Item B1 FL DEPT OF HEALTH, MONROE COUNTY
State Fiscal year July 1-June 30
FY 2013 FY 2014 FY 2015
BOCC ANNUAL BUDGET ALLOCATION 939,070 939,070 1,165,070 Contract expenditures made in State FY14, received
IMMUNIZATION CONTRACT - 226,000 - reimbursement in State FY15
TOTAL ALLOCATIONS 939,070 1,165,070 1,165,070
Note:Date discrepancies between County FY and State FY
FY 2013 FY 2014 FYTD 2015
BOCC Revenues Received State FY 908,581 915,681 993,583
Immunization contract Rec'd State FY - - 77,358
908,581 915,681 1,070,941
FY 2013 FY 2014 2015 FY 2015 FY 2016
Budgetary Cost Summary Actual Actual FYTD at Full Year Budget
3/27/15 Budget Request Request
Personnel Expenditures 625,793 772,812 583,921 891,376 861,669
Operating Expenditures 235,944 222,597 165,289 117,300 275,118
Capital Outlay Expenditures 48,881 - 156,394 156,394 28,283
Total Expenditures 910,618 995,409 905,604 1,165,070 1,165,070
{note:
Variance Expenditures to Receipts Five
(under/(over)expended) (2,037) (79,728) 165,337 months
remain in
Carred forward approx$4k from FY12 Stnta FY
FY 2013 FY 2014 2015 FY 2015 FY 2016
Expenditures by Department
Actual Actual FYTD at Full Year Budget
3/27/15 Budget Request Request
Community Health Services 243,357 185,114 294,058 361,767 283,220
Immunization Specific Services - 127,137 175,857 184,901 349,250
Family Planning Services 151,263 169,581 127,598 185,521 229,621
Disease Prevention Services 515,999 513,577 308,090 'note:Five 432,881 302,980 *includes immunization inFY12-13
Total Expenditures 910,618 995,409 905,604 months 1,165,070 1,165,070
remain in
State FY
Sustainability Blueprint
Purpose
The Florida Department of Health in Monroe County has experienced significant funding
reductions during the past several years.
• Non-Categorical State General Revenue was $1,768,372 for FY 2008-09. For the current
year FY 2014-15,that figure has been reduced to $1,178,492 - a reduction of 33.4%.
• Following on the heels of the State direction to transition out of providing primary care in
2012, and the opening of a local FQHC in Key West which offered a new medical home for
many of our clients, came the implementation of Medicaid managed care in 2013. .FDOH-
Monroe has sustained substantial reductions in Medicaid earnings;from an all-time high of
$451,706 in FY2009-10,to only$80,431 in FY2013-14, a reduction of 82.2%.
As revenue projections were in decline beginning in FY 2008-09, FDOH-Monroe obtained
additional monetary support from Monroe County Board of County Commissioners for specific
initiatives and responses to local public health threats. The additional funds have not been
sufficient to offset losses in General Revenue and Medicaid earnings, and it is clear that further
increases are unlikely. It is expected that county contributions will remain static at best.
The executive leadership meets on a regular basis to closely monitor revenue, expenses, and
staffing levels. Every vacancy is reviewed, and essential duties are analyzed and re-assigned. This
has allowed us to eliminate positions to compensate for overall decreasing revenue, and delayed
the need for a formal workforce reduction. Staffing levels have been reduced dramatically, and
OPS positions utilized to minimize additional costs of benefits. As an example of innovation in this
area was the unique opportunity realized in late 2013, when a front desk vacancy occurred in our
Middle Keys clinic. We were able to partner with CMS, and share office and clinic space with them
in exchange for front desk coverage. This saved CMS a great deal of ongoing expense in
commercial rent, and FDOH-Monroe the continuing cost of a FTE plus benefits. While savings of
$800,000 have been realized from staffing reductions of 10.5 FTEs between FY2010-11 to FY2013-
2014, constant downsizing brings a very real potential for burnout, excessive turnover in key
positions, and negative impact on our ability to maintain the levels of services needed to respond
to issues of public health significance.
