HomeMy WebLinkAboutBOH agenda 092618
ORANGE COUNTY BOARD OF HEALTH
MEETING AGENDA
DATE: September 26, 2018
TIME: 7:00 P.M.
PLACE: Whitted Building, 3rd Floor Meeting Room
300 West Tryon Street
Hillsborough, NC 27278
TIME ITEM
7:00 p.m. I. Welcome New Employees
7:00 – 7:05 II. Public Comment for Items NOT on Printed Agenda
public Comment for Items ON Printed Agenda will be
handled during that agenda item
(Please sign up for both on sheet near the entrance to room.)
Please limit your comments to 3 minutes.
7:05 – 7:10 III. Approval of September 26, 2018 Agenda
7:10 – 7:15 IV. Actions Items (Consent)
A. Minutes of August 22, 2018 Susan Elmore
7:15 – 7:50 V. Educational Sessions
A. Nutrition Update/Employee Health and Wellness Renee Kemske
(20 minutes) (relative to BOH Strategic Plan Priority: Physical Activity and Nutrition)
B. Medicaid Transformation Update (15 minutes) Quintana Stewart
7:50 – 8:10 VI. Action Items (Non Consent)
A. BOH Policy (20 minutes) Rebecca Crawford/
Quintana Stewart
8:10 – 8:35 VII. Reports and Discussion with Possible Action
A. Health Director Annual Evaluation Susan Elmore
B. Committee for 2019 Vice-Chair Selection Susan Elmore
C. Health Director Report Quintana Stewart
D. Media Items Kristin Prelipp
8:35 – 8:40 VIII. Board Comments
8:40 IX. Adjournment
BOARD MEMBERS: To ensure a quorum, SEND E-MAIL to lstrange@orangecountync.gov advising her of your
attendance at this meeting OR CALL 919-245-2411.
Compliance with the “Americans with Disabilities Act” and Title VI - Interpreter services and/or special sound equipment are available on
request. Call the Immigrant and Refugee Health Program Manager at 919.245.2387 to request an interpreter or other accommodation.
Conforme a la “Ley sobre Estadounidenses con Discapacidades” (ADA) y el Título VI – los servicios de intérprete y/o equipo de sonido
especial están disponibles a solicitud. Llame a la Administradora del Programa de Salud para Inmigrantes y Refugiados al 919-245-2387 para
solicitar un intérprete u otros arreglos o adaptaciones.
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ORANGE COUNTY BOARD OF HEALTH
August 22, 2018
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ORANGE COUNTY HEALTH DEPARTMENT MISSION STATEMENT: To enhance the quality
of life, promote the health, and preserve the environment for all people in the Orange County
community.
THE ORANGE COUNTY BOARD OF HEALTH MET ON August 22, 2018 at the Orange
County Health Department, 300 West Tryon Street, Hillsborough, NC.
BOARD OF HEALTH MEMBERS PRESENT: Susan Elmore – Chair, Timothy Smith –Vice-
Chair, Keith Bagby, Bruce Baldwin, Commissioner Mia Burroughs, Barbara Chavious, Paul
Chelminski, Jessica Frega and Liska Lackey.
BOARD OF HEALTH MEMBERS ABSENT: Jennifer Deyo and Sam Lasris.
STAFF PRESENT: Quintana Stewart, Health Director; Coby Jansen Austin, Director of
Programs and Policy; Hannah Baldwin, Dental Hygienist; Lakaya Craig, Temporary FSA Zone
Navigator; Rebecca Crawford, Financial and Administrative Services Director; Dominika
Gazdzinska, Community Outreach Specialist; Victoria Hudson, Interim Environmental Health
Director; Donna King, Health Promotion & Education Services Director; Kimberly Powell,
Advance Practice Practitioner; Kristin Prelipp, Communications Manager; Juliet Sheridan,
Health Informatics Manager; Beverly Scurry, BOH Strategic Plan Manager;and La Toya
Strange, Administrative Assistant II.
GUESTS PRESENT: None.
I. Welcome New Employees
Susan Elmore, Chair, called the meeting to order. She began by introducing new BOH member,
Keith Bagby. Mr. Bagby gave a brief introduction of himself including that he recently became
the chair of the ABC Board and is recently retired. The rest of the BOH members introduced
themselves to Mr. Bagby. Quintana Stewart, Health Director, welcomed new employees
Hannah Baldwin, Lakaya Craig, Dominika Gazdzinska, Kimberly Powell and Juliet Sheridan.
II. Public Comment for Items NOT on Printed Agenda: None.
III. Approval of the August 22, 2018 Agenda
Motion was made by Barbara Chavious to approve the agenda, seconded by Liska
Lackey and carried without dissent.
IV. Action Items (Consent)
A. Minutes of June 27, 2018 Meeting
Motion was made by Jessica Frega to approve the minutes of June 2018, seconded by
Bruce Baldwin and carried without dissent.
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ORANGE COUNTY BOARD OF HEALTH
August 22, 2018
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V. Educational Sessions
A. Cybersecurity
Jim Northrup, Chief Information Officer, shared information on how Orange County tackles
cybersecurity and vulnerabilities. The presentation was a general overview as to not disclose
any confidential security information. Below is a summary:
• Data must be protected. The OC servers are backed up at 2 different locations and the
tapes are moved offsite at least 25 miles away which is the recommended minimum
distance.
• The number 1 reason that hacking occurs is due to people clicking on links.
• OC has a fairly sophisticated filtering system. Currently 30% of email gets delivered to a
mailbox; it used to be 2-3%.
• Multiple audits are completed throughout the year.
• OC IT is big on user-education. OC IT conducts phish testing, provides video training on
key cybersecurity access for all staff and minimizes known vulnerabilities such as poor
passwords. Eventually, OC IT will not allow the individual to log in if they don’t complete
the cybersecurity training.
• OC IT is working on a continuity operation plan. A restoration process/plan is also in
place. After the County’s 4th cyberattack, restoration was completed in 12 hours which is
a big improvement from the 2 ½ weeks (24 hours/day) it took for restoration during the
1st attack thanks to the OC IT restoration plan.
• Six years ago, OC didn’t pay the ransomware when it was attacked and 99.98% of data
was restored. Restoration takes the most time as there are millions and millions of files.
To restore 1 serve driver takes 1 day.
• OC IT has a web tracking system that can track what an individual clicks. Trying to
identify people that are already on our network is an issue, not necessarily those that are
trying to get in. OC IT needs to protect from the inside. Penetration testing is conducted
and the reports are analyzed.
• In response to the question of protecting healthcare data, it was shared that OCHD is
one of the earliest partners of IT in terms of being proactive.
• These measures have been critical in preventing a Mecklenburg County government
situation.
The BOH had questions that were addressed by Mr. Northrup.
B. 4th Quarter Financial and Billing Dashboard Reports
Rebecca Crawford, Financial & Administrative Services Director, gave a report on the 4th
quarter revenue and billing accuracy. The report is as follows:
• Total Health Department Budget vs. Actuals: Average YTD monthly revenue in FY18
after the fourth quarter is $276/month or $3.5 million for the entire fiscal year,
representing 98.5% of our overall budgeted revenue for the year. This is an increase of
~$600k over FY 16-17. Expenses were lower than revenues at 94% of the total overall
budget due to multiple contracts that crossed into the beginning of FY 18-19 and will be
spent out by August 2018, which was $9.8 million compared to year end FY 16-17,
which was $9.2 million.
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• Total Billing Accuracy: Continuing with the goal of 90% billing accuracy set in FY 14-
15, the average billing accuracy rate for medical for FY 17-18 was 91% as compared to
the year-end average of 96% in FY 16-17. The average billing accuracy rate for dental
for FY 17-18 was 101% as compared to 100% in FY 16-17.
• Dental Earned Revenue by Source: The FY 17-18 average monthly revenue
($42.5/month) for the fourth quarter is below our budget projection ($43.4k/month) but
above our FY 16-17 average of $39.8/month. FY 17-18 dental earned revenue totaled
$511k at the end of the fiscal year, compared to $478k at the end of FY 16-17.
• Medical Earned Revenue by Source: Medical earned revenue for the fiscal year was
below the budgeted projection for FY 17-18 ($686k) at $609k since we had a provider on
maternity leave until the end of December, provider turnover at the end of the fiscal year,
and reduced appointments available to allow for Epic preparation.
• Grants Fund Revenue: FSA received a multi-year grant for $100k per fiscal year for 3
years at the end of FY 17-18. These funds will carry through FY 18-19 and FY 19-20.
We’ll track these and any other multi-year grants through this section of the financial
report on an ongoing basis.
• Note for FY 18-19 Revenue: FAS (Finance and Administrative Services Division)
anticipates medical revenue will be delayed for the first 3 months of FY 18-19 as we
close out billing in the Patagonia Electronic Medical Record System (EMR) and begin
billing in the new Epic EMR. UNC has built an incredible billing system for the Health
Department, however it is the first system like it they have ever built and we continue to
work through anticipated system issues, which will delay billing to commercial insurance
and Medicaid. Patients are still being seen so revenue will catch up in the latter part of
the Fiscal Year.
FAS also anticipates a potential delay in Environmental Health revenue as the division
transitions to a new Central permitting system in October. Staff are training frequently
now to reduce the impact on county residents and prepare for the upcoming Go Live.
The BOH members had questions that were addressed by Ms. Crawford.
C. Fluoride Ad Hoc Committee Update
Liska Lackey, BOH member, began by reminding the Board that the role they have in reviewing
a policy in which they have no authority is due to their duty to protect the public’s health while
recognizing that OWASA has that authority. Ms. Lackey then reviewed the proposed plan for
addressing key components in the November 3, 2017 letter in which OWASA requested a
review of fluoridation. Ms. Lackey acknowledged and praised the fluoride committee members
that provided input into this proposed plan. Board suggestions included making sure there is
focus on the at-risk population and having local experts (e.g. those in the triangle area)
participate. The Board came to a general consensus and all agreed on the proposed plan. Ms.
Lackey will generate a letter for the Board chair’s signature to be sent to OWASA.
The BOH members had questions that were addressed by Ms. Lackey.
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D. Family Success Alliance Update
Coby Jansen Austin provided an update on the Family Success Alliance and its strategic
planning process. Below are highlights:
• Currently, navigators are still assisting families in zone 4 and 6. They are actively
working to recruit their 4th cohort of students and their families into the navigator
program.
