Transcript Overview of Department of State health services

TEXAS DEPARTMENT OF STATE HEALTH SERVICES
PROCESSES AND PROGRAMS
John Hellerstedt, M.D.
Commissioner
Texas Hospital Association
Leadership Fellows Program
September 8, 2016
Presentation Overview
• Overview of Department of State Health Services (DSHS)
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Transformation
DSHS – Public Health Agency
Legislation and Rules
Stakeholder Engagement
• Public Health Initiatives
• Selected Highlights
• Zika Update
• Closing Remarks
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OVERVIEW OF DEPARTMENT OF STATE HEALTH
SERVICES (DSHS)
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Health and Human Services (HHS)
System
Governor
Inspector
General
HHS Executive
Commissioner
Chief Deputy
Executive
Commissioner
Legal Services
Chief Ethics
Officer
System
Internal Audit
Chief of Staff
Ombudsman
External
Relations
Chief Operating
Officer
*State Operated
Facilities
Division
Medical & Social
Services
Division
Transformation
Policy and
Performance
Information
Technology
Commissioner
Protective Services
(DFPS)
Procurement &
Contracting
Services
Financial
Services
Commissioner
Public Health
(DSHS)
System Support
Services
*Commissioner
Aging & Disability
(DADS)
*Regulatory
Services
Division
Administrative
Administrative Services
Services Division
Division
Access &
Eligibility
Services
Health,
Developmental
& Independence
Services
IDD & Behavioral
Health Services
Community
Community Services
Services
Medicaid &
CHIP Services
On September
September 1,
1, 2017,
2017, DADS
DADS ceases
ceases to
to exist
exist and
and
* On
its remaining functions transfer to the Regulatory
its remaining functions transfer to the Regulatory
and
and State
State Operated
Operated Facilities
Facilities Divisions.
Divisions.
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HHS System Transformation
• S.B. 200 (84R), reorganizes the HHS System, moving
client services, regulatory, and facility operations to HHSC
• Transfers client services and certain administrative services
9/1/2016
• Transfers state hospitals, certain regulatory functions, and other
administrative functions 9/1/2017
• Focuses Department of State Health Services (DSHS) on
public health
• Abolishes State Health Services Council and creates HHS
System Executive Council 9/1/2016
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Department of State Health Services
Other Sunset-Related Changes
• S.B. 202 streamlines DSHS’ occupational regulatory functions
• Discontinued eight programs effective 9/1/2015
- Bottled and vended water
- Opticians
- Bedding
- Rendering
- Contact lens dispensers
- Personal emergency response systems
- Indoor air quality in state buildings
- Tanning bed facilities
• Transferred four programs to Texas Medical Board effective
1/1/2016
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Respiratory care practitioners
Medical radiologic technologists
Medical physicists
Perfusionists
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Department of State Health Services
Other Sunset-Related Changes
• Transfers 13 regulatory programs to Texas Department of
Licensing and Regulation and reconstitutes associated
independent boards as advisory committees
• Seven programs transfer by October 3, 2016
- Athletic trainers
- Dietitians
- Midwives
- Orthotists & prosthetists
- Fitters & dispensers of hearing instruments
- Speech-language pathologists & audiologists
- Dyslexia therapists & practitioners
• Six programs transfer by August 31, 2019
- Laser hair removal
- Massage therapists
- Sanitarians
- Code enforcement officers
- Mold assessors & remediators
- Offender education providers
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Department of State Health Services
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Department of State Health Services
• Vision - A healthy Texas
• Mission - Improving the health, safety, and well-being of
Texans through good stewardship of public resources, and
a focus on core public health functions
• Goals
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Improve health through prevention and population health strategies
Enhance public health response to disasters and disease outbreaks
Reduce health problems through public health consumer protection
Expand the effective use of health information
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Department of State Health Services
At-A-Glance
• Address a broad range of health
challenges
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Chronic diseases
Infectious diseases
Emergency response
Food safety
Maternal and children’s health
Access to health care services
• Collect healthcare data
• Centers for Health Statistics
• Vital Statistics
• Manage public health programs
• Regulation of health care
facilities
• Health care professions
• Radiation
• Drugs
• Medical device
• Regulation and licensing
• Health-related businesses,
equipment, facilities, and
occupations
• Operate and maintain stateowned facilities
• Direct inpatient/residential
services 24/7
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Department of State Health Services
Overview
• $2.2 billion FY 2017 budget
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29% is General Revenue (GR)
40% is Federal Funds
20% is GR Dedicated
11% is Other Funds
• 6% of Health and Human Services System budget and 2% of
state budget
• 11,669 FTEs (~8,000 in state hospitals)
• ~160 DSHS sites
• Everything from Alzheimer’s and Ambulances to Zoonosis and
Zebra Meat
• Impacts everyone in Texas, every day
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Department of State Health Services
Programs and Services
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Disease Control and Prevention Services
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Family and Community Health Services
