10 Ky. health departments nationally accredited, 30 in pipeline

By Melissa Patrick
Kentucky Health News

Ten Kentucky health departments are now nationally accredited, with about 30 more in the pipeline, placing Kentucky third in the country for the number of health departments to have earned this status.

The Public Health Accreditation Board accredited Louisville Metro Public Health and Wellness on Aug. 17, making it the 10th in the state.

What does it means for a health department to be accredited? "It means that it is one of the finest health departments in the nation, and that it can assure its citizens that it has the capacity to meet any of the public health problems that that community might address," said PHAB Chair Dr. Douglas Scutchfield, the Peter Bosomworth Professor of Health Services Research and Policy at the University of Kentucky.

Kentucky has led the way in getting its health departments accredited. In 2013, Franklin County Health Department in Frankfort, Three Rivers District Health Department in Owenton and the Northern Kentucky Independent District Health Department were among the first 11 health departments in the nation to be accredited.

Since then, the Barren River District Health Department in Bowling Green, Bullitt County Health Department in Shepherdsville, Christian County Health Department in Hopkinsville, Green River District Health Department in Owensboro, Madison County Health Department in Richmond and the Lexington-Fayette County Health Department have been added.

Health departments are accredited for five years, and must re-apply for accreditation.

New state Health Commissioner Hiram Polk, who served seven years as the chair of the accrediting body for Surgery of America, emphasized the importance of accreditation, saying he plans to make sure the state Department for Public Health is accredited during his tenure, and encouraged all of Kentucky's local health departments to do the same.

"The accreditation process is hugely valuable," he said in an interview. "The process makes you better."

Scott Lockard, director of the Clark County Health Department, which plans to apply for its accreditation in January, agreed.

"We have already benefited from the process of preparing for accreditation," he said, because the process has created a "culture of quality improvement" in his organization. He said that because of the application process, which requires a community health assessment, his department now looks at programs based on what the community needs and the expected outcomes, instead of simply whether the funding is available to provide a service.

"Accreditation assures the public that there is a base level of professionalism that they can expect," Lockard said. "[And] feel confident that the health department in their community is serving them with high quality programs."

Scutchfield said engaging community partners in the community health assessment and community health improvement plan, which are both early accreditation requirements, often re-establishes relationships in the community that have been lost.

"Frequently people are unaware of the capacity and the activities of their local health department," he said. By engaging them in the process, it allows the health department to collaborate with others, like local hospitals, non-profits, fire-departments and schools, to help them with their missions, he said.

Scutchfield also noted that becoming accredited improves a health departments performance, governance and management systems, promotes quality improvements, helps departments better identify strengths and weaknesses, and helps boards and departments better provide their required 10 essential public health services. It also assures that certain plans and programs are in place to respond to both emergent and non-emergent situations.

"It provides credibility and accountability to the community. The community knows and can believe that its health department has met the rigorous standards of now some 150 health departments, out of the 2,600 in the United States," he said. "This is an important thing for health departments to do."

Six of the state's 61 health departments are losing their directors; pandemic made some of them delay or advance their departure

By Melissa Patrick

Kentucky Health News

Nearly 10 percent of the state's health departments are losing their directors, with five retiring and one resigning. And the 61 district and county health departments are losing other staff due to fatigue and stress of the pandemic.

Some of the directors who are leaving say it's due in part to the pandemic; others say it made them stay an extra year. "Many of us did not want to leave during the height of the Covid response," said Dr. Kraig Humbaugh, commissioner of the Lexington-Fayette County Health Department.

Sara Jo Best, president of the Kentucky Health Departments Association, said the pandemic has caused exhaustion, stress and depression among many public-health employees and has likely contributed to retirements.

"The health-department employees were either loved or hated at various times throughout this pandemic," Best said. "So it wasn't uncommon for us to get threatening phone calls, for us to have terrible encounters with individuals. People thought we were doing too much or they thought we weren't doing enough. There were a lot of things that got politicized that should not have. So you know, not only did they work long hours, gave up weekends, gave up holidays, didn't see their families, but on top of that, sometimes they were subject to a lot of verbal abuse and sometimes physical threats."

Best said she didn't know the number of retirements. The state Department for Public Health declined to provide the number of employees or the names of the directors who are retiring without an open-records request. Best provided the names of directors who are leaving by Aug. 1, the most popular date for state workers; some are already gone, due to accumulated vacation and sick time.

Besides Humbaugh, the retiring directors are Lake Cumberland District Health Department Executive Director Shawn Crabtree; Northern Kentucky Health Department District Director of Health Dr. Lynne Saddler; Graves County Health Department Director Noel Coplen; and Ashland-Boyd County Health Department Public Health Director Maria Hardy.

Kayla Bebout, public health director at the Christian County Health Department, is resigning, effective July 16. 

Kayla Bebout

Bebout, who has been in public health for 14 years and director since 2017, said the pandemic was not the only reason she was leaving, but it played a role in her decision. Bebout said she is moving to a job outside public health and hopes to come back eventually. 

"I feel the personal need to step away mentally, spiritually, physically for little bit, and to get refreshed," she said. "I have intentions of hopefully coming back to public health, but at this moment, I've got to do what is best for me, personally and professionally and that is to step away for just a little bit." 

The state has 61 district and county health departments, with most counties as part of a district.

Coplen, of Graves County, has worked in the state system for 34 years, 28 with the health department, said he had decided to not leave during the height of the pandemic. "I just felt like I owed it to my community and my staff that was working so hard, all of our public-health partners," he said, adding that he is leaving now because "It was time for me to retire."   

Shawn Crabtree

Lake Cumberland's Crabtree, who has 30 years invested in the state retirement system, 20 as district health director, said likewise.

"Actually, Covid prompted me to stay," he said. "I was gonna retire last August. But, you know, my board and my community and my staff have always been good to me and they're important to me, and I saw this pandemic being . . . the thing that I've been training for, for the last 19, 20 years. And I really didn't want to walk out and leave the people that's been good to me. And, you know, it was an overwhelming experience. So to think about handing that off to someone who may or may not have had . . . any kind of background or expertise, I just, I didn't feel like it was the right thing to do."

Crabtree said he was leaving because it makes financial sense to do so. "There just comes a time when you're in the retirement system, that financially it doesn't make sense to continue to work at the job," he said. State employees 57 or older can retire with full benefits when their age and years of service equal 87.

Hardy, of Ashland, said in a text reply to a voice mail that she has planned for three years to retire on July 31 of this year.

Dr. Lynne Saddler

Northern Kentucky's Saddler, who has worked in public health for 30 years, 11 in Northern Kentucky, acknowledged that the pandemic has been hard on her and her staff. She said that in January, she realized that the "stars aligned" and it became evident that for a number of reasons it was time for her to retire -- one reason being it's time for the department to do its community health assessment and reset priorities.

"I felt like it really should be done under new leadership, the person who's going to carry the health department forward to its next chapter should be the one at the helm going through these planning processes," she said. "And so it was a good stopping spot for me and it was good for the agency." 

Humbaugh was senior deputy commissioner of the state health department before becoming commissioner of Lexington's department in 2016. He said he would be seeking other opportunities.

"I know that there are several people that are leaving, but some of us actually kind of stayed on . . . because this was so important," he said. "I told our board last winter that I [thought] we'd have more control over Covid this summer, so it would be a good time for me to transition away."