• Recruiting for two more part-time navigators (with benefits) has occurred. The Social
Worker Supervisor II position was reposted. Full-time navigators work with 20 families.
There are 596 participants and 147 families that the navigators are assisting.
• There are still 10 non-profits agencies that are working with the Family Success Alliance.
• Parent Council was launched and has been meeting since February. They’re also going
to give input on the strategic plan.
• An external evaluation will be developed to determine if the families were satisfied with
their services.
• The strategic planning process has involved 2 full day retreats where discussion
regarding the mission, vision, values and primary strategies (family empowerment,
systems change and foundational support) occurred. Ms. Austin asked the Board for
their feedback.
• Goals of the primary strategies are to have parents be change leaders, expansion which
may possibly take a year and to start building relationships as it’s harder to engage with
other partners not already involved with the Family Success Alliance. An invitation for
new partners has been extended.
The BOH members had questions that were addressed by Ms. Austin.
VI. Action Items (Non-Consent)
A. FY 17/18 Delinquent Accounts
Per the department’s Delinquent and Uncollectable Accounts policy (15.0), uncollectible
accounts must be administratively written off of the general ledger. The purpose of this
accounting function is to precisely account for funds which are truly unrecoverable. The last
administrative write-offs were performed by the Board of Health in August 2017 (Personal
Health, Dental Health, and Environmental Health) for FY 2016-2017.
Personal Health, Dental Health, and Environmental Health continue to participate in the NC
Debt Set-Off Program, which allows the county to collect debts on delinquent accounts with a
balance between $50 and $4,000 through the customer’s tax refund. The Health Department
anticipates collecting payments on delinquent accounts being pursued through the NC Debt
Set-Off program; therefore, those accounts are not included in this write-off request.
Based on the definitions of uncollectible accounts in the department’s policy, the following table
represents all uncollectible debt from clients for FY 2017-2018.
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Division
Number of
Uncollectable
Accounts
Write-Off
Amount
Personal Health 98 $1,750.60
Dental Health 76 $1,843.21
Environmental
Health 2 $300.00
Total $3,893.81
We request to administratively move a total of $3,893.81 in uncollectible debt from ‘active’ to
‘inactive’ status for the reasons indicted in the table above.
The customer will never be informed that a debt has been written off. If a customer whose
account had been determined uncollectible returns to clinic within three years, the delinquent
write-off amount will be reactivated and the billing process resumed. Likewise, if a customer
requests a non-required service from Environmental Health, the delinquent write -off amount will
be reactivated and the billing process resumed.
The BOH members had questions that were addressed by Ms. Crawford.
Motion to administratively move a total of $3,893.81 in uncollectable debt from “active” to
“inactive” status was made by Mia Burroughs, seconded by Jessica Frega and carried
without dissent.
B. BOH Policy Review
Quintana Stewart began by informing the BOH members that she has reviewed the Operating
Procedures to ensure that all Accreditation requirements were met. Suggested edits/revisions
discussed regarding the Operating Procedures were:
• In section “C. Committees”, the current subcommittees that are in the Strategic Plan
need to be listed.
• Language needs to reflect diversity and the benefits of including such language into the
Board’s Operating Procedures. A draft will be formed and will be voted on at the next
BOH meeting.
VII. Reports and Discussion with Possible Action
A. Health Director Report
In addition to her report, some of the highlights Ms. Stewart gave are below:
• There are multiple strategic plans in process. The Racial Equity Commission will have
staff and community focus groups to assist with their process. The Family Success
Alliance had 2 days of strategic planning that discussed the program and its future
direction. The Leadership Team is working on individual department plans.
• Fulfilling a request by the Board, Ms. Stewart was accepted into the Municipal and
County Administration Program at UNC SOG. She also expressed excitement about
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being accepted into the NC Public Health Leadership Institute and has already started
coursework.
• The NCALHD presented the OCHD the Challenge Award for its 2013 work on tobacco
policy.
• Ashley Rawlinson and Healthy Carolinians will host its 2nd Suicide Prevention Walk on
Friday, September 21st in Hillsborough at Gold Park.
• The NCPHA will take place in Charlotte. Several of our staff are on the agenda
including Victoria Hudson (a poster presentation), Nicholas Cordeiro (oral health) and
Iulia Vann and Tommy Green (F.I.T. Program).
Susan Elmore added that the ANCBH also has awards. She encouraged staff to go to their
website and complete an application next year as it’s a great opportunity to reward for a job well
done.
B. Media Items
Kristin Prelipp, Communications Manager, briefly mentioned the article topics of the F.I.T.
Program, a radio interview hosted by Frank Stasio in which Dr. Evan Ashkin and Tommy Green
participated, rabies and the Safe Syringe Program that were included in the Media Items packet.
Media items were in the packet which focused on Orange County’s events and our
involvement in various efforts.
VIII. Board Comments
None.
IX. Adjournment
Jessica Frega moved to adjourn the meeting at 9:05pm and Commissioner Mia
Burroughs seconded.
The next Board of Health Meeting will be held September 26, 2018 at the Orange County
Health Department, 300 West Tryon Street, Hillsborough, NC at 7:00 p.m.
Respectfully submitted,
Quintana Stewart, MPA
Orange County Health Director
Secretary to the Board
Agenda Item Number:
ORANGE COUNTY BOARD OF HEALTH
AGENDA ITEM SUMMARY
Meeting Date: September 26, 2018
Agenda Item Subject: Community Health Grant- Nutrition Services
Attachment(s):
Staff or Board Member Reporting: Renée Kemske, Nutrition Program Manager
Purpose: ____ Action
_X _ Information only
____ Information with possible action
Summary Information: OCHD was initially awarded funding ($122,065) for a Community
Health Grant from the Office of Rural Health from September 2017 to June 30, 2018
with the goal of increasing access to primary care and self-management support
services for adults with chronic conditions. OCHD used the funding to pilot a voucher
program covering the costs of the fee for nutrition services, to provide diabetes testing
supplies for primary care patients and to offer diabetes classes in Spanish. UNC
Family Medicine is a partner on this grant and used funds to increase the number of
chronic disease management classes offered. The partners also initiated a Community
Health Collaborative to increase awareness of local resources and to formalize referral
systems.
OCHD was awarded additional funding for FY18-19 ($145,917) to expand the pilot
program by developing a transportation assistance program, replicating the nutrition
services voucher program at the Chatham County Public Health Department and by
providing funding and support for the Department on Aging cholesterol screenings and
wellness events. UNC Family Medicine also plans to offer the chronic disease
management classes in Spanish.
Recommended Action: ___Approve
___Approve & forward to Board of Commissioners for action
___Approve & forward to ___________________________
_X_Accept as information
___Revise & schedule for future action
___Other (detail):
Community Health Grant
Nutrition Update
ORANGE COUNTY HEALTH DEPARTMENT
NUTRITION SERVICES
Renée Kemske, MPH, RD, LDN, Nutrition Program Manager
OBJECTIVES
Provide an overview of
Nutrition Services
Discuss goals/progress of
Community Health Grant
Present upcoming plans for FY18-19
OVERVIEW OF SERVICES
Medical Nutrition Therapy
Diabetes Self-Management Education Services
Employee Wellness Services
CDC Minority Diabetes Prevention Program
NUTRITION COUNSELING
NUTRITION COUNSELING
Medical Nutrition Therapy (MNT)
Provided by an RD who works with the referring medical
provider to improve conditions such as diabetes, heart
disease, and obesity
Conducts thorough review of medical history,
medications, labs, diet, and lifestyle patterns
Develops a personalized nutrition treatment plan/goals to
improve health outcomes
MEDICAL NUTRITION THERAPY (MNT)
MNT Data
Total Encounters for
FY 2017-2018: 782
Health
Department
415 53%
Non-Health
Department
367 47%
Types of clients Count %
Maternal Health 163 21%
Child Health 148 19%
PC 87 11%
FP 17 2%
Adult Non
Health-Dept
Referrals
250 32%
Child Non
Health-Dept
Referrals
117 15%
MEDICAL NUTRITION THERAPY (MNT)
Clients by Payment Type (782 Total)
Payer Count %
Medicaid 328 42%
Insurance 240 31%
Self-Pay 214 27%
DIABETES SELF-MANAGEMENT
EDUCATION SERVICES (DSME)
DIABETES SELF-MANAGEMENT
EDUCATION SERVICES (DSME)
Participants will receive 10-hours of education:
Initial health assessment
Two 4-hours group education classes on the
basics of diabetes care
Follow-up appointment 3 months after the group
class (1-hour group)
COMMUNITY HEALTH GRANT
Background
Submitted Application-March 2017
Community Health Grant through the Office of Rural Health
Awarded $122,065
Ten -month period (September 2017-June 2018)
To increase access to primary care and self-
management support services for residents with chronic
disease.
COMMUNITY HEALTH GRANT
Target Population:
Adults who are uninsured
or who have Medicaid or
Medicare
Adults with any of the
following conditions:
Obesity
Pre-diabetes or diabetes
Abnormal lipids
Hypertension
GRANT SPECIFIC AIMS
Supplement staff funding and operational costs
Medical Nutrition Therapy
Diabetes Self-Management Education Services
Create a voucher program covering the costs of the
minimum fee for nutrition services ($20)
Cover the cost of A1C tests and SMBG supplies for
people with diabetes
Increase accessibility of interpretation services for LEP
patients (MNT and DSME Interpreters)
GRANT SPECIFIC AIMS
Funds to supplement costs for UNC Family Medicine to
offer at least two Living Healthy classes
Stanford Curriculum chronic disease classes
Hire Community Health Worker
Establish relationships with people in the community offering
support to better manage chronic conditions
Increase awareness of services/link people to services (outreach
and marketing)
Teach Living Healthy classes
Conduct focus groups
GRANT SPECIFIC AIMS
Convene Community
Partnership/Collaborative
Medical providers and
community agencies
Partnership Goal
To increase community
awareness of services and
linking residents to care
through formal referral
systems
COMMUNITY PARTNERSHIP AIMS
Conduct a needs assessment/gap analysis of current
services in Orange County (chronic disease focus)
Increase outreach and awareness of services available
to residents (medical providers, organizations, residents)
Develop coordinated programing and referrals systems
Conduct focus groups to gather input on resident needs
and barriers to care
CHG FY17-18 YEAR IN REVIEW
Voucher Program
Provided 134 appointments
105 Medical Nutrition Therapy
29 Diabetes Self-Management
Education
Tripled the # of primary care clients seen (31 v. 87)
Diabetes Testing Supplies
Developed and implemented protocol to offer A1C tests and
diabetes testing supplies at no cost for uninsured clients
CHG FY17-18 YEAR IN REVIEW
DSME Spanish Classes
Held 2 classes (4 sessions)
Purchased simultaneous interpretation
devices to aid in interpretation
MNT Behavior Change Incentives
Purchased water bottles, calorie tracking book, step tracker in
May 2018 for MNT clients
CHG FY17-18 YEAR IN REVIEW
Success Stories
One Spanish LEP client has lost 20# since starting MNT appts
(October 2017). Client reported she would not have been able
to afford the service without the voucher and reported it was the
support of the service that helped her lose weight.
