NOTICE OF PUBLIC HEARING REGARDING PROPOSED CHANGES IN HEALTH CARE SERVICES PROVIDED BY FRESNO COUNTY

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1 NOTICE IS HEREBY GIVEN that a public hearing will commence on Tuesday, September 23, 2008, at 9:00 a.m. (subject to continuance on that date of the hearing) at the Fresno County Board of Supervisors Chambers, 2281 Tulare Street, Third Floor, Fresno, CA 93721, to consider proposed changes of the Fresno County Department of Public Health health care services, effective November 14, The proposed changes are due to an identified shortfall in revenue for Fiscal Year in the amount of $2,063,296. To mitigate this deficit, one or more of the following service areas will be considered for elimination or reduction by the Board of Supervisors on September 23, 2008: 1. Department of Public Health Public Health Nursing Field Services Expected Savings: $1,244,304 annually Proposed Change: Eliminate the Public Health Nursing Field Services unit. Public Health Nursing Field Services provides case management and health supervision for medically fragile children referred primarily by hospital neonatal intensive care units and Child Protective Services (CPS). These nurses and support staff also provide field response to public health threats, such as meningitis and E. coli outbreaks that have occurred in recent years. 8.0 Public Health Nurse, 1.0 Supervising Public Health Nurse, 1.0 Supervising Office Assistant, 3.0 Office Assistant positions Patients Affected: The Public Health Field Services unit serves approximately 1,200 clients annually. Fifty percent of clients receiving services were new mothers with medically fragile infants that were discharged from neonatal intensive care units and special care nurseries. The program will no longer provide case management and health supervision services for children at risk of placement in Foster Care. The Department will continue to receive referrals for medically fragile infants and will accept those clients that meet criteria for other Department of Public Health Nursing case management programs. Field Unit Public Health Nurses will no longer be available for immediate redirection to assist in investigation and mitigation of public health threats. 2. Department of Public Health Specialty Clinic Expected Savings: $443,849 annually Proposed Change: Eliminate the Department of Public Health Specialty Clinic. The Specialty Clinic provides services to prevent sexually transmitted diseases through diagnosis, treatment, medical follow up, contact investigation and partner notification. Other Services include: Pap smear testing, colposcopy, and follow up referrals for abnormal cervical findings. 1.0 Licensed Vocational Nurse, 1.0 Nurse Practitioner, 1.0 Medical Assistant, 3.0 Office Assistant positions Patients Affected: The Specialty Clinic provides services to approximately 5,500 patients per year. Closure of this clinic will require patients to receive care from private providers. Clients will continue to receive Health education and outreach services for sexually transmitted diseases and staff will attempt To Whom It May Concern: refer patients to private physicians for those seeking care at the Department of Public Health.

2 3. Department of Public Health Clinical Laboratory Services Expected Savings: $200,273 annually Proposed Change: Eliminate clinical testing involving surveillance and diagnosis of communicable diseases by the Public Health Laboratory. The information generated by the testing is used for the purpose of monitoring infectious disease outbreaks and used for the purpose of planning containment strategies. 1.0 Clinical Laboratory Technologist Patients Affected: Approximately 12,100 patients are served annually by the Public Health Laboratory s clinical testing. Clinical testing is performed for services such as communicable disease control, family planning services, Child Health and Disability Prevention program (CHDP), public health nursing, jail medical services, mental health, as well as, hospitals and clinics locally and regionally. 4. Department of Public Health Public Health Nursing Case Management for Patients with Active Tuberculosis Expected Savings: $662,397 annually Proposed Change: Eliminate tuberculosis public health nurse case management services in the Department of Public Health Chest Clinic. This program ensures that patients with tuberculosis complete recommended evaluation and treatment. Staff conduct health assessments, collect specimens, deliver medication and educate patients. Staff also identifies patients who have reactions to their medication or who are not compliant with their treatment. The program provides mandatory reporting of verified cases of tuberculosis to the State. 4.0 Public Health Nurse, 1.0 Office Assistant positions Patients Affected: active tuberculosis cases and suspect cases will not receive case management services. The outcome may result in many patients diagnosed with active tuberculosis receiving inadequate services resulting in an increase incidence of failed treatment, potential for multi drug resistant tuberculosis and increasing the spread of tuberculosis in Fresno County. In addition, mandated reporting requirement will not be provided to the State. 5. Department of Public Health Directly Observed Therapy for Tuberculosis Patients Expected Savings: $349,498 annually Proposed Change: Eliminate the Directly Observed Therapy program. This program ensures that patients with tuberculosis receive prescribed treatment by directly observing the ingestion of medication. Directly Observed Therapy (DOT) workers watch as patients ingest the correct medication at the correct dose at the correct time. Workers observe therapy either in the clinic, in the home or in the patient s workplace. 5.0 Medical Assistant,.8 FTE Office Assistant positions