He stressed that while the state has made great progress against Covid-19, it's important to remember it is not over yet, and the mental health needs of public-health employees should continue to be addressed. 

Mental health, public health and the pandemic

Challenges of fatigue, stress, depression and post-traumatic stress disorder among public-health workers have been widely reported during the pandemic.

A recently released Centers for Disease Control and Prevention survey of more than 26,000 public-health workers found that 53% reported symptoms of at least one mental-health condition in the past two weeks, including PTSD (37%), depression (32%), anxiety (30%), or ideas of suicide (8.4%). Symptoms were more prevalent in those who were not able to take time off or worked more more than 40 hours a week. 

In response to many of these concerns, Best said the state health department has surveyed its employees and provided some mental-health training, and local departments have done internal assessments and offered supports. 

"We hired a group to come in and do sessions with our staff," said Best, who is the public health director at the Lincoln Trail District Health Department. 

Crabtree, of Lake Cumberland, reiterated some of what Best said about the stress of the pandemic, saying his staff never knew when they picked up the phone if it would be in support or in opposition of their work. "That's a grind," he said. 

He said one way his agency handled the stress is to give staff opportunities to take some time off if they were feeling burnt out or overwhelmed, even when it was not convenient to do so.

Dr. Kraig Humbaugh

Humbaugh said the Lexington department has "recharge moments," encouraging employees to take breaks and do any number of given activities, like yoga or working on a puzzle. In addition, he said employees have access to an employee-assistance program.

Saddler, from Northern Kentucky, said her agency also works on supporting employees' mental health, first and foremost by talking about it, and making sure everyone knows they have a comprehensive and  confidential employee-assistance program. 

"There are times in our lives, all of us, including me, when you need to have that person, that objective person to talk to and work through things and that there's no shame in it and that it's something to take advantage of because it is so beneficial," she said. 

Saddler added that it's important to know that "we are all forever changed personally and professionally by this pandemic," and that she tries to convey to her staff that "we need to be kinder and gentler to ourselves and we need to be kinder and gentler to each other moving forward."

State Health Commissioner Steven Stack told Jack Brammer of the Lexington Herald-Leader that he knew there always has been public criticism of government, but dissent from sound medical advice took “an emotional toll” on him as he and Gov. Andy Beshear tried to save lives.

“What kept me going?” Stack asked himself. “A lot of people out there who I think and hope saw someone who cared.”

Kentucky Public Health Association honors 10 public-health leaders, two health departments and a racetrack

Public health promotes and protects the health of people and their communities, largely through surveillance and prevention programs, and much of what people in public health do often goes unnoticed. But once a year the Kentucky Public Health Association honors outstanding contributors to public health. Here are the award winners for 2018, honored during the association's 70th annual conference on April 27 in Covington.

Sue Thomas-Cox, a nurse administrator with the Chronic Disease Branch of the state health department, won the Outstanding Public Health Nurse Award. Among other achievements, Thomas-Cox was instrumental in obtaining a multimillion-dollar Centers for Disease Control and Prevention grant to increase colorectal cancer screening in the state. Due in large part to her work, the state has moved from 49th to 19th in colorectal cancer screening, annual cases of such cancers have declined more than 25 percent, and mortality from them has fallen more than 30 percent.

Melinda Carey, an administrative specialist with the department's Division of Epidemiology and Health Planning, won an award for her contributions in the area of administrative support. Carey's nomination came with 26 letters of support, several of which described her as "the go-to person" who "goes the extra mile and makes the workplace enjoyable."

Robert Slaton of Georgetown, who has served in various health leadership capacities for more than five decades, was honored for his lifelong contribution to the improvement of public health. He was state health commissioner,  Gov. Brereton Jones' special assistant for health reform, external affairs director for the former Trover Clinic in Madisonville, and held several positions with the University of Louisville. He was a founding member of the group that developed Passport Health Plan. He is chair of the Community Advisory Council of the Foundation for a Healthy Kentucky and the national advisory board of the Institute for Rural Journalism and Community Issues, which publishes Kentucky Health News. “His contributions to improved health outcomes in the commonwealth will long outlive his numerous years of service to the people,” a nominator wrote.

Jennifer Hunter, director of clinical services at the Northern Kentucky District Health Department, received a career achievement award. Hunter has worked as a public-health nurse for 28 years. A few highlights: leading a team of six nurses in relief efforts in Mississippi after Hurricane Katrina in 2005; and her work around the heroin epidemic, including a hepatitis C testing pilot that has since gone statewide, advocating for syringe exchange programs, and her work with women with substance-use disorders.

Doraine F. Bailey, who works with the breastfeeding support services at the Lexington-Fayette County Health Department, was honored for her "exceptional contribution to the health and well-being of mothers and children in Kentucky."  Bailey was described as a "tireless champion for breastfeeding and maternal education," going beyond her job requirements to promote breastfeeding at community events and by serving as a guest lecturer in the University of Kentucky nutrition and dietetics program.

John Q. Moses, an HIV linkage navigator with the Lexington health department, was honored for his "significant contribution to benefit our most vulnerable population -- the indigent and uninsured." Moses has spent his career serving those at risk for and affected by HIV and STDs and was instrumental in launching Lexington's syringe exchange program.

The Christian and Todd County Health Departments were honored for their work on the August 2017 solar eclipse, which required several years of "hard work and planning to prepare for the influx of people and potential dangers." Visitors from over 47 states and 25 countries attended events in the area.

Nancy Merk, a board-certified lactation nutrition supervisor and regional breastfeeding coordinator with the Northern Kentucky Health Department, was honored for her 30 years in public health. Merk's leadership was instrumental in the health department receiving the Loving Support Award of Excellence Gold Level Award for Exemplary Breastfeeding Support and Practices from the U.S. Department of Agriculture.

Shana M. Peterson, a health educator at the Jessamine County Health Department, was awarded for her exceptional contribution in health education. Peterson has implemented many evidence based health education prevention programs in schools and has been a strong advocate for local smoke-free policies.

Lorrene Rawlins, nursing director at the Wedco District Health Department in Bourbon, Harrison and Scott counties, was honored for her exceptional home health services. Through her leadership, Rawlins was able to reduce costs in other areas of her department to create a budget to directly care for indigent patients.

Jody L. Schweitzer, a state epidemiologist, won the first-ever Outstanding Epidemiologist of the Year award. She was honored in large part for her work in implementing the state's immunization information system, the Kentucky Immunization Registry, which has been recognized on the state and national level.

Kentucky Speedway was honored "as an industry who has demonstrated exemplary leadership for the commonwealth's health. "

As health departments face crippling pension costs, unless lawmakers intervene, health boss promotes a new model for them

Without a reprieve from pension-contribution rules, 42 county health departments will close in the next year, and 22 more will the following year, says the Department of Public Health, which made this map.

By Melissa Patrick
Kentucky Health News

Under the gun of new pension rules, Kentucky's health commissioner wants local health departments to drastically cut services, but he says the departments need the legislature to give them one more reprieve from big pension bills that would put dozens of them out of business in the next 12 months.

Dr. Jeffrey Howard, the health commissioner, says his plan calls for a system that would assure the survival of public health in the state, and would ultimately improve the state's health outcomes.

Dr. Jeffrey Howard, health commissioner

Howard created this new model largely in response to the state's pension crisis, which on July 1 will require health departments to increase their pension obligation from 49.47 percent to 83.43 percent of payroll -- unless a special session of the General Assembly changes that.