DSME Class Evaluation Data
100% of participants had improved knowledge of diabetes self-
care behaviors
Spanish LEP clients rated the class as excellent and liked the
simultaneous interpretation devices used
CHG FY17-18 YEAR IN REVIEW
Living Healthy Classes
Offered 5 Classes (54 people)
Rogers Road Community Center,
UNC Family Medicine, Passmore Senior Center
Standardized Evaluation tool
(Patient Activation Measure)
Scores increased by five points pre/post the classes
Participants ranked their satisfaction at 4.9 out of 5
CHG FY17-18 YEAR IN REVIEW
Living Healthy Classes
Offered 5 Classes (54 people)
Rogers Road Community Center, UNC
Family Medicine, Passmore Senior
Center
Standardized Evaluation tool
(Patient Activation Measure)
Scores increased by five points
pre/post the classes
Participants ranked their
satisfaction at 4.9 out of 5
CHG FY17-18 YEAR IN REVIEW
Community Health Worker/Outreach Progress
Regularly updated provider/community contact sheet for
disseminating information (478 contacts)
Provided two mass mailings/emails to contacts regarding
services (44 practices and 159 medical providers)
Provided 29 on-site visits to medical practices and 69
email/phone call follow-ups
Conducted 58 additional outreach efforts
CHG FY17-18 YEAR IN REVIEW
Community Health Collaborative
Held 4 meetings: 11/2/17, 1/11/18, 4/26/18, 6/21/18
Partners: PHS, OCHD, UNCFM, YMCA, OCDOA,
CCPHD, CCNC, Carolina Health Net
Started resource guide of community partners to increase
awareness of local services
CHG FY17-18 YEAR IN REVIEW
Older Adult Focus Group
May 2018,10 Participants
Passmore Senior Center
Barriers to Care Key Points
Decreased awareness of
chronic disease programs
Transportation and cost
Communication
Preferred methods: mail, senior times and email
CHG FY17-18 YEAR IN REVIEW
Latino Community Focus Group
May 2018, 7 Participants
St. Thomas More Church
Barriers to Care Key Points
Decreased awareness of
chronic disease programs
Cost, time and language
Communication
Preferred methods: text
messaging, email, church
FY18-19 GRANT OVERVIEW
Awarded $145,914 (July 2018 - June 30, 2019)
OCHD to continue voucher program covering the
minimum fee costs
CCPHD to replicate voucher program ($15)
Cover the cost of A1C tests and SMBG supplies for
people with diabetes
Supplement staff funding and operational costs
FY18-19 CHG SPECIFIC AIMS
Transportation Assistance Program
Pilot program for high risk individuals to increase access
to care
Convened committee (9/7/18)
Assessment criteria
Vendors
Safety and legal factors
Initial implementation plan
FY18-19 CHG SPECIFIC AIMS
Expand Collaboration with
OC Department on Aging
Provide financial support for
quarterly cholesterol
screenings
Provide targeted outreach to
older adults through existing
wellness programming
FY18-19 CHG SPECIFIC AIMS
Train Community Health Worker in Spanish Living
Healthy Curriculum - provide at least 1 class in
Spanish
Increase accessibility of interpretation services for LEP
patients
MNT interpreters
Offer at least 2 diabetes classes in Spanish
GRANT SPECIFIC AIMS
Continue Quarterly Community Collaborative
Meetings
Medical providers, community organizations and residents
Formalize a referral and feedback system between
services and increase community awareness of services
Conduct Final Focus Group
Review data analysis and develop action plans based on
analysis
SUMMARY/QUESTIONS
Provided an overview of
Nutrition Services
Discussed goals/progress of
Community Health Grant
Presented plans for FY18-19
Agenda Item Number:
ORANGE COUNTY BOARD OF HEALTH
AGENDA ITEM SUMMARY
Meeting Date: September 26, 2018
Agenda Item Subject: Medicaid Transformation Update
Attachment(s): Medicaid Transformation Presentation 2018
Staff or Board Member Reporting: Quintana Stewart
Purpose: ____ Action
_X Information only
____ Information with possible action
Summary Information:
In September 2015, the NC General Assembly enacted Session Law 2015-245, which
directed the transition of Medicaid from a fee-for-service structure to a managed care
structure. On August 10, 2018 NC DHHS released a Request for Proposal for PrePaid
Health Plans (PHPs) in Medicaid Managed Care. This update will outline the
requirements for PHPs and the impact of this for the Local Health Departments in NC.
Recommended Action: ___Approve
___Approve & forward to Board of Commissioners for action
___Approve & forward to ___________________________
__X_Accept as information
___Revise & schedule for future action
___Other (detail):
Agenda Item Number:
ORANGE COUNTY BOARD OF HEALTH
AGENDA ITEM SUMMARY
Meeting Date: September 26, 2018
Agenda Item Subject: Board of Health Policy Review
Attachment(s):
Staff or Board Member Reporting:
Purpose: ____ Action
_ Information only
__X__ Information with possible action
Summary Information: The Board will review and discuss the Board of Health
Operating Procedures to ensure processes are efficient and in compliance with NC
General Statue 130A. The Board will review the requested revisions to detail Board
Composition and updated Committee listings. Additional revisions will be made as
needed and the Board will be asked to approve the policy.
Proposed revisions include:
III. Composition
A. The composition of the Board of Health is governed by NCGS 130A-35(b)-(d)
which states the composition of the board shall reasonably reflect the
population and makeup of the county.
B. For purposes of Board composition, diversity includes, but is not limited to,
professional experience, cultural and educational background, geography,
age, gender, race and ethnicity. When assessing Board composition or
identifying suitable candidates for appointment/re-appointment, the Board will
consider candidates on merit and statutory requirement with consideration to
the benefits of diversity.
C. The Orange County Board of Health is committed to ensuring diversity among
members and values the benefits that diversity brings. Diversity promotes the
inclusion of different perspectives and ideas, mitigates against group think
and ensures that the Board has the opportunity to benefit from a variety of
skills, backgrounds and experiences.
D. The Board’s commitment to diversity shows internal and external
stakeholders that the organization emphasizes diverse constituencies and
does not discriminate against minorities, thereby enhancing the Board’s
reputation with county government and citizens.
C. Committees
3. Physical Activity & Nutrition to replace Access to Care
5. Social Determinants of Health to replace Childhood and Family Obesity
Prevention
Recommended Action: _X_Approve
___Approve & forward to Board of Commissioners for action
___Approve & forward to ___________________________
___Accept as information
___Revise & schedule for future action
___Other (detail):
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section III: Board Processes
Process A: Operating Procedures
Reviewed by: Health Director
Approved by: Health Director, Board of Health
Review Annually (July) Page 1 of 7
Original Effective Date: February 8, 1979
Revision Dates: 12/18/1980, 4/16/1981; 4/26/1984; 11/16/2000; 2/23/2007; 10/24/2007; 4/23/2009, 7/24/12,
11/5/13, 11/14, 8/15
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Purpose
To outline operating procedures for the Board of Health in accordance with pertinent state,
local and federal requirements for the operation of the Board.
I. Name and Office
The name of this organization is the Orange County Board of Health (hereinafter
“Board”). The principal office of the Board is located at 300 West Tryon Street,
Hillsborough, NC 27278.
II. Charge to the Board
The Board is the primary policy-making and adjudicatory body (NCGS 135A-25(a))
for the health department and is charged to protect and promote the public health of
Orange County (NCGS 130A-39).
III. Composition
A. The composition of the Board of Health is governed by NCGS 130A-35(b)-
(d) which states the composition of the board shall reasonably reflect the
population and makeup of the county.
B. For purposes of Board composition, diversity includes, but is not limited to,
professional experience, cultural and educational background, geography, age,
gender, race and ethnicity. When assessing Board composition or identifying
suitable candidates for appointment/ re-appointment, the Board will consider
candidates on merit and statutory requirements with consideration to the benefits
of diversity.
C. The Orange County Board of Health is committed to ensuring diversity
among members and values the benefits that diversity brings. Diversity
promotes the inclusion of different perspectives and ideas, mitigates against
group think and ensures that the Board has the opportunity to benefit from a
variety of skills, backgrounds and experiences. Increasing diversity at the board
level is an essential element in supporting the attainment and sustainability of
its strategic objectives. Diversity allows the board to make more effective
decisions for the department and community residents as well as enhances its
reputation among county government and citizens.
D. The Board’s commitment to diversity shows internal and external
stakeholders that the organization emphasizes diverse constituencies and does
not discriminate against minorities, thereby enhancing the Board’s reputation
with county government and citizens.
A. Diversity will include and make good use of the differences in the skills,
knowledge, professional experience, cultural and educational background
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section III: Board Processes
Process A: Operating Procedures
Reviewed by: Health Director
Approved by: Health Director, Board of Health
Review Annually (July) Page 2 of 7
Original Effective Date: February 8, 1979
Revision Dates: 12/18/1980, 4/16/1981; 4/26/1984; 11/16/2000; 2/23/2007; 10/24/2007; 4/23/2009, 7/24/12,
11/5/13, 11/14, 8/15
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gender, age, race, ethnicity, geography, and other qualities of the individual
members as a whole.
IV. Terms of Office
A. By NCGS 130A-35 (c), members shall serve three year terms and no member
may serve more than three consecutive three-year terms unless the member is
the only person residing in the county who represents one of the professions
designated in subsection (b) of NCGS 130A-35.
B. It is the policy of the Orange County Board of Health that members may serve
three, three-year consecutive terms. Members appointed to fill unexpired
terms are eligible to subsequently be appointed to three additional terms.
V. Officers and Committees
A. Chair and Vice-Chair
The Board members shall select a Chair and Vice-Chair by majority vote each
year at the last meeting of the calendar year.
