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Home My WebLink AboutBOH Agenda 102319ORANGE COUNTY BOARD OF HEALTH MEETING AGENDA DATE: October 23, 2019 TIME: 7:00 P.M. PLACE: Whitted Human Services Center 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 October 23, 2019 Agenda 7:10 – 7:15 IV. Actions Items (Consent) A. Minutes of September 18, 2019 Timothy Smith 7:15 – 8:15 V. Educational Sessions A. Community Engagement Using Racial Equity Toolkits Allison DeMarco (20 minutes) (relative to All BOH Strategic Plan Priorities) B. Customer Satisfaction Survey Victoria Hudson/Carla Julian/ (20 minutes) Pam McCall C. 1st Quarter Financial Reports & Billing Dashboard Reports Rebecca Crawford (15 minutes) D. Advisory Board Update Beverly Scurry (5 minutes) (relative to BOH Strategic Plan Priority: Engagement) 8:15 – 8:40 VI. Action Items (Non-Consent) A. Debt Set Off and Debt Write Off Rebecca Crawford (15 minutes) B. BOH Policy Review Rebecca Crawford, (10 minutes) Beverly Scurry 8:40 – 9:00 VII. Reports and Discussion with Possible Action A. Health Director Annual Evaluation Timothy Smith B. Present Chair/Vice-Chair Slate Timothy Smith C. Health Director Report Quintana Stewart D. Media Items Kristin Prelipp 9:00 – 9:05 VIII. Board Comments 9:05 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. MINUTES-Draft ORANGE COUNTY BOARD OF HEALTH September 18, 2019 S:\Managers Working Files\BOH\Agenda & Abstracts\2019 Agenda & Abstracts/ September Page 1 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 September 18, 2019, at the Orange County Health Department, 2501 Homestead Road, Chapel Hill, NC. BOARD OF HEALTH MEMBERS PRESENT: Timothy Smith, Chair, Jessica Frega, Vice Chair, Bruce Baldwin, Jennifer Deyo, Aparna Jonnal, Liska Lackey, Sam Lasris and Alison Stuebe. BOARD OF HEALTH MEMBERS ABSENT: Keith Bagby and Commissioner Earl McKee. STAFF PRESENT: Quintana Stewart, Health Director, Donna King, Health Promotion & Education Services Director; Jenna Luna, Public Health Nurse I; Kristin Prelipp, Communications Manager; Beverly Scurry, BOH Strategic Plan Manager and La Toya Strange, Administrative Assistant II. GUESTS PRESENT: None I. Welcome Timothy Smith, Chair, called the meeting to order at 7:05pm. Quintana Stewart, Health Director, introduced the new employee in attendance: Jenna Luna. II. Public Comment for Items NOT on Printed Agenda: None. III. Approval of the September 18, 2019 Agenda Motion was made by Bruce Baldwin to approve the agenda, seconded by Alison Stuebe and carried without dissent. IV. Action Items (Consent) A. Minutes Approval of August 28, 2019 Meeting Motion to approve Consent Agenda with minor edits to the August 28, 2019 minutes was made by Sam Lasris, seconded by Alison Stuebe and carried without dissent. V. Educational Sessions A. BOH Member Training Wayne Raynor from the North Carolina Institute for Public Health began by introducing and giving a brief background of himself. His presentation was titled “Roles and Responsibilities of Local Public Health Governing Boards”. Each member was given a packet that included a copy of the presentation along with other educational materials. Learning objectives were to 1) describe key concepts underlying the practice of public health and the role a board of health MINUTES-Draft ORANGE COUNTY BOARD OF HEALTH September 18, 2019 S:\Managers Working Files\BOH\Agenda & Abstracts\2019 Agenda & Abstracts/ September Page 2 plays in carrying out core functions and essential services, 2) identify the laws and statutes regulating the local public health system, and 3) describe the guidelines and expectations for being an effective board member. The covered training content was divided into six sections. • Public Health Milestones and Current Challenges • Public Health Functions and Essential Services • Legal Responsibilities and Authority • Local Governance Boards • Board Members’ Work • Effective Governance Time was allowed for questions and the completion of registration and evaluation materials associated with the training. The BOH members had questions that were addressed by Mr. Raynor. VI. Reports and Discussion with Possible Action A. Health Directors Report In addition to her report, Ms. Stewart mentioned the following: • Ms. Stewart began by expressing her appreciation for Mr. Raynor for his presentation. She also thanked the Board for their support. • Last night, the BOCC approved Dr. Lee Pickett for the BOH Veterinarian seat. Dr. Pickett currently sits on the Animal Services Advisory Board. She’ll be attending our October Board meeting. • On September 3rd, the Department of Health & Human Services announced that the Medicaid Transformation transition to managed care will go-live on February 1, 2020. There will not be two stages; all regions in the state will have the same start date. The OCHD is still working on finalizing the contracts. • The OCHD Diabetes Self-Management Education Program has been selected for the 2019 John Bowdish Community Award from the Division of Public Health for the North Carolina Diabetes Advisory Council. Renee Kemske, Program Manager, and Ms. Stewart will take receipt of the reward on November 8th in Raleigh. • Ms. Stewart briefly mentioned that the BOH will work on the e-cigarette policy soon referencing that the Trump Administration announced plans to ban flavored e-cigarettes due to the deaths and illnesses caused by vaping. Ms. Stewart also reminded the Board of some upcoming events which included: • September 20, 2019 - “Be the Light” 3rd Annual Suicide Prevention Walk; 6pm – 7:30pm Carrboro Town Commons, 301 W. Main Street at Carrboro Town Hall • September 24 – 27, 2019 – NCALHD Meeting & NC Public Health Association Fall Education Conference, Greensboro, NC • September 30, 2019 – Orange County Opioid Task Force Meeting • October 10, 2019 – Groundwater Training, sponsored by the Health Equity Council, 9am-12pm, 300 West Tryon Street, BOCC Room 230, Hillsborough, NC MINUTES-Draft ORANGE COUNTY BOARD OF HEALTH September 18, 2019 S:\Managers Working Files\BOH\Agenda & Abstracts\2019 Agenda & Abstracts/ September Page 3 B. Media Items Kristin Prelipp, Communications Manager, briefly mentioned articles regarding Krishnaveni Balakrishnan participating on a panel regarding home health and safety and an article that briefly mentioned the OCHD but focused on the law, drug- addicted moms and the process of termination of parental rights. Media items were in the packet which focused on Orange County’s events and our involvement in various efforts. VII. Board Comments BOH member, Jessica Frega, recommended the Groundwater Training stating that it was a much more condensed version of the Racial Equity Institute training. When BOH member, Timothy Smith, asked about reservations, Beverly Scurry offered to send the information to the Board. The Board asked about the Opioid Taskforce. Ms. Stewart informed them that it was created at the request of Commissioner Renee Price. Ms. Stewart will co-lead this initiative whose objective is to reduce the stigma around opioid abuse, to produce a strategy to address additional treatment options and to better educate the community. In response to Mr. Smith’s question of whether the Board could attend, Ms. Stewart provided the time and date of the meeting which is September 30th at 8:30am. VIII. Adjournment A motion was made by Jessica Frega to adjourn the meeting at 8:55 p.m., was seconded by Alison Stuebe and carried without dissent. The next Board of Health Meeting will be held October 23, 2019 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: October 23, 2019 Agenda Item Subject: Engaging Community for Comprehensive Planning through a Racial Equity Lens Attachment(s): Full report https://drive.google.com/file/d/18VcugaiLxEJhbMZAMSM- 8XCRCS_E1QKG/view?usp=sharing Staff or Board Member Reporting: Purpose: ____ Action _ X_ Information only ____ Information with possible action Summary Information: In 2018, a student team from SW 490, Economic Justice, worked with Carrboro Alderman Damon Seils to produce a racial equity analysis of community engagement plans for the Town of Carrboro’s upcoming Comprehensive Plan process. Using a racial equity toolkit from the Government Alliance for Race and Equity (GARE), the student team developed recommendations relevant to community engagement efforts at all levels of government. 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): Recommendations for the Community Input Stage of the Carrboro Comprehensive Plan using the Racial Equity Toolkit Susanna LaRochelle Aklesia Maereg Klaus Mayr Sean Nguyen SoWo 490 THANK YOU to our community partners for your support: Damon Seils, Carrboro Board of Alderm en Beth Vazquez, Chapel Hill People’s Academ y Anna Richards, Chapel Hill-Carrboro NAACP Maddie Hayes & April Oo, Refugee Community Partnership Trish McGuire, Carrboro Planning Director SorAngela Hoyos, Com m unity Specialist at El Centro Hispano Anita Jones-McNair , Recreation and Parks Director Rebecca Buzzard , Project Manager Racial Equity Toolkit 1.St e p # 1 – What is your proposal and the desired results and outcomes? 2.Step #2 – What’s the data? What does the data tell us? 3.Step #3 – How have communities been engaged? Are there opportunities to expand engagement? 4.Step #4 – What are your strategies for advancing racial equity? 5.Step #5 – What is your plan for implementation? 6.Step #6 – How will you ensure accountability, communicate, and evaluate results? Sou rce : https://www.racialequityalliance.org/wp -content/uploads/2015/10/GARE- Racial_Equity_Toolkit.pdf Carrboro’s Progress ●Targeted outreach for 203 Project: ○Having information in different languages so community members don’t feel excluded ○Gathering focus groups to collect direct input from community ○Holding public engagement meetings ○Canvassing ●Carrboro’s Equity Report: Town -wide initiatives ○Opportunities to attend Racial Equity Institute training ○Broad -based marketing to ensure all community members are reached ○Program s for all populations ○Joined Government Alliance on Race and Equity (GARE) With all this work being done, there is always more to be done! Considering a Changing Population Minority growth rates in Orange County between 1990 and 2016: Multiracial: 2,352 to 3,171 Asian/Pacific Islander : 2,352 to 11,4 6 0 Hispanic: 1,2 7 9 t o 11,8 7 0 Black : 14 ,8 0 7 t o 16 ,6 2 5 (from Orange County 2017 State of Community Report) Trends are reflected in Carrboro too: Change in Minority Growth Rates in Carrboro Between 2000 and 2010 Asian : (+58%) Native American : (+15%) Latinx : (+12%) Mixed Race: (+19%) Black : (-20%) (from Carrboro Equitable Growth Profile) Evidence that Carrboro’s work is paying off! Changing Demographics Historic Underrepresentation Given future orientation of this project, there is a need for different strategies of weighing different population’s input… More weight on growing populations that were historically less represented in town decisions Deepening Community Partnerships ●Engagement starts with trust in the system in place ●Strong existing relationships between m inority groups and community organizations ○El Centro, RCP, NAACP, etc. ●Incentivizing and equipping community organizations to participate ○Need for more resources, funding, and personnel ○Provide avenue for them to have more input in community engagement process ○Provide incentives (monetary, personel, etc.) Town of Carrboro Community Organizations Minority Groups Additional Recommendations to Explore: ●Commission on Racial Equity ●Focus groups ●Canvassing ●Community events ●Question Campaign We thank you for your time! Questions? Agenda Item Number: ORANGE COUNTY BOARD OF HEALTH AGENDA ITEM SUMMARY Meeting Date: October 24, 2018 Agenda Item Subject: Customer Satisfaction Survey 2019 Attachment(s): Personal Health Client Input Surveys 2019 Staff or Board Member Reporting: Pam McCall, PHSD Director; Victoria Hudson, Interim EH Director; Carla Julian, Dental Clinic Manager Purpose: ____ Action _ _X Information only ____ Information with possible action Summary Information: Per Board of Health Policy and Accreditation standards, each year the Board of Health will receive from the staff of the Health Department the results of patient and client input on services received, including any corrective actions deemed necessary to improve services. Personal Health: Medical clinic clients were surveyed for one week at both sites during the month of June. There were a total of 85 completed surveys. Responses were overwhelmingly positive about the care received. The negative responses and comments reflected concern about wait times and difficulty getting an appointment. We attribute this to staff shortages during that time. Dental Health: Ongoing patient satisfaction surveys sent by email or text 2 days after appointments through Solutionreach have only an 11% response rate. Paper surveys were done for one week in August 2019 for a total of 32 Spanish and 44 English surveys. Responses were primarily positive but comments indicated some improvements are needed in check-in and checkout procedures. Environmental Health: Environmental Health Customer Satisfaction was measured by survey for the period September 2018- June 30, 2019. The annual cycle was adjusted to align with the fiscal year. There were 98 responses. The overall satisfaction with Environmental Health Retail Food Inspections Program, Lodging, and Institutions is 85% “excellent or good.” The overall satisfaction with Environmental Health Onsite Water Protection Program services is 86% “excellent or good.” An area of improvement includes improving client satisfaction with response time. 