During the past few years, our executive leadership team also reviewed the use, and costs to
maintain clinical facilities, and decided to move our largest clinic out of commercially rented space,
into a County owned building. This move was completed in June of 2014, and will result in annual
savings of approximately$80,000 per year in rent and utilities. In the long run,this may also give
rise to additional economies in staffing requirements as well.
Background
State Non-Categorical General Revenue in FY 2007-08 was $1,768,372, decreasing to $1,701,626 in
FY 2008-09; $1,552,597 in FY 2009-10; $1,454,945 in FY 2010-11; $1,138,406 in FY 2011-12; 1
$1,085,560 in FY 2012-13; $1,056,345 in FY 2013-14; and increased to account for the increase in
the cost of benefits, up to $1,178,492 in FY 2014-15.
Florida Department of Health in Monroe County
Sustainability Blueprint
In FY 2011-12, FDOH-Monroe produced a Business Plan, as part of the requirements of the Public
Health Accreditation Board's public health accreditation process._ The Business Plan set forth our
public health priorities, and our strategies to sustain the deliveryof quality services to the
community residents and visitors. Five strategic goals were identified: 1) Organizational
Excellence; 2) Increased Prevention; 3) Compliance with 2015 Mandate for Onsite Sewage
Standards; 4) Public Health and Medical Preparedness; and 5) Sustainability.
At that time,.leadership identified Increased Prevention efforts as the highest priority for our local
Health Department. This need is critical in our community as Monroe County has been
designated by the Health Resources and Services Administration as a Medically Underserved
Area/Population since 1995. Specific Strategic Objectives for increasing and improving disease
prevention efforts were set in the following major areas of our operations:
• Immunizations: increase opportunities, improve rates, decrease re-emergence of vaccine
preventable diseases, increase percentage of persons immunized against seasonal flu, and
increase pertussis,tetanus, and diphtheria prevention efforts through mass vaccination
points of dispensing.
• Mosquito-borne disease: continue work with external partners to eliminate incidences of
dengue fever, and market dengue prevention efforts directly to the community.
• HIV/AIDS: expand HIV/AIDS outreach and prevention in the community to reduce
numbers of new cases; provide HIV/AIDS testing throughout Monroe.County; provide
HIV/AIDS primary care and treatment, including ADAP services, nutritional counseling and
assistance, monitor adherence, and promote healthy behaviors.
• Clinical Nursing: maintain robust STD testing and treatment program, decreasing the
percentage of syphilis cases, continue to offer Refugee Health screening services, and
Family Planning services and products, county-wide.
• Community Nursing: county-wide, provide Healthy Start and WIC services, maintain
Epidemiology Program, including STD surveillance and outreach, Hepatitis and Liver Failure
Prevention, TB Program,Tobacco Education and Outreach, Wellness activities, and School
Health Program,to impact healthy behaviors and improve health outcomes.
• Environmental Health: Maintain the most extensive Beach Water Quality Monitoring
program in the state, provide Sanitary Nuisance Complaint Response, Pool inspections,
Food Hygiene inspections, Biomedical Waste Program, monitor Small Quantity Waste
Generators, perform Mobile Home Park inspections, conduct Tanning Facility inspections,
and Body Art and Piercing Facility inspections,to ensure a health and safe environment for
residents and visitors.
As Monroe County is particularly vulnerable to weather-related events, it is critical to have public
health and medical preparedness plans at the ready. Our statutory responsibilities include
coordination and provision of care for "special needs" residents in the event of a declared 2
emergency. Public Health and Medical preparedness is a continuing strategic priority for our
health department. - -
Florida Department of Health in Monroe County
Sustainability Blueprint
To prepare for, respond to, and recover from all hazards,the following objectives must be met:
• Increase agency work force emergency response capabilities through training and
exercises, including regular participation in local, regional, and state preparedness
exercises.
• Completion of Project Public Health Ready certification.
• Expansion of membership in Health and Medical Emergency Response Coalition.
• Increase community awareness of personal/family preparedness planning through
marketing efforts.
