNAR)
Need. Addressed /Rationale
Streptococcus pneumoniae bacteria harm more people in the United States each year than all the other
vaccine - preventable disease combined. The pneumococcal bacteria causes invasive disease (mostly
blood infection or bacteremia) and meningitis (inflammation of the brain and the spinal cord coverings).
It is the leading cause of bacterial meningitis in the U.S.; hitting children < 1 year of age hardest. The
burden of pneumococcal - related diseases is about 5,013,900 reported cases per year nationwide. These
diseases cause 25 % -40% of middle ear infections in children. About 200 U.S. children die each year
from pneumococcal disease. Demand for the universal distribution of Prevnar is high among parents and
physicians.
Infrastructure /Capacity Improvement
Purchase and distribute pneumococcal conjugate vaccine (Prevnar) for children. CDC's National
Immunization Program will cover the cost for vaccinating 68.2% of the eligible population. An
estimated 31.8% of the children are not covered by federal funding sources and will receive this vaccine
through this request.
buagez
$13,113,249 in State appropriations for the purchase of pneumococcal conjugate. vaccine. No local
funding is requested and no additional Full Time Equivalents.are.required..
PUBLIC HEALTH TASK FORCE 2004: PRELIMINARY RECOMMENDATIONS
PUBLIC HEALTH IMPROVEMENT PLAN
MINORITY REPORT: STRUCTURE & ORGANIZATION COMMITTEE
The State Health Director and the reunited Divisions of
Public Health and Environmental Health should be
located in the Department of Environment, Health
Natural Resources (DEHNR) with the state health
director reporting directly to the Secretry.
Budget FTEs
No new funds requested: (0),
(0 ) .Local
Attachment 4: Joint BOCC /BOH 04/01/04
Healthy Carolinians of Orange County Community Priority
Issues Plan 3/26/2004
Concern
Related Issues
Who is affected?
Current Actions
Proposed Solutions
Possible partners
Child Abuse and
Substance Abuse
Children and
Advocates for
Continued
DSS, FVPC, OCHD,
Neglect
Mental Health
families
Children committee
collaboration
Exchange Club, OPC,
*Already working
Injuries
provide education and
between agencies
OCPYC already
on this area
awareness
and families to
involved
Data based
DSS /CPS, new MRS
improve outcomes,
priority
system
provide more
FVPC education on
prevention and early
DV
intervention
Parent education
Obesity and
Physical
Everyone
Healthy Choices
Weight management
County Government
Overweight
Activity
committee (HC)
programs
Major employers
*Already working
Colon Cancer
Orange on- the Move
Behavioral
BCBSNC
on this area
Access to Care
(Coop Ext)
interventions
OCS
Community
Air Quality?
School Health
Increased physical
CHCCS
Priority #2
advisory committees
activity
Restaurant Assn
(OCS /CHCCS)
Improved Nutrition
Winners Circle
Employee wellness
(OCHD)
programs
Mental Health
Substance Abuse
Everyone
OPC reform
School -based mental
OCS
*Already working
Suicide
Youth- Community
health programs
CHCCS
on this area
Child Abuse
Backyard, Voices
OPC
Community
Access to Care
committee (HC)
Horizons
Priority #4
Barriers to Care Dental Health
Low- income
Community Care
Expand access via
Triangle United Way
Community Mental Health
Uninsured
Coalition
more Medicaid
UNC Hospitals
Priority #1 Substance Abuse
Underinsured
SHAC clinics
providers?
Private Providers
Cancer
Northern Orange
Health Check outreach
Develop low -cost
BCBSNC
Suicide
Immigrants
insurance program?
Overweight
Minorities
Disenfranchised
P
is
Attachment 4: Joint BOCC /BOH 04/01/04
Healthy Carolinians of Orange County Community Priority
Issues Plan 3/26/2004
Concern
Related Issues
Who is affected?
Current Actions
Proposed Solutions
Possible partners
Substance Abuse
Mental Health
Everyone
Youth- Community
OPC
Community
Suicide
Men 16 -24
Backyard, Voices
BCBSNC
Priority # 3
Child Abuse
committee (HC)
OCS
Access to Care
CHCCS DATF
CHCSS
Freedom House
Dental Health
Access to care
Low - income etc,
Mobile clinic for
?
UNC
Community
see above
seniors is planned
SHAC
Priority #S
OCHD
DOA
Air Quality
Physical
Everyone
Asthma Coalition
Advocate for policy
Comm. for the Envr.