B. Secretary
The Orange County Health Director shall serve as Secretary to the Board, but
the Director is not a member of the Board. The Health Director may delegate
the duties of the secretary that are set forth in these operating procedures to an
appropriate local health department employee.
C. Committees
The Board shall review the existing committee structure annually and make
decisions regarding the number and types of standing committees. Board
members are appointed to committees in January of each year. Only Board
members may serve as committee members of standing Board committees and
the number of Board members on any single committee must be at least two
members and may not exceed five members.
The Board shall have the following standing committees:
1. Executive Committee
To provide the structure for the work of the Board of Health and act as an
advisor to the health director and senior management staff as needed.
Chair and Vice-Chair are committee members.
2. Nominating and Bylaws Committee
To develop and present an annual slate of officers for Board consideration,
to oversee the board recruitment process, and to recommend operating
procedure changes as needed. Members are appointed by the Chair on an
ad hoc basis.
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section III: Board Processes
Process A: Operating Procedures
Reviewed by: Health Director
Approved by: Health Director, Board of Health
Review Annually (July) Page 3 of 7
Original Effective Date: February 8, 1979
Revision Dates: 12/18/1980, 4/16/1981; 4/26/1984; 11/16/2000; 2/23/2007; 10/24/2007; 4/23/2009, 7/24/12,
11/5/13, 11/14, 8/15
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3. Access to CarePhysical Activity and Nutrition
To oversee the action steps and deliverables outlined in the Access to Care
Physical Activity and Nutrition section of the Board of Health Strategic
Plan
4. Mental Health and Substance Abuse
To oversee the action steps and deliverables outlined in the Mental Health
and Substance Abuse section of the Board of Health Strategic Plan
5. Childhood and Family Obesity Prevention Social Determinants of
Health
To oversee the action steps and deliverables outlined in the Childhood
and Family Obesity Prevention Social Determinants of Health section of
the Board of Health Strategic Plan
All standing committees are subject to the North Carolina open meetings
laws and shall comply with the provisions of those laws.
6. Temporary Committees
The Board may establish and appoint members for temporary committees
as needed to carry out the Board’s work. Temporary committees must
limit their work to the specific charge outlined by Board motion and may
include members that are not serving on the Board of Health.
All temporary committees are subject to the North Carolina open meetings
laws and shall comply with the provisions of those laws.
VI. Meetings
A. Regular Meetings
The Board shall hold regular meetings no less than quarterly. As a general
rule, the Board will meet monthly. A calendar of regular meetings and
location of each meeting will be established at the last regular meeting of the
calendar year for the next calendar year. The dates may be adjusted annually
based on Commissioner meeting dates for the year to enable the
Commissioner member of the Board to attend. The requirements of the open
meetings law shall apply to all regular board, regular or ad hoc committee or
task for meetings. Notification of the public will be in compliance with open
meeting law notification.
B. Agenda
The Secretary to the Board shall prepare an agenda for each meeting. Any
board member who wishes to place an item of business on the agenda shall
submit a request to the Secretary at least five working days before the
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section III: Board Processes
Process A: Operating Procedures
Reviewed by: Health Director
Approved by: Health Director, Board of Health
Review Annually (July) Page 4 of 7
Original Effective Date: February 8, 1979
Revision Dates: 12/18/1980, 4/16/1981; 4/26/1984; 11/16/2000; 2/23/2007; 10/24/2007; 4/23/2009, 7/24/12,
11/5/13, 11/14, 8/15
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meeting. For regular meetings, the Board may add items to the agenda or
subtract items from the agenda by a majority vote. The agenda for a special or
emergency meeting may be altered only if permitted by and in accordance
with the North Carolina open meetings laws.
C. Presiding Officer
The Chair of the Board shall preside at Board meetings if he or she is present.
If the Chair is absent, the Vice-Chair shall preside. If the Chair and Vice-
Chair are both absent, another member designated by a majority vote of
members present at the meeting shall preside.
D. Quorum
A majority of the actual membership of the Board, excluding vacant seats,
shall constitute a quorum. A member who has withdrawn from a meeting
without being excused by a majority vote of the remaining members shall be
counted as present for purposes of determining whether or not a quorum is
present.
E. Voting
Each Board member shall be permitted to abstain from voting, by so
indicating when the vote is taken. A member must abstain from voting in
cases involving conflicts of interest as defined by North Carolina law. If a
member has withdrawn from a meeting without being excused by a majority
vote of the remaining members, the member’s vote shall be recorded as an
abstention.
F. Minutes
The Secretary shall prepare minutes of each Board meeting. Copies of the
minutes shall be made available to each Board member before the next regular
Board meeting. At each regular meeting, the Board shall review the minutes
of the previous regular meeting as well as any special or emergency meetings
that have occurred since the previous regular meeting, make any necessary
revisions, and approve the minutes as originally drafted or as revised. The
public may obtain copies of Board meeting minutes at the Board of Health
website
(http://www.orangecountync.gov/departments/health/agendas_and_minutes.p
hp).
VII. Contract Negotiations
The Health Director is authorized to enter into a contract with any governmental or
private agency or with any person, for the provision or receipt of public health
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section III: Board Processes
Process A: Operating Procedures
Reviewed by: Health Director
Approved by: Health Director, Board of Health
Review Annually (July) Page 5 of 7
Original Effective Date: February 8, 1979
Revision Dates: 12/18/1980, 4/16/1981; 4/26/1984; 11/16/2000; 2/23/2007; 10/24/2007; 4/23/2009, 7/24/12,
11/5/13, 11/14, 8/15
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services. The Board of Commissioners or its designee must approve contracts
requiring payment for services rendered to the Health Department. The Health
Director will discuss with the Board contracts that represent significant deviation
from current Board of Health policy prior to authorizing that contract.
VIII. Amendments to Operating Procedures
These operating procedures may be amended at any regular meeting or at any
properly called special meeting that includes amendment of the operating procedures
as one of the stated purposes of the meeting. A quorum must be present at the
meeting at which amendments are discussed and approved, and any amendments
must be approved by a majority of the members present at the meeting.
IX. Other Procedural Matters
The Board shall refer to Bell, II, A. Fleming. Suggested Rules of Procedure for Small
Local Government Boards, Second Edition, Institute of Government, The University
of North Carolina at Chapel Hill, 1998 to answer procedural questions not addressed
in this document, so long as the procedures prescribed in Suggested Rules of
Procedure for Small Local Government Boards do not conflict with North Carolina
law.
X. Rules Development Procedure
The board shall evaluate the need for adoption of rules to protect and promote the
public health. In addition, existing rules should be evaluated periodically for the need
for revisions to respond to new risks, advances in technology, or changes in statutes
or state regulations.
A. The Board will follow the procedures outlined in NCGS 130A-39.
1. Not less than 10 days before the adoption, amendment or repeal of any
local board of health rule, the proposed rule shall be made available at
the office of the county clerk, and a notice shall be published in a
newspaper having general circulation within Orange County. The notice
shall contain:
a. A statement of the substance of the proposed rule or a
description of the subjects and issues involved.
b. The proposed effective date of the rule, and
c. A statement that copies of the proposed rule are available at
the local health department.
A local board of health rule shall become effective upon adoption
unless a later effective date is specified in the rule.
2. Copies of all rules shall be filed with the secretary of the local board of
health and will be made available to all Board of Health members.
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section III: Board Processes
Process A: Operating Procedures
Reviewed by: Health Director
Approved by: Health Director, Board of Health
Review Annually (July) Page 6 of 7
Original Effective Date: February 8, 1979
Revision Dates: 12/18/1980, 4/16/1981; 4/26/1984; 11/16/2000; 2/23/2007; 10/24/2007; 4/23/2009, 7/24/12,
11/5/13, 11/14, 8/15
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3. A local board of health may, in its rules, adopt by reference any code,
standard, rule or regulation, which has been adopted by any agency of
this State, another state, any agency of the United States or by a
generally recognized association. Copies of any material adopted by
reference shall be filed with the rules.
XI. Adjudication Procedures
A. The Board will follow all procedures as specified in NCGS 130A-24. In the
case where a member of the public is appealing a decision on the application
of an Orange County Board of Health adopted rule or concerning the
imposition of administrative penalties by a local health director, the process
will include the following steps:
1. The aggrieved party shall provide written notice of appeal to the Health
Director within 30 days of the challenged action. The notice shall
contain the name and address of the aggrieved person, a description of
the challenged action and a statement of the reasons why the challenged
action is incorrect.
2. The Health Director shall notify the Board within five working days of
receipt of the appeal and transmit all documents upon which the
challenged action was taken.
3. The Board of Health shall hold a hearing within 15 days of the receipt of
the notice of appeal from the health director to the Board. The Board
will give the person not less than 10 days notice of the date, time and
place of the hearing. The local board of health shall issue a written
decision based on the evidence presented at the hearing. The decision
shall contain a concise statement of the reasons for the decision.The
hearing must meet the requirements of procedural due process.
a. No contact outside the hearing with parties involved or
between board members.
b. Board members with any bias must not participate.
c. Board must allow the appellant’s attorney to attend and
advise his/her client.
d. Board must take sworn and relevant testimony.
e. Board must provide for cross-examination of witnesses.
f. Board must keep detailed or verbatim minutes.
4. The proceedings shall be recorded and a transcript of the hearing shall
be prepared and be available to the appellant and/or the Board upon
request.
5. At the next regularly scheduled Board meeting following the hearing,
the Board must issue a written decision based on the evidence presented
at the hearing. The decision shall contain a concise statement of the
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section III: Board Processes
Process A: Operating Procedures
Reviewed by: Health Director
Approved by: Health Director, Board of Health
Review Annually (July) Page 7 of 7
Original Effective Date: February 8, 1979
Revision Dates: 12/18/1980, 4/16/1981; 4/26/1984; 11/16/2000; 2/23/2007; 10/24/2007; 4/23/2009, 7/24/12,
11/5/13, 11/14, 8/15
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reasons for the decision and the Secretary will transmit the final written
decision of the Board to the person appealing via certified US mail.
6. A person who wishes to contest a decision of the Board of Health shall
have a right of appeal to the district court having jurisdiction within 30
days after the date of the decision.
XII. Annual Review of the Health Director
The Board will annually review the performance of the Orange County Health
Director using the process detailed in the Board of Health Policy and Procedure
Manual, Section III, B.d. Annual Performance Review Process for Health Director.
