September 24, 2024 Board of Health Meeting Minutes

Otero County Board of Health Meeting

September 24, 2024, 11:00 am
Otero County Courthouse, Rm. 107
La Junta, Colorado

Members Present: 
Dr. Paul Yoder, President and Medical Officer
Dr. R.J. Nelson, Vice President
Lindsey Hart
Dr. David Trujillo

Member(s) Absent:
Mark McCuistion

Ex Officio:
Jim Baldwin, Otero County Commissioner
Richard Ritter, BOH Secretary, OCHD Executive Director 
Amy White-Tanabe, Otero County Administrator

Government:
Tim Knabenshue, Otero County Commissioner

Legal:
Nathan Shultz, J.D., OCHD Attorney

OCHD Staff:
Marie Mora-Menges, Nursing Program Director
Chris Coffield, RHC
Dr. Janell Maier, Disease Prevention & Control/EPR Program Director
John Miller, Business Manager
Donna Starck, STEPP Program Director

Minutes

1. Call to Order: A quorum being present, the meeting was called to order by Dr. Yoder. 
2. Public Notice Posting (Pursuant to C.R.S. 25-1-509(2)(f), C.R.S. 24-6-402 (2)(c)(I), & C.R.S. 24-6-402(2)(c)(III)): The 2024 BOH meeting schedule was posted on the BOH website on 11/30/2023, and the agenda was posted in the designated public locations in all OCHD offices and on the BOH website by 9/18/2024.
3. Public Comment: There were no public comments.
4. Consent Agenda (ACTION ITEM)
   1. Approval of Minutes (previously sent on 8/1/2024 & 9/17/2024)
      1. July 30th, 2024, Regular BOH Meeting
   2. Contract Ratification (Pursuant to C.R.S. 25-1-508 (5)(k) & C.R.S. 25-1-511 (3))
      1. 2024-2025 CDPHE ELC 2.2 Purchase Order
         • Number: PO,FHCA,202500002964
         • Purpose: CDPHE financial support for OCHD’s Epidemiology and Laboratory Capacity (ELC) activities.
         • Status: Fully Executed
         • Term: 8/1/2024-7/31/2025
         • Amount: $105,367.59
      2. 2024-2025 Trailhead/AmeriCorps Master Services Agreement
         • Contract : 24ACD-CPHW05
         • Purpose: Extension of Trailhead’s support for OCHD’s AmeriCorps member.
         • Status: Fully Executed
         • Term: 9/1/2024-8/31/2025 (total of 450 hours during this term)
         • Amount: $8,735.29
      3. 2024-2025 CDPHE PHEP Contract Amendment #1
         • Purpose: CDPHE support for OCHD’s Emergency Preparedness and Response Program.
         • Status: Fully Executed
         • Term: 8/20/2024-6/30/2025
         • Amount: $74,116.00
           • No change to the current contract amount. This amendment updates the contract language.
      4. 2024-2025 Crowley County/SECOR Professional Services Agreement
         • Purpose: Support for OCHD’s Tri-county (Bent, Crowley, Otero) CTC/CSUPRC school-based SUD prevention activities.
         • Status: Fully Executed
         • Term: 8/28/2024-8/27/2025
         • Amount: $588,311.60
      5. 2024-2025 Trailhead Institute’s RHC Master Services Agreement
         • Contract: RHC Region 6 HB1244
         • Purpose: Trailhead Institute’s support for OCHD’s Regional Health Connector (RHC) Program.
         • Status: Fully Executed
         • Term: 7/1/2024-6/30/2025
         • Amount: $56,000.00
      6. 2024 Crowley County Public Health Services Contract
         • Purpose: Crowley County support for OCHD’s public health services in Crowley County.
         • Status: Fully Executed
         • Term: 1/1/2024-12/31/2024
         • Amount: $16,197.00
   3. Approval of Consent Agenda and Approval/Ratification of Items Therein: R. Nelson moved to approve the Consent Agenda and ratify the items therein, D. Trujillo seconded, motion carried. 
5. Old Business
   1. None
   2. Addendum/Addenda: None
6. New Business
   1. Budget (Pursuant to C.R.S. 25-1-508 (5)(k) & C.R.S. 25-1-511 (3))
      1. Financial Summary Report (Based upon Tyler Financial Systems reports dated 9/18/2024)
         • July 2024
           • Revenues: $200,013.68  
           • Expenditures: $140,808.00 
           • Surplus: $59,205.68 
           • Fund Balance: $2,821,258.38 
         • August 2024
           • Revenues: $279,837.72 
           • Expenditures: $138,723.99
           • Surplus: $141,113.73
           • Fund Balance: $2,962,372.11 
      2. Approval of Expenditures (ACTION ITEM): D. Trujillo moved to approve the July 2024 & August 2024 expenditures in the amounts of $140,808.00 & $138,723.99 respectively, R. Nelson seconded, motion carried. 