Community
Activity
Asthmatics
changes at state and
EPA
Priority #6
Very Young and
national levels
OCHD
Very Old
Close study of data
Major employers
High rate of
Overweight
Higher rates in
American Cancer
Outreach through
Lineberger Cancer
cancer - Colon,
Access to Care
African-
Society?
African- American
Center
prostate, breast
Disparity
Americans
MAN for Health
Churches with health
UNC -SPH, SHAC
Data based
Cost of care
promotion program
Church leaders and
priority
congregations
Suicide
Mental Health
More data?
MHA
OPC
Prevention
Substance Abuse
OCHD
Data Based
Injuries
OCS
Priority
CHCSS
Unintentional
Child Abuse
Everyone
Safe Communities
HSRC
Injuries
Substance Abuse
Elderly -falls
Advocates for
IPRC
Data Based
Youth - MVI
Children
UNC
Priority
De t of Aging
Healthy Carolinians of Orange County Community Priority Issues Plan
Please consider the following questions as you review the
table above.
1. Of the 7 remaining issues that we are not currently
working on, how should we prioritize them/ which ones
should we focus on first?
2. Do you think any of the issues could be collapsed
together into a single priority committee? Describe
3. For each of those 7 issues, who might take a lead role,
in establishing a priority committee or who can we
partner with to begin planning?
4. For the priority areas we are already working on, is
anything missing?
Attachment 4: Joint BOCCBOH 04/01/04
3/26/2004
Key to abbreviations:
BCBSNC — Blue Cross/Blue Shield NC
CHCCS — Chapel Hill Carrboro City Schools
DATF — Drug Abuse Task Force
DSS /CPS — Dept of Social Services /Child Protective Services
DV — Domestic Violence
EPA- Environmental Protection Agency
FVPC- Family Violence Prevention Center
IPRC — Injury Prevention Research Center (UNC)
HC — Healthy Carolinians
HSRC - Highway Safety Research Center
MRS — Multiple Response System
MV I- Motor Vehicle Injury
SHAC — Student Health Action Coalition (UNC)
OCHD — Orange County Health Department
OCS- Orange County Schools
OPC — Orange- Person - Chatham Mental Health Center
UNC -SPH - University of North Carolina - School of Public
Health
Attachment 5: BOCC /BOH Joint 04/01/04
FINAL DRAFT
Executive Summary: Orange County Community Health Assessment 2003
Title: For Orange County — Choose Health!
Orange County is a wonderful place to live, and our health statistics bear that out. We
have many reasons to celebrate including good health and quality of life. Most Orange
County residents are able to live a healthy lifestyle. But like any place, we also have
areas of concern and residents who are unable to choose health because they lac
resources, access to, or knowledge of available services. Healthy Carolinians of Orange
County is working to improve the health of all residents of Orange County by working
together with community members to promote healthy lifestyles, advocate for better
access to health care services and programs, and in so doing, empower all our residents to
choose health.
( (put this in a sidebar box ?) What is Healthy Carolinians 2010? Healthy Carolinians
organizes community coalitions to address the leading health issues. These groups work
together to achieve the Healthy Carolinians 2010 health objectives developed by the
Governors Task Force on Healthy Carolinians. Healthy Carolinians 2010 objectives
mirror the national Healthy People 2010 objectives, developed by the US Department of
Health and Human Services. The overall goals of Healthy Carolinians include increasing
the span of healthy life, removing health disparities and promoting preventive health
services. There are dozens of objectives that cover 12 focus areas of health including
access to health care, chronic disease, community health, disability, environmental
health, health promotion, infant mortality, infectious disease, injury, mental health, older
adult health, and oral health. The hope is to achieve all of the objectives by the year
2010.)
Over the course of 2003, Healthy Carolinians of Orange County and the Orange County
Health Department worked with many community members to assess the health of
Orange County residents. This publication is a summary of the results from the
community health assessment.
The full assessment report is a result of both primary and secondary data gathering and
analysis involving more than 700 residents and more than 50 agencies and organizations
throughout Orange County. This summary does not reflect all of the data or nuances in
the full report, rather it is intended to provide county residents with a picture of areas of
celebration and areas of concern for our county.