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Coordinates with local health departments and jurisdictions on public health services
and activities
Office of Assistant Deputy Commissioner
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Develops and implements population-based public health initiatives aimed at
improving health outcomes across the lifespan
Regional and Local Health Services
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Implements programs to protect, promote, and improve the public’s health by
decreasing health threats and sources of disease
Provides oversight for state hospitals, academic affairs, health policy, health statistics,
vital statistics, and border health
Regulatory Services
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Provides public health oversight of individuals and entities that provide consumer and
health services and goods to the general public
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REGULATORY SERVICES
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Regulatory Functions
• Establish standards within
statutory authority, through a
stakeholder-inclusive rule
development processes
• Provide public/licensee
education and technical
assistance
• Issue licenses/certifications
• Conduct compliance activities
(inspections, surveys, sampling,
and complaint investigations)
• Perform internal quality
assurance activities to ensure
appropriateness and consistency
of regulatory activities
• Initiate enforcement actions
to promote compliance
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Regulatory Services
• Public health oversight of individuals and entities that provide
consumer and health services and goods to the general public
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Food and Drug Safety
Environmental Health
Radiation Control
Health Care Professionals Services
Health Care Facilities Services
Disaster Preparedness and Response
Emergency Medical Services and Trauma Care System
• 22 Trauma Service Areas (TSAs)
• Each TSA has a Regional Advisory Council (RAC)
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Trauma Service Area Map
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Regulatory Services
RAC Responsibilities
• Create and maintain both trauma and stroke system plans
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Minimize the time from onset of injury/illness to appropriate definitive quality care
Tailored response based on regional resources and patient needs
Arrangement of available resources (EMS providers, hospitals)
Coordination of effective delivery of emergency health care service
• Facilitate participation of EMS and designated trauma facilities
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There is at least one level III (advanced) designated trauma facility in each RAC
RAC participation is required for designated facilities and EMS entities that receive
DSHS funding
• Maintain all hazards emergency preparedness and response
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Emergency Medical Task Forces (EMTFs) exist within each RAC to handle
disaster preparedness coordination
Establish plans and secure needed equipment and supplies
Participate in training and exercises
Collaborate with other partners in response
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Legislature and State Agencies
• The state legislature sets policy and budget priorities
• State agencies, including DSHS, are limited to the authority the
legislature grants them through statutes, federal rules, and
appropriations riders
• Implement, operate, and maintain what the legislature decides
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Implementing laws and federal rules
Receiving and distributing funds
Formulating strategic goals
Adopting rules
Determining service delivery or tactical approaches
Acting as the authority on key public health issues
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84th Legislative Session
Selected Legislation
• Rider 81 – Public Health Inventory and Action Plan
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Requires DSHS to do a comprehensive inventory of the roles, responsibilities, and
capacity relating to public health services
Inventory is being used to establish statewide priorities as well as regional goals
and strategies for the public health system
• S.B. 18 – Graduate Medical Education (GME) Research
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Requires DSHS to conduct research on the GME system in Texas to identify
specialties and subspecialties that are at critical shortage levels
• Special Provision Rider 45 – Early Elective Deliveries
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Requires DSHS and HHSC to take specific steps to improve data and oversight to
reduce the rate of early elective deliveries in Texas
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84th Legislative Session
Selected Legislation
• S.B. 200, Section 2.31 – Chronic Respiratory Disease Strategic Plan
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Requires the development of a strategic plan to significantly reduce morbidity and
mortality from chronic respiratory disease, including asthma and chronic
obstructive pulmonary disease (COPD)
• S.B. 200, Section 2.32 – Human Papillomavirus (HPV) Strategic Plan
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Requires the development of a strategic plan to significantly reduce morbidity and
mortality from HPV-associated cancer
• H.B. 2950 – Task Force on Infectious Disease Preparedness and
Response
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Creates an advisory panel to the Governor to provide expert, evidence-based,
assessments, protocols, and recommendations related to infectious disease response
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85th Legislative Session
Potential Areas of Interest