The third identified priority is specific to Monroe County, and is responsive to the State of Florida's
mandate in Chapter 2010-205, Laws of Florida. Our Environmental Health Program has been
focused on Onsite Sewage Treatment and Disposal Systems to ensure compliance with the
legislatively mandated level of treatment for effluent discharged. To achieve compliance with this
law, the following strategic objectives were identified:
• Reallocate and train staff to focus on increased cooperative effort with Monroe County
officials and those of the Florida Keys Aqueduct Authority to implement a plan to assist
property owners who will be impacted by the mandate, and be required to install
performance based onsite sewage treatment.
• Perform outreach to educate and hand inquiry from property owners required to comply
with mandate.
• Achieve 100% compliance, county-wide, by December 31, 2015.
Because of the intense financial pressures we anticipated, and the impact of legislative changes
and budget cuts on federal and state levels, sustainability was identified in our Business Plan as an
over-riding strategic goal, along with maintaining and promoting organizational excellence. These
business strategies were applied across all administrative, clinical, and community-based
programs. Several strategic objectives and initiatives were identified to maintain and develop a
motivated work force to ensure service delivery is efficient, responsive to community needs, and
works to prevent, minimize, and contain communicable diseases, environmental hazards, and risky
behaviors;they include:
• Implement reorganizational plan to eliminate unfilled or newly vacant positions, and
ensure current work force is retained.
• Implement succession plan for retiring managers.
• Develop cross-training program to maximize efficiencies.
• Consolidate projects that will lead to a reduction of program-related expenses.
• Actively seek grant opportunities that will benefit the residents of Monroe County.
• Increase client collection, and reimbursements, and refer zero-pay patients to community
partners when available. 3
• Create internal benchmarking to track productivity.
• Reduce administrative rate.
Florida Department of Health in Monroe County
Sustainability Blueprint
Key Challenges/Opportunities to Address
As a result of the business planning, and the necessary actions taken by the FDOH-Monroe,
beginning in earnest in 2010, and continuing to the present-time, we are in a good position to
address the challenges and opportunities we will face in the next 12 to 24 months. However,we
will not be able to proceed without reducing some programs and activities that we have
historically been able to sustain, including some we have identified as priorities,without securing
additional revenues. Cost containment and continued downsizing of staff will not be sufficient to
fill the gap that funding cuts and revenue reduction create.
The key factors that will continue to impact the scope of services we will be able to sustain and our
fiscal management are:
• Additional reductions, or stagnation of State and County General Revenue funding
• Reductions in all areas of Fee-for Service revenue—medical, as well environmental with
central sewer system projected to be complete during calendar year 2015
• Uncertainty of level of maintenance in for Federal Ryan White programs
Since 2012, a considerable amount of staff resources have been dedicated to the accreditation
process. While there was some Federal Schedule C revenue dedicated to accreditation ($8,100 in
FY 2013-14), compensation for the employees involved exceeded the amount received. Similarly,
a Community Health Assessment and Community Health Improvement Plans were produced in
2013, and updates are in process. Dedicated funding for these important, and arguably core
public health functions, is lacking ($28,505 in FY 2013-14). As we move forward, we may need to
turn to external sources to ensure that the assessment and public health policy development work
continues. The statutorily created Health Council of South Florida,which is funded through
assessments on health care facilities, has historically focused more on the major urban community
of Miami-Dade than our rural county. This planning body may need to assume a more active role
in the future as we face the challenge of meeting the demands of basic public health service
delivery.
In order to stay within our FY 2014-15 projected revenues, we will need to severely limit work
being done on the Community Health Assessment and community health improvement planning.
In FY 2013-14, $123,676 was allocated to Community Health Development, which will now be
reduced. In addition, we will implement the succession plan for our retiring Director of Clinical
Nursing: this position will.be filled by an existing staff member at her existing salary, presenting a
savings of$103,860 in salary and benefits.
Finally, we will begin to reduce expenditures for the training of staff in connection with their
emergency duty roles. Historically, NIMS training has been recommended for all ICS positions, 4
both on the "A" and "B" shifts. This training has been done at local expense, and involves a
significant amount of travel expense, as Monroe County is rarely chosen as a training location. In �- -'—
FY 2013-14,funding in the amount of$116,142 was allocated to Monroe,while a total of$222,940 L
Florida Department of Health in Monroe County
Sustainability Blueprint
was expended on staff time and activities in Preparedness, with no emergency activations. Unless
a dedicated funding source can be identified in the future to address these training expenses, we
will need to call upon Regional resources to fill specific ICS roles where we have gaps, and to
provide direct assistance with our emergency response.