(Box with web address "The full report is available on -line at the following link:
www.co.orange.nc.us/he,alth/CHAReport-p-d-f it can also be found in the Chapel Hill,
Carrboro and Orange County Public Libraries ")
Two overarching themes emerged from this assessment. The first is that the cost of
living and the cost of staying healthy are too high in Orange County and the second is
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that there are significant health disparities between minority populations and the white
population. While Orange County boasts one of the highest median incomes in the state,
we also have one of the highest rates of poverty in the Triangle area. The issue of health
disparities is not unique to this county, however in a county with health statistics that
present a picture of good health overall, it is of heightened, concern.
(include graph comparing quality of life indicators by race ?)
This summary will provide a brief snapshot of ten areas of celebration and ten areas of
concern for Orange County. The areas of concern will require a total community
commitment to affect change. They tend to be complex issues that have deep tendrils in
many facets of our lives. To find out how you can become involved in the change, please
contact the Coordinator of Healthy Carolinians of Orange County at 968 -2022 ext 291.
Committees and work groups are currently being formed to address the top ten areas of
concern. Healthy Carolinians needs community participation to find creative solutions so
that all Orange County residents can choose health as their first priority.
Areas of celebration:
• Low heart disease death rates.
Orange County already has a lower death rate than the Healthy Carolinians heart disease
objective for 2010. The death rate in Orange County is 190.7 per 100,000 and the
statewide objective for 2010 is 219.8 deaths per 100,000. This can, in large part, be
attributed to an excellent health care system that has active screening, treatment, and
aftercare programs. UNC Hospital's Cardiac Rehabilitation program has been very
successful in providing aftercare and secondary prevention measures for those with heart
conditions. Heart disease is still the leading cause of hospitalization in the county. While
this data is clear cause for celebration, there are disparities even in this success as
minorities experience higher death rates than whites do.
• Extremely low teen pregnancy rates.
The 2002 rate of teen pregnancy in Orange County for young women ages 15 -19 was
23.1 per 1000 compared to the state rate of 64.1. Only one other county in North
Carolina reported a lower rate. Despite this good news, there were still 114 pregnancies
among women 18 or younger in the year 2002, including 6 pregnancies to girls ages 12-
14. Again, there are significant disparities between whites and minorities with a four-
fold difference in pregnancy rates. Several area programs are working to prevent teen
pregnancy such as Teens Climb High at the Women's Center and the Teen Talk peer
education program through Planned Parenthood. The Adolescent Parenting Program
through DSS works with teen mothers to help them stay in school and avoid second
pregnancies.
• Excellent educational systems.
Nearly half of Orange County residents possess a bachelor's degree or higher compared
to a 20% national average. This is in large part due to the presence of UNC at Chapel
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Hill, consistently ranked as one of the top public universities in the nation. Educational
achievement for both public school districts is also higher than the state averages on mo st
indicators. Chapel Hill- Carrboro City Schools is rated as the top achieving school district
in the state. Both districts also experience lower than state average drop out rates,
although there is a considerable difference between the two districts.
• Strong UNC Health Care System
The UNC Health Care System contains physician practices located in community settings
both in this county and in other counties, extensive outpatient services, specialty referral
services, and four hospitals (Children's, Women's, Neuropyschiatric, and North Carolina
Memorial). In addition, the hospital is a Level III Trauma Center. While UNC is a state
hospital that serves patients from all 100 counties in North Carolina, nearly 38Th Care
Orange County residents saw a physician associated with one of the UNC Heal
System practices in the past year.
• Low diabetes rates.
The death rate due to diabetes in Orange County is far below both the 2010 North
Carolina Healthy Carolinians goal and the US Healthy People 2010 goal. It is difficult to
determine how many people are actually living with diabetes, though the 2002
Behavioral Risk Factor Surveillance Survey indicated only 3% of Orange County
residents had been told by their doctor that they were diabetic. A low death rate may
indicate that those persons with diabetes are successfully managing their disease; not that
we have less of it in our population.
"I have learned a lot that I didn't know before about my condition (diabetes),
medications, and how to take them. This clinic was very helpful.
Diabetes Foot Clinic Paf•ticipant
• Low smoking rates.
Only 12.8% of Orange County adults reported that they were smokers in 2002. The NC
2010 objective is 12.5 %. Among high school students however, the rates are higher.
Both school districts are now 100% tobacco free and there is a new teen tobacco
prevention project being implemented in both school districts. A significant number of
area tobacco fanners have begun growing alternate crops such as strawberries, lessening
the dependence of the community on tobacco. (Include number for Quit Now NC?)
