By BILL LUNDQUIST
GOLD BEACH A plan to restructure the Curry County Public Health Department was officially adopted this week by Curry County Commissioners Rachelle Schaaf and Lucie La Bont.
Commissioner Marlyn Schafer was home ill. The commissioners adopted the plan Tuesday after hearing a presentation by Dr. Bill Swartz, chairman of the Public Health Department Task Force.
Other task force members included Linda Brown, Barbara Kemp, Diane Pace, Dale Thomas and Public Health Director Barbara Floyd. Schafer is the liaison commissioner to the task force.
Swartz said he was pleased with the final product of the task force. He was also pleased that the Public Health Department will remain under the control of Curry County.
Swartz said he had mixed feelings, however. He said the department would have to trim its work force and the services available to citizens. He said it would have to cut employees who were doing excellent jobs.
Swartz said the task force was formed when the commissioners said there was no longer any money available from the county's general fund to run the Public Health Department.
During the fiscal year ending June 30, the Public Health Department received $148,000 from the general fund.
The absence of that money in the coming fiscal year, said Swartz, amounted to a 20 percent budget cut for the department. As a result, said Swartz, "The recommendations to restructure the Public Health Department represent a major paradigm shift.
"The department is currently patterned to operate primarily as a local government-directed social service.
"The new paradigm recommended by the task force is for operations to be patterned as a not-for-profit health care business."
He said, for example, the department will have to figure out what it costs to give a flu shot, and how many shots it must give per hour to make a profit.
The task force made recommendations for changes in four areas: clinical services, grants/awards/programs, financial management, and administration.
The task force analyzed client activity at the department's offices in Brookings, Gold Beach and Port Orford from July through March.
It found that an average of nearly 12 clients a day received services. Fee-for-service revenues made up about 57 percent of departmental income.
The task force recommended the Brookings clinic be reduced to seeing patients three days a week, the Gold Beach clinic two days a week and the Port Orford clinic one day a week.
It recommended appointment scheduling be adjusted to target 20 clients a day. That will mean the department, like private medical offices, will now overbook appointments to compensate for "no-shows."
"The task force believes it is possible to see the additional number of clients in the time allotted and still provide reasonable quality time for each client," said Swartz.
He said that volume of clients is periodically reached now, suggesting that it can be done on a more regular basis.
Staff hours assigned to provide clinical services will be cut. The change in staff assignments amounts to a loss of two-and-a-half full-time employees.
Each office will have a staffing team, including: a receptionist, a nurse provider, a nurse assistant or second nurse provider, and volunteers.
Steps will be taken to optimize collections. Billing slips will be numbered to match the number of clients.
Receptionists will be trained to facilitate successful third-party payment, or cash payments, for client services.
Swartz said the department receives revenue streams from 19 different federal, state and local agencies, amounting to 43 percent of income.
He said the requirements and reporting mechanisms vary for each grant and award.
Swartz said the overhead and administration costs of complying with those requirements are not currently charged to the grants, awards and programs, meaning they have been subsidized by the county's general fund.
The Finance Department will work with Floyd to develop the reports necessary to maximize deductions for those costs and still comply with agency regulations.
As with clinical services, staff hours for grants, awards and programs will be cut. In all, the department will lose about a third of its staff, saving $234,777 a year.
Some assignments will be handled by a six-tenths-time public health educator. In the future, that position could be filled by a nurse provider.
Currently, said Swartz, the primary fiscal tracking system is the county's monthly revenue and expenditure reports.
The reports use the modified accrual system of accounting mandated by the state for consistent state-wide auditing.
Swartz said the system under-projects revenue in July and August and does not correct for that until September of the following fiscal year.
"In its present form," he said, "this method of fiscal reporting is inadequate for judging financial performance of a health care business, and for making intelligent financial adjustments in a timely manner."
A data tracking system will be introduced to project financial performance and guide adjustments to client scheduling and staff assignments.
It will be displayed in a graphic form designed to be quickly and easily understood by the staff.
The system will count the number of clinic days open at each office. It will count client visits and sort them by type of visit.
It will count the number of staff hours assigned in support of clinic days at each office. It will determine the average dollar reimbursement by visit type.
All the information will be entered into an Excel spreadsheet designed to produce at-a-glance reports.
The reports will show the total number of client visits per month, the average number of client visits per day, and the average number of staff hours per day at each office, compared with established performance targets.
They will show the average reimbursement for each type of office visit. The reports will be reviewed monthly and adjustments will be made.
The Ahlers billing and collection system will be upgraded to begin reporting clinical revenues on an accrual basis, and to guide the efficient collection of accounts receivable.
Swartz said that would require advanced training of the existing staff, and identification of the appropriate person to oversee those activities.
He said, however, that the changes in financial management were designed to be simple.
"What we're suggesting here is Business 101."
"The task force emphasizes that success of this restructuring is highly dependent upon the immediate implementation of the revised client schedule and staffing assignments," said Swartz.
"The department director will have to really roll up her sleeves and put on her thinking cap," he said.
Swartz said the county commissioners and Public Health Advisory Board would also need to be involved.
"Implementing the recommended changes will require substantial staff training, supervision and problem solving from the director," he said.
"Initially, we envision this to be substantial, with hands-on involvement at all three locations.
"Meeting assurances and reporting requirements of all grants and awards will also require attention in reassigning and redirecting, especially in the early stages of change."
Swartz said the director would receive training and advice from the task force at first, and later from the county commissioners and Finance Department.
The task force recommended rewriting the job description for the director to reflect the advanced training needed to upgrade skills in financial management and health care service administration.
Swartz said those services could also be provided by a financial officer, upgraded billing and collection position, or outside consultant, though it would cost more.
"The commissioners should view themselves as a board of directors for a not-for-profit health care business," said Swartz.
He said the business would require their oversight and guidance.
"Short term," he said, "they will need to assure implementation, evaluate performance, and monitor outcomes of all key recommendations.
"Short term, they should immediately direct the Finance Department to design an adjustment to the monthly revenue/expenditure report so it continuously adjusts for the distortion associated with the mandated modified accrual accounting methods.
"Long term, the commissioners will need to work with the Public Health Department and the Finance Department to establish reliable performance indicators."
The task force, director and commissioners will meet at 10:15 a.m. July 8 to assess progress and evaluate performance.
Swartz said the Public Health Advisory Board could help by assisting with public relations, community outreach and broadcasting information about the changes in the department.
"We put a plan on the table," said Swartz. "The task force feels it can work, but nothing has changed at this point."
He said he personally feels it was wrong for the commissioners to withdraw all county financial support for public health and put it all in public safety.
La Bont said public health is public safety, but half of the general fund must go to mandated programs like the sheriff's office and the jail. She said union-negotiated health insurance benefits also take a lot of money.
Swartz said he accepted that fact, and it is included in the budget, but he will be back next year to campaign for more money for public health.
Schaaf had County Accounting Manager Rene Sinclair explain that about $57,000 was contributed from the general fund to the Public Health Department to help with unemployment costs caused by the restructuring.
Pace said most departments receive general fund support that, unlike the unemployment cost, is not mandated.
La Bont said the county is not mandated by the state or federal government to do public health.
Floyd said, "I appreciate the commissioners' willingness to rethink their decision to shut us down. I'm very appreciative of every person on the committee.
"Overall, a very positive thing happened here. The staff is ready to go forward. We're determined to give it our all. We want to move forward and make it work."
She said she would have the new system in budget form, program by program, by the end of the week.