      3. 2023 OCHD Fiscal Performance (based upon Tyler Financial Reports dated 8/1/2024): At the end of 2023, OCHD’s fund balance was $3,066,617.18, which represents an increase of $467,063.68 over the 2022 year-end fund balance of 2,599,553.50. Revenues for 2023 amounted to $2,203,381.50, and 2023 expenditures were $1,736,317.82. OCHD received 110.37% of its budgeted revenues, and only expended 86.82% of its budgeted expenditures. This large surplus follows a nationwide trend. In a Pewtrusts.org article dated 5/10/2022 and entitled Budget Surpluses Push States’ Financial Reserves to All-Time Highs (Budget Surpluses Push States’ Financial Reserves to All-Time Highs | The Pew Charitable Trusts (pewtrusts.org)) the following statement appears “During fiscal 2021 alone, states grew their collective rainy day funds by $37.7 billion, or an increase of roughly 50% from a year earlier—driving the total held among all states to a record high of $114.6 billion. Moreover, amid widespread budget surpluses, states reported the largest annual increase in leftover general fund budget dollars (known as ending balances) in at least the past 21 years.”
      4. Fund Balance Importance: The fiscal reserves of the fund balance are critical funds that are used in times of necessity and after use should eventually be replenished to a sufficient level dictated by generally accepted financial/accounting principles. They serve as a protection by covering deficits caused by lost funding, unexpected expense, leadership transition, etc. Fund balances are required by C.R.S. 29-1-103 (2) if an adopted budget shows expenditures exceeding revenues. Regarding reserves in a fund balance, three important questions should be considered:
         • Liquidity: Does the organization have adequate cash to meet its month-to-month operating needs?
         • Adaptability: Does the organization have flexible funds that allow for adjustments, growth, and change?
         • Durability: Does the organization have access to funds to address a variety of future needs to deliver its mission over the long-term?
         • Regarding its ability to respond to the projected deficits, OCHD is in good financial shape. During the last 24 years OCHD has been deliberately building its fund balance to withstand financial tempests. In July 2000 (the month before R. Ritter was employed as executive director) OCHD reserves amounted to $104,699. The approved budget for that year was $837,237. The reserves at that time amounted to 12.5%. In fact, for one month during these fiscally troublesome times OCHD literally went bankrupt, with an approximate -$6,000 fund balance. At the September 2000 staff meeting, R. Ritter devoted most of the meeting to the budget and the dire necessity for staff to work together to build the fund balance. Subsequent staff meetings always had (and continue to have) a budget component. OCHD staff answered the call, and today the department is
           very well positioned financially.
         • “Trigger Point”: From the 3/26/2013 BOH Meeting, “R. Ritter has identified the “trigger point” to consider staff and operational adjustments, and that point is when the fund balance reaches or is approaching 25% of the operating budget at the end of a calendar year without a balanced budget or surplus identified for the subsequent year(s).” Principal factors to consider when contemplating financially driven operational adjustments: Statutory, regulatory, & contractual requirements.
         • In a 9/24/2024 Governing article titled “The Coming Policy Backwash from the COVID Revenue Wave” the following statements appeared:
           • “…states and localities need to plan ahead for more cyclical self-sufficiency and expect more-stringent strings on future federal bailout funds.”
           • “Recipients of countercyclical aid should be required to demonstrate that they have prudently maintained a federally qualifying rainy-day fund as a condition of receiving that aid.”
           • “Bluntly, states and municipalities must learn to be rainy-day savers because modern Congresses clearly won’t.”
         • Pew Trust article dated 3/12/2022, the following statement appeared: “Deposit extraordinary revenue into the rainy-day fund”
      5. Fund Balance Multi-Year Perspective 2001-2023: At the beginning of 2001, the fund balance was $181,723.74. At the end of 2023, the fund balance was $3,066,617.18, which is 16.8752 times the beginning amount in 2001.
