Introduction to the New L.A. County Department of Public Health UCLA Healthcare Collaborative - June 7, 2007 Jonathan E. Fielding, M.D., M.P.H., M.B.A.

Introduction to the New L.A. County Department of Public Health

UCLA Healthcare Collaborative - June 7, 2007

Jonathan E. Fielding, M.D., M.P.H., M.B.ADirector of Public Health and Health Officer

L.A. County Department of Public Health

Los Angeles County – General Information

• 4,300 square miles• 89 incorporated cities and 2 islands• 9.9 million residents (more than 42 States)• 46% Latino, 32% White, 13% Asian/Pacific

Islander, 10% African American, 0.3% American Indian

• Over 100 different languages spoken by significant size populations

Background• Public Health <20% of Dept Health Services budget• Public health with new major responsibilities related to

emergency preparedness• Major public health concerns

– New and old diseases: SARS, monkeypox– Possible terrorism: smallpox, plague, dirty bombs, chemicals,

agro-terrorism etc.

• Recognition of chronic diseases as major health burden for county

• DHS with preoccupying issues: Medi-Cal waiver, High Desert, Rancho Los Amigos, new Med Center, MLK

Los Angeles CountyPublic Health Function 2005

• Vision– Healthy People in Healthy Communities

• Mission: – To protect health, prevent disease, and promote

health and well-being • Public Health stats:

– Annual budget of over $650 million– 4,000 employees– 39 programs of great diversity– Many special high visibility projects, some very

controversial

Major Objectives of DPH• Protect the public against the harmful health

effects of natural or man-made disasters.• Protect the public’s health by minimizing the

impact of serious communicable diseases as well as foodborne and environment-related illness.

• Help all individuals, families, and communities prevent chronic diseases and injuries.

• Help communities reduce ethnic and racial health disparities.

DPH Mandates and Obligations• Core Public Heath Mandates

– County is required to have a Health Officer and is responsible for taking measures necessary to preserve and protect the public health. Exception: Long Beach, Pasadena, and Vernon.

– Health Officer required to implement local ordinances and state laws, and orders from State Health Officer.

– Examples of basic mandated functions: vital statistics, communicable disease control, environmental health, laboratory, maternal and child health, nutrition services, chronic disease services, and public health nursing.

• Financial/Administrative/Contractual Mandates– CMS, CHDP, Alcohol and Drug, AIDS Programs, Health

Facilities • Board Policy/Community Need Obligations

– Women’s Health, HALT, HIV treatment for non-indigent.

Key Public Health Activities• Health Protection

– Bioterrorism Preparedness and Response– Assuring conditions to protect health (e.g., apartment and food facility

inspections, environmental health programs)– Licensure of hospitals/long term care facilities

• Disease and Injury Prevention and Control – HIV/AIDS Prevention– Acute Communicable Disease Control – TB and STD Control Programs – Injury and Violence Prevention– Toxics Epidemiology

• Health Promotion– Maternal, Adolescent & Child Health– Alcohol and Drug Programs– Chronic Disease Control

• Physical Activity & Nutrition Programs & Obesity Work Group• Tobacco Control

• Policy Development• Monitoring Health Risks and Surveillance of Diseases

3.6% 4.8%11.0%

52.3%

3.7%

7.5%

2.6% 1.6%0.2%

2.8%8.3% 0.4%

0.0%

1.1%

0%

10%

20%

30%

40%

50%

60%

CommunicableDisease Control &Prevention FTE =

526

Community HealthServices FTE =

602

EmergencyPlanning

FTE = 207

Health ProtectionFTE = 891

HealthAssessment

FTE = 257

SpecialPrograms

FTE = 1678

Administration FTE = 208

NCC

Revenue/IFT

Funding Source Comparison As Part of Total AppropriationFiscal Year 2006-07 Board Adopted Budget

Public/Personal Health’s Role: Prevention v. Treatment

Public Health• Inspects wholesale and retail

food establishments and maintains Food Facility Rating system

• Screening, health education, and case management of childhood lead poisoning and education to avoid other toxins

• Community level actions to reduce tobacco use

Personal Health• Treats patients for food

poisoning

• Treats children who have been exposed to lead and other toxins

• Treats patients with tobacco-related health problems

Public Health Clinical Services

• Unlike Personal Health, Public Health provides very few direct clinical services.