)
Good dental prevention indicators.
This is particularly true of children where we have had success with early prevention
programs. 85% of the fifth graders receiving screening were cavity free in 2001-2002,
right at the NC 2010 objective. 49% of fifth graders had sealants on their permanent
teeth. All major public water systems in Orange County fluoridate their water, a
significant preventive measure for reducing caries.
Good maternal and infant health indicators.
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Orange County rates for infant deaths, low birth weight, and neonatal mortality are all
either right at the NC 2010 objectives or are slightly better than those desired levels.
90% of Orange County women who were pregnant started prenatal care in the first
trimester, which meets the 2010 obj ective. Unfortunately, this is also an area where there
continue to be disparities between whites and African- Americans.
• Low crime rates.
Residents often stated during focus groups that they found Orange County to be a safe,
secure place to live. Over a ten -year period, the average was 6,092 index crimes per year,
the vast majority of which were larcenies. The crime rate both on the state and local level
has dropped over the past ten years, and the rate of crime in Orange County remains
lower than the state average.
"In our community, police and courts are tremendously talented and caring and work
very hard to collaborate "
• High level of physical activity.
Based on data from the 2002 Behavioral Risk Factor Surveillance Survey, 51.4% of
Orange County adults participate in the recommended amount of physical activity. The
current recommendation is for adults to perform at least 30 minutes of moderate physical
activity on 5 or more days of the week. The NC 2010 Goal is only 20 %, so we are far
ahead on this measure
Causes for Concern.
While the areas of celebration are evidence that Orange County lives up to its reputation
of being an excellent place to live and raise a family, secondary data reveals some areas
of concern and residents have identified other areas important to them that need serious
attention to improve our collective living situation. This summary will highlight ten
areas of concern starting with six issues that were chosen by the community for focus and
another four health issues that are strongly substantiated by recent statistics.
• Barriers to receiving health care services, primarily the cost of healthcare,
the lack of insurance, and the geographic availability of services.
This was the top community priority. Despite the affluence of Orange County with a
median family income of $59,874, nearly 15% of Orange County residents are without
health insurance; and more than 14% were living below the federal poverty level.
Barriers to health care services go beyond affordability, although affordability of health
care was the number one concern that arose in the community assessment. Other barriers
include the disparity in treatments provided to minority residents even when they access
health care, and the concentration of services in the southern part of the county was also
noted as a barrier to northern residents, especially those with lower incomes and without
adequate transportation.
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"A healthy community would be less about the `haves' and the `have nots'. It would be
for everyone, and everyone would participate. "
" I took my child there ... and when I showed them my Medicaid card, they told me they
couldn't see him, and I left with my spirits on the floor.
Obesity among children and adults.
Obesity was the second issue selected by the community for a priority area of focus.
There has been an alarming increase in overweight and obesity in all age groups in NC
ion
and Orange County is no exception. In this county, almost 50% of the over 45 population
is overweight and over 20% of women are obese according to the 2002 Behavioral Risk
Factor Surveillance Survey. Of particular concern is overweight and obesity in,children,
as this could have long -term implications for heart disease, diabetes, and stroke.
Overweight and obesity is a complex web that includes both nutrition and physical
activity. Community attention to both is necessary to effect long lasting results.
The Healthy Choices Committee of Healthy Carolinians is focused on adult health
promotion including increasing physical activity, improv ing nutrition, and decreasing
obesity and overweight, while the Cooperative Extensions Orange on the Move
Coalition, is focused on these same issues for children. and the tell you about being
"When you're a freshman, you go to health [class], a cafeteria, and you can't eat healthy
overweight, and nutrition .... and then you go to the f Y
[foodj there. "
Orange County Teen
• High rates of substance abuse.
Applying 1 n g national stud y statistics to Orange County data, the Orange, Person, Chatham
Mental Health Authority estimates that there could be between 5,600 and 11,000 Orange
county residents.who are in need of some type of substance abuse service. Data indicates
that in a best case scenario only half of those who need such services are receiving them.
Alcohol use by middle and high school students is also alarmingly high as is the
prevalence of drug use by high school students. There is very little difference between
the districts in the use of either alcohol or drugs. This area was the third of the high
priority areas chosen for further work by the community.