In the regular session that ended in April, Gov. Matt Bevin vetoed a bill that would have offered some temporary relief to health departments. He has said he will call a special session to deal with the issue, but he and legislators have yet to secure the agreement and votes needed to pass a bill into law.

Without any relief from this added pension contribution and everything remaining the same, Howard's Department of Public Health says 42 health departments would close in the next 12 months, and 22 more would run out of reserves and be forced to close in the the next 24 months.

A taxing situation?

One of the departments most in danger, in Anderson County, recently raised its local property tax from 30 cents per $1,000 in assessed valuation to 52.5, cents to pay for its possible extra pension obligation, Ben Carlson reports for The Anderson News. Without relief from the added pension liability, the agency is slated to pay an extra $140,470 a year.

However, raising local taxes doesn't seem to be a popular option among the 113 counties that have a health tax.

Of the 23 counties that have reported their tax rates for the coming year, only five have proposed an increase, and minutes of the local health board meetings do not indicate that the increases are being driven by the need to cover higher pension costs, said Mike Tuggle, the state health department's assistant director for administration and financial management. He said in an email that the department will continue to receive tax resolutions through early October.

Using local tax dollars to fund public health would result in huge inequities, said Scott Lockard, director of the Kentucky River District Health Department, which covers some of the state's poorest and unhealthiest counties.

"Communities that need public-health services the most, that have the highest poverty rate, that have the poorest health outcomes, also have the least ability to raise local revenue," Lockard said. He added that when he was the health director in relatively wealthy Clark County, his tax base was about the same as it is for all seven counties in his district, which has about three times as many people.

"In Eastern Kentucky, we cannot raise enough local tax revenue to address this problem. And shifting the burden from the state to the locality is just not going to work for these poor communities," he said. He added that Howard's new plan is designed to address some of these inequities.

Crisis = Opportunity?

Howard says the crisis has created an opportunity.

He told a statewide board of health meeting in January that the state can take the opportunity to move away from a public-health system that is "an inch deep and a mile wide" and transform it in a way that will improve health outcomes across the state. "This is truly an opportunity to transform a system that has needed transforming for many decades," he said at the meeting, shown on YouTube.

Howard's plan calls for departments to scale back their services, and only be required to provide four "core public health" areas. He said it doesn't matter if the department implements these programs or if a community partner does, only that the department is committed to making sure they are in place.

The core areas include: foundational public health services, five areas that are required by law or regulation; the Women's, Infants and Children nutrition program; the HANDS program, which stands for Health Access Nurturing Development Services for child rearing; and harm reduction and substance-use disorder programs, including syringe exchanges.

The plan also requires health departments to perform community health assessments, which many of them already do, to determine their local public health priorities beyond those core requirements.

However, under Howard's new plan, before a department could implement a program to address a local need, such as diabetes management, it must first see if the need is already being addressed elsewhere, and if it is, they would be asked to work with that agency to either support or complement its program instead of creating a new one.

If the need is not being met in their community, a department would then have to present its proposed program to a newly formed advisory board, which would review the request to make sure it meets a list of five criteria, including whether it is data-driven, offers an evidence-based solution, is adequately funded, includes a performance and quality management plan; and has an exit strategy.

At the January meeting, Howard said the plan has the support of the Kentucky Health Departments Association, the Kentucky Association of Local Boards of Health, the Kentucky Public Health Association and the University of Kentucky's Center of Excellence in Rural Health. The health-department association has long promoted a similar model called "Public Health 3.0," on which Howard's plan is based.

Howard said the plan also has the support of his colleagues at the health department and Gov. Matt Bevin. He said it will be introduced to lawmakers during the 2020 session, noting that it will require "some overwhelming legislative buy-in." He also said he needs lawmakers to hold the pension rate at 49.47% for one more year to give him time to get this plan in place.

Scott Lockard

The new model has already been embraced at the Kentucky River department, which covers Knott, Lee, Leslie, Letcher, Owsley, Perry and Wolfe counties.

Why? "We are one of the most financially fragile health departments in the state," Lockard said. "We are redirecting our resources just to our foundational services, and basically we're going to be focusing on what we are statutorily mandated to do."

Under the higher pension rates, the Kentucky River department's extra pension obligation is about $1.3 million each year, and it has less than one year of unrestricted resources available before it would be forced to close, according to a spreadsheet provided by Tuggle. That makes it the fourth-worst-off department in the state.

Lockard said he has been working for the last year toward this "public health transformation" model. He said his agency has cut its payroll costs by $900,000, renegotiated contracts with pediatric therapists, is working toward referring all cancer screenings out of the department, and will be discontinuing all maternity services.

Bottom line, he said, if a program is not financially viable or is not statutorily mandated, it must go. And if somebody else can meet the need in the private sector, we need to let them do it.

He ended his interview with a warning: "I feel like we are facing truly a tipping point in public health, that if we do not make the right choices now and put a sustainable public-health funding model in place, the health outcomes for the people of this state are going to be impacted for generations."

Most health departments support overhaul of their funding, though some would lose; spreadsheet lists estimated impact on all

The logo used by state and local health departments

By Melissa Patrick
Kentucky Health News

Driven by the state's pension crisis and a non-equitable funding model, Kentucky health departments warn that if the state doesn't change its requirements for how they prioritize available public health resources -- and how they are funded -- many of them will have to cut essential services, and half could close their doors.

Legislators and health-department officials are seeking a complete overhaul of the state's public health system, not only to help it survive in the face of a $40 million deficit in 2020, but also focus on core programs to improve the state's poor health outcomes.

"House Bill 129 codifies the prioritization of public health funding at every resource level -- state, local and federal -- to programs that provide the most significant opportunity to improve Kentucky's overall health," said Allison Adams, president of the Kentucky Health Department Association. "It also codifies the methodology in how that funding is distributed at the local level so that it is equitable at each county level."

The current system funds each health department with the same formula, regardless of its ability to generate local funds. The new formula would take that into account, making it more equitable, Adams said. In other words, departments that have more resources would get less state funding under this model.

A spreadsheet prepared by Adams' group estimates that 14 of the 61 county and district health departments would get less state funding, and the rest would get more, using a formula based on a county's population, its ability to support its health department with its current taxing authority, how many employees the county would need to provide only the health services required by law, and an estimated increase in environmental fees.

Several district health departments, which serve multiple counties, would get the largest annual increases. Barren River, which serves eight counties in Southern Kentucky, would gain $1,018,200; Lake Cumberland, which serves 10 counties to the east, would gain $1,377,842; and Elizabethtown-based Lincoln Trail would gain $1,054,679.

The 14 departments that would get less funding would be in Breathitt, Bullitt, Clark, Fayette, Franklin, Johnson, Knox, Madison, Marshall, Montgomery, Oldham, Whitley and Woodford counties, and the Wedco District Health Department, which serves Harrison, Nicholas and Scott counties. The losses range from $36,729  in Whitley County to a high of about $1 million for the Lexington-Fayette County Public Health Department.

Dr. Kraig Hambaugh, director of the Lexington agency, cautioned that the numbers in the spreadsheet are estimates, with many based on assumptions. He said that even with the predicted gains and losses, the model is designed to make sure every county's core public health needs can be met.

Humbaugh also stressed that the new model is just one part of the departments' funding puzzle, since it doesn't address their looming pension obligations. He said that if nothing changes before July 1, the beginning of the next fiscal year, the current pension obligation of 93 percent of payroll would make his department use about $6 million of its $17 million budget for retirement costs.