• Categorical clinics: TB, STD, and Immunizations

• Represented 6.5% of Public Health’s budget in

FY 2004-05

Rationale for Creating New DPH• The CAO report (2006) cited five reasons for

creating a separate Public Health department:– Different mission than rest of Dept of Health

Services– New health threats

• Growing need to promote emergency preparedness

• Now DPH is a first response agency– Budget impact – Size and complexity– Eliminates a layer of management

Arguments Against Separation

• Departments share a mission of improving the health of Los Angeles County residents– Many areas of overlap, as evidenced by the MOU– May hinder the integration of prevention activities into

personal health care– Dilution of communication and advocacy efforts in

areas of overlapping interest

• Fiscal concerns– Skepticism that new department could be created at

no additional cost to the County

Arguments Against (cont)• Client services concerns

– Could result in fragmented care for patients who would have to coordinate services between two departments

– No clear value for the constituents of Los Angeles County

• Bureaucratic concerns– Creates an extra layer of bureaucracy– Would further stretch an already under-resourced administrative

infrastructure

• Concern that separation of Mental Health resulted in poor communication and relations between departments

Timeline for DPH-DHS Separation• April 19, 2005 - Supervisor Knabe’s motion to consider

separating Public Health from DHS to allow for “better and more efficient service”

• June 9, 2005 – CAO report on separation sent to Board• June 28, 2005 - Board approved separation in concept • December 13, 2005 - Implementation plan submitted to Board

– Board of Supervisors delayed the vote pending development of an MOU between departments

• February 28, 2006 - MOU presented to Board; – Board deferred a decision pending the exploration of alternatives

to make Public Health semi-autonomous within DHS• May 30, 2006 - Board unanimously approved creating a

separate department• July 6, 2006 - New Department of Public Health is established

Monitoring Department Separation• Separation implemented July 6, 2006• No changes to services offered by either DHS or

DPH• Need to ensure integration of services

– MOU to address areas of shared responsibility or provision of services by one department to the other

– Biweekly meetings between departments to assure smooth transition and continued collaboration

MOU with Health Services

• Oral health• Radiology• Pharmacy• Laboratory• Preventive Services• Tuberculosis• STD• Women’s Health

• HIV/AIDS• Immunizations• Substance Abuse• Homeless services• Family Planning• California Children’s

Services• Administrative areas

Addresses areas of shared responsibility or interdependency, including:

Benefits of New Department Status

• Raises the visibility of public health issues in the County– No longer shadowed by issues related to County’s hospital

system– Issues such as emergency preparedness get more attention– Increased understanding of key governmental public health

functions and role in health protection

• Gives DPH greater control of its own administrative priorities– Budget– Human resources– IT

• Easier for DPH to work with supporting County agencies

Benefits of New Department Status

• Allows DPH to provide broader perspective on issues such as health care system reform

• DPH now a stakeholder with its own voice in various forums– Emergency Management Council– Transition process from CAO to CEO

• Easier for DPH to forge close partnerships with other agencies

• Easier to recruit senior managers

Challenges Associated with Separate Department

• Increased accountability• Increased scrutiny • Separation is sometimes incorrectly cited as

reason for problems– e.g. longstanding insufficient administrative staffing

• More difficult to receive county funding for new problems/ initiatives/ projects

• Administrative support units still understaffed– Were understaffed before split, now both DPH and

DHS administrative support units are still understaffed

General Challenges Facing DPH(not related to the separation)

• Labor Force– Critical hard-to-fill vacancies

• Environmental Health, Health Facilities, Laboratory• Top level management vacancies

– Classification Needs• Many items too generic or DHS-specific• Salary ranges not competitive (e.g., Nutritionist, Health

Educators)– Financing of Unavoidable Cost Increases

• Board-Approved COLAs• Other Unavoidable Cost Increases

(e.g., Nursing Compensation Plan, Pension Bonds, etc…)

General Challenges Facing DPH(not related to the separation)

• Information Technology– Adequate staffing for a variety of roles and appropriate

classifications– Information security– Disaster recovery– Internet: complexity and design

• Space Needs– DPH leases most if its space, so limited flexibility in staff

placement– No available space at DHS facilities for DPH– Administration, Veterinary PH Program, IT, etc. have no

permanent home yet

LA County Public Health – Healthy People Build Healthy Communities

• For more information, please visit www.lapublichealth.org