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): Customer Satisfaction Survey Reports 2019 Environmental, Dental, and Personal Health Victoria Hudson, Carla Julian, Pam McCall ENVIRONMENTAL HEALTH OVERALL SATISFACTION ENVIRONMENTAL HEALTH RESPONSE TIME •Response time is the processing time from the receipt of the application through the date of disposition (issued, approved, denied, or withdrawn). The response time may include: –Initial evaluation of the application for accuracy and completeness, –Background research, –Field visits/ evaluations/ investigations, –Examination of premises plus adjacents, and –Legal analysis of proposed operations. –Time to write, draft, draw, or otherwise generate a reports and site plans. ENVIRONMENTAL HEALTH How would you rate staff promptness and response time? Dental Health Patient Satisfaction Surveys 1.Ongoing through Solutionreach Patient Engagement Software Sent by text or email one day after visit 11% Response Rate 85 Responses Since 5-2019 2.Paper Spanish and English Surveys Conducted Week of Aug. 19, 2019 Provided at Checkout 32 Spanish 44 English Dental Health Patient Satisfaction Surveys •Spanish Paper Survey Results: Aug 2019 –90% satisfied with overall experience –90% agreed front desk staff and dentists were courteous and responsive to needs –87% agreed dental assistants or hygienists were courteous and responsive to needs –93% satisfied with interpretation services –All positive open-ended survey responses, such as “Excellent service and care” –One needs improvement comment •“shorter wait time (for next appt) and flexible schedule” Dental Health Patient Satisfaction Surveys •English Paper Survey Results: Aug 2019 –82% satisfied with overall experience –86% agreed front desk staff and dentists were courteous and responsive to needs –89% agreed dental assistants or hygienists were courteous and responsive to needs –Mostly positive open-ended survey responses, such as “Everyone was kind and attentive. Love, love this place” –Two Needs Improvement Comments •“Front desk staff is not pleasant at all, and I had to wait 20 minutes to check out.” •“Check in was confusing and pricing scale/range was not clearly explained at check in.” Medical Clinic Services Paper surveys collected during one week at each site in June 2019 N=37 Chapel Hill clinic N=48 Hillsborough clinic Responses about care received and treatment by staff overwhelmingly positive. Some negative responses about ease of making appointments and wait times. Medical Clinic Services- Sample Client Comments •I like coming here very much. Always a good experience. •Possibly decrease waiting time for patients during visit. •I think it’s ok how it is very friendly. • I am satisfied with the services provided. •Sync lab hours with appointment so I don’t make 2 visits. •Maybe have more doctors so that they can see more patients and there are available appointments. Agenda Item Number: ORANGE COUNTY BOARD OF HEALTH AGENDA ITEM SUMMARY Meeting Date: October 23, 2019 Agenda Item Subject: 1st Quarter Financial Report FY 19-20 Attachment(s): 1st Quarter Financial Report 1st Quarter Billing Dashboard Staff or Board Member Reporting: Rebecca Crawford Purpose: ___ Action _X_ Information only ___ Information with possible action Summary Information: Total Health Department Budget vs. Actuals: Average YTD monthly revenue in FY19-20 after the first quarter is $216k/month or $647k YTD, representing 20% of our overall budgeted revenue for the year. As usual though, the total first quarter revenue is skewed down due to the majority of state funds not eligible to be drawn in July (this is typical) and allocations of Medicaid Max funds will not be transferred into our budget until the end of the fiscal year. Expenses are in line with revenues, at 19% of the overall budget. Total Billing Accuracy: The medical and dental billing accuracy measure continues to be a challenge as we work with UNC and the Dental EHR, Eaglesoft, to improve the accuracy of the reporting system for Health Department revenue and is not included in this quarter’s dashboard. Dental Earned Revenue by Source: The FY 19-20 average monthly revenue ($53.4k/month) for the first quarter is above our budget projection ($45k/month) and our FY 18-19 average of $47k/month. We are seeing the direct impact of adding the additional Dental Hygienist in FY 18-19 and will potentially exceed our projected annual revenue related to this position ($72,157) since the dental clinic is fully staffed. FY 19- 20 dental earned revenue totaled $160k at the end of the first quarter compared $118k at the end of the FY 18-19 first quarter. Medical Earned Revenue by Source: Medical earned revenue is currently below the budgeted projection for FY 19-20 ($57k/month) at $43k/month due to provider turnover and as clinic staff continue to work through issues with the billing in the Epic EMR. Our EMR Quality Improvement team called the “Epic Optimization Team” along with clinic staff have made a large amount of progress in improving our revenue from medical clinic services from the Epic system and the monthly average revenue of $43k/month is already higher than it was in FY 18-19 at $41k/month. We anticipate this trend toward increased revenue will continue to improve. Medical clinic revenue totals $130k for first quarter FY 19-20. Environmental Health Earned Revenue by Source: Environmental Health earned revenue is currently below the budgeted projection for FY 19-20 ($54k/month) at $41k/month. It is a seasonal trend to see lower revenue in the first quarter of the year than in later quarters due to spring pool inspections; however, the decreased revenue is directly related to the limited number of temporary staff available to complete WTMP inspections. EH had 7 temporary Environmental Health Specialists (EHS) working regularly to complete the inspections at this time last year and now have only 2 temporary EHS working irregularly. We found it difficult to recruit and retain the temporary EHS this summer given the heat. As a result, permanent staff in EH are adding WTMP inspections to their current workloads in order to complete them as required by the end of the fiscal year. Grants Fund Revenue: FSA has drawn $200k of the multi-year Kenan grant. Expenditures are tracking as anticipated and will continue to increase as we fill the vacant Navigator position in November. This position was dependent upon additional United Way funds in order to hire at the full time equivalent level, which were approved by the BOCC in September. 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 First Quarter Financial Report FY 2019-2020 General Fund TOTAL HEALTH Q1 YTD ACTUAL ANNUAL BUDGET % OF ANNUAL BUDGET Revenue Donations Health Promotion & Edu (400)(400)(5,310)7.53% Personal Health 0 0 (2,000)0.00% Donations Total (400)(400)(7,310)5.47% Internal Allocations Dental Health 0 0 (41,477)0.00% Personal Health 0 0 (334,658)0.00% Internal Allocations Total 0 0 (376,135)0.00% Service Revenue Dental Health (160,970)(160,970)(541,000)29.75% Environmental Health (123,048)(123,048)(648,761)18.97% Personal Health (129,657)(129,657)(681,125)19.04% Service Revenue Total (413,675)(413,675)(1,870,886)22.11% State Allocations Environmental Health (1,156)(7,896)(44,600)17.70% Finance and Admin Services (11,844)(18,969)(42,921)44.20% Health Promotion & Edu (11,776)(26,458)(63,706)41.53% Personal Health (118,113)(152,781)(551,907)27.68% State Allocations Total (142,888)(206,104)(703,134)29.31% Grants Project Revenue AFDO Grant 0 0 (3,000)0.00% CC4C Accesscare (34,022)(34,022)(147,686)23.04% Community Health Grant (9,171)(9,171)(145,914)6.29% MDPP (2,855)(2,855)(18,174)15.71% PCM Accesscare (37,433)(37,433)(167,334)22.37% Piedmont Hlth Srv - Nutr (3,474)(3,474)(33,800)10.28% FIT Grant (3,164)(3,164)(19,561)16.17% United Way - FSA 0 0 (31,809)0.00% Grants Project Revenue Total (90,119)(90,119)(567,278)15.89% Revenue Total (647,082)(710,298)(3,524,743)20.15% Orange County Health Department First Quarter Financial Report FY 2019-2020 General Fund TOTAL HEALTH Q1 YTD ACTUAL ANNUAL BUDGET % OF ANNUAL BUDGET Expenditures Salaries 1,263,812 1,263,812 6,556,974 19.27% Benefits 521,743 521,743 2,351,457 22.19% Travel 2,870 2,870 20,173 14.23% Training 7,492 7,492 59,769 12.53% Certifications & Licensing 1,971 1,971 10,987 17.94% Mileage 6,808 6,808 64,201 10.60% Telephone 20,509 20,509 113,249 18.11% Postage 2,394 2,394 14,273 16.77% Equip Repairs 0 0 13,025 0.00% Equip Rent 699 699 1,200 58.22% Duplicating 1,961 1,961 12,250 16.00% Printing 478 478 14,649 3.27% Advertising 0 0 10,685 0.00% Dues 3,246 3,246 6,869 47.26% Subscriptions 200 200 1,400 14.26% Dept Supplies 5,310 5,310 41,073 12.93% Edu Supplies 0 0 16,074 0.00% Office Supplies 3,677 3,677 27,198 13.52% Medical Supplies 40,637 40,637 147,514 27.55% Bloodborn Path Supplies 143 143 1,200 11.90% Pharmacy Supplies 36,460 36,460 161,000 22.65% Comp Supp/Software 658 658 6,433 10.23% Contracted Srv 100,758 100,758 873,539 11.53% X-Ray 874 874 22,625 3.86% Lab Srv 12,241 12,241 131,410 9.32% Bonds & Insurance 0 0 10,815 0.00% Uniforms 2,155 2,155 6,100 35.33% Community Proj 1,518 1,518 46,356 3.28% Innovations Project 1,372 1,372 15,000 9.15% Accreditation Project 3,250 3,250 3,250 100.00% Credit Card Exp 2,488 2,488 11,000 22.61% Nicotine Replacement Therapy 0 0 10,000 0.00% Capital Exp Under $500 3,998 3,998 5,263 75.96% Equipment 1,736 1,736 1,736 99.99% IT Equipment 543 543 600 90.52% Expenditures Total 2,052,002 2,052,002 10,789,347 19.02% Orange County Health Department First Quarter Financial Report FY 2019-2020 Grants Fund TOTAL HEALTH Q1 YTD ACTUAL ANNUAL BUDGET % OF ANNUAL BUDGET Revenue Kenan Grant 0 (200,000)(300,000)66.67% Revenue Total 0 (200,000)(300,000)66.67% TOTAL HEALTH Q1 YTD ACTUAL ANNUAL BUDGET % OF ANNUAL BUDGET Expenditures Salaries 11,857 47,829 184,249 25.96% Benefits 5,001 19,061 60,996 31.25% Training 0 100 3,496 2.86% Mileage 37 295 3,061 9.63% Contracted Srv 0 0 27,568 0.00% Community Proj 0 1,577 10,730 14.69% IT Equipment 0 9,568 9,900 0.00% Expenditures Total 16,895 78,429 300,000 26.14% BOH GOVERNANCE DASHBOARD Q1 FY19-20 209 212 226 $0 $100 $200 $300 $400 $500 $600 J A S O N D J F M A M JThousandsTOTAL HEALTH DEPARTMENT REVENUE vs. Budget Projections & Prior Year Personal Health HPES FAS Environ Health Dental Total OCHD Revenue ($.6M/y) FY19-20 Budget Proj ($294k/m, ~$3.5M/y)YTD Mth Avg ($216k/m, ~$2.6M/y) FY18-19 Mth Revenue ($3.5M/y) 58 54 49 $0 $10 $20 $30 $40 $50 $60 $70 J A S O N D J F M A M JThousandsDENTAL EARNED REVENUE BY SOURCE vs. Budget Projection & Prior Year SELF PAY INSURANCE MEDICAID Total Earned Revenue ($160k YTD) FY19-20 Budget Proj ($45k/m, $541k/y)YTD Mth Avg ($53.4k/m, ~$641k/y est) FY18-19 Mth Revenue ($559k/y)FY18-19 Mth Revenue - Avg ($46.6k/m) 55 41 34 $0 $10 $20 $30 $40 $50 $60 J A S O N D J F M A M JThousandsMEDICAL (PH) EARNED REVENUE BY SOURCE vs. Budget Projection & Prior Year SELF PAY INSURANCE MEDICAID Total Earned Revenue ($130k YTD) FY19-20 Budget Proj ($57k/m, $681k/y)YTD Mth Avg ($43.2k/m, ~$518k/y est) FY18-19 Mth Revenue ($487k/y)FY18-19 Mth Revenue - Avg ($40.6k/m) 37 39 47 $0 $10 $20 $30 $40 $50 $60 $70 $80 J A S O N D J F M A M JThousandsENVIRONMENTAL (EH) EARNED REVENUE BY SOURCE vs. Budget Projection & Prior Year Wells Tattoo Parlors Septic Samples Public Pools Food and Lodging Fees Total Earned Revenue ($123k YTD) FY19-20 Budget Proj ($54k/m, $649k/y)YTD Mth Avg ($41.k/m, ~$492k/y est) FY18-19 Mth Revenue ($594k/y)FY18-19 Mth Revenue - Avg ($49.5k/m) Agenda Item Number: ORANGE COUNTY BOARD OF HEALTH AGENDA ITEM SUMMARY Meeting Date: October 23, 2019 Agenda Item Subject: Orange County Advisory Board Update Attachment(s): Advisory Board Report Staff or Board Member Reporting: Beverly Scurry Purpose: ___ Action _X_ Information only ___ Information with possible action Summary Information: The Board of Health identified action steps related to engagement in the 2018-2020 Strategic Plan. One of these action steps is to receive biannual updates on actions of other Orange County advisory boards that relate to the BOH strategic plan priorities. The summary provided contains BOH top priorities related information from various Orange County advisory boards from April 2019 to September 2019, as available from the boards. 