XIII. Compliance with North Carolina Law
In conducting its business, the Board shall comply with all applicable North Carolina
laws, including but not limited to open meetings laws, public records laws, and the
laws setting forth the responsibilities and duties of local boards of health. To assist
the Board in compliance, the local health director shall maintain a current copy of
relevant North Carolina General Statutes and make them available to Board members
on request.
Agenda Item Number:
ORANGE COUNTY BOARD OF HEALTH
AGENDA ITEM SUMMARY
Meeting Date: September 26, 2018
Agenda Item Subject: Fee and Eligibility Policy Review
Attachment(s): Draft Fee and Eligibility Policy
Staff or Board Member Reporting: Rebecca Crawford
Purpose: ____ Action
_X__ Information only
____ Information with possible action
Summary Information:
The Board of Health reviews its policy manual annually. Updates to two sections of the
Fee and Eligibility section of the policy are recommended below:
I.E. Fee and Eligibility Policy
Staff recommends making the following revisions to the Fee and Eligibility Policy
for the purposes of clarification, to be in compliance with state requirements, and
to update according to system changes:
- Service Limitation/Denial (Section V.C.): Expanded the section stating that
Family Planning patients will never be refused service due to an outstanding
balance or inability to provide proof of income to include Maternal Health and
Child Health patients at the recommendation of the DHHS Administrative
Consultant.
- Fees Collection (Section VII.E.): Clarified that clients are given a statement
showing the cost of services after charges are processed upon request
rather than at the time services are received since the Epic Electronic Medical
Record (EMR) system is unable to produce a statement until after charges
are processed, which may not occur until after the patient has left the clinic.
- Fees Collection (Section VII.I.): Updated the Billing Cycle section to specify
the billing statement process for the Epic Electronic Medical Record (EMR)
system since it differs from both the Patagonia EMR and Eaglesoft EMR that
was detailed in the previous version.
Recommended Action: ___Approve
___Approve & forward to Board of Commissioners for action
___Approve & forward to _______________
_X__Accept as information
___Revise & schedule for future action
___Other (detail):
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section I: Board Adopted Policies
Policy E: Fee and Eligibility Policy
Reviewed by: Financial Review Committee, Health Director
Approved by: Board of Health, Health Director
Page 1 of 8
Original Effective Date: January 25, 2001
Revision Dates:, 2/4/13, 8/12/13, 10/22/2014, 9/22/2015, 4/26/2016, 9/2018
I. Purpose
A. Public health services are increasingly costly to provide. The Health Department serves
the public’s interest best by assuring that all legally required public health services are
furnished to all citizens. The department provides recommended and requested public
health services based upon the priorities established by the Board of Health.
B. Fees are a means to help provide services to the residents of Orange County. Fees help
finance and extend public health services when government funding is not sufficient to
support the full cost of providing all required and requested services.
C. Fees for Orange County Health Department services are authorized under North Carolina
G.S. 130A-39, provided that:
1. They are in accordance with a plan recommended by the Health Director and
approved by the Board of Health and the Orange County Board of Commissioners.
2. They are not otherwise prohibited by law.
3. They are deposited to the account of the local Health Department for public health
purposes in accordance with the provisions of the Local Government Budget and
Fiscal Control Act.
D. Fees for services must also be in compliance with N.C. Administrative Code, Title X
Regulations, and Women’s and Children’s Health Program Rules.
E. There will be no charge for Title X Services provided for individuals with income less
than 100% of the Federal Poverty Level (FPL.)
II. Policy Implementation
The implementation of this policy is delegated to appropriate financial or support staff in
each division of the health department.
III. Income Eligibility
A. Definitions
1. Definition: A family is defined as a group of individuals who are living together as
one economic unit. Individuals are considered members of a single family or
economic unit when their production of income and consumption of goods are
related. A pregnant woman is counted as a family of two in determining family size.
2. Income eligibility requirements apply to: Dental Health, Family Planning, Child
Health, Maternal Health, Adult Health, Nutrition Services, Family Home Visiting,
and Primary Care Services.
3. The Health Department utilizes a sliding fee scale based on Federal Poverty
Guidelines in accordance with the Fee Schedule approved annually during the
County Budget process. NC DPH updates and issues the scale yearly. Specifically,
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section I: Board Adopted Policies
Policy E: Fee and Eligibility Policy
Reviewed by: Financial Review Committee, Health Director
Approved by: Board of Health, Health Director
Page 2 of 8
Original Effective Date: January 25, 2001
Revision Dates:, 2/4/13, 8/12/13, 10/22/2014, 9/22/2015, 4/26/2016, 9/2018
the health department uses the 101% - 250% Federal Poverty Level sliding scale.
Determination of Sliding Fee percentage is based on gross income and family size.
4. Verification of income is required at time of enrollment for services, at the annual
financial interview, or if there is a change in the work status in the family unit for
clients to be eligible for the sliding fee scale.
a. An annual gross income statement is preferred for evaluation.
i. Gross income is defined as the total of all cash income before deductions for
income taxes, employee social security taxes, insurance premiums, bonds,
etc. For self-employed applicants, net income after business expenses. Gross
income does NOT include money earned by children for babysitting, lawn
mowing and other tasks.
ii. In general gross income includes: salary, wages, commissions, fees, tips,
overtime pay, unemployment compensation, public assistance money,
alimony and child support payments, Social Security benefits, VA benefits,
Supplemental Security Income (SSI) benefits, retirement & pension
payments, worker’s compensation, bonuses, prize winnings and other sources
of cash income except those specifically excluded.
B. Sources
1. Sources of income verification may include, but are not limited to:
a. Current pay stub
b. Self-employment accounting records
c. Letter documenting current employment and wages from employer
d. Recent income tax return
e. Unemployment or workers compensation receipt
f. Public assistance letter
g. Prior income verification through enrollment in other Health Department
programs
2. If an individual claims “no income” (except for minors consenting to specific
services under G.S. 90-21.5), a signed “Verification of Income and/or Residency”
form (Attachment A) indicating financial support from another party must be
submitted.
3. Failure to provide verification within 30 days or less of date of service will result in
charges being assessed at 100% of sliding fee scale. The client will receive
notification of required income verification at the time the initial appointment is
made.
4. The client must read, sign and understand the “Determination of Eligibility Payment
Plan for Clinical Services” and “Statement of Financial Responsibility Payment
Plan” form (Attachment B) at their initial visit and annual financial reviews.
C. Environmental Health
Persons seeking Environmental Health services must obtain and properly complete an
application for service and pay the corresponding fee for service (all applicants pay at the
100% pay status) before an appointment for a field visit will be scheduled. Sometimes
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section I: Board Adopted Policies
Policy E: Fee and Eligibility Policy
Reviewed by: Financial Review Committee, Health Director
Approved by: Board of Health, Health Director
Page 3 of 8
Original Effective Date: January 25, 2001
Revision Dates:, 2/4/13, 8/12/13, 10/22/2014, 9/22/2015, 4/26/2016, 9/2018
additional fees may be necessary if during service delivery it is determined that the
correct fees were not initially paid, or services requested are more than applied for.
Wastewater Treatment Management Program (WTMP) and Mobile Home Park fees are
the only Environmental Health services invoiced after the inspection. These inspections
are not application based but occur on a regulated, recurring schedule.
IV. Residency Requirements
A. Any individual, Orange County resident or non-resident, may be eligible for services
provided by the Health Department. Exceptions include non-STD Communicable Disease
cases, designated Family Home Visiting programs (Orange County residents only), and
when prohibited by law or regulation.
B. Proof of Residency may be determined by using the US Postal and/or Orange County
GIS website and one of the following: Driver’s License, Government-issued
identification, Pay Stub (Within the last 30 days), Utility bill (Within the last 45 days);
Current rental or lease agreement; Personal or property tax bill; Student identification,
and Matrícula Consular (Mexican ID Card 1). Clients without one of the above
identifying information sources but reportedly living within the county will be required to
produce a written statement or letter from the head of household, verifying that the
person resides in their home. Special cases will be referred to the Clinic Manager or
Supervisor. Failure to provide proof of residency may result in referral to another
resource.
C. Proof of Residency in Orange County is required for self-pay patients to be eligible for
the sliding fee scale when requesting Maternal Health, Child Health, Primary Care,
Nutrition Services, and Dental Health Services. Out-of-county residents will be assessed
at 100% of charges not covered by a third party payer source.
V. Service Limitation/Denial
A. Services will not be denied based solely on the inability to pay, with the exception of
those services that require a flat or minimum fee. Emergency dental services and urgent
primary care services will be provided to clients regardless of any outstanding balance
due.
B. Otherwise, services may be denied if the department does not have the resources needed
to provide a quality non-mandated service or the individual does not meet the residency
or financial requirement.
1 The Matrícula Consular de Alta Seguridad (MCAS) (Consular Identification Card) is an identification card issued by
the Government of Mexico through its consulate offices to Mexican nationals residing outside of Mexico. Retrieved from
http://en.wikipedia.org/wiki/Matr%C3%ADcula_Consular on October 14, 2012.
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section I: Board Adopted Policies
Policy E: Fee and Eligibility Policy
Reviewed by: Financial Review Committee, Health Director
Approved by: Board of Health, Health Director
Page 4 of 8
Original Effective Date: January 25, 2001
Revision Dates:, 2/4/13, 8/12/13, 10/22/2014, 9/22/2015, 4/26/2016, 9/2018
C. Family Planning, Maternal Health, and Child Health clients will never be refused service
due to an outstanding balance or inability to provide proof of income. Health Department
clients are eligible to receive Family Planningthese services regardless of their
participation in other programs. Family Planning, Maternal Health, and Child Health
services are voluntary to all clients.
D. Maternal and Child Health clients who are at 60% to 100% pay status may have services
limited or denied for failure to make payments based on designated Payment Plans
(“good faith” effort).
E.D. Falsification of eligibility by the client may result in denial or limitation of services.
F.E. The Health Department shall not deny a service due to religion, race, national origin,
creed, sex, marital status, familial status, sexual orientation, veteran status or age.
G.F. The Health Department shall assure that no otherwise qualified handicapped
individual, solely by reason of his/her handicap, be excluded from participation in, be
denied the benefits of, or be subjected to discrimination under any program or activity
covered by this agreement.
H.G. The Health Director can override any decision to deny or limit services to a client in
accordance with the existing fee waiver process.
VI. Fees for Services
A. In order to facilitate early entry into prenatal care or family planning services, pregnancy
tests will be provided free of charge unless they are required as part of another service.