3 Patients Affected: Directly Observed Therapy services are currently being provided to 58 patients diagnosed with active tuberculosis disease or infected with multi drug resistant tuberculosis. 6. Department of Public Health Evaluation, Diagnosis and Treatment of Tuberculosis Patients Expected Savings: $257,359 annually Proposed Change: Eliminate tuberculosis diagnosis and treatment. This specialty clinic provides health care to patients with active tuberculosis and patients exposed to active tuberculosis. Physicians and staff in this clinic provide evaluation, diagnosis and treatment to nearly all patients in Fresno County that are diagnosed with active tuberculosis and the people they exposed. The County Tuberculosis Controller and Deputy Health Officer provides consultation for tuberculosis management and treatment to private medical physicians in the community. 1.0 Public Health Physician, 0.5 Office Assistant positions Patients Affected: Elimination of this program will eliminate tuberculosis treatment for 60 patients. 7. Department of Public Health Nursing Case Management for Patients Exposed to Active Tuberculosis and Patients with Latent Tuberculosis Infection Expected Savings: $143,732 annually Proposed Change: Eliminate nursing case management for patients exposed to active tuberculosis and treatment for patients with latent tuberculosis infection. This program ensures that patients exposed to active tuberculosis are tested for tuberculosis and that patients diagnosed with latent infection are treated appropriately. Nursing staff conduct health assessments, collect specimens, deliver medication and educate patients. Staff also identify patients who have reactions to their medication or who are not compliant with their treatment. The program provides mandatory aggregate reporting for tuberculosis program evaluation..8 Staff Nurse, 0.5 Office Assistant positions Patients Affected: The program is currently providing services for over 100 patients diagnosed with latent tuberculosis infection per month. Deleting this program would result in discontinuing the treatment of patients diagnosed with latent tuberculosis infection. 8. Department of Public Health Social Worker Case Management for Patients with Tuberculosis Expected Savings: $104,328 annually Proposed Change: Eliminate Social Worker case management of patients with tuberculosis. This service provides case management for patients who may fail to comply with tuberculosis treatment due to social, economic and cultural challenges. Social Work staff interview and assess patients and together with the multidisciplinary team of Nurses and Doctors develop care plans. Staff educate and counsel patients in the clinic and in the home. Staff also determines patient eligibility and facilitates delivery of financial, housing, nutrition and medication benefits to ensure compliance with tuberculosis treatment. 1.0 Social Worker

4 Patients Affected: Eliminating this program would result in tuberculosis patients being denied Social Worker assessments for social, mental health and physical needs and providing essential services necessary for successful treatment outcomes. This programs has a current caseload of 28 persons. The impact of deleting this essential service provided by the SW would increase the incidence of noncompliance, increase the incidence of multi drug resistant tuberculosis due to sporadic treatment and increase the number of tuberculosis cases requiring Health Officer Orders, quarantine and detention which would be very costly. 9. Department of Public Health Targeted High Risk Screening for Tuberculosis in Homeless Shelter Residents Expected Savings: $41,040 annually Proposed Change: Eliminate tuberculosis screening in homeless shelters. This program reduces the incidence of tuberculosis exposure among homeless shelter residents, employees and volunteers. Residents of homeless shelters are at increased risk for active tuberculosis and are more likely to transmit tuberculosis. Program staff screen each resident prior to entry into a homeless shelter and then every 6 months. Further medical evaluation and treatment is provided when indicated. The program has decreased the likelihood of a tuberculosis outbreak in Fresno County.2 Staff Nurse, 0.2 Office Assistant positions Patients Affected: Deleting this program will result in approximately 120 homeless patients not receiving screening with skin testing, chest x rays or sputum collection per month. 10. Department of Public Health Chlamydia Screening and Prevention Program Expected Savings: $182,376 annually Proposed Change: Eliminate the Chlamydia Screening and Prevention program. This program is Chlamydia screening and treatment program for high risk adolescents in the juvenile justice facility. A minimum of 55% of female bookings are screened during the intake process. Currently 13 16% test positive for Chlamydia. All positive results are treated immediately and those leaving the facility prior to treatment are given the proper referral for treatment follow up..09 Staff Nurse,.03 Office Assistant,.05 Epidemiologist,.03 Clinical Laboratory Technologist positions Patients Affected: Approximately 600 high risk adolescents are screened annually at the Juvenile Justice Campus. 11. Department of Public Health Family Immunization Clinic Expected Savings: $1,271,341 annually Proposed Change: Eliminate the Family Immunization Clinic. This clinic immunizes primarily lowincome children to prevent the occurrence and transmission of vaccine preventable diseases such as hepatitis, polio, whooping cough, meningitis, measles, mumps, rubella, chicken pox and influenza. Staff also provided physical exams, screening tests and immunizations to 150 children sheltered at