$1,800,000
$1,600,000 NON CATEGORICAL GENERAL
REVENUE
$1,400,000 MEDICAL FEE FOR SERVICE
$1,200,000
$1,000,000 / ENVIRONMENTAL FEE FOR
SERVICE
$800,000 MEDICAID REVENUE
$600,000
$400,000 COUNTY FUNDING
$200,000
FY07-08 FY08-09 FY09-10 FY10-11 FY11-12 FY12-13 FY13-14
KEY SUSTAINABILITY CHALLENGES IN CURRENT ENVIRONMENT AND HIGH-LEVEL ACTION
Financial Trends
As a result of the financial analysis leading up to the FY 2011-12 FDOH-Monroe Business Plan, and
constant monitoring since that time, we have avoided a formal workforce reduction, and
maintained the prevention services as prioritized. In order to stay within our FY 2014-15 revenues,
immediate action must be taken to further reduce expenditures and avoid lay-offs. We have
identified reductions in staffing due to retirement,training and travel expense connected with
Preparedness efforts, and seeking other means to conduct Community Health Planning and
Assessments.
5
With the implementation of the Patient Protection and Affordable Care Act (PPACA), commonly
referred to as the Affordable Care Act (ACA), beginning in late 2013,the majority of FDOH-Monroe
clients have obtained health insurance in the Health Insurance Marketplace or via two Specialty - --
Florida Department of Health in Monroe County
Sustainability Blueprint
Medicaid Managed Care providers for HIV/AIDS patients. This has increased the ability of FDOH-
Monroe to receive higher rates for services than when previously uninsured clients were charged
sliding fee scales for services. While welcome,this revenue stream is not anticipated to replenish
the loss of prior fee-for-service income from Primary Care services or from standard Medicaid.
In the next twelve to twenty-four months, Federal Ryan White programs are anticipated to
undergo significant structural and funding changes as more clients nationwide gain health
coverage through the ACA. FDOH-Monroe serves as the area's Lead Agency for Federal and State
HIV grants including Ryan White.These funding sources represented $2.2M in FY 2013-14 for the
provision of direct health care services plus administrative costs. There is a potential to reduce
costs in coming years by moving some existing contracted services in-house, but additional
solutions will be necessary to adapt to these additional revenue changes.
For FY 2015-16,the sustainability of the primary care program for persons living with HIV/AIDS
depends upon successful reapplication by FDOH-Monroe Ryan White Part C Grant. FLDOH-Monroe
has applied for continued Part C funding for calendar years 2015 and 2016 and are anticipating
approval for approximately$500,000+ each year. Additional economies associated with this
program may be achieved by contracting with a CHD 340B Pharmacy to maximize cost savings for
pharmaceuticals, as well as the potential to bring medical case management and other services
currently being provided by contractors in-house.
For the continuation of all other medical services, including Immunization, Family Planning, STD
surveillance,testing, and treatment, Epidemiology, Refugee Health screening, School Health,TB
screening and response, Hepatitis and Liver Failure Prevention, Health Start, and WIC, will depend
largely on current state, federal, and county funding remaining at current levels. Reductions in
any of these areas will likely require essential public health services to be curtailed.
Should the State of Florida implement a Medicaid expansion in FY 2015-16, some opportunity to
increase revenues may be presented. At that time, should state direction allow for primary care
expansion,this scenario could allow for a new revenue stream.
Historically, FDOH-Monroe has not provided dental services for adults or children, or child health
services, choosing to focus resources on primary care for low-income, uninsured adults. Referrals
for dental care for AIDS/HIV clients are provided under the current Ryan White funding level.