B. In order to facilitate early identification of and referral for hypertension, two blood
pressure screenings will be provided in the clinic free of charge. Borderline readings will
be checked free until determined to be normal or the client is referred for further
evaluation. Follow-up of clients with a diagnosis of hypertension will be charged
according to the fee policy.
C. Fees are not charged for diagnosis and treatment of sexually transmitted diseases, or
investigation and control of communicable diseases. There is also no charge to clients for
any State-provided vaccine.
D. Fees are charged for health and dental services provided to individuals unless prohibited
by law or regulation. Fees are established based upon cost analysis, Medicaid and
Medicare rates, comparable provider rates and/or state or contractual agreements. The
Health Director shall inform the Board of Health and the Orange County Board of
Commissioners of these adjustments in a timely manner.
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section I: Board Adopted Policies
Policy E: Fee and Eligibility Policy
Reviewed by: Financial Review Committee, Health Director
Approved by: Board of Health, Health Director
Page 5 of 8
Original Effective Date: January 25, 2001
Revision Dates:, 2/4/13, 8/12/13, 10/22/2014, 9/22/2015, 4/26/2016, 9/2018
E. Fees may be charged to clients for “non-program” specific services without being
adjusted on a sliding fee scale (flat fees).
F. Fees may be charged for education, community-based limited clinical services (such as
influenza shots) and screening services provided to individuals or groups. The following
applies to these services:
1. They include orientation, field training, dental screening and education, and/or other
health promotion activities such as infant and toddler car seats, bike helmets, or
equipment rental.
2. The Health Director will negotiate fees for services where fees have not been
previously determined.
3. Income eligibility requirements do not apply to these services.
G. Per NC General Statute Chapter 7B, Subchapter 4, Article 35, and confidentiality
regulations, emancipated minors and other individuals requesting confidential services
will be considered a family of one for determination of charges. Private insurance will
also not be billed for minors receiving services for which they can consent unless
permission is received from the minor.
H. Persons requesting any program services may be encouraged to apply for Medicaid, as
applicable.
I. The Personal Health Services Division clinical and nutrition services will use the
appropriate sliding fee schedule for services when adjustable fees are allowed; all other
fees will be charged at 100%.
1. Clients, who require services provided on the sliding fee schedule, are expected to
pay the appropriate fee in full based on sliding fee guidelines.
2. This schedule will require assessment of the client’s financial status on an annual
basis or when a financial status change occurs, as specified in section III.
J. Dental Health Services, Primary Care Services, and Nutrition Services will use a sliding
fee schedule for all services, with a minimum charge to be established at the annual fee
review during the budget preparation process.
1. The minimum charge for dental, primary care, and nutrition services will apply
regardless of the determination of the client’s financial status.
2. If a client is determined to fall at the 0% pay level, the minimum charge will be the
only charge levied and collected unless the client is deemed homeless.
3. Minimum charge is due at time of service.
K. Fee schedules will be reviewed annually during the budget process and adjusted as
appropriate; a complete cost analysis for purposes of fee adjustments will be performed
every five years. The process for this cost analysis includes a review of the following
elements:
a. Most recent vaccine and drug purchase costs
b. Most recent lab pricing lists
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section I: Board Adopted Policies
Policy E: Fee and Eligibility Policy
Reviewed by: Financial Review Committee, Health Director
Approved by: Board of Health, Health Director
Page 6 of 8
Original Effective Date: January 25, 2001
Revision Dates:, 2/4/13, 8/12/13, 10/22/2014, 9/22/2015, 4/26/2016, 9/2018
c. Most recent Medicaid Cost Settlement data for procedure costs
d. Environmental Health equipment, labor, and staff costs
e. Review of fee schedules of surrounding jurisdictions
f. Analysis of existing self-pay client base and how increased costs would affect
their ability to get necessary care
L. Based on G.S. 130A-41, the Health Director is authorized to enter into contracts, which
may include negotiated reimbursement rates.
M. The Health Director may not make exceptions to the Fee Policy except to accommodate
specific situations through the fee waiver process (Attachment C).
N. Any minimum administrative fee or flat fees shall be applied without discrimination to all
patients.
O. There will be no “schedule of donations”, bills for donations, or any other implied
coercion for donations from clients as a condition for being seen at the Health
Department. Donations to the health department can be made through the Orange County
Community Giving Fund. Fees for services will not be waived because of client
donations.
P. Fees for 340b drugs dispensed to Medicaid patients will be reviewed and set annually
based on the average, annual cost to the County to purchase the drugs.
VII. Fee Collection
A. Environmental Health service fees are paid before an appointment is scheduled. Field
staff cannot accept fees in the field.
B. Fees collected from Medicaid and Medicare and other third party insurance for a covered
service, combined with payment of any applicable co-pays and co-insurance, constitutes
full payment for that service.
C. A co-payment, deductible, or balance of charge can be collected at the time of service
from individuals covered by other third party insurance plans when OCHD is a member
of their provider panel (exception family planning). For Family Planning clients, family
income should be assessed before determining whether co-payments or additional fees
are charged; if their family income is verified to be at or below 250% FPL, they should
not pay more (in copayments or additional fees) than what they would otherwise pay
when the schedule of discounts is applied. With regard to other insured clients, payments
towards a deductible for clients whose family income is verified to be at or below 250%
FPL should have the appropriate sliding fee schedule applied.
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section I: Board Adopted Policies
Policy E: Fee and Eligibility Policy
Reviewed by: Financial Review Committee, Health Director
Approved by: Board of Health, Health Director
Page 7 of 8
Original Effective Date: January 25, 2001
Revision Dates:, 2/4/13, 8/12/13, 10/22/2014, 9/22/2015, 4/26/2016, 9/2018
D. If OCHD is not on the insurance provider panel, the client will be charged for the
service(s) based on the Health Department’s fee schedule. The client will be provided
with documentation of services for submission of a claim to their insurance company.
E. At the time services are receivedAfter charges are processed, the client will be given a
statement showing the cost of services for that visit as well as their total account balance
upon request.
F. Payment is due at the time services are rendered.
G. When the client is unable to pay in full at the time services are rendered, a payment plan
is established, and the client must sign a “Payment Agreement Form” (Attachment D)
except for minimum-fee or flat-fee charges. Client must then make a payment in any
amount in order to activate the payment plan.
H. When a client requests “no mail”, discussion of payment of outstanding debt shall occur
at the time the service is rendered. A remark regarding “no mail” is entered into the
medical data system. No letters or other correspondence concerning insurance or past
due accounts will be sent to any client that requests “no mail”. Reasonable efforts will be
made to collect charges without jeopardizing client confidentiality.
I. The Billing Cycle for the Health Department (by Division) is as follows:
1. Personal Health Division
a. Billing statements will be sent no more than three days after charges post to client ledger.
Statements will be sent to clients for the next two consecutive months for balances due.
After three consecutive months with a past due balance, accounts will be forwarded to the
County Attorney Office and pursued through debt set-off in accordance with the county
policy. Accounts with a balance of less than $50 will remain delinquent until paid or
written-off.
1.2. & Dental Health Divisions
a. Bill statementss will be sent monthly by the tenth of the month for two months
after services have been rendered indicating a statement of balance due. Every
quarter, all accounts with a balance $50 or more that are more than 60 days past
due will be forwarded to the County Attorney Office and pursued through debt
set-off in accordance with the county policy. Accounts with a balance of less than
$50 will remain delinquent until paid or written-off.
b. If a debt is not paid, when the client attempts to make another appointment, the
client will be told they have a previous balance, and they must have an active
payment plan or make a payment at time of next service except for Family
Planning clients.
2.3. Environmental Health Division
a. An initial invoice for additional or miscellaneous Wastewater Treatment
Management Program (WTMP) charges is mailed with the inspection form.
b. If no payment is received within 90 days, a second notice is mailed.
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section I: Board Adopted Policies
Policy E: Fee and Eligibility Policy
Reviewed by: Financial Review Committee, Health Director
Approved by: Board of Health, Health Director
Page 8 of 8
Original Effective Date: January 25, 2001
Revision Dates:, 2/4/13, 8/12/13, 10/22/2014, 9/22/2015, 4/26/2016, 9/2018
c. If no payment is received after an additional 30 days and the debt is $50 or
greater, the account is forwarded to the County Attorney’s Office, which will
pursue it through the county’s debt set-off procedure.
d. Debt owed by a corporation or non-individual is dissolved upon sale of property.
e. The county attorney’s office has deemed debt that becomes part of an estate will
become dissolved.
f. If the client presents and voluntarily wishes to pay on the account, any amount
the client offers will be accepted, documented in the client file, and a receipt will
be provided.
g. Mobile Home Parks are billed annually on the calendar year. The procedure is
the same as noted above.
J. Insurance and Third Party Billing
1. Where a third party is responsible, bills are to be submitted to that party;
2. Third parties authorized or legally obligated to pay for clients at or below 100% FPL
are properly billed.
3. Third party bills (including Medicaid) show total charges without any discounts
unless there is a contracted reimbursement rate that must be billed per the third party
agreement.
4. The health department will bill insurance and managed care organizations for which
provider approval has been established. The patient will be responsible for all
deductibles, coinsurance and non-covered charges.
5. Patient or parent/guardian signature is required to give authorization to file claims
and provide necessary information to the insurance company (Attachment E).
6. Patients, or the accompanying parent/guardian of an un-emancipated minor with
appropriate insurance benefits, who receive public health services will be given the
opportunity to choose whether to have insurance filed in order to avoid breach of
confidentiality or pay the associated fee according to where the patient falls on the
sliding fee scale.
VIII. Review and Approval
A. This Policy shall be reviewed annually by members of the Financial Review Committee.
The committee shall have representatives from each division, and must also include the
Health Department’s Finance and Administrative Services Director
B. Any policy revisions must be approved by the Health Director and the Board of Health.
Agenda Item Number:
ORANGE COUNTY BOARD OF HEALTH
AGENDA ITEM SUMMARY
Meeting Date: September 26, 2018
Agenda Item Subject: Health Director Annual Review
Attachment(s): Board of Health Policy III.B.d
Staff or Board Member Reporting: Susan Elmore
Purpose: ____ Action
____ Information only
_X__ Information with possible action
Summary Information:
Per Board of Health Policies and Procedures (Policy III.B.d), the Board completes a
required annual review of the health director’s performance in accordance with the
Statutory Requirement in GS130A-41.