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): Submitted October 14, 2019 O RANGE C OUNTY A DVISORY B OARD S UMMARY A PRIL 2019 – S EPTEMBER 2019 Board of Health Engagement 10/23/19 1 Biannual Report Board of Health Engagement B OARD BOH P RIORITY S UMMARY Orange County Schools Board of Education Substance Abuse and Mental Health, Physical Activity and Nutrition, Equity The School Health Advisory Board, chaired by Valerie Green and Richard Lewis received a grant for $4,500 from NC Healthy Schools. Mrs. Green also received a $3,000 grant from Action for Healthy Kids. The FSA Agreement to conduct K Readiness Program at New Hope Elementary was approved in May. The Board stated they are committed to all racial equity policies including creating a more diverse workforce and getting bilingual support in schools. A Juvenile Court/School Liaison MOU was approved. The liaison will partner with Chatham County and Chapel Hill Carrboro City Schools to provide counseling services to assist students involved in the juvenile court system and those who may be at risk. Dr. Dena Keeling was hired as the first ever Chief Equity Officer and is conducting equity training with District Leadership. In August, the Board Chair made a statement to denounce any hate, symbols of intimidation, or intimidation activity in the community following the disturbing KKK demonstration. The Board will be vigilant to keep students, staff, parents, and community safe and secure. Proposed agenda items for 2019-2020 school year that may be of interest to the BOH: • Student Achievement Data – Examine sub groups data and over several years • Data on the effectiveness of early education efforts (K-2) • Early Education Opportunities – Dual Language at New Hope • Full time Translator • Lactation Stations • Historically Underutilized business report • Updates on Equity Plan • Opportunity Gaps • Equity Task Force • Communication Plan for our community • Safety and Security • Equity Task Force Charter • Funding for the next phase of Equity work 10/23/19 2 Chapel Hill/Carrboro City Schools Board of Education Currently no updates related to the Board of Health. DEAPR – Parks and REC Council Physical Activity and Nutrition Little River Park conducted a survey as they begin to develop a new master park plan for future development of the park. Blackwood Farm Park Phase ll will have increased parking. A new park office and learning center will be built with a future nature center within it. A disc golf course will also be built. A new drive into the park is also coming. The council reviewed the Parks and Recreation Master Plan Recommendations: 1) Continue funding for operation and maintenance of existing facilities and parks. a. There is now a dedicated fund in the budget for park operation and maintenance. 2) Open the planned parks. a. Fairview and Blackwood Farm Parks are now open. 3) Complete the protection of preserves. a. Hollow Rock Nature Park has opened and activity continues on this front. 4) Formalize and build multi-partner facilities. a. Commitment with the Town of Chapel Hill to work on Millhouse Road Park. The department has done less well with the schools. Using school gyms has been problematic. 5) Development a Master Park Plan for the Mountains-Sea- Trail and work toward making the connection with adjacent counties. a. This has been done and passed by the BOCC and work is going on with this plan. 6) Build more trails and connect more open spaces a. Like with the Multi-Modal trail in consideration 7) Work to improve trails and improve healthy lifestyles design. 8) Add programs where residents have identified needs. 9) Examine the role of community centers and how we are meeting community needs. a. The County now has three community centers running. The Council should speak more about their recreational offerings, especially as they address the needs of low income folks. Is equity being considered with all our programs? 10/23/19 3 Board of County Commissioners Social Determinants of Health, Physical Activity, Substance Abuse & Mental Health The Board voted to approve a Resolution in Response to Recent Acts of Racial and Ethnic Intimidation on the Campus of UNC- Chapel Hill. (Unanimous) The Board voted to authorize the Chair to sign a letter to the North Carolina Association of County Commissioners expressing Orange County’s preference to align its Medicaid Tailored Plan Region with Durham and Wake counties. (Unanimous) The Board considered applications from six (6) landowners/farms to certify qualifying farmland within the Caldwell, Cedar Grove, High Rock/Efland, and Cane Creek/Buckhorn Voluntary Agricultural Districts; and voted to enroll the lands in the Orange County Farmland Preservation Voluntary and Enhanced Voluntary Agricultural District programs. (Unanimous) The Board voted to approve a Resolution Endorsing HR 1384 - Improved Medicare For All. (Approved 6-1) The Board voted to approve a proclamation declaring August 1, 2019 through July 31, 2020 as a year of remembrance to commemorate the 400th anniversary of unfree Africans first arriving in English North America. (Unanimous) The Board voted, with three amendments, to approve a Resolution Condemning the Ku Klux Klan and Other Similar Groups. (Unanimous) Chapel Hill Town Council Physical Activity and Nutrition, Equity Mayor Hemminger proclaimed April 24, 2019 be NAACP Appreciation Day in Chapel Hill. The Town passed a resolution which noted how UNC-CH and the Town were working together to create a safe environment for all. The resolution mentioned the recent incidents on campus and expressed strong support for UNC-CH's efforts to address them. The Town proclaimed May 18, 2019 to be Kids to Parks Day in Chapel Hill recognizing the physical and mental health benefits of having an active lifestyle and being connected to neighbors. Carrboro Board of Aldermen Physical Activity and Nutrition; Social Determinants of Health The Board approved a Resolution In Response To Recent Acts Of Racial Intimidation On The Campus Of UNC-Chapel Hill. Mayor Lavelle proclaimed May as “Bicycle Month,” May 8th as “Bike to School Day,” May 13th through May 19th as “Bike to Work Week,” and May 17th as “Bike to Work Day” in the Town of Carrboro. The Alderman approved participants on the Orange County Climate Change Committee. The Board passed a Resolution Supporting The Passage Of The Medicare For All Act Of 2019. Mayor Lavelle proclaimed June as Recreation and Parks Month in the Town of Carrboro. Hillsborough Board of Commissioners Social Determinants of Health Commissioners will be supporting the Health Department in evaluating the use of no smoking signs in Hillsborough. 10/23/19 4 Orange Unified Transportation Board (TAS/OUTBoard) Physical Activity & Nutrition Currently no updates related to the Board of Health. Healthy Carolinians of Orange County All Social Determinants of Health • Worked with OC Transportation Demand Manager to promote the Transit Academy and Go Passes for teens. This committee also worked with Mobility Manager at the Department on Aging to promote transit workshops and activities. • UNC Family Medicine staff presented Medicaid transformation information and updates to this committee in a Care for Carolina Presentation. • This committee promoted the Cardinal Innovations and Dept. on Aging Mental Health First Aid training and QPR Training for Suicide Prevention • The committee also worked with members to promote the Caregiver 101 series as well as UNC Family Medicine Living Healthy series Mental Health and Substance Abuse • This committee worked hard throughout the summer on planning the Suicide Prevention Walk which was September 20th at the Carrboro Town Commons. Speakers for the event were Jodi Flick, LCSW and Joanna Bowen. The event was a success. Physical Activity and Nutrition • This committee continues to be involved with their partners including the OC Food Council and Orange County School’s CATCH program. • In July the group received a presentation from Erika Cerwin, founder and CEO of BeSpree. This is an app/program designed to connect chronic condition patients with physical activity. BeSpree is not about one-on-one activities but believes that groups can come together and can inspire a community to be healthy together. As an individual begins to use the app and show interest in various programs, the app will be able to suggest similar programs that can appeal to the user; similar to how Netflix suggests movies based on your watching history. The app is free to users and there is a fee for organizations. The fee will not only cover promotion and advertising for their agency and programs but will also allow them to receive data in return. Organizations will pay $10/month (basic) or $30/month (premium). The app will help individuals 1) explore what’s going on and what’s available in the community, 2) schedule activities, and 3) engage in activities. 10/23/19 5 Community Health Assessment • Over the summer, the CHALT (CHA Leadership Team) has been receiving coordinating: o CHA Door-to-Door Surveys  Collected 197 completed surveys total, 3 shy of the 200 goal. o Online Survey  As of September 12th there were 133 responses o Physical surveys collected from:  DSS  Seymour & Passmore Centers  Community Events • Cedar Grove Ruritan Family Fun Day • Cedar Grove National Night Out • Cedar Grove Senior Event o Focus Groups planned include:  Homeless FG  Refugee FGs • The Karen/Burmese FG • The Swahili/Kinyarwanda FG  Hispanic/Latinx FG  Formally Incarcerated FG  Youth FG o Listening Sessions  Recruiting volunteers to assist  October 29th – 12p – 2p @ Cedar Grove Community Center  November 12th – 5:30p – 7:30p @ Whitted Human Services  November 15th – 12p – 2p @ Chapel Hill Public Library  November 21st – 5:30p – 7:30p @ Southern Human Services Center Family Success Alliance (FSA) Social Determinants of Health, Equity April • FSA received a presentation from the Transit Dept. to better understand how transportation works in Orange County to better support families. FSA recommended supporting the Transit Academy which gives an overview of transit services. • The Council discussed exploring space in Zone 4. The idea of creating a detailed mapping of space needs and the different locations available was suggested. There is currently a great need and interest in finding a space to gather in large groups. It was suggested to pull together as a community and build something that could accommodate everybody. 10/23/19 6 June • There are two phases planned to expand the reach of FSA that are anticipated by the current strategic plan. 1) Phase I will focus on opening FSA up in fall 2019 to families who live in the Zones but their children do not attend Zone Schools. 