5 the Craycroft Youth Center last year. Staff also linked un insured children and their families to Child Health and Disability Prevention and Medi Cal services..05 Public Health Physician,.97 Supervising Public Health Nurse, 2.73 Licensed Vocational Nurse, 2.0 Health Aide,.47 Supervising Office Assistant, 4.86 Office Assistant, 1.75 Public Health Nurse, 2.0 Health Education Specialist, 1.0 Health Education Assistant, 1.0 Health Educator positions Patients Affected: Clinic staff provides immunization services to approximately 6,500 children annually. 12. Department of Public Health Flu Clinic Expected Savings: $11,663 annually Proposed Change: Eliminate the Flu Clinic program. The program reduces the incidence of pneumonia and death due to influenza among seniors and high risk children. Services are provided at the Department of Public Health and at nearly 30 rural and poor urban neighborhood sites Supervising Public Health Nurse,.04 Public Health Nurse,.03 Licensed Vocational Nurse,.03 Office Assistant,.007 Supervising Office Assistant positions. Patients Affected: Approximately, 8,000 seniors and high risk children are immunized annually in this program. 13. Department of Public Health Travel Clinic Expected Savings: $59,710 annually Proposed Change: Eliminate the Travel Clinic program. This clinic protects Fresno County residents from contracting diseases still prevalent in foreign countries and introducing these diseases into this county upon their return. Clinic staff provide immunizations once a week to children and adults in preparation for foreign `travel. Individuals receive information, education, and anticipatory guidance regarding required and recommended vaccinations for their destination..01 Supervising Public Health Nurse,.21 Public Health Nurse,.24 Licensed Vocational Nurse,.12 Supervising Office Assistant,.11 Office Assistant positions Patients Affected: Elimination of the Travel Clinic would eliminate travel vaccinations for approximately 1,200 individuals. 14. Department of Public Health Early Intervention Program Expected Savings: $399,470 annually Proposed Change: Eliminate the Early Intervention Program (EIP). The Early Intervention Program (EIP) program provides residents who are living with HIV infection the knowledge, skills, and support to change or adapt behaviors known to be associated with increased risk for HIV infection, as well as other types of communicable diseases. EIP services include the provision of health education, risk reduction, medical services, counseling, assessment and case management to individuals who

6 tested positive for HIV or have been diagnosed with AIDS, and bridge services. Bridge services reduce the occurrence of HIV transmission by linking newly HIV infected individuals to comprehensive community HIV treatment services..55 Health Education Specialist, 1.7 Communicable Disease Specialist,.82 Senior Licensed Mental Health Clinician, 1.0 Social Worker positions. Patients Affected: Services would be eliminated for 75 clients that are currently case managed in EIP and another 55 clients receive services in the Bridge component of EIP. Elimination of this program may lead to client s not receiving HIV medical care due to lack of third payer source. Clients will also be at greater risk for transmitting HIV due to lack of access to health education, psychosocial, bridge services, and medical care. 15. Department of Public Health Main 1225 M St North 1265 M St South 2280 Fresno St Reduction of Adult Jail Medical Services Expected Savings: $1,242,012 annually Proposed Change: Reduce medical services provided at the adult detention facilities. This program provides medical screening, emergency medical response, and ongoing care for all inmates within the guidelines of the Title 15, Code of Regulations mandate. Assistant positions 1.0 Head Nurse, 6.0 Staff Nurse, 3 Licensed Vocational Nurse, 1.0 Office Patients Affected: Approximately 42,000 inmates are booked into the Fresno Adult Detention facilities each year. Deletion of positions will reduce the capacity of the Department to provide health services for patients in custody. Priority service calls for inmates in crisis will not be delayed. Reduction in capacity will result in increased wait times for routine follow ups on inmates and patients with low acuity health complaints and medical conditions which may result in some patients being released prior to treatment. 16. Department of Public Health 3333 E. American Ave Reduction of Medical Services Provided at the Juvenile Justice Campus Expected Savings: $856,993 annually Proposed Change: Reduce medical services at the Juvenile Justice Campus to conform to minimum Title 15 standards. Services provided would be limited to sick call (M F), response to emergencies, dispensing of pharmaceuticals for medical treatment, and provision of diabetic/other physical care. 6.0 Staff Nurse, 1.0 Nurse Practitioner positions Patients Affected: Service delays are expected for approximately 2,000 juveniles that are seen monthly at Juvenile Justice Campus Medical program. Priority service calls for patients in crisis will not be delayed. Reduction in capacity will result in service delays for routine follow ups on patients with low acuity health complaints and medical conditions. 17. Department of Public Health

7 500 E. Elkhorn Ave, Caruthers Elimination of On Site Medical Services at the Elkhorn Boot Camp Expected Savings: $137,098 annually Proposed Change: Elimination of on site medical services at Elkhorn Boot Camp. This proposal would eliminate sick call, medication dispensing, and emergency medical response at the Elkhorn Boot Camp. 1.0 Staff Nurse Patients Affected: On site medical services would be eliminated for approximately 400 patients per month that currently receive medical services at the Elkhorn Boot Camp.