CURRENT FUNDING BY PROGRAM AND PROJECTIONS FOR THE NEXT TWO FISCAL YEARS
See separate spreadsheet
6
Florida Department of Health in Monroe County
Sustainability Blueprint
Financial Sustainability Measures to be Implemented
In order to maintain sustainability of key public health functions and the infrastructure necessary
to provide basic public health services, FDOH-Monroe will be implementing the following actions:
ACTIVITY ANTICIPATED SAVINGS OR OUTCOME MEASURE
MAINTENANCE OF REVENUE
Staff reductions $157,000 Effective cross training&
Two already identified vacancies will to be succession plans
filled.Additional positions will follow as
vacancies occur
Reduce Community $ 60,000-$100,000 Shift to Health Council
Health Planning
Reduce Preparedness $ 90,000 Shift to Regional Staff
Training and Expenses.
Maintain Grants $500,000 Ryan White Part C
Secure new grants $ 28,000 Tobacco/Wellness
Reduce Pharmacy Costs $ 65,000 Ryan White
via 340b Pricing Contract . .
Conclusion
The mission of FDOH-Monroe continues to be to protect, promote, and improve the health of the residents
and visitors to Monroe County. We strive to meet the public health needs of our community through
clinical care, disease surveillance and control, environmental health services, emergency preparedness,
health education, and vital records. We have effectively managed our expenses in the face of significant
and continuing revenue reductions. We have forged a strong partnership with the Monroe County Board of
County Commissioners,who have provided needed funding to support a robust immunization program.
We remain committed to our focus on improving health through prevention efforts, and will continue to
closely monitor all revenues and expenditures, and to pursue funding opportunities that will enable us to
sustain the level of services our community deserves. For our services to be comparable to those offered by
other County Health Departments in Florida, additional State General Revenue will be required. Our
unique, 127-mile chain of islands presents financial challenges to public health service delivery not
presented to land-based counties. Our relatively small population (73,000) is spread along the island chain
and ebbs and flows with the seasons. Meanwhile, nearly three million visitors pass through Monroe County
on an annual basis. FDOH-Monroe must maintain facilities and the ability to provide services in multiple
locations to be effective. Our staff has risen to meet the challenge: developing new approaches and
initiatives,forging community partnerships, and maximizing resources. With additional State investment,
we will continue to be reliable and innovative, and have the ability to fulfill our mission.
7
•
Florida Department of Health in Monroe County
A Rick Scott
Mission:
To protect,promote&improve the health Governor
of all people in Florida through integrated Flon`• a
state,county&community efforts. HEALTH John H.Armstrong, MD, FACS
Monroe County State Surgeon General&Secretary
Vision:To be the Healthiest State in the Nation
2015-2016 Budget Request
The Core Contract between the Florida Department of Health —Monroe County (FLDOH-Monroe) and
the Monroe County Board of County Commissioners (BOCC) details the arrangement,terms and
conditions of tax funding for Public Health purposes. For the coming fiscal year, FLDOH-Monroe
proposes the following uses for County funds:
FLDOH-Monroe plans to continue its County Immunization Program for year three, and plans to
continue efforts to network, create partnerships, and leverage resources to promote a healthy
environment, educate citizens, and continue community health improvement planning to benefit all
residents.
A. Personnel $ 638,273
FLDOH-Monroe's largest budget line item is for staffing. Many functions required for performing
Public Health services in Monroe County are funded minimally by the State, or not at all, yet are
necessary for the health and well-being of residents. Items such as Epidemiology, Tuberculosis
and Ebola monitoring, handling MRSA incidents, investigation of sanitary nuisance cases, water
quality, biohazard situations, rabies and food-borne illness investigations,family planning
activities, and immunization programs are some examples.
1. Environmental Health Personnel $154,050
Fund 3.1 Full Time Equivalent (FTE) positions for Environmental Health Specialists
throughout the Lower, Middle and Upper Keys for staff time and activities for non-
billable services such as water quality, community meetings, sanitary nuisance, rabies
investigations, biohazard situations, mold complaints and other unusual public health
situations requiring a response from the department. Two prior examples: MRSA
associated with whale stranding, and salmonella questions associated with iguana
interactions with humans.
1) Epidemiology Personnel $ 62,025
Fund 1.0 FTE for non-billable services for tracking, reporting and monitoring of the
incidence and prevalence of disease. This involves detection, identifying the source
and cause of infectious disease in our community with transient visitors from around
the world.