2) Phase II will take place over the next couple of years and will focus on expending the navigator program to other zones within the county. • Coby Austin, Director of FSA, left the program in June. In the interim, Health Director Quintana Stewart will work more closely with staff to support the Family Success Alliance until a new Director is hired. • The navigators will become Health Department Employees starting July 1st. August • Frank Porter Graham Bilingüe Elementary School, this past summer school was awarded FSA innovation grant funds to focus on summer programming. Both summer and after- school programs focused on exploring topics in Identity, Diversity & Racism, exploring how we fit in the community with culture and language and what we feel on the inside. At the end of the summer, children created a public service announcement focusing on anti-racism, where students took an example of an historic event that happened and explained how that was wrong and how they would see things improve in the future. • FSA Expansion - As of September 2019, FSA will have 9 full-time navigators. FSA plans to have 4 navigators working in each zone and the 9th navigator to focus on family connections - work with families who are not eligible for the navigator program. Justice Advisory Council Substance Abuse & Mental Health; Social Determinants of Health Jail/Mental Health Workgroup • In April the Jail/Mental Health Committee hosted a Sequential Mapping Workshop for Orange County. DHHS has received a grant to conduct SIM workshops in interested counties. The workshop is 1 ½ days and is designed for local decision makers to come together, evaluate the flow of people through the local criminal justice system and identify strengths and weaknesses. The county will receive a map showing resources and gaps and an action plan with ways to improve the system. Following the workshop there were give identified priority gaps: 1) Crisis Diversion Center and Day Center 2) Increased Access to Case Management 3) Affordable and Accessible Housing 4) Data Collection 10/23/19 7 5) Addressing Social Determinants of Health • Orange County is participating in pilot study called Medication Assisted Treatment or MAT program. It is a collaborative effort between Jail, FIT, Southern Health Partners, Piedmont Health, Criminal Justice Resource Department (CJRD) working with Dr. Evan Ashkin of UNC. If someone enters jail on suboxone, then it will continue. The Health Department supplied pregnancy tests for this program as well as 50 Naloxone kits. Criminal Justice Resource Center (CJRD) • CJRD recently hired a new position of Legal Restoration Counsel (Emma Ferriola-Bruckenstein). Emma is an attorney who is passionate about legal restorative efforts for justice- involved individuals. Her primary work will be expanding the Driver’s License Restoration Program and filing expungement motions and certificates of relief on behalf of eligible justice-involved residents in Orange County. In other words, she will be helping people get their driver’s licenses restored especially if the primary barrier is an inability to pay fines/fees. She will also be helping people expunge their criminal records at no cost to them. • As a result of the Sequential Intercept Model (SIM) Workshop mentioned above, Orange County, NC formed a Task Force to address the needs of community members who have repeated encounters with the criminal justice and emergency medical systems. The purpose of the Task Force is twofold: 1) Enhance care coordination for these individuals to improve healthcare access, treatment, and overall stability. 2) Identify gaps and barriers in our service systems that contribute to instability so that we may develop solutions to reduce and ultimately eliminate these gaps. • Other Projects Being Considered and Researched by CJRD 1) A sobering center - a place where law enforcement and/or EMS could take someone who is publicly intoxicated, rather than our current options of jail, ED, or detox. It’s a place where someone can safely “sober up,” under medical supervision, and be offered treatment if they are ready. If they are not ready, that’s okay too, and they are discharged once they meet certain criteria (vital signs have stabilized, etc.) https://nationalsobering.org/ 2) A new work group is starting up to explore the possibility of creating a day center in Orange County (a place for people to go and “be” during the day and 10/23/19 8 get recovery support or other case management support). It’s likely that any kind of new facility or program would offer some kind of combination of services. Agenda Item Number: ORANGE COUNTY BOARD OF HEALTH AGENDA ITEM SUMMARY Meeting Date: October 23, 2019 Agenda Item Subject: Delinquent and Uncollectible Accounts Report and Bad Debt Write-Off Request Attachment(s): Delinquent and Uncollectible Accounts Policy 5 Year Historical Review of Bad Debt Write-Off Staff or Board Member Reporting: Rebecca Crawford Purpose: _X_Action ___ Information only ___ Information with possible action Summary Information: 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 2018 (Personal Health, Dental Health, and Environmental Health) for FY 2017-2018. 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 but a summary of the amount received through the NC Debt Set-Off program for the period of July 1, 2018 – June 30, 2019 is included below: Division Number of Accounts Set- Off Amount Received through NC Debt Set-Off Personal Health 26 $2,596.74 Dental Health 38 $4,788.51 Environmental Health 6 $739.87 Total 70 $8,125.12 Based on the definitions of uncollectible accounts in the department’s policy, the following table represents all uncollectible debt from clients for FY 2018-2019. Division Number of Uncollectable Accounts Write-Off Amount Personal Health 178 $3,547.86 Dental Health 62 $3,059.70 Environmental Health 5 $408.00 Total 245 $7,015.56 We request to administratively move a total of $7,015.56 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. 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): 5 Year Historical Review of Bad Debt Write-Off $- $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 FY 14-15 FY 15-16 FY 16-17 FY 17-18 FY 18-19 Bad Debt Write-Off Trends Personal Health Dental Health Environmental Health 0 20 40 60 80 100 120 140 160 180 200 FY 14-15 FY 15-16 FY 16-17 FY 17-18 FY 18-19 Number of Uncollectable Accounts Personal Health Dental Health Environmental Health Agenda Item Number: ORANGE COUNTY BOARD OF HEALTH AGENDA ITEM SUMMARY Meeting Date: August 28, 2019 Agenda Item Subject: BOH Policy Review Attachment(s): Community Assessment Policy Section l C, Confidentiality & Conflict of Interest Statement Appendix H, Board Review of Reports and Documents Section ll, Operating Procedures Section lll Staff or Board Member Reporting: Beverly Scurry Purpose: __X_ Action _ _ Information only ____ Information with possible action Summary Information: It is time for annual review of BOH Policies and Procedures. The policies will be presented in groups. The first five policies up for review include: Section l lA - Compliance with Public Health Laws/Regulations lB – Program Policy and Policy Adoption lC - Confidentiality Agreement and Conflict of Interest Statement lC Appendix H lD – Requests for Environmental Services and Assessments lE – Fee and Eligibility Policy lF - Community Assessment Policy lG - Community and Public Input Policy lH – Policy and Procedures for Complaints Section ll - Review of Reports and Documents Section lllA – Operating Procedures Staff Recommendations for Consideration: lA - Compliance with Public Health Laws/Regulations • Rescind Policy o The policy is fully summarized in Policy lllA Operating Procedure under section XVl lB – Program and Policy Adoption • Rescind Policy o The policy is fully summarized in Policy lllA Operating Procedure under section Xlll lC - Confidentiality Agreement and Conflict of Interest Statement • Rescind Policy o The policy is fully summarized in Policy lllA Operating Procedure under section lV and Appendix H lD – Requests for Environmental Services and Assessments • No Change lE – Fee and Eligibility Policy • Will be voted on and reviewed separately by Rebecca Crawford lF - Community Assessment Policy • Section lb – formatting updated and included community-based organizing groups to show support to the community • Section ld – updated link to Community Health Assessment Guidebook • Section lg – OCHD staff and community volunteers added to assist in collection of primary and secondary data • Section lh – *New Section* states - Primary and secondary data collected should be disaggregated by race, ethnicity, gender, sexual identity, etc. when possible to account for racial and health disparities among marginalized groups. • Section lk – *New submission date for CHA* –- first Monday in March following the year of assessment • Section lm – o Link updated for Community Health Assessment Action Plan o *New submission data for CHA Action Plan* - first Monday in September following the year of assessment • Section llb - *New Section* states that the SOTCH report should include – A review of disaggregated data by race, ethnicity, gender, sexual identity, etc. to account for health disparities in the county among marginalized groups. • Section lld – wording change to reflect when SOTCH report is due – during the years a CHA is not submitted lG - Community and Public Input Policy • Rescind Policy o The policy is fully summarized in Policy lllA Operating Procedure under section XllB lH – Policy and Procedures for Complaints • Rescind Policy o The policy is fully summarized in Policy lllA Operating Procedure under section XllC ll – Review of Reports and Documents • Title of Policy – Board Adoption was removed from title • Community Health Assessment – This section now only refers to Section l, Policy F • State of the County Health Report – This section now only refers to Section l, Policy F • Board of Health Strategic Plan – This policy changed from every two years to every four years, to match the CHA cycle • Annual Immigrant and Refugee Report and Cardinal Innovations Healthcare Report – These reports were added to reflect reports used as evidence in Accreditation lllA – Operating Procedures • ll Charge to the Board – This section was updated to explain policy-making, rule- making, and adjudication. o llA Policy-Making – *New Section* - This section was updated to include more language about BOH program and policy adoption • lll Composition – This section was updated to list the specific positions of BOH members • lV New Board Member Tasks – *New Section* This title was changed to reflect the three tasks new boards members must complete – Confidentiality and Conflict of Interest and Oath of Office. o The Confidentiality and Conflict of Interest policy was rescinded and folded into this section of Operating Procedures – lV-B o This section has an appendix which is the Statement of Confidentiality and Conflict of Interest that all board members must sign o The Oath of Office Policy was rescinded and folded into this section of Operating Procedures lV-C • V Terms of Office – o A - wording change to reflect composition of board in section lll o B – wording change • Vl – Resignation of Board Member from Current Term of Office - *New Section* - o This section was rescinded in the Process for Recruitment and Reappointment Supplemental Process and added to Operating Procedures Vl • Vll Removal from the Board - *New Section* - This section added to reflect process of BOH member removal • Vlll Compensation - *New Section* - This section reflects BOH member per diem received • lX – C-Committees – o Formatting change – The statement: .All standing committees are subject to the North Carolina open meetings laws and shall comply with the provisions of those laws – was moved up from Vlll – C.5. o *New Section*The Process for Recruitment and Reappointment Supplemental Process was rescinded and included in this section of the Operating Procedures due to relevance. • X – Meetings o B - Special Meetings - *New Section* - This section was added to outline instances in which the BOH may need to call a special meeting o D Presiding Officer – wording change to reflect proper pronoun usage – Will now simply state - The Chair of the Board shall preside at Board meetings if present. o G Minutes – link updated to reflect new online locations for minutes o H Closed Session - *New Section* - This section added to reflect BOH procedure for closed session • Xlll – Other Procedural Matters o A - Parliamentary Procedures - *New Section* - This section added to reflect Robert’s Rule of Order used at BOH meetings o B – Public Comment - *New Section* - This policy was rescinded and added to Operating Procedures to explain process for getting public input o C – Procedure for Complaints – *New Section* - This policy was rescinded and added to the Operating Procedures to explain process for complaints. It mainly directs folks to our Admin Policies where the complaint processes are located. • XlV – Policy-Making Procedures - *New Section* The Program and Policy Adoption Policy was rescinded and added to Operating Procedures • XVll – Annual Review of Health Director o This section was updated – The Annual Performance and Review Process for Health Director Supplemental Process was rescinded and added to this already existing section of the Operating Procedures. • XVlll – Compliance with NC Law – Sections B & C were part of rescinded Compliance with Public Health Laws/Regulations Policy and added to this section of Operating Procedures to reflect legal consult options for the BOH and location of manuals for laws and regulations in the department. 