All that said, he recognized that his department would lose money under this new model, but said he still supported it.

"This shouldn't turn into an us-versus-them kind of game, one health department versus the other, because we're all part of one larger system that is designed to promote health in the commonwealth and to protect the public's health," he said.

He added that he felt HB 129 also shows legislators and the public that local health departments are willing to do their part to economize and use their resources wisely.

Adams said the association has been talking about this new funding methodology for about five years and that association members have had opportunity to vet it. Further, she said an over-whelming majority of the departments supported the new model during a roll-call vote.

"This is a funding methodology that provides equitable resources to all of our communities so that we can provide the most basic public health services at each county level," she said.

HB 129, sponsored by Rep. Kim Moser, R-Taylor Mill, passed the House Health and Family Services Committee, which she chairs, on Jan. 16. It is now in the Appropriations and Revenue Committee. The "Public Health Transformation" bill  has 20 bipartisian sponsors.

Pension woes

This new model has been in the works for several years, but gained momentum after health-department pension obligations were set to jump from 49.47% of payroll to 93%.

During a special session last summer, lawmakers gave health departments, regional universities and quasi-governmental agencies the choice of staying in the Kentucky Retirement System and paying the full obligations or leaving the system, either by paying a lump sum or buying their way out over time. Those that choose to leave would need to move employees to a 401(k)-type plan.

The departments say none of these choices are viable, and none have left KRS. The state Department for Public Health has said that without some relief from their pension obligations, dozens of health departments are at risk of closing.

Gov. Andy Beshear has proposed giving the departments about $16.5 million in each year of the budget as a way to freeze their employer contribution rate at 67.41% of payroll. The Democratic governor's proposal would have to be approved by the Republican-controlled legislature.

Lawmakers are working on another pension solution through HB 171, sponsored by Rep. Jim DuPlessis, R-Elizabethtown, which would change how health departments, regional universities and quasi-governmental agencies, pay for their pensions altogether. It would move away from the current  percentage-of-pay" formula and move to one that requires entities to pay what they owe the pension system over 27 years, which is often called "level dollar funding." It passed the House State Government Committee Feb. 6 and is expected to be sent to the Appropriations and Revenue panel.

What is Public Health Transformation?  

The new public health model calls for health departments to only be required to provide four "core public health" areas. They include services required by law or regulation; the federal Women's, Infants and Children nutrition program; the HANDS program, which stands for Health Access Nurturing Development Services for child rearing; and harm reduction and substance-use-disorder programs, including syringe exchanges.

"The programs that we've identified that are the most basic, which we call foundational services, are the programs that have been identified as comprehensive public-health systems," Adams said. "So if we provide those at every level, over time we should expect better health, better health outcomes and longer life expectancies."

The plan also requires departments to perform community health assessments, which many of them already do, to determine local public health priorities beyond the core requirements. Such priorities would have to meet certain criteria for the department to address them and would also need to be funded separately.

For example, a vaccination clinic run by the Todd County Health Department that serves only Amish and Mennonite families would be considered a local public health priority.

"It’s a niche need in Todd County that the public health department, because of strict state and federal funding guidelines, has struggled for years to fund," Alex Acquisto reports for the Lexington Herald-Leader. She notes that the program costs about $5,000 a year.

Photo by Silas Walker, Lexington Herald-Leader

The clinic serves about 3,000 people, or a fifth of the county's population, Acquisto reports, telling of  their monthly horse-and-buggy trips to the clinic to get vaccinations for their infants and toddlers, most of whom only speak Pennsylvania Dutch.

Until a decade ago, when the clinic started, virtually none of the Amish or Mennonites in the area were vaccinated. "If you have a fifth of your population who isn't vaccinated, then your whole public is at risk," Jennifer Harris, the health department's director, told Acquisto.

The bill would also allow health departments, for the first time, to refuse state program funding that their counties don't need in order to invest in the services they do need.

"Without passage of this bill, in Todd County, the Amish and Mennonite and public-school vaccination clinics would be some of the first services cleaved from the budget, because Harris can no longer afford them," Acquisto writes.

The bill also requires local governments to ensure a minimum public-health tax rate of at least 1.8 cents per $100 of assessed property value, or equivalent alternative funding, to be allocated toward foundational public-health programs.

And to help offset some of the added cost, health departments are asking for a one-year reprieve on a rule that restricts increasing environmental fees to no more than 5% each year. After that year is up, the statute would go back into place. This would allow health departments to bring those fees in line with what they actually costs, since they are currently subsidizing the difference.

At the committee meeting, Moser said, "The public health transformation initiative will result in a more simplified and a more focused public health model that prevents duplication, encourages shared responsibilities and resources and expertise to create economies of scale, a fairness across the state, and clearly defines the role throughout the system."

Three Kentucky health departments in first group up for national accreditation; requires local health assessment, improvement plan

By Molly Burchett
Kentucky Health News

Three Kentucky health departments are among the first in the nation to be considered for national accreditation, a process that could help improve patient care and put the agencies in closer touch with their communities' needs.

The national Public Health Accreditation Board will make its first accreditation decisions next week. Among the first group being considered are the Franklin County Health Department, the Three Rivers District Health Department in Carroll, Gallatin, Owen and Pendleton counties, and the Northern Kentucky Independent District Health Department, in Boone, Grant, Kenton and Campbell counties.

The decision will be a historic one, and this is an exciting time for the board and Kentucky, said board Chair Dr. Douglas Scutchfield, professor of health services research and policy at the University of Kentucky College of Public Health.

The accreditation program was launched in September 2011 after a seven-year development process aimed at advancing quality and performance and value in the departments, and their accountability to stakeholders, Scutchfield said.

Departments are assessed by rigorous standards tested in 30 diverse health departments across the country to ensure essential public health services are provided in the community, according to the board's website. Two of the 12 "domains" of the standards deal with administration and governance. In Kentucky, state law makes county health boards responsible for the health of the county. Counties served by district health departments still have county boards.

Accreditation can help a board and department identify opportunities to improve performance and management, and to improve relationships with the community, since the process requires a community health assessment, a community improvement plan and a strategic plan to address the need of the community, said Scutchfield.

The process, often called "Mobilizing for Action through Planning and Partnerships," can help boards and departments be better prepared to proactively respond to emerging and re-emerging health challenges. For a PDF of Franklin County's MAPP document, click here.

The accrediting board has received 108 applications from health departments around the nation: 13 state health departments, 94 local health departments and one tribal agency. In addition to the three Kentucky agencies being considered in the first group, the other Kentucky departments that have applied for accreditation and are awaiting site visits are Lexington-Fayette County, Barren River District, Madison County and Christian County, Jill Midkiff, chief spokesperson for the Cabinet for Health and Family Services, said in an email.

The accreditation process encourages departments to move away from the "silo" model to collaborate with community programs. In Christian County, it has changed the way department employees view their jobs, because they have to continuously reflect on their methods and brainstorm for ways to improve, Health Department Director Mark Pyle told Nick Tabor of the Kentucky New Era.

"Accreditation will likely open new revenue streams," Tabor writes. "But in a way, the process matters more than the status designation."

Midkiff said, "In addition to benefiting from the process itself, our federal and state resources in public health are increasingly shrinking, we are being asked to do more with less. And there is a need for transparency within agencies."

