Report 2017-124 All Recommendation Responses

Report 2017-124: San Diego County's Health and Human Services Agency: It Cannot Demonstrate That It Employs the Appropriate Number of Public Health Nurses to Efficiently Serve Its Residents (Release Date: July 2018)

Recommendation #1 To: San Diego County Health and Human Services Agency

To better ensure and demonstrate that it efficiently meets public health needs of at-risk county residents, and that it employs the appropriate number of PHNs in the right locations to address those needs, the Health Agency should measure and assess PHN efficiency. Specifically, the Health Agency should direct the chief nursing officer to begin developing and implementing PHN efficiency measures by January 1, 2019. These measures could address such factors as caseload, case complexity, and overtime.

Annual Follow-Up Agency Response From January 2020

As California Children's Services (CCS) and the Health Care Program for Children in Foster Care (HCPCFC) were two areas highlighted by the auditors, we have focused on these programs to develop efficiency measures. Additionally, we have developed guidelines to identify and monitor the elements for appropriate PHN staffing.

CCS

The CCS program implemented the use of a case complexity tool beginning in January 2019 to assess and redistribute case assignments to equalize PHN workload. PHNs and support staff received training on the tool. Using the complexity data obtained thus far, CCS caseload assignments are now being redistributed based on complexity scores to equalize PHN workloads. The program will continue to monitor and track PHN caseload complexity levels, PHN workload management, equitable distribution of PHN assignments and the appropriate allocation of CCS resources. In addition, the CCS program has eased PHN workload by adding additional case management positions to support case management needs.

HCPCFC

The HCPCFC developed the Foster Care Public Health Nurse Caseload Complexity Tool. The tool captures PHN care coordination services. The PHN interventions are documented and assigned complexity points for each child. During November and December 2019, quality assurance was performed on each PHN's completed tool to evaluate appropriate utilization, accuracy, and standardization. Beginning January 2020, the program terminated the Statistical Reporting System (SRS) practice for recording the PHN workload. At the same time, the program implemented the Complexity Tool to document caseload complexity and workload. Throughout the first year of implementation, the program will continue to evaluate the effectiveness of the tool and make improvements where needed.

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented

1-Year Agency Response

As California Children's Services (CCS) and the Health Care Program for Children in Foster Care (HCPCFC) were two areas highlighted by the auditors, we are continuing our work with these programs to develop the efficiency measures.

CCS:

The CCS team developed and refined a case complexity tool.

Staff have attended educational sessions and the tool is currently being implemented.

The CCS team is past midpoint in implementing a complexity determination system that will support balance work assignments.

Next Steps: Train 2 Senior Public Health Nurses increasing the number of teams from 20 to 22.

Continue to assign complexity scores to each case at the time of opening to CCS or annual eligibility renewal.

Monitor complexity determination through the quality assurance process.

Assess accuracy of complexity determination.

Provide re-training as needed.

Redistribute caseload based on complexity scores to equalize PHN workloads. (01/01/2020)

HCPCFC:

Foster care has drafted a case complexity tool that was adapted from the one use in Los Angeles. The tool is in pilot and will be presented for approval in August 2019 and then fully implemented in September 2019.

Monitoring PHN caseloads monthly to assess the need for additional support:

One additional PHN stationed with Adoptions to assist with higher caseload

One additional PHN serves in float role to assist where needed.

Senior PHN position added to support focus on psychotropic medications.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

We have collected and reviewed available data, and reached out to key stakeholders to ensure our process in developing these metrics is evidence-based and inclusive. We have reached out to the County Health Executives Association of California; and on January 3, we attended their executive team meeting via conference call to discuss a collective effort to address efficiency measures for services staffed with Public Health Nurses.

As California Children's Services (CCS) and the Health Care Program for Children in Foster Care (HCPCFC) were two areas highlighted by the auditors, we are starting with these programs in developing the efficiency measures.

CCS:

-The CCS team has developed a case complexity tool.

-Staff have attended educational sessions and the tool is currently being implemented.

-The implementation will be completed once all CCS PHNs have received training and all CCS charts have been reviewed as part of the required annual review.

Healthcare Program for Children in Foster Care (HCPCFC):

-Foster Care is working to assess and develop a case complexity tool that is evidenced based, and is also coordinating with Child Welfare Services to assess caseload distribution. The goal is to begin piloting a tool in March with implementation by the end of April 2019.

-Monitoring PHN caseloads monthly to assess the opportunity to provide additional assistance as need.

-Hired an PHN to assist with caseload management, also in the process of recruiting a Senior PHN to assist with psychotropic medication care coordination and caseload relief.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

Although the Health Agency is not yet measuring and assessing the efficiency of its public health nurses, its chief nursing officer is taking steps in this direction as we recommended. Specifically, two of the Health Agency's programs that utilize public health nurses, California Children's Services (CCS) and the Healthcare Program for Children in Foster Care (HCPCFC), are developing and beginning to implement case complexity tools.

60-Day Agency Response

As acknowledged in the report, standard efficiency measures for public health nursing services do not exist. The County is prepared to assist the state in developing efficiency metrics that could be used throughout the State of California in order to create standardized tools for all statewide jurisdictions. The County has contacted the County Health Executives Association of California, to discuss their potential assistance. In addition we have contacted Los Angeles to see what measures they have in place - a trip is planned to LA to discuss with their managers/leadership.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #2 To: San Diego County Health and Human Services Agency

To better ensure that its PHNs are prepared for future public health emergencies, the Health Agency should distribute its surge plan to its PHNs and train them on its protocols.

60-Day Agency Response

Effective August 3, 2018, the Health Agency distributed its surge plan to all Public Health Nurses and their supervisors through its policy management system. The Health Agency will continue to incorporate Surge Plan protocols into educational opportunities for nurses, including during new hire Orientation, Mass Care and Shelter Training for Nurses, and Annual Skills Day events.

California State Auditor's Assessment of 60-Day Status: Fully Implemented

All Recommendations in 2017-124

Agency responses received are posted verbatim.