The purpose of this discussion is to determine this year’s process for the annual review,
with guidance available in the attached policy for the information flow and input into the
performance evaluation.
The annual review will occur during closed session at the November 2018 meeting.
Recommended Action: ___Approve
___Approve & forward to Board of Commissioners for action
___Approve & forward to ___________________________
___Accept as information
___Revise & schedule for future action
_X_Other (detail): Determine annual review process and
solicit board members to carry out tasks as needed.
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section III: Board Processes
Process B: Supplemental Processes d. Annual Performance Review Process for Health Director
Reviewed by: Board of Health
Approved by: Board of Health, Health Director
Review Annually (July) Page 1 of 2
Original Effective Date: January 2000
Revision Dates: 4/23/09, 1/2014, 11/2014
S:\MANAGERS WORKING FILES\BOH\AGENDAS & ABSTRACTS \2018 Agenda & Abstracts\September 2018\VII.A. Attachment
III.B.d.Evaluation of Health Director.doc
Annual Performance Review Process for Health Director
Purpose
To provide the Board with a process for accomplishing the required annual review of the health
director’s performance in accordance with the statutory requirement GS 130A-41.
Guidelines:
1) Orange County Personnel Policies are followed in conducting this review.
Steps in the standard process are:
• Preparation of an annual work plan by the employee and supervisor.
• Preparation of performance notes at the end of the plan year that relate to the objectives
contained in the work plan.
• A conference between the employee and the supervisor regarding the employee’s
performance for the year.
• Supervisor prepares a Work Planning and Performance Summary after the conference which
outlines the findings of the discussion and makes the final recommendation as to
performance.
• Supervisor forwards all paperwork to Human Resource Director.
2) In the case of the Health Director, the “supervisor” of the Director is the entire Board. The Chair
assumes the responsibility of managing the information flow and input into the performance
evaluation. This may include the formation of an ad-hoc committee to assist in the completion of
the performance evaluation.
1. The Health Director prepares performance notes relevant to the year and emails them to all
Board members.
2. The Chair schedules a meeting with the County Manager to obtain input on the Health
Director’s performance.
3. The Chair may or may not solicit additional feedback, including from senior management
staff and direct reports at the Health Department through electronic or in-person methods
each year. A 360⁰ evaluation should be conducted at least every 5 years.
4. The Chair presents these findings to the full Board at a closed session of the Board and a
general discussion of performance is then held. The Board reaches agreement on a
recommendation and then the health director is called into the room and the Chair guides the
discussion by Board members.
5. The Board is required to keep minutes during the closed session, including any motions made
and actions resulting from such motions and transmit them to the Secretary (Health Director)
for the permanent record.
6. Board members indicate changes they would like to see included in the following year’s work
plan and those areas are discussed with the Health Director in the meeting.
Following the meeting, the Chair writes the performance summary, finalizes the paperwork, obtains
the Health Director’s signature and sends it to the Human Resources Director for the County. The
ORANGE COUNTY HEALTH DEPARTMENT
Board of Health Policy and Procedures Manual
Section III: Board Processes
Process B: Supplemental Processes d. Annual Performance Review Process for Health Director
Reviewed by: Board of Health
Approved by: Board of Health, Health Director
Review Annually (July) Page 2 of 2
Original Effective Date: January 2000
Revision Dates: 4/23/09, 1/2014, 11/2014
S:\MANAGERS WORKING FILES\BOH\AGENDAS & ABSTRACTS \2018 Agenda & Abstracts\September 2018\VII.A. Attachment
III.B.d.Evaluation of Health Director.doc
Human Resources Director processes the remaining paperwork. The goal should be to have the
performance review complete within 30 days of the hiring date anniversary.
Agenda Item Number:
ORANGE COUNTY BOARD OF HEALTH
AGENDA ITEM SUMMARY
Meeting Date: September 26, 2018
Agenda Item Subject: Committee for 2019 Vice-Chair Selection
Attachment(s):
Staff or Board Member Reporting: Susan Elmore
Purpose: ____ Action
____ Information only
_X__ Information with possible action
Summary Information:
Per the Board of Health Policies and Procedures, the Board shall elect a Chair and
Vice-Chair by majority vote each year at the last meeting of the calendar year. This
discussion’s purpose will include asking for volunteers to serve on the Committee for
Vice-Chair Selection.
Recommended Action: ___Approve
___Approve & forward to Board of Commissioners for action
___Approve & forward to ___________________________
_X_Accept as information
___Revise & schedule for future action
___Other (detail):
Health Director’s Report
September 2018
• September 6, 2018 - Meeting with Dr. Mike Steiner, UNC Pediatrics & Adolescent
Medicine, Dr. Robert Murphy, Executive Director for Center for Child & Family Health
in Durham, NC and Dr. Alison Steube, Medical Director of Lactation and Associate
Professor of OB/GYN at UNC to discuss the efforts to implement a Postnatal Nurse
Home Visiting program here in Orange County. Durham, Guilford and Forsyth Counties
have established programs and there is interest in replicating such a program in Orange.
We currently do some postnatal home visiting via our CCN programs, so we’re
brainstorming ways to expand the program to a universal program. Follow-up meeting
scheduled.
• September 7, 2018 - NC DHHS Administrative Site Visit completed by Administrative
Consultant Kathy Brooks. OCHD received feedback that policies and processes meet or
exceed expectations with regard to fiscal management and reporting. This includes the
department’s practice with regard to billing and re-billing. Rebecca and her team are to
be commended for their great work.
• The Racial Equity Commission completed their community focus group with
approximately 12 community members present to give feedback on health department
services and programs. An online survey has also been sent to all department staff.
• As of Tuesday, September 11, 2018 the health department began to plan and focus
heavily on response activities for Hurricane Florence. The Emergency Operation Center
(EOC) was activated on Wednesday, September 12th. Health Department staffed the
Health & Medical Station 24/7 thru Sunday, September 16th. I appreciate all the Division
Directors for their willingness to work throughout the response period. Kudos to staff for
stepping up to assist our sister department, DSS, with Shelter Operations. In addition to
the nurses and environmental health staff that traditionally assist with shelter operations,
various staff from the department also worked in other roles in the Shelter, specifically
the Smith Middle School Shelter on Saturday night. Our colleagues across the County
have expressed their gratitude for our help.
• As a result of Hurricane Florence, the first week of Municipal and County Administration
course was cancelled and rescheduled for December 4th – 7th. The Annual NCPHA
Conference in Charlotte, NC has been postponed until December 12th -14th in Charlotte.
Upcoming Events
• Departmental Strategic Plan Sessions scheduled for September 25, 2018 and
October 1, 2018. Working with Consultant, Deitre Epps, Race for Equity, LLC.
• September 28, 2018 - Annual UNC PHield Trip – a way of introducing incoming public
health students from UNC to local governmental public health; approximately 40-50
students will come to Hillsborough to learn from staff what local public health looks like
in practice. Donna King serves as lead on this and has an afternoon of fun and engaging
activities planned.
Inspired By A Modest North Carolina Program, New Bills Aim To Lower Maternal Mortality Rates In The U.S. | HuffPost
https://www.huffingtonpost.com/entry/maternal-mortality-rate-social-causes_us_5b87276ae4b0511db3d47c1c?4is[8/30/2018 1:42:41 PM]
HEALTH 08/30/2018 05:45 am ET | Updated 2 hours ago
Inspired By A Modest North Carolina
Program, New Bills Aim To Lower
Maternal Mortality Rates In The U.S.
Kamala Harris and Kirsten Gillibrand’s newly proposed legislation focuses on
social problems and medical interventions.
By Anna Almendrala
EDITION
Inspired By A Modest North Carolina Program, New Bills Aim To Lower Maternal Mortality Rates In The U.S. | HuffPost
https://www.huffingtonpost.com/entry/maternal-mortality-rate-social-causes_us_5b87276ae4b0511db3d47c1c?4is[8/30/2018 1:42:41 PM]
MICHAEL KOVAC VIA GETTY IMAGES
Sens. Kirsten Gillibrand (D-N.Y.) and Kamala Harris (D-Calif.) have proposed complementary bills to improve maternal health and
pregnancy outcomes.
Efforts to drive down the rates of maternal mortality in the U.S. tend to focus on how doctors
and hospitals can change the way they administer medical care. Yet research shows that
things like loving relationships, safe homes and being part of a fair and equitable community
also play an important role in whether a woman has a positive experience with pregnancy and
giving birth.
So experts were heartened by a pair of complementary bills, announced over the past week,
that tackle this problem from both sides. The most recent national proposal, a bill from Sen.
Kirsten Gillibrand (D-N.Y.) announced Tuesday, would give money to states and hospitals
who need help standardizing their childbirth and postpartum treatment plans to evidence-
based best practices, and would help maternal mortality review committees investigate deaths
to figure out how they can be avoided in the future.
These kinds of quality improvements dominate the national debate about how to improve
Inspired By A Modest North Carolina Program, New Bills Aim To Lower Maternal Mortality Rates In The U.S. | HuffPost
https://www.huffingtonpost.com/entry/maternal-mortality-rate-social-causes_us_5b87276ae4b0511db3d47c1c?4is[8/30/2018 1:42:41 PM]
maternal care. California, for example, has managed to cut maternal deaths by more than half
since 2006, while the rest of the country’s maternal mortality rate continues to rise. Experts
attribute this to the state’s maternal quality care collaborative, a network of hospitals and
public health agencies that share real-time data in the hopes of improving performance on
preterm births, cesarean sections and other factors that can complicate a woman’s care.
But focusing solely on the medical care delivered at a hospital doesn’t address the nine
months of prenatal care a woman typically receives during her pregnancy, as well as the
postpartum period in which she is at a high risk of medical complications related to birth.
A different bill, proposed by Sen. Kamala Harris (D-Calif.) last week, takes an unusual
approach by focusing on the community and social stressors that might make pregnancy
more dangerous for women, especially women of color. It suggests that investing more
money to improve the quality of these mothers’ lives may also help avoid birth-related
complications and deaths.
Given their late introduction in the legislative session and the lack of support from Republican
senators, both bills have a slim chance of passing the Senate. But they could be poised to
move quickly if the Democrats win a majority in Congress. If that happens, would Harris’ plan
to focus on the social factors affecting pregnancy and childbirth work? One modest state
program could give us a preview.