Midkiff said accreditation "may make the agency more competitive for grants in the future. We are actually seeing quality improvement and performance management requirements being written in many federal grants now, so it is being expected at the national level."

Although accreditation is completely voluntary, it is being encouraged for local health departments by the state Department for Public Health, which is in the process of applying for its own accreditation in 2014. Midkiff said the department just completed its state health assessment, which is now being reviewed, and is beginning to assemble partners to write a state health improvement plan, which should take about a year.

Kentucky Health News is an independent service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Health boards support legislative agenda to change how public health is delivered and paid for, to make Kentucky healthier

By Melissa Patrick
Kentucky Health News

At their first-ever statewide meeting, Kentucky's local boards of health voted for their state association to adopt a legislative platform aimed at modernizing the state's public health systems in order to improve Kentucky's overall health.

The "Kentucky's Public Health 3.0" plan calls for local health departments to demonstrate measurable outcomes, a supportive framework of state laws, and secure funding for all the services the law requires them to provide. The goals match the recently launched national Public Health 3.0 initiative.

During the online meeting Jan. 12, former Pendleton County judge-executive Henry Bertram, the president of the Kentucky Association of Local Boards of Health, implored board members to support the plan as a way to improve the health of Kentuckians and to better use taxpayer dollars: "We’re not spending our money correctly.”

"It's a call to action," said Bertram, who has been a member of his local health board for 16 years. He added, “The biggest voice in Kentucky for public health is the board members. . . . And I say that because many of you are elected officials that sit on those boards of health. You're county judges, you're magistrates," and medical professionals. "You've got a voice in your community.”

Bertram went on to say that while Kentucky has some excellent local health directors, "Many of us who sit on local boards of health don’t know what our responsibilities are." He said that when he became judge-executive, he didn’t even know that he was on the health board by virtue of his office.

He said it is the responsibility of health board members to fully understand why Kentucky's health is so poor and be able to explain why change is necessary.

“We’ve got to step up; we’ve got a challenge in front of us and we’ve got to hit it head-on," he said.

The plan has also been endorsed by the Kentucky Public Health Association and the Kentucky Health Department Association.

What exactly is Public Health 3.0?

Georgia Heise, health director for the Three Rivers District Health Department in Northern Kentucky, opened the meeting by stressing that Public Health 3.0 is a "grass-roots initiative" meant to improve the health of Kentuckians, not part of "Obamacare." She said in a telephone interview that such a false perception could cause some people, including legislators, to not even listen to the proposal.

“We have to separate population health, the health of our citizens, from politics. We have to. We cannot continue to do the same old, same old thing and expect different results," said Heise, who is also the president of the National Association of County and City Health Officials.

Graphic from Kentucky Health Departments Association presentation

Heise said people must first realize that "public health is not clinical, medical care," but is grounded in prevention through population-health initiatives.

"The work that has already been done with this initiative can be explained and it can be defended and that is what we need you board of health members to help us do with our legislators," she said.

Dr. Karen DeSalvo, acting secretary for health in the U.S. Department of Health and Human Services, appeared via video recording and commended Kentucky for leading the way with this initiative. She focused her comments on the plans call for health departments to join forces with community stakeholders to address the social determinants of health, because "We know that health is more than health care. . . . Our goal is to change the conversation in this country and get every sector involved in improving health and well-being."

For example, health department officials should be included in planning and zoning meetings to make sure newly developed properties include sidewalks, said Allison Adams, director of the Buffalo Trace District Health Department and the KHDA president. Health officials should advocate for "health in all policies," she said.

Adams noted that social and economic factors, such as education, employment, income, family and social supports, and community safety, contribute to 40 percent of a typical person's health, and "none of those things happen inside the walls of the health department. . . . But it's our job to be conveners of bringing these groups that affect these health factors together and letting them know . . . decisions they make and the things they do, how that influences health and the opportunity to be healthy."

The plan also calls for public-health leaders to be the chief health strategists in their communities; encourages health departments to work toward national accreditation; and calls for increased county-level health data so they can make more informed decisions.

What state law requires each Kentucky health department to do
(Click on image to view a larger version)

At the state level, the plan calls for "enhanced and substantially modified funding" for public health. Adams said it is largely funded programmatically, but departments get "very little funding" for their statutory requirements, the things that state law requires them to do. She estimated a $40 million gap between funding and what it costs to meet the requirements.

"There’s no doubt about it, our funding needs to be modified," Adams said. "We need to figure out a way to spend $1 that affects 10 people, instead of $1 that only affects one person." But she acknowledged, "Change is never easy. There will be difficult decisions to make."

But as she described Kentucky's dismal health statistics, noting that the state ranks 45th for health, she said it's time to do something differently, because what we've been doing isn't working.

"My goal is for us across the state of Kentucky to get as angry about the fact that we are 45th in the nation as we would when our basketball teams fall out of the top 25," Adams said. "I think if we could all get angry about that, we could move mountains here in the state of Kentucky."

State's new health commissioner, Dr. Jeffrey Howard, is called 'a breath of fresh air' by a local director who's seen six of them

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Kentucky's recently installed health commissioner is a 30-year-old doctor, two years short of being a surgeon, a goal he still plans to achieve. But right now he's in charge of public health in a state with huge health issues, and local health departments with big financial issues.

Dr. Jeffrey Howard is still learning. He will graduate from Harvard University's master's of public health program in May and has enrolled in a master's of business administration program that he plugs away at on Saturday mornings.

He started working at the Kentucky Department of Public Health in July 2017 when then- Commissioner Hiram C. Polk asked him to come on as a senior adviser. Howard said he got to know Polk when he was a surgical resident at the University of Louisville, particularly after he was named the 2014 Hiram C. Polk Jr. Student of the Year. He became acting commissioner in November 2017 after Polk resigned, and was appointed commissioner in July.

Commissioner Jeffrey Howard talks with Kentucky Health News
reporter Melissa Patrick. (Photo by state spokesman Doug Hogan)

Howard said in an interview that one of the reasons he's uniquely qualified for the job is that he's at the beginning of his career, not the end, and is "young, bright and innovative."

Kentucky River District Health Department Director Scott Lockard, who has worked in public health for 28 years, praised Howard at a session on health at the recent Shaping Our Appalachian Region Summit, where Howard spoke.

"We can see that he is sincere. He has a passion for what he is doing," Lockard said. "To me, his willingness to look internally at processes and say, 'We can do better,' is a breath of fresh air."

Howard added that he's also experienced the issues around substance abuse "from the inside out," having lived with an addicted mother and stepfather until he was 14, and because he was "born, bred and raised" in Eastern Kentucky and understands the culture that prevails in rural areas and often leads to poor health outcomes.

Howard told the story of how his grandmother, a "brittle diabetic" with bilateral amputations, kidney failure resulting in dialysis, and early onset Alzheimer's disease, who didn't know much about her disease and like many Eastern Kentucky folks, "you don't talk about your illness." She died at 55.

"I understand probably better than most people why rural Kentuckians make the decisions they do," he said. "We have a culture in Kentucky, and especially rural Kentucky, on how we handle our own personal health that leads to poor outcomes. I do it all the time."

Fran Feltner, director of the University of Kentucky's Center for Excellence in Rural Health, said she was energized by Howard's heart.

"I think that somebody from our region that understands our Appalachian culture will do such a great job at the state to represent us, as well as the rest of the state," Feltner said. "And I'm honored that he is truly from his heart working on the issues that we have in rural Kentucky. I think he's going to make a big difference and I'm ready to join him and work really hard to make that difference."

