Transformation 2.0: modernizing public health

Rep. Greenlick to introduce bill to begin decade-long upgrade to Oregon’s public health system. Cash-starved rural counties following different paths to fulfilling those services.

As more and more counties across Oregon contemplate relinquishing their public health responsibilities either to the state or local coordinated care organizations, Rep. Mitch Greenlick plans to introduce a bill next month to begin a decade-long process to modernize the state’s public health system.

The bill, co-sponsored by Sen. Laurie Monnes Anderson and others, will ask for $500,000 for the Oregon Health Authority to devise a 10-year plan for each county to improve its services “so that every Oregonian has access to modern public health,” Greenlick said.

The legislation is based on findings by a 15-member task force, which included Greenlick, to study the regionalization and consolidation of public health services. The task force concluded last September that the state needs new laws to establish “foundational capabilities” as the minimum requirements for public health, and it asked the Oregon Health Authority to develop “a timeline, detailed implementation plan and budget for implementation by wave of the foundational capabilities and programs throughout the state.”

The report defined those “foundational capabilities” as assessment and epidemiology, emergency preparedness and response, communications, policy and planning, leadership and organizational competencies, health equity and cultural responsiveness, and community partnership development.

“We’re in the middle of transformation on the medical care side. We need an equivalent transformation on the public health side,” Greenlick said.

A big problem is funding. Many rural counties have long depended on timber sales revenue, and as that has largely declined these local governments are running out of money to finance a public health department. Nationwide, Oregon ranks 46th in per capita funding for public health – with $13.37 allocated per person, compared to a national median of $27.40.

“Many counties in southern and eastern Oregon are going to be broke,” Greenlick said. “The county board or the county judge is the public health department, and when they can’t figure out how to have law enforcement or a jail, they’re not really worried about public health.”

Sen. Jeff Kruse, who represents Curry County and parts of Coos, Douglas and Josephine counties in the southwest corner of the state, agrees that elected officials see public safety as their first priority.

That has led to discussions in Douglas County about turning over public health either to the state or the local coordinated care organization. The Lund Report covered the story last month.

In Josephine County, Diane Hoover, the public health director, is close to ironing out a unique partnership with the local coordinated care organization, AllCare, for it to provide one nurse practitioner and a handful of nurses at the public health department in Grants Pass, for preventative services like family planning, immunizations, and testing and treatment for sexually transmitted diseases.

Hoover is currently getting by with a staff of one nursing supervisor, one home visiting nurse, and one contract nurse performing immunizations to serve a county of 85,000 people.

“Now, we are really struggling with providing care the way we want to provide it,” she said. Her department can only afford to stay open four days a week.

The partnership “is going to open up our capacity for the underserved in Josephine County in a huge way,” Hoover said. “Previously, I had a nurse practitioner one day a week; now we’ll serve them four days a week. All those new people with OHP having trouble accessing services will have a new place to go.”

The new staff will not act any differently under the partnership. Patients will check in at the front counter with a county employee, like they always do, before seeing a provider, who will be paid by AllCare but work under the directives of the Josephine County medical director.

“My contract with OHA keeps me in charge of quality. I can’t delegate quality,” Hoover said.

As for Douglas County, officially it is scheduled to relinquish its public health authority and stop operating most public health programs on July 1, according to the Oregon Health Authority's public health division, which has developed a plan to protect the health of county residents. On its web site the agency states, “This issue is unprecedented, so the public health department (PHD) will be completely transparent as we navigate how public health services will be provided in Douglas County.”

For now, Kruse said, the county is still in charge. “They’re looking at whether it’s a straight transfer to the CCO, or if they should hand it back to the state,” he said, adding that two years ago the county asked the Oregon Health Authority for guidance, but never received a reply.

“We asked, ‘If we can’t afford to do this anymore, how’s it going to work?’ And what we’ve received from the state is nothing. We don’t want to just walk away, we want to have a game plan for a transition. What’s the best way to go about it? And the response has been, ‘We’ll get back to you.’ I’m very dissatisfied with the performance of the Health Authority.”

If coordinated care organizations do begin to fulfill public health services, they will likely need to expand their panels of providers, Kruse said. “Most panel of providers don’t necessarily include all disciplines. Those are the sort of things we should be looking at.”

And, Greenlick points out, there are certain duties that no coordinated care organization can cover for local governments.

“If Curry County gives up public health, there won’t be restaurant inspections, there won’t be clean water,” Greenlick said. “There will probably be epidemic tracking because that’s something the state could do relatively easily. Right now, the only way is to find a more efficient way to deliver these services.”

Cooperation among counties is one possibility, But even that isn’t always easy. Wasco County is considering pulling out of the North Central Public Health district that it formed with Sherman and Gilliam counties. At a public meeting last November, county commissioner Steve Kramer cited rising costs as the reason for the switch. Wasco County has yet to request assistance from the state’s public health division, a spokesman for the Oregon Health Authority said.

Christopher can be reached at [email protected]

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