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 I: Board Adopted Policies Policy EB: 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:, 10/2014, 9/2015, 4/2016, 9/2018, 10/2019 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 EB: 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:, 10/2014, 9/2015, 4/2016, 9/2018, 10/2019 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 EB: 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:, 10/2014, 9/2015, 4/2016, 9/2018, 10/2019 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 EB: 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:, 10/2014, 9/2015, 4/2016, 9/2018, 10/2019 C. Family Planning, Maternal Health, and Child Health clients will never be refused service or be subject to variations in service due to an outstanding balance or inability to provide proof of income. Health Department clients are eligible to receive these services regardless of their participation in other programs. Family Planning, Maternal Health, and Child Health services are voluntary to all clients. D. Falsification of eligibility by the client may result in denial or limitation of services. 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. 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. 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 charges will be adjusted to 0% on the sliding fee 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.B. Fees are not charged to self-pay clients 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.C. 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. E.D. Fees may be charged to clients for “non-program” specific services without being adjusted on a sliding fee scale (flat fees). ORANGE COUNTY HEALTH DEPARTMENT Board of Health Policy and Procedures Manual Section I: Board Adopted Policies Policy EB: 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:, 10/2014, 9/2015, 4/2016, 9/2018, 10/2019 F.E. 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.F. 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.G. Persons requesting any program services may be encouraged to apply for Medicaid, as applicable. I.H. 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.I. 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.J. 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 c. Most recent Medicaid Cost Settlement data for procedure costs d. Environmental Health equipment, labor, and staff costs ORANGE COUNTY HEALTH DEPARTMENT Board of Health Policy and Procedures Manual Section I: Board Adopted Policies Policy EB: 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:, 10/2014, 9/2015, 4/2016, 9/2018, 10/2019 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.K. Based on G.S. 130A-41, the Health Director is authorized to enter into contracts, which may include negotiated reimbursement rates. M.L. The Health Director may not make exceptions to the Fee Policy except to accommodate specific situations through the fee waiver process (Attachment C). N.M. Any minimum administrative fee or flat fees shall be applied without discrimination to all patients. O.N. 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.O. 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. 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. ORANGE COUNTY HEALTH DEPARTMENT Board of Health Policy and Procedures Manual Section I: Board Adopted Policies Policy EB: 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:, 10/2014, 9/2015, 4/2016, 9/2018, 10/2019 E. After 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. 2. Dental Health Divisions a. Bill statements 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. 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. 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. ORANGE COUNTY HEALTH DEPARTMENT Board of Health Policy and Procedures Manual Section I: Board Adopted Policies Policy EB: 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:, 10/2014, 9/2015, 4/2016, 9/2018, 10/2019 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: October 23, 2019 Agenda Item Subject: Health Director Annual Review Attachment(s): Board of Health Policy III.B.d Staff or Board Member Reporting: Timothy Smith 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 2019 meeting. Recommended Action: ___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 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 \2019 Agenda & Abstracts\October 2019\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 \2019 Agenda & Abstracts\October 2019\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: October 23, 2019 Agenda Item Subject: Elections (Chair and Vice-Chair) Attachment(s): Staff or Board Member Reporting: Timothy Smith 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 getting nominations for each position for a vote that will take place at next month’s meeting. We will be presenting the slate of officers. Recommended Action: ___Approve ___Approve & forward to Board of Commissioners for action ___Approve & forward to ___________________________ ___Accept as information ___Revise & schedule for future action ___Other (detail): Health Director’s Report October 2019 1. Orange County Opioid Task Force – We had a productive meeting on September 30, 2019. The group finalized a one page summary to explain the purpose of the group and the initial priorities to be addressed. The task force has elected to address 1) Education, 2) Reduce oversupply of prescription opioids and 3) Expand treatment and recovery oriented systems of care. Commissioner Price petitioned the BOCC to support the formation and activities of the Task Force. This was approved via Consent Agenda during the October 15, 2019 BOCC meeting. • Board of Health Veterinarian Member – Dr. Lee Pickett was officially appointed to the BOH during the September 17, 2019 BOCC meeting. Dr. Pickett completed her new Board Member orientation on Monday, September 14, 2019. • Medicaid Transformation Update: On Monday, September 3, 2019, the Department of Health & Human Services (DHHS) announced that we will move to a statewide transition to managed care on February 1, 2020, meaning managed care will launch in one phase rather than two as originally planned. On October 8, 2019, DHHS expanded the Medicaid transition regions of Carolina Complete Health (CCH) to now include our region, Region 4. Beneficiaries in our region will now have the option to choose from all 5 of the available Prepaid Health Plans (PHPs). In addition to Carolina Complete Health, the other statewide PHP contracts were awarded to: o AmeriHealth Caritas North Carolina, Inc., o Blue Cross and Blue Shield of North Carolina, o United Healthcare of North Carolina, Inc. and o WellCare of North Carolina, Inc. • Cardinal Innovations – I met with King Jones, Director of Community Health & Wellness to discuss Cardinal’s new Regional Health Councils. Orange County will be part of the Central Region Health Council which includes Alamance, Caswell, Chatham, Person and Orange. The purpose of the Regional Health Council is to develop, approve and oversee regional health assessments and health improvement plans. The overall goal is to ensure Cardinal is reinvesting in the community and providing services that each region identifies as their specific need. Members to the Council will be appointed by the Board of Directors via an application process. Each County will maintain their local Advisory Council while still participating on the Regional Health Council. • The Health Equity Council (HEC) hosted the REI Groundwater Training at Whitted on October 10, 2019. There were approximately 195 participants in attendance. They also hosted an afternoon session for community partners to discuss in more detail how to examine/address the groundwater in Orange County as a community and within our respective sectors. It was a successful event. • NCCARE 360 is coming to Orange County! We are scheduled to begin community onboarding in December. NCCare360 is the statewide coordinated network that includes a robust data repository of shared resources and connects healthcare and human services providers together to collectively provide the opportunity for health to North Carolinians. It has been launched in 12 other counties and under implementation in 9 counties. The goal is for the program to be statewide by December 2020. • I will start as a new Board Member for the Orange County Partnership for Young Children this month. The Board Retreat and Strategic Planning Sessions are scheduled for October 22 – 23, 2019. Legislative Updates • The NC Commission for Public Health has adopted and approved a new sanitation rule effective October 1, 2019. This amended rule requires that all licensed child care centers test all drinking water faucets and food preparation sinks for lead contamination within one year, and new centers must test upon application for a license. After that, child care centers will test their water once every three years. If a child care center finds elevated concentrations of lead in the center’s water, they will be required to take immediate action. • Public Charge Rule – Injunction Granted – The public charge rule was scheduled to go into effect on October 15, 2019. On Friday, October 11th, multiple courts stopped this, meaning the existing rules will remain in effect until further notice by the federal courts. Immigrants and their families can and should continue to access benefit programs for which they are eligible without fear of certain negative impacts on their immigration statuses. The new forms that were going to be required for immigration applications will not be used until the court decides on the legality of the rule. We do not know when the injunction will expire. There have been past injunctions in federal cases (such as the implementation or continuation of DACA) that have lasted for years. Upcoming Events • October 18, 2019 – County Employee Appreciation Lunch; 11:30am – 2:30 pm at David Price Farmer’s Market Pavilion • October 21, 2019 – Family Success Alliance Advisory Council Meeting, 1pm – 3pm, Whitted Building • October 23, 2019 – Meeting with State Medical Examiner • October 24, 2019 – Panelist for Orange County Department of Aging’s Project EngAGE; a senior leadership training program with the mission of recruiting and training Orange County older adults to become community resource leaders. • October 29-30, 2019 – NC GARE Cohort Team Meeting in Charlotte, NC. • November 8, 2019- OCHD will host UNC Public Health Students for the Annual UNC Phield Trip. 