Howard added that even though his grandmother died when he was 15, she had a "profound impact" on him because when they were alone she would tell him he was going to be a doctor, which he said made no sense since his father had dropped out of high school in ninth grade, his mother and step-father were addicted, and no one in his family had ever gone to college.

"That impact gave me the public-health bug that I didn't know I had until two or three years ago," he said.

Local needs and solutions

Howard said he is driven by his desire to improve health outcomes in Kentucky, which leads the nation in cancer and deaths from it; heart disease; adult asthma and chronic obstructive pulmonary disease; obesity, and diabetes.

He is also working to improve the relationship between the state and local health departments, and has created an advisory committee led by local health department directors that meets weekly to talk about the issues facing the departments.

"My firm belief is that the issues of health and health outcomes in Kentucky exist locally and the solutions are local," Howard said. "I've tried to bring an air of transparency as far as how public health is run from the state to locals, so that they know and understand what we're dealing with here and how our funding streams are driven and how that we can better support them."

Howard said he is also working to make sure that "small wins" in public health are celebrated, by emphasizing them at state and local meetings, and to uplift all health department employees at both levels by sending personal notes that recognize both celebrations and concerns.

"I realized early on that our local health departments felt at arm's length, and I didn't want that," he said. "So one of my goals was to bring those relationships closer together."

Lockard, who sits on the advisory council said, "I feel more a part of the Department of Public Health right now, the statewide department. I feel like there is a more sincere effort being generated right now to be a sincere partner with the local health departments, to really be concerned about what is needed at the local level and how do we work together to make that happen."

Lockard, who has worked with six health commissioners in his 28 years said of Howard: "I've seen many different commissioners, many different styles, all of them had their strengths, all of them had their opportunities for growth, and I'm just very excited to be working with this commissioner. I think he's the right man in the right place at the right time and I just hope he stays a while with us."

Pension crisis and local health departments

Howard said the strength of the state health department is its people, who work with a commitment to their jobs that was "through the roof." He said its weaknesses and threats include lack of money, especially for employee pensions.

This year, the legislature froze for one year the pension contributions of health departments and 11 of the state's 14 community mental health centers, which were facing increases in pensions of 49.5 to 83.4 percent, averaging 69 percent.

Lockard said, "July 1 of 2019 is the cliff that we're all afraid of falling off, so we're doing things differently now. We're trying to look, we're trying to plan. Of course we're going to try to advocate to see if we can postpone this," as the legislature let County Employees Retirement System do, phasing in changes over 10 years. "What can we do? How can we change our mode of operation?"

Lockard said his Kentucky River health department, which serves Lee, Wolfe, Owsley, Leslie, Perry, Knott and Letcher counties, "is in the most challenging financial shape of any health department in the Commonwealth."

Howard said he was working with his advisory committee and the Kentucky Health Departments Association on a plan for what to do if the health departments get no further relief from their pensions.

Howard said making health departments pay more than 49 percent of payroll to fund pensions "isn't sustainable for any business model," and as many as nine departments would have to close in 14 months if the planned increases took effect. He said the "prudent thing to do" is to start sharing resources across jurisdictions, and that must be driven by local health directors.

"I don't want health departments to close, because I know how important those local health departments are," he said. "But we've got to get to the point where we're sharing services, we have to do that." Without sharing, "We are really going to have to look at" redrawing the boundaries of district health departments, "and I know a lot of locals don't want that," he said.

Kentucky's health issues

Opioids: Howard called substance abuse "by far the number one health issue in Kentucky," noting that almost four Kentuckians die a day from it. He said his agency's main role is to gather and analyze data, but "I think you're going to see more education programs, more awareness programs. You're certainly going to see funding for treatment to a degree that you've never seen before."

Adverse childhood experiences: "It's one of those issues that is incorporated into every discussion involved in some manner."

Hepatitis A: In the same month Howard became acting health commissioner, the health department declared an outbreak of hepatitis A in Kentucky. Since August 25, it has reported 1,562 cases, 881 hospitalizations and 12 deaths. Howard said the epidemic will likely last another eight to 12 months in the state. The primary risk factors remain illicit drug use and homelessness; so far, no cases have been linked to a contaminated food source.

Asked what message he wanted to convey about hepatitis A, he said, "I would really like to emphasize that you are OK to go out to eat in your local restaurants. The risk of getting Hepatitis A from an infected food worker as long as they are adhering to normal precautions is very minimal."

Statewide smoking ban: Howard's position is the same as that of Gov. Matt Bevin: "Localities should decide what is right for them, and so I will never go out and say we need a statewide smoking ban. What I will say is smoking is bad and I think you ought to have that conversation locally. If you want me to be a part of that conversation and come into your locality and say smoking is bad, then I'll do that because that's what I believe, but I won't tell you from a state level that this is what I demand you do, and I think that's fairly consistent with our governor's position."

Innovation and partnerships

Howard has several initiatives in motion that involve partnerships with other organizations.

One partners UK and the Foundation for a Healthy Kentucky to adapt how health departments do their community health assessments so they ultimately allow local agendas to drive the state assessment. UK will produce an academic publication of this first-of-its-kind process, and the foundation will spread the word about how important community assessments are.

Community health assessments are a systematic examination of the key problems and assets in a community, which are then used to develop strategies to address community needs. Howard said he considers them to be the "cornerstone to driving public-health outcomes in Kentucky."

Howard has also commissioned research by UK's College of Business and Economics to show how investments in health affect the economy. He expects it to be ready in the spring of 2019.

"One of the things that I want to emphasize is that health and the economy are linked. We talk about it a lot, but I want to be able to give you some numbers," he said. This will help "me to emphasize the role of public health" and to "talk to our citizens and our legislators in really tangible terms."

Howard is also working on an initiative to align the efforts of the department with health-care providers, and with UK to study how state health departments work with medical societies on public-health issues.

State health commissioner retiring after seven years in the job, fighting for public health and expanding its role

By Tara Kaprowy
Kentucky Health News

After dealing with the aftermath of 9/11, an anthrax scare, H1N1 flu, the worst ice storm in Kentucky's history and a series of budget cuts, it's been a busy decade for Dr. William Hacker at the state health department. But after 10 years at the agency, seven as its boss, Hacker will retire at the end of the month.

He is getting great reviews for his work as commissioner, which has included expanding the role of public health beyond its traditional roles, including disaster response and prevention.

"Dr. Hacker has always provided quality leadership," said Scott Lockard, president of the Kentucky Public Health Association. "He has been a great advocate for public health. He has been well respected both in state and on the national level and he will be deeply missed."

"Dr. William Hacker has been an exemplary leader for public health and has led by example with his professional and genteel leadership style," said Linda Sims, director of the Lincoln Trail District Health Department and president of the Kentucky Health Department Association. "Dr. Hacker has been instrumental in helping local health departments during budgetary challenges with guidance and support. The development of new services and screenings for children have increased under his efforts that will make a difference for many years to come."

Hacker, a native of Manchester, joined the department in February 2001 to work in the maternal and child health division. He'd practiced as a pediatrician in Corbin for 18 years and subsequently spent six years with Appalachian Regional Health Care.

Just eight months after he came on board at the health department, his role expanded drastically. "On 9/11, we were asked how many burn beds we had available in Kentucky because they felt they would be flying burn victims to us," he said. "We had never had funding to establish the ability to actually track the beds available. Public health did not have a role to play in critical health care. But they called on public health that day."