      6. Fund Balance Recommended Amounts: Good financial principles dictate having between 3 to 6 months (25%-50%) of the operating budget in the fund balance. OCHD’s operating budget for 2024 is $1,979,314.00 (July 2024 Tyler Financial Report dated 9/4/2024). 25% of this amount is $494,828.50, and 50% is $989,657. OCHD’s fund balance beginning 1/1/2024 was $3,066,617.18 (12/31/2023 Tyler Balance Sheet report dated 8/1/2024), which is approximately 154.93% (or 18.592 months) of the proposed 2024 operating budget.
      7. 2024/2025 OCHD Budget Version 2 Approval and Adoption (ACTION ITEM)
         • Version 2024.2025.2
           • Overview
             • 2024 Budget Estimate
               • Revenue Estimate: $2,569,626
               • Expenditure Estimate: $2,049,370
               • Surplus Estimate: $520,256
             • 2025 Budget Request
               • Revenue Request: $2,064,419
               • Expenditure Request: $2,480,770
               • Deficit Estimate: $416,351
               • Deficit Offset: OCHD Fund Balance
           • Notes
             • This budget was sent to the Otero County fiscal staff and BOH on 9/10/2024.
             • Major 2025 Deficit Factor: The CTC/CSU SECOR grant is a one-time payment in full, and not on a monthly cost-reimbursement structure. The entire $588,311.60 will be deposited in 2024, with a projected $196,103.88 in expenses for 2024. The projected expenses for 2025 will be $392,207.73, with no deposits in 2025. This will lead to a deficit for 2025.
             • Otero County Government Information: CoLA ($50/month), performance evaluation increases (up to 3%), health insurance increase (7%).
             • Future Deficit Offsets: It is R. Ritter’s intention to use the fund balance to support staff and operations during times of deficit, which will happen, OCHD will have years when expenditures exceed revenues. C.R.S. 29-1-103(2) states “No budget adopted pursuant to this section shall provide for expenditures in excess of available revenues and beginning fund balances.” The foregoing applies to local government budgets, including OCHD’s. Thus, deficits are allowed if there are sufficient reserves to cover them in addition to projected revenues.
           • Approval/Adoption: R. Nelson moved to approve and adopt the 2024/2025 OCHD Budget Version 2 as detailed above, D. Trujillo seconded, motion carried.
   2. Personnel
      1. Status Change
         • Bianca Monnet, Full-Time: Ms. Monnet has transitioned to full-time WIC effective 9/3/2024.
   3. WIC Site Visit: OCHD’s WIC Program had a site visit from CDPHE on 9/17/2024-9/19/2024. Amy Armstrong, CDPHE WIC consultant to OCHD, performed the site visit. On 9/19/2024, Ms. Armstrong, the WIC Team, and R. Ritter had an exit meeting, during which Amy shared that the OCHD WIC Team is doing great work, specifically very good interactions with clients, good counseling styles, very personable, friendly, and warm. The few findings were very minor and readily correctable. Ms. Armstrong will provide a written report within the next few weeks. Very significantly, the OCHD WIC Program is well on its way to remediate all the findings (some are already corrected) listed on the 2024-2025 OCHD WIC Application Conditional Approval letter (shared with the BOH at the 7/30/2024 BOH Meeting). Congratulations and thanks to Ms. Monnet, Ms. Mora-Menges, and Ms. Segura on a job very well done!
   4. OCHD SUD Program Overview: Just as the OUD/SUD epidemic has grown in numbers and complexity over the years, so has OCHD’s response to it. OCHD’s response began pre-COVID-19 Pandemic as a HRSA planning grant, partnering with The Schreiber Research Group (TSRG) (https://tsrg.org) and the Pueblo Department of Public Health and Environment (PDPHE). The COVID-19 Pandemic reared its ugly head during this planning grant, and most certainly caused unanticipated challenges to the operationalization of said grant. Later, OCHD applied for and was awarded a CDPHE Overdose to Action (OD2A) grant to expand the SUD work. OCHD continued to partner with TSRG during this grant period. TSRG applied for, and was awarded, an SUD HRSA Implementation grant, focusing on the Counties of Bent, Crowley, and Otero. After the OD2A grant ended, OCHD partnered with TSRG to fulfill grant deliverables in the specified region. Additionally, TSRG applied for, and was awarded a Peer Recovery Support Specialist (PRSS) Trainee grant from HRSA. This grant led to and supported OCHD’s PRSS training program. More specifically, here are some bullet items providing more detail to this overview:
      1. Data dashboard: TSRG collects, analyzes, and reports data every six months,
         adhering to the requirements of a Health Resources and Services Administration
         (HRSA) Implementation IV grant. Information specific to SUD in Southeast, rural
         Colorado can be accessed at https://www.tsrg.org/community-outreach/dashboard
      2. CTC/CSU-PRC SECOR Grant: OCHD’s CTC Program, in partnership with Colorado State University-Prevention Research Center (CSU-PRC) (https://www.chhs.colostate.edu/prc/), through a generous grant from SECOR, is offering school districts in Bent, Crowley, and Otero Counties the opportunity to participate in an evidence-based program called the Blues Program. This program is a school-based prevention program for adolescents, ages 15-18, with depressive symptoms or adolescents who are at risk of onset of major depression. In addition to the implementation of the Blues Program, CSU-PRC is providing a robust evaluation component.
      3. The SAPIP (Substance Abuse Prevention and Intervention Program) Project, in collaboration with OCHD’s CTC Program, the Las Animas School District (Bent County) and TSRG, developed a baseline report outlining recommended prevention strategies for rural school districts. The project also assembled a team of prevention experts, including the CSU Prevention Center, CU Boulder, and the Colorado Department of Education, which ultimately helped create partnerships to secure funding through SECOR.
      4. TSRG’s partnership with Valley-Wide Health Systems, the Rural Recovery Network, and the Pew Charitable Trusts produced a comprehensive report, a peer reviewed journal article, a guidebook, and training videos on providing Medications for Opioid Use Disorder (MOUD) to individuals with OUD incarcerated in rural county jails.
      5. TSRG has partnered with the University of Nebraska and the Colorado Consortium to apply for grant funding to evaluate the impact of unpredictable release times from rural county jails, which can hinder access to treatment and transition services during a critical period when individuals are at heightened risk for overdose and return to use.
      6. In partnership with Elevate Healthcare, Fort Lyon, Denver Recovery Group, the Department of Human Services, the Otero County Sheriff, OCHD, and TSRG, a grant was submitted to establish a satellite methadone clinic in La Junta. This clinic would reduce the need for individuals in Southeast Colorado to travel to Pueblo or Lamar for daily methadone dosing.
      7. Needle Disposal Kiosks: R. Ritter has made contact with a member of La Junta City Council regarding Kiosk placement, and the city council member was in favor of further exploration. However, there has been staff turnover at CDPHE in the program overseeing kiosk placement, and OCHD is awaiting communication from the new CDPHE point of contact before progressing further.
      8. SUD Program Director: It became readily apparent early on that, due to the complexity, nature, and amount of SUD work to be done, OCHD would need an SUD Program Director to oversee this important work. Ms. Arlene Cooke was our first director, and she worked under, and was supported by, both the OD2A and HRSA Implementation Grants. After her resignation (effective 6/17/2024), Mr. Chris Menges was hired to replace Ms. Cooke. OCHD’s SUD Program continues to be supported by the HRSA grants through TSRG.
      9. PRSS Trainee Program: This is currently being funded by an HRSA grant through TSRG. OCHD hires individuals in active SUD recovery (some previously homeless as well) and places them for training and work at facilities that provide professional Peer Recovery Support Specialist (PRSS) services. This is somewhat akin to an internship, the PRSS trainees are OCHD employees, they are paid by OCHD (and reimbursed from HRSA through TSRG), and they are assigned a training facility. TSRG provides specific, PRSS supervision and training that culminates in a Colorado Providers Association (COPA) (https://coprovidersassociation.org/) PRSS Certification. OCHD provides general staff supervision through the SUD Program Director. The PRSS trainees also receive needed general, remedial training (i.e., computer, typing skills) that are essential for them to navigate and succeed in the modern place of business. This is a grant-dependent, term-limited program. At the end of the grant subsidy, the trainees’ employment with OCHD ends and they are prepared to enter the workforce as a certified PRSS.