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. Leading To Health After prison:Community health worker Tommy Green drivesabout100milesaweekvisiting clients scattered around Orange County, North Carolina, and helping them cope with life after prison. He has the use of three offices but does much of his work in his car. doi:10.1377/hlthaff.2019.01163 After Prison, Healthy Lives Built On Access To Care And Community A North Carolina program helps recently released inmates connect to health care, social services, and support. BY ROB WATERS J ustin Jones got hooked on prescription painkillers after he flipped his truck as a teen- ager, put his head through thewindshield,andfractured his wrist and sternum. When doctors would no longer write prescriptions for him, he began buying—and selling— drugs on the streets of Durham and Hillsborough, North Carolina. His first arrests came before he turned twenty. At first, he used prescription pills like the Oxycodone he knew, but when they were too scarce or expensive, he turned toheroin.Athispeak,Jonessaysmatter- of-factly, he was consuming about $2,000worthofheroinadayandselling ittofeedhisaddiction.He’slostcountof how many times he’s been in and out of prison but guesses that it’s more than fifteen. Jones, who is now thirty-two, tells me allthisinthespaciouslivingroomofhis parents’home on the wooded outskirts of Hillsborough. A buck’s head adorns the living room wall; an American flag flapsfromthetidyfrontporch.Acursive tattoo of the family’s name decorates Jones’s left forearm. Eachtimehewasreleased,Jonessays, the same thing happened: He’d try to stop but would be using again within two weeks.“I would try to do better, but I didn’t have a stable system, I didn’t have insurance,”he says.Without insur- ance, his access to doctors or treatment programs was greatly limited. (North Carolina is one of fourteen states that have opted not to expand eligibility for Medicaid to low-income adults who aren’t disabled.) He almost resumed the pattern after his last release, in December 2018.“I startedhangingaroundthesamepeople and doing the wrong things,”he recalls. “Then I said,‘Well, I need to stop this.’” His probation officer put him in touch with another former inmate, a commu- nity health worker named Tommy Green, who brought me to the Joneses’ home in July 2019 and introduced me to his client. Green has been out of prison since 2015, and he started working last year fortheFormerlyIncarceratedTransition (FIT)Program,whichhelpspeoplecom- ingoutofprisongetaccesstohealthand social services. Green called Jones a few times,“but I blew him off, thinking I didn’t need the program,”Jones recalls. “But then I saw I was going downhill, and I was like,‘Damn, I need to do something.’” He had another motivation, too: sur- vival. Jones says that in the six months since he was released, ten friends, most of them recently released inmates, have 1616 Health Affairs October 2019 38:10 Photograph by Rob Waters overdosed and died. He’s had several nearmissesovertheyearshimself,over- dosing but somehow surviving. He de- cided he didn’t want to tempt fate any more. In Search Of A ‘Normal Life’ Overdoses are common among recently released inmates because while inside, inmates with opioid use disorder either go through withdrawal or take smug- gled drugs—usually Suboxone, a pre- scription opioid substitute. As a result, when inmates are released, Jones says, “your tolerance is so low, you can’t take asmuch,butyoumaythinkyoucan.You get out, and bam, next thing you know you’redead.Me,Iusedtodoagram.But getting out of prison, there’s no way I can do half of that.” A2018studyinthe AmericanJournalof PublicHealth backshimup.1 Itexamined North Carolina death reports and found thatintheperiod2000–15,1,329former inmates died of opioid overdoses. The most dangerous time was in the first two weeks after release, when former inmates were forty times more likely thanmembersofthegeneralpopulation tosufferafataloverdose;overthecourse of a year, they were eleven times more likely to do so. Green was unfazed when Jones blew him off. He’s a patient man who knows what it’s like to come out of prison and struggle to find housing, health care, and employment. As Green often tells his clients,“I served eleven years, eight months,six days,andsixhours”instate prison for an armed robbery. It was his first and only conviction, for a crime he committed at the age of twenty-one. He makes no excuses for his actions then. He grew up in a middle-class fami- ly with two working parents, but he was drawn to trouble early.“I was always playing on the edge,”he says. He fell in with a group of people “I shouldn’t have beendealingwith,”hesays,“andIchose to be a criminal.”After he was convicted in 2003 and found himself in prison, he resolved to transform himself. “I made up my mind that if I lived through this experience, I would never jeopardizemylife,myfreedom,myfam- ily again,”he says.“And I also made a vow to help anybody I can [avoid] mak- ing these same mistakes.” InprisonGreenavoidedconflictswith other inmates, partly because he’s big and powerfully built—“a man of size,” as he puts it, whom nobody wanted to mess with—and he read voraciously. When he checked his library card seven years into his term, he found he’dread over a thousand books. When he finally got out, Green moved back into his old room in his father’s house,andthreemonthslaterhelanded a job as a parking lot attendant. He earned two promotions there before learning last year that the FIT Program was hiring a community health worker toworkwithnewlyreleasedinmates.He jumped at the opportunity and had just the right background and skills. Today his prison experience is an as- set that gives him street cred, empathy, and instant entrée with his clients. It’s also a prerequisite for his job.“This is like the only profession where being a criminal is a plus,”he says.“But you have to be a reformed criminal, of course.” When Jones was ready, he met with Green and, a few days later, with Evan Ashkin, a professor of family medicine at the University of North Carolina (UNC) at Chapel Hill who serves as the primary care doctor for FIT patients in Orange County. Ashkin founded the FIT Program and works as its statewide medical director. He is certified by the Drug Enforcement Administration to prescribe Suboxone and began doing so for Jones, as he does for seven other FIT patients. Jones says that his daily dose of Sub- oxone “keeps me from withdrawal and makesmeabletoliveanormallife.”The drug, which combines buprenorphine and naloxone, occupies the brain’s opi- oid receptors, keeping users from get- ting high from other opiates.“If I go out right now and get some heroin or a pain pill, it’s not going to affect me,”Jones says. He knows this to be true because he’s tried, and “it didn’t do nothing. A big waste of money.” Tackling Systemic Barriers For Ashkin, starting the FIT Program grew out of a sense of social commit- ment that was nurtured by his residency at the University of California San Fran- cisco (UCSF) in the 1990s, during the height of the AIDS epidemic. He moved to North Carolina in 1998 and ran a sec- tion of the family residency program at UNC Chapel Hill that worked to provide care to the underserved. “I started to understand that if they had a history of incarceration, that led tofurtherbarriersandreally,reallypoor access to health care services,”Ashkin says. Because North Carolina didn’t ex- pandMedicaid,whenpeoplewereincar- cerated,“it was the first time they had aconstitutionalrighttohealthcare.And they were getting diagnosed with high blood pressure, diabetes, and chronic kidney disease.” When they get out, most recently re- leased inmates have other priorities than health care, like getting housing and reporting to their probation offi- cers. Since health care isn’t high on the list, and they can’t afford it anyway, many simply don’t get care—even when they have serious health, mental health, or substance use problems. Even clinics that aim to serve low-income people of- tenrequirecopaymentsof$20or$25for clinical visits and $4 to $10 for medica- tions, Ashkin says. The lack of coordination shocked Ashkin, who laughs at his own naïveté. Getting help:Justin Jones (right) has been addicted to opioids and has shuttled in and out of prison at least fifteen times. Now, with the help of community health worker Tommy Green and the Formerly Incarcerated Transition Program, he’s getting medication that keeps him off heroin and protects him from a fatal overdose, like the ones that have killed ten of his friends this year. Photograph by Rob Waters October 2019 38:10 Health Affairs 1617 “I was certain you couldn’t be released fromprisonwithallthosemedicalprob- lems and not have a follow-up appoint- ment,”he says.“That was incorrect.” He learned that prison health care is soseparatedfromthehealthcaresystem outside that there was no easy way to bridge the two. Another former UCSF resident had come to the same conclu- sion. Shira Shavit, now a clinical profes- sor of family and community medicine at the university’s medical school, did part of her residency at nearby Alameda County Jail in the early 2000s and later recruited physicians to work at San Quentin Prison. She succeeded—but the young doctors she enlisted soon be- came demoralized. “They started feeling,‘What am I do- ing?’”Shavit recalls.“‘I’m caring for these patients, they’re getting healthy, andthenthey’rereleasedanddon’thave any access to services. Then they come back [to prison] on a parole violation and they’re sicker than when they left.’” Several studies have found that in- mates coming out of prison are signifi- cantly more likely to die—and not only from drug overdoses. A 2007 study in the New England Journal of Medicine tracked 30,327 people who were re- leased from prison in Washington State in the period 1999–2003 and compared them to other Washington residents matched by age, sex, and race. 2 During the first two weeks after release, the for- mer inmates were morethan 12 times as likely to die of any cause and 129 times more likely to die of an overdose. Over two to three years the former inmates were 3.5 times more likely to die than theotherresidents.Atotalof443former inmates died, nearly a quarter of them from an overdose. Heart disease, homi- cide, suicide, cancer, and auto accidents were the other leading causes of death. Shavit and her colleagues saw the need to build better linkages between prisons and the community. In 2006 they started a pilot program in a com- munity health center run by the San Francisco Department of Public Health. They called it the Transitions Clinic, and its aim was to connect former in- mates with chronic health conditions to health, social, and support services within two weeks of their release. Shavit and colleagues began the proc- ess by conducting focus groups to get input from people who’d been incarcer- ated.Onepieceofadvicestoodout:They would need to overcome the natural dis- trust of the health care system felt by people who had long been outside of it and often felt ignored or disparaged by its practitioners. Thebestwaytodothat,theyweretold, was to hire people who had been incar- cerated themselves and put them at the center of the program. Community health workers like Green now fill that role, connecting and building rela- tionships with potential patients and serving as supporters, advocates, and mentors. The focus groups had another sugges- tion, too: People with a history of incar- ceration didn’t want to be segregated from other patients and served in a sep- arate program. Instead, they wanted to feel like part of the community and to “sit in the waiting room with kids and familiesandtherestof thecommunity,” Shavit says. Since its start thirteen years ago in San Francisco, the Transitions Clinic has grown: Now the Transitions Clinic Network, it contains thirty-four affiliat- ed clinics in twelve states and Puerto Ricothatfollowthesamemodel,includ- ing the FIT Program in North Carolina. Ashkin started FIT with support from the North Carolina Division of Public Health. The first site, in Durham, opened in 2016. A grant from the Duke Endowment and a contract with the North Carolina Department of Public Safety, which administers the state’s fifty-five prisons, enabled the program to expand to Orange County, where Green works, and to the counties that include Charlotte and Raleigh, the state’s largest cities. Ashkin hopes to start a program in Greensboro this year and to provide greater access to mental health services in all FIT sites. Maintaining and growing the pro- gram is challenging because of the state’s decision not to expandMedicaid. The grants and contracts Ashkin has ob- tained help pay the salaries of commu- nityhealthworkerslikeGreenandcover the copays that patients would other- wise have to shell out at safety-net com- munity clinics. The clinics lose money foreveryuninsuredclientAshkinbrings them. “They’re hoping to get more insured patients to offset the cost of treating the uninsured, and I keep bringing them more uninsured patients,”he says.