Three weeks later, suspicious white powder started appearing in the mail, and public health offices nationwide were called again. Though anthrax spores were not found in Kentucky, envelopes containing white powder were, and they needed to be tested by public-health officials.

Dr. Rice Leach, then the commissioner, asked Hacker to establish the Public Health Preparedness Branch of the Division of Epidemiology and Health Planning, marking a major shift for the department. Traditionally, public health had not been involved in incident management, which occurs when first responders are sent in to handle a crisis. "We were the backup to deal with consequence management," Hacker said. "But when you're dealing with bioterrorism, public health needs to step in. There was a lot of learning that went on between law enforcement, emergency medical services and public health. That was a cultural shift. We were forced through the natural evolution of events to step up to the plate."

In 2004, following Leach's retirement, Republican Gov. Ernie Fletcher named Hacker commissioner. He established the Kentucky Outreach and Information Network, which expanded the department's ability to reach vulnerable populations like senior citizens and people with language, hearing or motor difficulties. Partnerships are still in place with other state agencies, Family Resource Youth Service Centers, literacy programs and faith-based organizations such as the Christian Appalachian Project. "We'd say, 'Here's the message we need to get out, whether we were talking about a hot weather advisory or how long is it safe to eat food out of your refrigerator if your electricity is out," he said.

In 2005, Hurricane Katrina struck New Orleans, prompting several thousand people to come to Kentucky. "We had to figure out how to take care of these people without any resources and many times without any family connections," Hacker said. Hurricanes Gustav and Ike followed, presenting similar challenges.

The next major disaster was the 2009 ice storm. The role of public health was to provide shelter, which Hacker called "a major challenge." But emergency stockpiles obtained by the Public Health Preparedness Branch proved useful. "We use cots, satellite radios and generators that were supposed to be used for an inflatable hospital," he said. "That provided power in Elizabethtown."

Emergency stockpiles were also tapped for items like face masks in 2009-10, when people started getting sick with H1N1. "We responded efficiently because of the training we had been planning for," Hacker said. In 2006, department officials prepared extensively for a bird flu "that is still smoldering," Hacker said, but has never reached the ability to spread quickly from person to person.

In the middle of all this, the state changed governors, but not health commissioners. Democratic Gov. Steve Beshear, who took office in December 2007, appointed a new secretary of the Cabinet for Health and Family Services, but showed confidence in Hacker by keeping him as commissioner of the cabinet's Department of Public Health. "I was prepared for Gov. Beshear to select someone else, but I was very pleased when he gave me the opportunity to continue to serve," Hacker said. Apart from Leach and Dr. Carlos Hernandez, Hacker has served one of the longest terms of any commissioner in the past 40 years.

Beshear told Kentucky Health News in July 2011, "Dr. Hacker’s commitment to public health and education is unassailable, and he provided great leadership and vision for our Department of Public Health. Dr. Hacker built teams, mentored, encouraged and connected organizations and people to achieve better outcomes for Kentuckians’ health. His success is largely driven by his belief in inclusion -- that bringing together many organizations can improve health in Kentucky. Kentucky will miss him."

Beshear's retention of Hacker greatly pleased Al Smith, who had just concluded 33 years as producer and founding host of "Comment on Kentucky" on KET. A former newspaper publisher in London and Western Kentucky, Smith helped Hacker campaign for a comprehensive hospital to serve Corbin and London. "He was ahead of his time, as usual, and we lost the political game," Smith recalled. "Fortunately, his great gifts have been appreciated by the state and other health providers who have kept him in leadership for many years. I hope there will be other opportunities for his influence and service at another time. . . . In or out of public service, Dr. Bill Hacker is a leader who always seeks the best for Kentucky."

Asked his biggest accomplishment, Hacker named two: leaving behind a capable team and establishing the Preparedness Branch, which he said is now deeply embedded. "I have a personal relationship with senior FBI agents that did not exist before," he said. "We have a very close partnership with emergency management officials. And we're close with the Department of Agriculture because of the correlation between animal diseases and human diseases. All those partnerships have positioned Kentucky's government entities to be more responsive."

That responsiveness, however, has a lot to do with funding, which Hacker said is his biggest worry, because public health tends to be invisible. "If you ask, most people think public health just takes care of poor people. We, in fact, take care of all forms of people. It's just we do our jobs well and so it's invisible to those folks unless they need a public health service."

Already, Hacker has dealt with several rounds of budget cuts and is worried that "political leaders and the public don't really understand the impact of what the future may look like" with a less well funded public health system. "It could mean slower response to diseases, slower response to disasters, less cervical cancer screening, less prenatal care. There's a whole host of services being provided but they cost money," he said.

Still, though it's not without concern for the future of the department, Hacker, 64, said it's time to head home. He will continue to live in Lexington. "My wife has some health problems and for 44 years she's made sacrifices to support my career. I think the time has come to reverse the equation," he said. "My decision to leave was a difficult one because I love the mission of public health. But it became clear to me that this was the right time to transition from employment to retirement. I will continue to support the mission of public health in any way I can contribute."

Dr. Steve Davis, longtime deputy commissioner of the department, will take over as interim commissioner Aug. 1. He called Hacker "a good doc and a good man. Simply put, we have been blessed to have him for many years."

Virus has spread too much for contact tracing to contain it, but tracing can still help, especially if more people would cooperate

By Lisa Gillespie
Kentucky Health News

In wide swaths of Kentucky, tracing the contacts of people with the coronavirus is no longer preventing its spread, because the spread has become too wide. Instead, it is, at best, slowing the disease rate. And many people don't cooperate with the contact-tracing process.

That’s according to several local health department officials, including Roanya Rice. She’s the public health director at the North Central District Health Department, which includes Spencer County, where over 10% of residents have tested positive for the virus, as of last week.

“It’s not a situation now that we can contact-trace our way out of,” Rice said. “The window of opportunity to contact-trace to eliminate the spread has come and gone.”

Some people don't welcome contact tracing, which usually includes an official request that they isolate for 10 days in case they have the virus. Gov. Andy Beshear said this week that there has been a decline in cooperation by people who have been identified as a recent contact or have tested positive..

Lincoln Trail District Health Department Director Sara Jo Best said she and her staff get the feeling that some people who have tested positive don’t want to provide a list of their recent contacts.

“I feel like there are cases that are not being 100 percent truthful in their contacts,” said Best, who is based in Elizabethtown. “I think they're intentionally leaving some of those off, because people don't want to be quarantined.”

Beshear said some people reached by contact tracers are unresponsive or don’t self-isolate as requested.

"They could lead to another spike,” he said. “This is a war. Whether we win or lose, how many Kentuckians we lose, it's all based on the number of battles that we win, or lose. So please, don't get tired. Let's pick it up. ... Lives depend on it."

Local health officials say most people cooperate when a contact tracer reaches out. They say they have only rough and unscientific estimates on the percentage of people who are not cooperative, because the state only recently provided a uniform platform for health departments to track cases. Department directors, when pressed, estimated noncompliance between 2% and 40%. 

Barren River District Health Department Director Matt Hunt said the people who are not cooperative in his eight-county region are mainly those without symptoms. His district includes Barren County, where more than 10% of residents tested positive for the virus Aug. 15-21, the most recent week of the White House Coronavirus Task Force report.

