The Joint Commission on Health Care received a staff briefing on November 2 on a draft report examining the structure and financing of local health departments. Staff were charged with cataloging and comparing public health services provided across the state; identifying standards used to evaluate the quality of health departments and determining whether local health departments are meeting those standards; comparing public health structure and financing in Virginia to other states to identify advantages and disadvantages; and recommending any necessary changes to the current system to advance the state’s public health goals. Public comments are due by close of business on Friday, November 18, and may be provided via email to email@example.com or via U.S. Mail at 411 E. Franklin Street, Suite 505, Richmond, VA 23219.
The draft report points out that there are advantages and disadvantages to centralized or decentralized structures of public health administration, but that there should be a standard array of services offered in all health departments, supported by a set of standard organizational skills and capacities, citing the Foundational Public Health Services model as a nationally recognized standard. While Virginia health departments offer most of the services outlined in the national model (including environmental health, maternal, child, and family health, and communicable disease control), state law does not require the remaining elements of the national model — linkage to clinical care or chronic disease and injury prevention — and these services are offered on an ad hoc basis.
Similarly, the draft report indicates that although local health departments demonstrate several of the capabilities outlined in the Foundational Public Health Services model, several areas need improvement, with accountability and performance management, information technology, and workforce development in need of the most attention. Commission staff indicate that there is no system to address overall performance of local health departments; the local government agreement outlining local departments’ responsibilities and funding is not used as an accountability mechanism. Local departments are operating with outdated technology, including paper medical records (although the Virginia Department of Health (VDH) is planning to use American Rescue Plan Act funding to implement electronic health records), and there is no central repository of data collected from local health departments. Workforce recruitment and retention are major challenges, with rates of voluntary resignations increasing over the last decade (led by resignations of public health nurses).
The report discusses local health departments’ community engagement and partnerships, noting that community partnerships appear to be developed on an individual basis but not in a systematic way. The Community Health Assessment process is a tool for such systematic community partnership development, and is recommended to local departments by VDH, but is not required. VACo assisted Commission staff in circulating a survey to counties regarding local governments’ relationships with their local health departments. Local officials who responded to the survey reported varying levels of collaboration between local governments and their local health departments.
In the report’s analysis of local health department funding, Commission staff note that it is difficult to determine the funding levels that would be necessary for local departments to align with the Foundational Public Health Services model, as community needs vary by locality and are not tracked systematically. Federal funds have increasingly comprised a larger share of public health funding, while state General Fund spending has been relatively flat when adjusted for inflation. The cooperative budgets for local health departments (composed of state general funds, local matching dollars, and revenues generated by the provision of services) vary widely on a per-capita basis; the report suggests that this variation may be attributable to differences in localities’ size and ability to provide matching dollars, as well as the needs of communities and the availability of other providers. The report includes a suggestion that fees for restaurant inspections be increased to cover the cost of providing the inspections, possibly through establishing fees that vary by type of establishment (the current permit is $40 per year, regardless of the size of the facility or the follow-up visits that may be required).
Policy options in the report include the following:
- Amend Virginia Code to require local health departments to ensure the availability of clinical services (either by the local department or by other providers) and facilitate access to and linkage with clinical care, and to provide chronic disease and injury prevention.
- Direct VDH to design a state performance management process for each local health department.
- Direct VDH to develop a centralized data system that will allow VDH to access necessary data from all local health departments.
- Provide additional funding to VDH for a loan repayment program for local health department staff, as well as a salary increase for local health department employees.
- Direct VDH to establish regional operations and facilities management positions to assist local departments.
- Direct VDH to require all health districts to participate in the Community Health Assessment process.
- Direct VDH to track cooperative budget funding per capita, compare that funding to the identified needs of each local department, and make adjustments as additional funding is available.
- Direct VDH to update environmental health services regulations to increase inspection fees and adjust fees based on the type of establishment.
- Direct VDH to adopt regulations to implement civil monetary penalties for facilities in violation of environmental health regulations (the report discusses this concept as a way to cover the cost of inspections and follow-up visits and to serve as a disincentive for facilities that are slow to correct violations).
The Commission will consider policy options for all studies conducted by Commission staff this year at its December 7 meeting.
VACo Contact: Katie Boyle