“If we don’t expand Medicaid, it will be- come harder and harder [to raise] pri- vate funds for this.” Today the FIT Program serves about 85 inmates, Ashkin says, a number he hopes to increase to 350 by year’s end. Butthat’sa small fraction of theroughly 25,000 North Carolina inmates who come out of prison each year. The failure to provide health and so- cialsupportstosomanyformerinmates fuelsrecidivismandviolence,saysDorel Clayton, another former inmate who was hired last year as FIT’s Durham County community health worker. Be- fore that, he worked as a supervisor for Bull City United. As described in a Health Affairs Blog post published con- currently with this article, Bull City United works to interrupt violence and retaliation in Durham’s high-crime neighborhoods.3 At FIT, Clayton contin- ues to collaborate with the staff of Bull City United because he sees the links between health, substance abuse, and community violence. Peoplewholackaccesstothecareand medications they need to treat their ad- diction or mental illness are more likely to self-medicate, Clayton says, by “get- ting the drug from street pharmacies, and that ties into a whole bunch of stuff.” Another factor is trauma.“Someone who is dealing with bipolar disorder or posttraumatic stress disorder—it might be a result of having seen gun violence andpeoplekilledrightinfrontofthem,” Clayton says.“So their mind-set is to continue to hurt one another. We try to educate, but the lack of resources, theinabilitytogethealthcareandinsur- ance definitely contributes to violence.” Ashkin learned that prison health care is so separated from the health care system outside that there was noeasywaytobridge the two. 1618 Health Affairs October 2019 38:10 Leading To Health The Case For Expansion Transitions Clinic Network cofounders Shavit,thenetwork’sexecutivedirector, andEmilyWang,itsevaluationdirector, have worked to build the case forexpan- sion by conducting regular evaluations that document the program’s effec- tiveness. An early evaluation found that recent- ly released inmates who got care from the Transitions Clinic in San Francisco made fewer emergency department vis- its than those who were offered care in a standard primary care clinic, resulting in an estimated savings of $912 per patient.4 A more recent study, published this year in BMJ, looked at outcomes at the Transitions Clinic in New Haven, Con- necticut.5 The authors found that in the twelve months after they were released from prison, patients who were getting cared for by the program were neither morenorlesslikelytoberearrestedthan another group of former inmates who were not part of the program. The big difference: When they were rearrested, Transitions Clinicpatients spent 45 per- cent fewer days locked up in jail or prison. Wang and her colleagues wrote that the ninety-four people in the control group would have spent 2,300 fewer days incarcerated if they’d been clients of the Transitions Clinic. The authors also found that the clinic’s pa- tients were less likely to be hospitalized for preventable conditions and spent 60percentlesstimeinthehospitalwhen they were admitted. While the authors couldn’tsaypreciselywhyclinicpatients spent less time imprisoned, they specu- lated that being part of the clinic helped patients get into drug treatment more quicklyorgavethemaccesstoadvocates who helped them bail out sooner. Green helps his clients in these ways and more. He once convinced a magis- trate to drop charges against one of his clients and often talks to parole officers on his clients’behalf. He works out of three offices scattered around the coun- ty to be accessible to his clients, but he spends most of his time in his mobile office:thecounty-ownedHondaCiviche usestogotoclients’homesorferrythem tocourtdatesordoctor’sappointments. Green manages a caseload of almost thirty-five former inmates and gives pri- ority to those he calls his high-touch patients,peopleheconsidersvulnerable and wants to connect with at least once a week. He drives with a Bluetooth ear- piece in one ear and makes me slightly nervous as he engages in animated phone conversations while making fre- quent U-turns. He logs about a hundred miles in a week, he says, while visiting up to fifteen clients. I’m pleased when he actually pulls over to call one client, Pete Jacobs, be- fore driving to his mobile home on a country road in Hillsborough. Jacobs isabigmanwho’sbeingtreatedforhigh blood pressure and heart problems, as wellas a leghematoma hesufferedin an auto accident. Before the accident, he did roadwork and landscaping. Now, he says, he’s unemployed and broke. Jacobs spent five years in prison on drugcharges,andwhilehewasthere,he was diagnosed with heart failure.When he got out, he went a few weeks without medication until his probation officer told him about the FIT Program and gave him Green’s phone number. Green checks in with Jacobs about how he’s doing as he drives Jacobs to an appointment at a county social services office and then to a local food pantry. Jacobs is hungry and has no money for food. Under North Carolina law, he’s ineligible for benefits from the Supple- mental Nutrition Assistance Program (formerly known as food stamps) be- cause of his drug conviction. At the food pantry, run by a local United Way affili- ate, he gets a few bags of groceries. Green helps him load the food in the car and then drives Jacobs back home. WithouttheFITProgram,Jacobssays, he doesn’t know how he’d get the food, health care, or medications he needs: “I don’t get Medicaid. I don’t get food stamps. I don’t get no check every month.” Still, he says, he’s doing a lot better. He’s taking fewer medications and no longerneedsdiuretics.“Myhealthisdo- ing good,”he says.“I take my medicine everyday.IgotDr.Ashkin.IgotTommy. And I made it through my probation.” Green’s next call is to Jeffrey Fradsham, who at that moment is at a construction site applying for a job. Green wants him to meet Marcus Pollard—a job placement specialist with the Reentry Council, a local agency that assists released inmates. We drive around looking for Fradsham and final- lypullovertothesideoftheroadtopick him up. He is covered in tattoos. Fradsham tells me he’s been in and out of prison since he was seventeen and learned to do tattooing there be- cause “the only thing to do in prison is fight or tattoo yourself.”He’s nothing if not ingenious: In prison he made tattoo needles out of the springs in ballpoint pens and used the motor of an old CD- ROM player to drive the needles. Out- side prison, he has worked as a profes- sional tattoo artist, so when we get to Pollard’sofficeinChapelHill,Fradsham tells him he’d like to go back to that line of work. He says he’s been offered a seat in a local tattoo parlorbut needs around $400 to buy a tattooing machine. If the offerfromtheparlorisreal,Pollardtells him,hecanprobablygethimthemoney. Fradsham has struggled with heroin addiction but says he quit cold turkey during his last stint in prison. He’s been out for ten months and struggles with posttraumatic stress disorder from the violence he experienced. He once watched a man get stabbed thirty-seven times “over nothing”with a shiv made from a light fixture. It’s difficult to be back outside, he says:“People move out of the way when I walk down the street.” Green drops Fradsham at his house, and we head to Hillsborough and the Orange County Jail, where Alison Zirkel, a social worker with the county’s Criminal Justice Resource Department, is about to meet with an inmate. She’s sitting at a card table in a small meeting room, near a bank of phones and a sign: “Inmates, pick up your phone first.” Inajailwithacapacityof120inmates, Zirkel typically works with 20–30 at any one time who have mental health orsubstanceabuseproblems—frequent- ly both—and little or no access to medi- cal care outside of custody. For many, the combination of being homeless andabusingsubstanceshasledtopublic intoxication, assaults, and fights. Without the FIT Program, Jacobs says, he doesn’t know how he’dgetthe food, health care, or medications he needs. October 2019 38:10 Health Affairs 1619 A deputy leads a tall, gray-haired man intotheroomandslidesthebarreddoor closed, securing it with handcuffs and a chain. Zirkel asks the man if he saw the psychiatrist the previous week. He says he did and was given a prescription for Prozac, which he started taking. Since he’s likely to get out soon, Zirkel suggests that he sign up with the FIT Program. She leaves and Green comes in.“I’ve been in your shoes,”he says.“I’ve been in this very jail.”The man, who asked to be identified only by his first name, Graylin, tells Green he has diabetes, hepatitis C, and high blood pressure. He does not have a drug abuse problem, he says, though he was arrested fordriv- ing under the influence. His big needs, he says, will be housing and transpor- tation. Graylin was released two weeks later, and Green has been helping him get services and housing. He’s also one of severalFITclients,includingJones,who will be able to get a free eight-to-twelve- week course of Harvoni, a drug made by GileadSciencesthateradicateshepatitis C. That supply of the drug normally costs $63,000–$95,000, but Ashkin and his colleagues have made arrange- ments with Gilead’s Patient Assistance Program. Medication-Assisted Treatment Until now, medication-assisted treat- ment (the prescribing of opioid substi- tutestopeoplewithopioidusedisorder) has been banned in nearly all jails and prisons, including the Orange County Jail—which leaves inmates to rely on smuggled drugs, primarily Suboxone, if they don’t want to go into withdrawal. One exception is the state of Rhode Island,whichinJuly2016beganprovid- ing three opioid substitutes—metha- done, buprenorphine, and naltrexone (a long-acting injectable opioid blocker)—to inmates with opioid use disorder. The state also organized a net- work of community clinics that could continue providing the drugs after peo- plewerereleased.Astudypublishedlast year in JAMA Psychiatry demonstrated the success of this effort. 6 The authors foundthatinthefirstsixmonthsof2016 (beforetheprogramstarted),twenty-six people recently released from prison died by overdose. In the first six months of 2017 (after the program was up and running),thenumberof fataloverdoses fellto nine.Evenmoreimpressively,ten people died in the first thirty days after release in 2016, compared with just one in 2017. The refusal of most correctional facil- itiestoprovideopioidtreatmentisdraw- ing mounting criticism, as well as court challenges. Last November, in a closely watched case,Pesce v. Coppinger, Judge DeniseJ.CasperoftheUSDistrictCourt for the District of Massachusetts issued a preliminary ruling that the sheriff of Essex County, Massachusetts, could not deny methadone to a man sentenced to serve time in the county jail. Despite a six-year history of addiction, the man was able to stop using heroin and hold onto a job after he was prescribed meth- adone in late 2016. Since the jail doesn’t allowinmatestohavemethadone,being sentenced there could throw him into withdrawal and disrupt his recovery. And that, Judge Casper said, would vio- late the Americans with Disabilities Act of 1990. SomeNorthCarolinajailsandprisons are starting to shift their stance. The Orange County Jail began making Sub- oxone available to a handful of inmates in August. Ashkin says that the initial priority will be people already on Sub- oxone from a community provider and pregnant women with opioid use dis- order, to prevent them from going throughwithdrawalandharmingthefe- tus or baby. Being on prescription Sub- oxone under the care of a doctor is con- sidered far less risky. Charles Blackwood, the elected coun- ty sheriff, says that providing medica- tion-assisted treatment in the jails will help inmates “transition from heroin to a drug that will allow them to control theircravings”andminimizethedisrup- tive effect on the jail population of hav- ing inmates go through withdrawal. “We ’ve got to try something new, somethinginnovative,”Blackwoodsays. “When I ran for sheriff, they didn't tell me ‘Get elected, mistreat people, and ignore their needs.’They said ‘Take care of your people. Serve the public.’If you plant a garden of discontent, you’re go- ing to have trouble, but if you plant a garden of good, it’s going to pay back.” Meanwhile, the North Carolina De- partment of Public Safety is starting a pilot program in three prisons that will give inmateswith a historyof opioiduse disorder who are “on their way out the door”achoiceofSuboxone,methadone, or naltrexone. This will give them a bridge into treatment and help them avoid death from overdose, says depart- ment spokesperson John Bull. The de- partment will also refer patients to the FIT Program in the counties where it operates. Bull says that “it’s a paradigm shift for North Carolina”that will give inmates a better chance to overcome ad- diction and lead better lives. Back in Chapel Hill, Warren Levy, a fifty-four-year-old Jamaican who grew upinBrooklyn,iswaitingtomeetGreen forthefirsttime.Levywasreleasedfrom prisonafewmonthsearlierafterserving a couple of stints. He has prostate can- cer, sickle cell trait, bipolar disorder, andahistoryofsubstanceabuse.Hetells Green he’s staying at a shelter for home- less men and working at Burger King, a job that’s bad for his fragile health.