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Future of public health: A balance of service, cost and efficiency
Hutchinson Leader - 11/8/2017
Would a plan to reduce expenses and make public health services more efficient reduce too much local control, or cost smaller partners too much?
That's the question members of the Meeker-McLeod-Sibley Community Health Board will spend the next year weighing. The six-member, joint-powers entity decided this past month not to integrate its three individual county public health departments.
It instead terminated a delegation agreement, which leaves one year for public health operations to act as they have been. A subcommittee formed by the board has that time to come up with an updated delegation agreement, or further explore integration.
WHAT IS A DELEGATION AGREEMENT?
In 1976, Minnesota lawmakers said health departments have to serve at least 30,000 people. In urban counties, that many were already served, but rural counties were forced to form partnerships. Meeker, McLeod and Sibley counties partnered in 1980.
To match state requirements, a community health director position was created.
"It was really formed on paper," said Allie Elbert, who holds that position today.
The state will only recognize a Community Health Board, such as the one formed by the joint-powers agreement, but not individual county entities. As a result, reports from all three counties are combined, and state money is funneled from the top down.
"(The director receives) the money, and divvies it out," Elbert said.
In doing so, the director instructs the head of public health staff of each separate county, but each county's staff stay within their county, replicating services required in each.
"The reason it works so well is we get along as a management team," Elbert said. "It's a collective leadership approach. I don't make a decision without them saying 'yes.'"
WHAT IS INTEGRATION?
Integration would merge the three individual county public health departments into a single entity.
Elbert said the conversation started in 2015 when the McLeod County Public Health director was retiring, and discussions started around sharing a director between Meeker and McLeod County.
"When we had that discussion we realized maybe we should talk about full integration," Elbert said.
She believes doing so would bring savings to the counties. For example, she said, the cost of pursuing grant dollars in each county represented money spent unnecessarily.
"Each county was overspending a minimum of $20,000 each year," Elbert said.
The problem was addressed in part by hiring one person to do grant work for all three counties, but merging the departments would make the process more efficient and take fewer hours.
"We overspend on most of our grants," Elbert said.
She also believes integration will make more efficient use of taxpayer money, which comes through state funding.
She said that in Sibley County, nurses can't do home visits because the county lacks the staff. In McLeod County, there is a waiting list.
"Nurses are wearing so many hats," Elbert said. "When you are part of so many programs, it is hard to do anything efficiently."
On the other hand, if the counties integrated service, Elbert believes fewer staff would be needed to take on child and teen checkup services. Right now, staff in each county are required to focus on the service because the counties operate separately.
"It could easily be done by one person or one-and-a-half for all three counties," she said.
Each county has to name an immunization nurse as the service operates now.
"(If merged), we could identify one staff to cover all three counties," Elbert said. "When we cover counties, it's monitoring (immunization) rates, assessing storage. It could easily be done by one staff person across all three counties, instead of three wearing a partial hat."
Merging, she said, would make it possible to organize staff so that there aren't too many people doing a job fewer could do. And that, she believes, would make more staff hours available for services that need more attention. It would also allow more specialization.
"We are really looking at creating a core WIC team," Elbert said. "So instead of having all of our nurses trained, we look at dietitians - we could offer more hours."
She also sees future savings in a merged department, so when staff retire, not all would need to be rehired.
When the vote came up to integrate public health, the two delegates from the Sibley County Board voted against, the two from the Meeker County Board voted in favor, McLeod County Commissioner Ron Shimanski voted "yes," and McLeod County Board Chair Joe Nagel voted "no."
"I voted against it because I feel at this point we would lose local control," Nagel said.
He said he believes the delegation agreement has added efficiencies over time, and has room to bring more.
"Some of the staff does get shared, like a McLeod dietitian can at times spend time in Meeker County," he said. "I believe we still have the ability to increase our efficiency."
Nagel said time working with joint-powers boards has made him hesitant to quickly agree to giving up local control as an elected official.
"I've seen what giving up local control can do," he said. "I've got to be certain everything is dialed in before I go along with it. I'm not saying long term it isn't the right move, but today I don't think it is."
He said that Community Health Service, as its own entity, could have levy control.
"That's something our county board has a consensus, not a true vote, but a concern about," Nagel said. "Typically those levies only happen in the time of a public health emergency."
Sibley County Board Member Bill Pinske said one hurdle for his county when it comes to integration started a few years ago. Sibley County has partnered its public health, and health and human services.
"We've already integrated part of our services," he said. "In our case, those departments are literally side by side, you go to the same window."
He said board members are also concerned about the cost to Sibley County if it were to integrate public health services with Meeker and McLeod counties, both of which have larger populations. As a smaller county, he said, it's possible integration could lead to more expenses if employees need to be paid more.
"If you merged, the schedule goes to the highest paying (county)," Pinske said. "No one is going to take the pay cut, and unfortunately, Sibley County has less than 15,000 people ? it's tough when small counties get hit with much more."
He said he understands it's possible integration could save money by improving efficiency, but he wants to see specific numbers to weigh.
Nagel said he was indifferent as to whether employees are county or CHS employees, but recognizes there is a financial concern.
"You lose local control. Where do benefits go, where do wages go? At the end of the year, the bill is still there," Nagel said.
He acknowledged that integration has worked in other counties around the state.
"I've been negative about it, but I know they work," he said. "I plan to visit with those people."