      10. Workforce development: This is similar to the PRSS Trainee Program detailed directly above, but with a much more robust and greatly expanded scope of work. This program is not yet operational because the successful HRSA Impact Grant awardees have not yet been notified. If awarded, this grant will support and provide the following:
          • Potential trainees in recovery will be assessed for their readiness to enter the workplace.
          • Those assessed to be ready for job placement will be placed at a pre-identified and prepared recovery friendly worksite.
          • Trainees will receive ongoing support from OCHD and TSRG.
          • Worksites will be identified in advance as a recovery friendly worksite, and they will receive ongoing support from OCHD and TSRG.
          • As an incentive for the workplace to become recovery friendly, and to accept as an employee those in active recovery, the trainees’ salary and fringe will be fully subsidized by the HRSA Impact Grant.
          • Current collaborators include Fort Lyon/CCA, RESADA, Valley-Wide Health Systems, Oxford House, and the Colorado Workforce Center. If awarded, OCHD will reach out to businesses within the 3-county region of Bent, Crowley, and Otero to begin active recruitment of recovery friendly workplaces.
          • There is an inextricable interaction and connection between SUD and homelessness. As we increase the number of those in recovery, and as we successfully recruit, support, and retain recovery friendly workplaces, it only stands to reason that this will have a positive impact on reducing the number of those experiencing both acute and chronic homelessness.
          • OCHD is a recovery friendly worksite. Within the last few years, OCHD has employed multiple individuals in active recovery, some of which had previously experienced homelessness. Without doubt, there are more examples of individuals, in Southeast rural Colorado, that once suffered from SUD and experienced homelessness, but now have college degrees, jobs, vehicles, and homes. These success stories highlight that recovery is absolutely possible!
      11. HRSA Quarterly Meetings: This is where communication, collaboration, and cooperation between individuals and agencies occurs. Special presentations are arranged to increase knowledge of SUD services in our region. It is a very well attended meeting. Sub-committees that are going to arise due to this meeting include Harm Reduction, Methadone Medication Unit (anticipated), PRSS
          Recovery, SECOR Region 19, Workforce Development, and Primary Prevention.
      12. Brochure: Thanks to very generous assistance from Otero DHS, and specifically Molly Gearhart, OCHD now has a brochure to help guide and direct those seeking assistance with SUD recovery.
      13. A Path Forward/Safety Jam Event: It is hoped that this will become an annual event that promotes recovery and reduces the stigma of SUD. The first event, held in June of 2024, was very successful.
      14. Fort Lyon Recovery Walk: This is an annual OCHD/Fort Lyon awareness event regarding recovery and stigma reduction.
   5. Addendum: N. Shultz apprised the BOH that they may be serving in an administrative
      hearing in the future, and then he gave an overview of an administrative hearing process
      and procedures.
7. Program Reports
   1. DCEP/EPR, Dr. Janell Maier: General information
   2. Nursing, Marie Mora-Menges: General information
   3. STEPP, Donna Starck: General information
   4. Vital Statistics, John Miller: General information
8. Executive Session: Not requested nor required.
9. Adjournment: With no further business, P. Yoder adjourned the meeting.

Respectfully Submitted, 

Richard Ritter
Secretary, Otero County Board of Health
Executive Director, Otero County Health Department