“It’s 100degreesinthere,andit’skillingme,” he says. Green tells Levy about the FIT Pro- gram and gives him the number of his personal cell phone. He also tells Levy about his own background of incarcera- tion “becauseI wantyou to feelcomfort- abledealingwithmeandtoletyouknow that I've navigated all the systems that you will have to navigate.” Levy is convinced.“Sign me up!”he says.Withintwoweeks,Ashkinhadseen him for an exam.▪ The refusal of most correctional facilities to provide opioid treatment is drawing mounting criticism, as well as court challenges. 1620 Health Affairs October 2019 38:10 Leading To Health This article is part of a series on transforming health systems published with support from The Robert Wood Johnson Foundation. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/ licenses/by/4.0/.Rob Waters (robwaters2@gmail.com) is an independent journalist in Oakland, California, who writes about health and science and contributes frequently to Kaiser Health News and STAT, among other publications. NOTES 1 Ranapurwala SI, Shanahan ME, Alexandridis AA, Proescholdbell SK, Naumann RB, Edwards D Jr, et al. Opioid overdose mortality among former North Carolina in- mates: 2000–2015. Am J Public Health. 2018;108(9):1207–13. 2 Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, et al. Release from prison—a high risk of death for former inmates. N Engl J Med. 2007;356(2):157–65. 3 Waters R. Interrupting violence in Durham, North Carolina. Health Affairs Blog [blog on the Inter- net]. 2019 Oct 7 [cited 2019 Oct 7]. Available from: https://www .healthaffairs.org/do/10.1377/ hblog20190821.440449/full/ 4 Wang EA, Hong CS, Shavit S, Sanders R, Kessell E, Kushel MB. Engaging individuals recently re- leased from prison into primary care: a randomized trial. Am J Public Health. 2012;102(9): e22–9. 5 Wang EA, Lin HJ, Aminawung JA, Busch SH, Gallagher C, Maurer K, et al. Propensity-matched study of enhanced primary care on contact with the criminal justice system among individuals recently re- leased from prison to New Haven. BMJ Open. 2019;9(5):e028097. 6 Green TC, Clarke J, Brinkley- Rubinstein L, Marshall BDL, Alexander-Scott N, Boss R, et al. Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system. JAMA Psychiatry. 2018;75(4): 405–7. October 2019 38:10 Health Affairs 1621 Local schools face measles threat, even with high vaccination rates - The Daily Tar Heel https://www.dailytarheel.com/article/2019/09/school-vaccines-0917[9/18/2019 1:32:16 PM] Privacy - Terms ×  Buy Photos 9/16/2019, 10:43PM Local schools face measles threat, even with high vaccination rates BY ELIZABETH HOLMES Centers for Disease Control and Prevention released a report last month confirming over 1,200 individual cases of measles in 31 different states since the beginning of the year, the highest number of cases reported in the U.S. since 1992. Although North Carolina is not currently among the long list of states affected by the measles outbreaks, a growing amount of unvaccinated children may increase the threat of contraction in schools across the country. The CDC reported that the majority of cases were found in communities that had lower vaccination rates. Tracy Sanders, nurse coordinator for Chapel Hill-Carrboro City Schools, said despite the district’s history of high vaccination rates, health officials are monitoring measles closely to prevent outbreaks and potential quarantines of affected students. “If measles were to come through, measles is much more contagious than pertussis (whooping cough) and Local schools face measles threat, even with high vaccination rates - The Daily Tar Heel https://www.dailytarheel.com/article/2019/09/school-vaccines-0917[9/18/2019 1:32:16 PM] is much more easily spread,” Sanders said. Last spring, Sanders said, school nurses were required to contact all students who had not received two doses of the measles, mumps and rubella vaccine, the state-mandated vaccine requirement to prevent measles, to inform their parents of the possible threat. The DTH reported earlier this year that in 2017, 92.2 percent of children aged 19-25 months had received their first MMR vaccine, down one percent from 2016. EDITORS PICKS UNC Health Care Systemintroduces new safetymeasures for platelettransfusions Chapel Hill pop-up gallerycelebrates the freedom toread 'Simplicity is freedom':Grammy Award-winningband Tinariwen to headlineat Cat's Cradle Mike DeFranco of the Orange County Health Department said the department also hosted a “measles symposium” to raise awareness of the required measles vaccine and how to address the disease, should it spread to North Carolina. The OCHD is responsible for administering guidelines to both Orange County Schools and Chapel Hill-Carrboro City Schools concerning outbreaks and preventative care on a case-by-case basis. “We reached out to a lot of community partners, some schools, just to say, ‘Hey, let’s have this conversation.’ We haven’t had a case in North Carolina or South Carolina, but in adjacent states, we have,” DeFranco said. Vaccination requirements and exemptions According to North Carolina General Statute 130A-152, every child in the state is required to be immunized against several different illnesses and diseases, including measles and whooping cough, upon entering kindergarten and the seventh grade. Students are given a 30-day grace period from their first day of enrollment to provide documentation proving they have been vaccinated or are exempt. Should the documentation not be provided, they are not permitted to go to school. There are only two ways in which a child may be exempt from such policies: by a licensed physician’s request, or by a statement of “bona fide religious belief.” According to General Statute 130A-156, if a Local schools face measles threat, even with high vaccination rates - The Daily Tar Heel https://www.dailytarheel.com/article/2019/09/school-vaccines-0917[9/18/2019 1:32:16 PM] physician licensed by the state of North Carolina deems a required immunization detrimental to a person’s health (i.e. allergic reaction), they have the authority to advise against vaccination. A statement of “bona fide religious belief” against immunization, however, does not need to be notarized nor signed by a religious leader or attorney. A parent, guardian or person in loco parentis of a child may write a document expressing why vaccination requirements conflict with their religious belief. Although personal or philosophical beliefs against vaccinations do not qualify as legal exemptions, there is no formal process of verifying whether a religious statement is truly applicable to a student. “It can’t really be checked,” said Penny Rosser, a nurse for Orange County Schools. “We just have to trust the parents.” Growing religious exemptions The North Carolina Department of Health and Human Services reported that 1.2 percent of children entering kindergarten for the 2017-2018 school year were exempted from state-mandated vaccinations for religious reasons, a 0.1 percent increase from the previous year. Western counties hold the highest percentage of unvaccinated students in the state, with Buncombe County — where Asheville is located — holding the highest percentage of unvaccinated students – about 5.7 percent of the 2,542 kindergartners of Buncombe County exempt from vaccines through religious exemptions. The state’s metropolitan hubs also saw an increase in religious exemptions in the past year – news station Fox 46 Charlotte reported that Mecklenburg County saw a 2.5 percent increase in non- vaccinated kindergartners and a "sharp" increase in non-vaccinations in Wake County. Rosser said that although parents do have a right to a religious exemption, she urges them to contact their health provider to make an informed decision. “Prevention is the name of the game,” Rosser said. “Talk to your doctor and ask for valid research on vaccines and potential complications.” The measles vaccine is not a fool-proof form of prevention, but Sanders said immunization guards against contraction and high-risk symptoms. “Vaccines are not 100 percent effective," Sanders said. "It’s not necessarily that people are not getting vaccinated and therefore, we’re getting all of these cases coming in. It’s just that if they get it, their symptoms will be much worse.” Sanders said although it’s too early in the 2019-2020 school year to know current immunization rates, Chapel Hill-Carrboro City Schools hope to have 100 percent compliance of all students by the 30th day of school. “The benefits far outweigh the risk,” Sanders said. “Vaccinations are the number one defense against many communicable diseases that can be deadly.” Local schools face measles threat, even with high vaccination rates - The Daily Tar Heel https://www.dailytarheel.com/article/2019/09/school-vaccines-0917[9/18/2019 1:32:16 PM] For parents on the fence about vaccinating their child, DeFranco said it’s important to investigate the research behind vaccines and their effects. “Clean water and vaccines have really, really helped push forward human longevity and I think there’s something to be said about that.” @holmesej city@dailytarheel.com Sign up for the OC Report and get all the Chapel Hill, Carrboro, Hillsborough news delivered to your inbox every week!  First Name Last Name Email* The OC Report/Orange County News Next up in A community persists through decades of environmental injustice: the story of Rogers Road. Why an Orange County resident is appealing the county's flag ordinance Protesters rallied in Pittsboro after confederate statue removal decision CITY & COUNTY Orange County Health Department says getting your flu shot helps protect the community – Carolina Connection https://carolinaconnection.org/2019/10/12/orange-county-health-department-says-getting-your-flu-shot-helps-protect-the-community/[10/14/2019 10:54:40 AM] NEWS FEATURES SPORTS ENTIRE PROGRAMS CAROLINACAST ABOUT OUR ALUMNI CONTACT Orange County Health Department says getting your flu shot helps protect the community October 12, 2019 By Britney Nguyen Tweets by @UNCConnection 00:00 Download Orange County Health Department says getting your flu shot helps protect the community – Carolina Connection https://carolinaconnection.org/2019/10/12/orange-county-health-department-says-getting-your-flu-shot-helps-protect-the-community/[10/14/2019 10:54:40 AM] Rite Aid promoted the flu shot on their band aids in 2015. (Whoisjohngalt / Wikimedia Commons). Some people choose not to get the flu vaccine during flu season because they do not think it is necessary, but Pam McCall at the Orange County Health Department says it is necessary to protect others in the community who may be more vulnerable to the virus. Britney Nguyen reports. Leave a Reply Your email address will not be published. Comment Name * Email *  BE THE FIRST TO COMMENT