"People have a perspective that alcohol addiction is only kids that come from a certain
type of family, and I don't think that's true. I work with just as many kids who come from
well - educated families who are well off as I do from lower - income families. I think
just that people who have more money hide it better, and have the ability to get private
treatment. "
Service provider
• Access to mental health services.
This was the fourth priority area of concern for the community. Residents felt that there
was already a shortage of mental health services and an inability to afford them.
Combined with the stigma associated with mental illness and the impending changes in
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mental health services due to statewide reform, there was great concern expressed about
mental health in Orange County. The Voices for Adolescents Committee of Healthy
Carolinians is working on a collaborative effort with the school systems, mental health
agency and other community agencies to improve mental health services for adolescents.
0 Access to dental health services for low- income populations.
Although also a celebration in that Orange County has positive preventive indicators, the
limited access to dental health services for low - income populations was ranked as the
fifth most important health issue. The high cost of dental care makes it virtually
unaffordable for those families with middle incomes who do not have dental insurance.
Increasingly high dental insurance premiums, high co -pays and deductibles are also
making it difficult for families to get dental care. Finding a provider that will accept
Medicaid is also an issue.
• Degrading air quality.
Finally, the community has concern over the quality of the air we breath. Though many
mentioned the beauty of living in Orange County, the quiet and green spaces, they also
lamented the traffic and problems with ozone and air pollution. Due to the crisscrossing
of the county by interstate highways 40 and 85 and a high level of commuter traffic due
partly to economic factors, the air quality of the county has become worse over the past
few years.
• High cancer rates.
Cancer was the leading cause of death in the County from 1999 -2001. The overall death
rate attributable to cancer is 213.5 per 100,000 in Orange County. Numbers of people
with lung, breast, colon, and prostate cancers are all high. And the breast cancer
incidence in Orange County was the highest in the state over the five -year period from
1996 -2000. There are also large disparities in the death rates between minority residents
and their white counterparts with minorities experiencing more than twice the rates of
colon and prostate cancer as whites. While cancers may not be totally preventable, early
screening and detection can often lead to improved health through early treatment. A
healthy lifestyle can also help reduce the risk of some forms of cancer. (maybe use a
graph here ?)
"Rising rates of cancer are a huge problem and they come from diet and smoking. "
Health care provider
0 High rates of reported and substantiated child abuse and neglect.
Orange County is ranked 51" among the 100 counties in the number of child abuse
investigations per 1,000 children. Reports of child abuse and neglect have increased over
the last four years. It is hard to determine whether this represents an increase in actual
abuse or reflects a growing community awareness resulting in more reports. Regardless,
this is of concern, since child abuse has long -term effects on children and families and
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ultimately our whole community. Strong collaborations have begun between related
service agencies and it will be important to continue and strengthen those collaborations.
The Advocates for Children committee of Healthy Carolinians has brought together over
15 community agencies to address the issue of child abuse, raise awareness about the
problem, provide education and training to professionals on recognition and response and
education and prevention information to parents.
• High suicide rates.
In Orange County in 2002, there were 12.8 suicides per 100,000, higher than the NC
2010 target of 8 and slightly higher than the state rate of 11.6. Substance abuse and
mental illness are both significant contributing factors to a high suicide rate. While
residents did not express a great deal of concern about suicides, substance abuse and
mental health were two of the community's top priorities.
• High unintentional injury rates.
While deaths and non -fatal injuries due to motor vehicle crashes were lower than the
Healthy Carolinians 2010 objectives, the number of such incidents that were alcohol -
related was extremely high, with 26.5% of fatal crashes and 7.9% of non -fatal crashes
being alcohol - related. In addition, the number of non -motor vehicle related injury deaths
were significantly higher than the state average with 29.4/100,000 deaths in Orange
County versus only 22.3/100,000 on average in the state. Non -motor vehicle related
injuries were the 5th leading cause of death in Orange County, most often caused by falls
and poisonings, and injuries and poisonings were the 4 leading cause of hospitalizations.
Call to Action
Many efforts are currently underway to address some of the priority issues especially in
the area of weight management and nutrition, but new initiatives will be needed to
address some of the more pressing and difficult issues such as barriers to accessing health
care and the need for more substance abuse services. The more difficult issues related to
the economy and the cost of living will require long term commitment on the part of
government and all residents to improve the quality of life for the citizens of Orange
County but particularly for those who face greater challenges economically, emotionally
and physically.