A portion of Harris’ bill relies heavily on the architecture of an innovative social program in
North Carolina called a pregnancy medical home. It incentivizes doctors to screen every
woman on Medicaid at their first prenatal appointment and assign them a pregnancy care
manager if they’re deemed to be at high risk for a dangerous birth, whether for medical issues
like a history of stillbirths, or for social issues like intimate partner violence or homelessness.
“Things like loving relationships, safe homesand being part of a fair and equitablecommunity also play an important role inwhether a woman has a positive experiencewith pregnancy and giving birth.
Inspired By A Modest North Carolina Program, New Bills Aim To Lower Maternal Mortality Rates In The U.S. | HuffPost
https://www.huffingtonpost.com/entry/maternal-mortality-rate-social-causes_us_5b87276ae4b0511db3d47c1c?4is[8/30/2018 1:42:41 PM]
Harris’ bill would replicate this by awarding $25 million to up to 10 states to create their own
version of the pregnancy medical home.
When North Carolina’s Medicaid agency launched this initiative in 2011, it wasn’t even
thinking about maternal mortality, said Dr. M. Kathryn Menard, one of the co-founders of the
North Carolina program and the director of Maternal-Fetal Medicine at the University of North
Carolina School of Medicine. Instead, the goal was to keep Medicaid costs down by
preventing preterm births and cesarean sections.
But one fascinating side effect of the effort may be that it helped to narrow the gap between
black and white women in terms of maternal mortality.
Harris’ bill notes that in 2004, pregnancy-related deaths of black women in North Carolina
were five times higher than those of white women. But by 2013, the latest year for which
statistics are available, the gap disappeared. Black women’s maternal mortality rate declined
to a rate of 24.3 deaths per 100,000 live births, while the maternal mortality rate for white
women saw a slight uptick, to 24.2 deaths per 100,000.
Meanwhile, in the rest of the U.S., black women die from pregnancy-related causes at a rate
that’s three times higher than that of white women.
These results caught the attention of Harris’ office, which confirmed to HuffPost that it
mentioned North Carolina’s program because it’s the only statewide approach connecting the
social issues affecting the health of mothers and babies to the prenatal care the mother
receives.
How The Program Works
Every woman who is on North Carolina’s Medicaid plan, a safety net health insurance
program, is supposed to answer a short two-page questionnaire during her first prenatal visit
about factors in her life that have been linked to riskier births. These could be medical, like a
history of stillbirth, hypertension or substance abuse, or social, like questions about
homelessness, domestic violence or recent sexual trauma.
These social issues connect directly to maternal and infant survival. Going hungry could lead
to intrauterine growth restriction, which is when the fetus doesn’t grow and thrive in the womb.
Domestic violence endangers the lives of both mother and child. High levels of the stress
Inspired By A Modest North Carolina Program, New Bills Aim To Lower Maternal Mortality Rates In The U.S. | HuffPost
https://www.huffingtonpost.com/entry/maternal-mortality-rate-social-causes_us_5b87276ae4b0511db3d47c1c?4is[8/30/2018 1:42:41 PM]
hormone cortisol have been linked to premature birth and low birthweight. And studies
suggest that a lifetime of racism could account for African-Americans’ poorer birth outcomes
compared to those of recent African immigrants.
Doctors are reimbursed $50 for going through the questionnaire with patients at their first
prenatal appointment ― an incentive that results in about an 80 percent screening rate, said
Menard.
Then women who score high on this risk assessment are paired up with pregnancy case
managers, who meet with them monthly or weekly throughout their pregnancies to check up
on them and try to help them surmount any barriers standing in the way of their prenatal
appointments.
Care managers help connect women to counseling, sign up for food stamps or put them in
touch with charities that give away cribs and car seats. They can also help them work on
longer-term goals, like finding a new job, housing or going back to school before the baby
arrives.
Finally, once a woman gives birth, the same care manager helps the woman make a
postpartum appointment with her doctor, acquire any contraception she may need while
adjusting to parenthood, and then transitions the woman to a primary care provider.
Nationwide, only about 40 percent of women see their OB/GYN within three months of giving
birth.
In all, more than 25,000 women ― almost 50 percent of all pregnant women on Medicaid in
North Carolina ― were part of the pregnancy medical home program in 2017.
—Dr. M. Kathryn Menard, one of the co-founders of the North Carolina program
The program appears to have achieved some modest results. Unintended pregnancies
among women on Medicaid have gone down slightly since 2012, from 52 percent to 45
“I hope they’ll learn from our experience andcall on us so that they don’t make the samemistakes along the way.
Inspired By A Modest North Carolina Program, New Bills Aim To Lower Maternal Mortality Rates In The U.S. | HuffPost
https://www.huffingtonpost.com/entry/maternal-mortality-rate-social-causes_us_5b87276ae4b0511db3d47c1c?4is[8/30/2018 1:42:41 PM]
percent, said Kate Berrien, a director at Community Care of North Carolina, the nonprofit that
operates the state’s pregnancy medical home program. Preterm births were also down 7
percent from 2011 to 2014.
In other states that have run pilot programs, the results are similarly encouraging. A small,
year-long experiment conducted with pregnant Medicaid patients in Texas found that
hospitals were able to cut down on visits to the emergency room and inpatient hospital days
for pregnant women, saving about $330,000 in ER services and almost $500,000 in inpatient
care.
A final analysis of this experiment also found that these Texas mothers were also significantly
less likely to deliver by C-section and that their newborns were significantly less likely to be
admitted to neonatal intensive care.
Michael Lu, senior associate dean at the George Washington University School of Public
Health and former director of the federal Maternal and Child Health Bureau in the Obama
administration, praised North Carolina’s program but also said it would be prudent to wait for a
more comprehensive evaluation before scaling it nationwide as Harris has outlined in her bill.
Still, he did agree that social issues can be a major stressor on bodies ― especially ones that
are already experiencing the physical stress of a normal pregnancy.
Lu compared the pressure of homelessness, unemployment and violence to the gunning of a
car engine ― sooner or later, the engine is going to wear out.
“Unemployment, poor housing, family and neighborhood violence, the lack of partner and
social support, and the experience of racism can affect pregnancy outcomes by causing
chronic stress, which in turn can cause wear and tear on the body’s organs and systems,” Lu
said. “That’s how these social determinants not only get under the skin but also get inside the
womb to affect pregnancy outcomes.”
Harris’ office hopes that this moment in history, when the American public is galvanized
around the issue of maternal mortality, will help pave the way for the senator’s bill and others
like it.
Inspired By A Modest North Carolina Program, New Bills Aim To Lower Maternal Mortality Rates In The U.S. | HuffPost
https://www.huffingtonpost.com/entry/maternal-mortality-rate-social-causes_us_5b87276ae4b0511db3d47c1c?4is[8/30/2018 1:42:41 PM]
—Dr. M. Kathryn Menard
Menard cautions that North Carolina’s declining racial disparity in maternal deaths can’t be
attributed solely to the program she helped create.
“The trend of narrowing the gap started before this program launched, and it continued in a
positive direction,” she said. “It’s also really important to not overstate what one can see in
statistics from uncommon events.”
For the past 15 years, an average of about 22 women have died annually in North Carolina
because of pregnancy-related causes. This means that a change of even just a handful of
women in either direction could change the rates of maternal mortality and racial disparity
wildly from one year to the next.
“It turns out that in 2013, the ratio of white to black was one,” Menard said of the racial
disparity statistics cited in Harris’ bill. “But the next year it could be three again, just because
these numbers are not that big.”
But she does allow that rates of maternal deaths among black women are going down. And
pregnancy medical homes could be playing a role.
When there’s no one else to count on, pregnancy caremanagers are there.
Public health experts may be waiting for more data before recommending that this program
go nationwide.
But LaTosha Scott, one of North Carolina’s 400 pregnancy care managers tasked with
attending to women with the riskiest pregnancies, feels from the bottom of her heart that this
program needs to be in “every state, every county and every area.”
It’s on social workers like Scott, 32, to help pregnant women surmount serious social issues
“It’s also really important to not overstate whatone can see in statistics from uncommonevents.
Inspired By A Modest North Carolina Program, New Bills Aim To Lower Maternal Mortality Rates In The U.S. | HuffPost
https://www.huffingtonpost.com/entry/maternal-mortality-rate-social-causes_us_5b87276ae4b0511db3d47c1c?4is[8/30/2018 1:42:41 PM]
so they can focus on the pregnancy at hand. Scott’s part social worker, life coach, fixer and
friend for the approximately 50 women she’s responsible for at any given time as a pregnancy
care manager in Orange County, North Carolina.
Scott remembers a recent patient who had become homeless and had all four children taken
into the child welfare system until she could find a new home. Meanwhile, the woman was
pregnant again and struggling to get everything ready for the birth.
Soon before her due date, she came to Scott with a problem: She had the car seat and
newborn supplies, but couldn’t see herself being able to lug it all on the bus to the hospital
once she was ready to give birth.
Scott took it all and stored it in her own office at the University of North Carolina Medical
Center in Chapel Hill. And when the woman gave birth, she carried the supplies up to the
postpartum wing of the hospital.
For more well-connected women, Scott’s role might be filled by a sister, best friend or auntie,
while wealthier women might be able to employ a doula, nanny or concierge to help them get
ready for the baby.
But for the women Scott sees, who may be struggling with homelessness or addiction, she is
one of the few emotional supports they can count on throughout their whole pregnancy.
“She’s able to focus more on the pregnancy because she knows now she has support,” Scott
said about her work. “It’s like, ‘I have Latosha to call on, and she can at least tell me where to
go.’”
Menard says she was surprised to see that North Carolina’s pregnancy medical home
program had caught the attention of a senator from California, as the initiative is still relatively
young and still considered novel.
But she says that whether or not Harris’ bill passes, she hopes it sparks an overdue
discussion about the social causes of maternal mortality in addition to the medical delivery
component of maternal care.
Menard also thinks states should not wait for a federal law to pass before starting their own
programs, and she invites anyone to contact her agency for insight into how to get something
Inspired By A Modest North Carolina Program, New Bills Aim To Lower Maternal Mortality Rates In The U.S. | HuffPost
https://www.huffingtonpost.com/entry/maternal-mortality-rate-social-causes_us_5b87276ae4b0511db3d47c1c?4is[8/30/2018 1:42:41 PM]
off the ground.
“I hope they’ll learn from our experience and call on us so that they don’t make the same
mistakes along the way,” she said. “We can get them there a lot faster than we got there.”
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