“We do have some that deny the test results, [say] that it can't be, [they] don't have symptoms,” Hunt said. “Those are typically asymptomatic individuals. Those are difficult conversations to have.”

Others have used a “critical worker exemption” to refuse quarantine after a high-risk exposure. State Health Commissioner Steven Stack announced Wednesday, Aug. 26, that he had eliminated the exemption for workers in food, health care, energy and other critical industries, saying it had become “fairly distorted . . . Health departments are finding all sorts of people are claiming they’re critical infrastructure workers.”

Meanwhile, health department directors across the state say the virus has spread so much within communities that contact tracing is not containing the spread of the virus. Lexington-Fayette County Health Commissioner Kraig Humbaugh said that’s partly because of how the virus works; the key time to get folks to quarantine is when they start to show symptoms. But many never have symptoms.

“Normally [the contacts] are infectious a couple of days before they even start to show symptoms, if they show symptoms, and then 25 percent of them don't,” Humbaugh said. “So you've got all those people that are also potentially infecting others in the community. It just kind of builds on itself. It is so much easier for this strategy to work when we're in the containment phase.”

Department for Public Health graphic; for a larger version, click on it.

Kentucky has funds to hire 700 contact tracers and has hired 550, with at least one in every county. That leaves room for 150 spots. Mark Carter, the state official leading contact-tracing efforts, estimates those new hires will be made by or around mid-October, depending on the spread of the virus.

“The Department for Public Health assessment of tracing state-wide is that we have sufficient tracers,” Carter said. “The primary issues have been in masking and social distancing; that places a burden on tracing. So, I think it would be fair to say tracing is helpful, but by itself it cannot stop the spread. I do agree that certain districts are in a mitigation phase,” not a containment phase.

With many Kentuckians ignoring the mask mandate and social-distancing guidance, which is difficult to enforce, health officials say contact tracing is the actionable thing health departments can do to fight the virus without a vaccine.

But the funding for tracers runs only through December, and it’s unclear whether Congress will provide more. Hunt, with the Barren River health department in Bowling Green, is hoping the money doesn’t run out before he needs the help the most.

“I want to try to stay two to three steps ahead,” Hunt said. “If I see a spike, like instead of having 25 or 30 to investigate a day, it jumps up to 75, then I’ll start to think about, okay, we need to bring more people in.”

Contact tracing does play a role in fighting the virus, even if it’s not containing spread. Public Health Director Clayton Horton of the Green River District Health Department in Owensboro said at the very least, tracers provide important education about the virus. And it can be critical for Kentuckians who were already living in relative isolation.

“We have people that are in isolation that don't have friends and family that can help support them,” Horton said. “We have people that have real needs in terms of food and medicine, and we're able to help with that, and if we weren't there, they certainly would break their isolation and put others at risk of becoming infected.”

Another issue that may add to noncompliance is the changing guidance from the federal Centers for Disease Control and Prevention about who should be tested. Horton said one recent change, already walked back, has already created confusion and resistance to the department’s guidance.

“We had contacted them to say, you've had contact with someone that was infected,” and advised them to quarantine, Horton said. “And they said, ‘Well, I just saw on the CDC website this morning that I don’t need to do these things,’ and it was just kind of a misinterpretation.”

CDC now says people who have been exposed but have no symptoms "may consider testing." Kentucky officials are still recommending that such people get tested, because people without symptoms can still spread the disease.

Non-existent numbers

By the start of September, the majority of state health departments should be using new technology to track covid-19 data, called the Contact Tracing and Tracking system. Data on the virus now, other than the raw numbers of who has tested positive, are almost nonexistent.

“As of next Monday (8/31), all but one local health department will be CTT; at that point we will be in a much better position to be able to report this data,” Carter said. I would say that by the end of September or mid-October, we will have some usable data from the system.”

At the start of the pandemic and even now, many departments were using paper charts to log cases; others were using internal systems.

Most health department directors said they’ve just been trying to keep on top of new cases and contacts. There hasn’t been time for analysis.

That's a real disadvantage, said Best, with the Lincoln Trail district. She wants to know the number of contacts who test positive for the virus. She wants to know the percent of people who never respond to their calls, and those who initially are cooperative but then no longer answer calls or emails. She wants to know not just her district's own numbers, but also the state-wide average.

“If I know that of one thousand contacts, 20 percent of those are probably going to convert to a positive, that helps me plan,” Best said. “Or if the state's average is 20 percent, and my average is 40 percent, maybe I need to re-look at how we're educating people on isolation and quarantine. I might need to evaluate what I'm doing because it's not it's not effective. It gives you kind of benchmarks like that when you're looking at data.”

And this information might just make contact tracing a stronger tool.

Health officials and advocates list Kentucky's top 5 health issues, including one newly identified: adverse childhood experiences

About 125 people worked on the state health assessment at the
Kentucky History Center in Frankfort on Wednesday, March 22.

By Melissa Patrick
Kentucky Health News

A group of about 125 people spent March 22 with officials from the Kentucky Department of Public Health to prioritize the top health issues in the state, and after a long, deliberate process decided they were substance abuse, obesity, tobacco, health-care access and adverse childhood experiences.

"Adverse childhood events" such as abuse and household dysfunctions, like having a household member in jail or coming from a divorced family, can have lasting effects on health and well-being.

ACEs affect 59 percent of Kentuckians, according to the 2015 Kentucky Behavioral Risk Factor Survey, the first one to include questions about 11 such events. The results showed that Kentucky has a higher-than-average percentage of people with six or more ACEs.

"There are things that happen to us early that make a huge difference as we get older," Dr. Connie White, senior deputy commissioner of the state health department, told the gathering of about 125 people, about half of them from outside the agency.

As for the other big issues, "Eating less, good exercise and not smoking would solve so many of our problems," said Deputy Secretary Tim Feeley of the Cabinet for Health and Family Services. He said the solution to Kentucky's health problems rested in early health education and personal responsibility.

"There isn't a pill that will fix everything," he said. "We need to make people more responsible, more in tune with their own health and we need to do that through education; we need to do that through access to good health care that encourages them to do it that way."

Various health officials reviewed data on the state's health, reminding the room full of health-minded participants that Kentucky has the nation's highest smoking rate (26 percent of adults) and the highest rate of new hepatitis C infections; has seen its opioid overdose deaths triple between 2006 and 2015; is largely sedentary; and has some of the nation's highest rates of cancer, diabetes, heart disease and obesity.

One of the few bright spots in the overview was the drop in the share of Kentuckians without health insurance, from 18 percent to 7 percent since the implementation of the Patient Protection and Affordable Care Act. This was largely because Kentucky expanded Medicaid under federal health reform to those who earn up to 138 percent of the federal poverty level.

Throughout the meeting, participants expressed concerns about Republican plan to repeal and replace the Patient Protection and Affordable Care Act, which among other things would phase out the Medicaid expansion, drop the requirement to cover 10 essential health benefits and turn Medicaid into a block grant program and give the states control of it.

Allison Adams, director of the Buffalo Trace District Health Department and president of the Kentucky Health Department Association, gave an overview of Public Health 3.0. This national initiative calls for local health-department leaders to become the "chief health strategists" in their communities, focusing on prevention and social determinants of health. This new approach to public health relies on health departments working with community partners to address the health needs of their community.

Participants wrapped up the day-long meeting by forming work groups centered around each of the five identified priorities. The groups were charged to find out what is already being done in the state around these issues, and to then decide the best holistic plan to "move the needle forward."