2) Disease Prevention Staff $ 40,400
Fund .8 FTE for surveillance, monitoring, counseling, education, and testing and
referrals for the tuberculosis, prevention, and sexually transmitted disease programs
for the Lower, Middle and Upper Keys
3) Licensed Clinical Providers $ 167,800
Fund 3.2 FTE for staff time and supervision of activities in the provision of health
services in the Lower, Middle and Upper Keys, including Family Planning, Disease
Prevention, Immunization and Health Counseling services to uninsured and lower
income Monroe County residents.
} Florida Department of Health, Monroe County Old'
2014-2015 Budget Request HEALTH
Monroe County
4) Clinical Support Staff $ 115,468
Fund 2.5 FTE for staff time, activities and administrative time in support of all health
services in the Lower, Middle and Upper Keys, including Family Planning,,
Immunization, Health Counseling, Refugee Health, Epidemiology, Infectious Disease,
Healthy Start, and the Women, Infants & Children Program (WIC).
5) County Immunization Staff $ 98,530
Fund 2.0 FTE for (1) RN to administer vaccines to County residents and (1) Nursing
Specialist (RN)to coordinate and continue year three of the local county initiative to
immunize adults in Monroe County against Tetanus, Diptheria,Acellular Pertussis
(TDaP), Pneumonia, and Human Papilloma Virus (HPV). The RN position manages the
program, reports on its pace and direction, implements reporting mechanisms, acts a
community subject matter expert, reports results and coordinates a media campaign
with the FLDOH Public Information officer and immunizes eligible citizens.
TDaP immunization is recommended for pregnant women and their families as
well as families of infants and small children to prevent the transmission of illness
to the youngest Monroe citizens. The HPV vaccine is recommended for girls age 9-
26 and boys age 11-26. FLDOH receives external funding to immunize persons
under the age of 18, but most men and women age 19-26 have not received this
immunization. The HPV vaccine has the potential to nearly eliminate future
cervical, perineal, perianal, head and neck cancers. Pneumonia vaccine is
recommended for people 65 and older, the very young, those with weakened
immune systems, and smokers.
B. Fringe Benefits $ 223,396
Full State benefits for Career Service employees include individual or family health
coverage, retirement, FICA, Medicare, life insurance, and paid leave. The fringe benefit
rate for Career Service employees is estimated by the State of Florida to be 35%.
C. Supplies & Equipment $ 219,944
TDaP 300 doses x $ 31.64 per dose $ 9,492
HPV 450 doses x $137.17 per dose $61,727
Seasonal Flu 1,000 doses x $ 15.69 per dose $15,690
Prevnar 13 (pneumonia) 100 doses x $ 147.72 per dose $14,772
Pneumococcal 23 (pneumonia) 150 doses x $ 68.22 per dose $10,233
Provide required immunizations for uninsured Take Stock in Children's
Experiment in International Living Scholarship recipients
Est. 10 participants at$225 cost of vaccine each $ 2,250
Additional vaccines for underinsured county residents $95,000
Statistical Software, PACE program $ 1,000
Portable Survey Equipment, PACE program $ 6,900
Data/Communications fees for PACE surveys $ 2,880
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.
Florida Department of Health,Monroe County Fora d
2014-2015 Budget Request HEALTH
Monroe County
D. Contractual Services $ 55,174
Advertising and Media Campaigns—PACE Program $ 6,883
Advertising and Media Campaigns—Adult Immunization $ 7,150
Media printing services for Community Health Improvement Plan
And Community Health Assessment/Almanac $ 5,650
Fleet Maintenance & Repair $ 7,025
Biomedical Waste Services $ 5,541
Translation Services for non-English speakers $ 3,920
Website design for PACE program $80/hour x 120 hrs $ 9,600
Website hosting service for one year, PACE program $ 600
Custodial services at FLDOH-Monroe sites $ 8,805
E. Capital Outlay $ 28,283
One small/mid-size SUV for in-county travel
As an addition to the fleet for one year,the vehicle will allow for additional staff activities
in water quality beach testing, increased inspection activities for the Cudjoe regional
wastewater project, and immunization outreach. The addition will allow for the
retirement of an older vehicle after the end of the Cudjoe regional project.
Grand Total = $1,165,070
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