• Using analysis of health data to identify efficiencies and
inform policy making
• Capacity and infrastructure of inpatient psychiatric
services system
• Infectious disease preparedness and response
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Statutes And Rules
• Statutes – created and passed by Legislatures as broad policy
mandates (the “what”)
• Rules – adopted by state agencies to provide more detailed
regulations (the “how”)
• Examples of DSHS rules initiated in response to statutes
• Newborn screening for critical congenital heart disease
(HB 470, 83rd Session)
• Photo identification badges for hospital personnel
(SB 945, 83rd Session)
• Standardized patient risk identification system – wrist-band colors
(SB 7, 82nd Session)
• Freestanding emergency medical care facilities
(HB 1357, 81st Session)
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Stakeholder Input
DSHS seeks stakeholder input in developing rules and policies
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Facilitating stakeholder meetings to obtain input on rule revisions
early in the development process
Posting draft rule revisions on the website
Sending draft rule revisions to stakeholder lists, trade associations, and
professional organizations, such as THA and TMA
Seeking advisory committee input
Receiving public testimony at HHS Executive Council meetings
Posting proposed rules in the Texas Register and considering
comments received during the formal public comment period
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DSHS PUBLIC HEALTH INITIATIVES
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Public Health Initiatives
Selected Highlights
• High Consequence Infectious Diseases
• Healthcare Associated Infections and Preventable
Adverse Events
• Neonatal and Maternity Services
• Maternal and Child Health
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High Consequence Infectious Diseases
Suspected Ebola Patients: Steps for Hospitals
• Screen all incoming patients for travel/exposure history and
symptoms
• Identify patients with travel/exposure history and symptoms of Ebola
and/or other high consequence infectious diseases
• Isolate those patients deemed to be at risk in a private room and limit
entry to room
• Protect staff who enter the room through the use of appropriate
personal protective equipment
• Inform hospital/facility infection control staff and local health
department
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Healthcare Associated Infections and
Preventable Adverse Events
• Preventing Healthcare Associated Infections (HAIs) and Preventable
Adverse Events (PAEs)
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Chapter 98, Texas Health and Safety Code, (Reporting of Health Care-Associated
Infections and Preventable Adverse Events), and 25 Texas Administrative Code,
Chapter 200 (Health Care-Associated Infections) require the DSHS to establish the
Texas HAI Reporting System
Created to provide the public with HAI data and to support quality improvement
and infection control activities in health care facilities
Texas General Hospitals and Ambulatory Surgery Centers (ASCs) are required to
report HAIs and PAEs
• Central Line Associated Bloodstream Infections (CLABSIs), Catheter Associated Urinary
Tract Infections (CAUTIs), and Surgical Site Infections (SSIs)
• Adverse health care-associated condition/event for which Medicare will not provide
additional payment to the facility or an event included in the list of adverse events
identified by the National Quality Forum
• Reporting information available at
www.dshs.texas.gov/IDCU/health/infection_control/hai/Reporting.doc
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Healthcare Associated Infections and
Preventable Adverse Events
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Healthcare Associated Infections and
Preventable Adverse Events
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DSHS produces annual report on HAI data. The 2014 annual is available
online.
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www.dshs.texas.gov/IDCU/health/infection_control/hai/HAI-Annual-Report.doc
Total 430 Texas health care facilities reported some HAI data in 2014 with 852
CLABSIs, 1,797 CAUTIs, and 2,906 SSIs identified
• CLABSI rates for Texas were statistically better than the national baseline
• CAUTI rates for Texas were statistically worse than the national baseline
• SSI rate for Texas was statistically better than the national baseline
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DSHS Certified Infection Control (CIC) Epidemiologists strategically located
in health service regions to help support facilities reporting and control of
HAIs.
DSHS HAI Audit Team conducts audits to validate data on reportable
infections associated with specified procedures.
Separately, hospitals may now enroll in DSHS-funded service for C. difficile
isolate typing and prevention consultations.
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Neonatal and Maternity Services
Improving Perinatal Outcomes
• Neonatal outcomes should be improved by objectively determining level of
care capabilities at each facility
• ~600 hospitals in Texas
• 254 hospitals report having obstetrical services
• Neonatal services are currently not tracked
• House Bill 15 (83R), Texas Health and Safety Code, Chapter 21,
Subchapter H
• Requires a level of care designation for neonatal and maternal care in order to
be eligible to receive reimbursement through the Medicaid program
• Neonatal Level of Care Designation required by 9/1/18
• Rules were adopted 6/9/16
• Maternal Level of Care Designation required by 9/1/20
• Perinatal Advisory Board has developed the first draft of rules; rules to be adopted
by 3/1/18
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Neonatal and Maternity Services
• House Bill 2131 (84R), Texas Health and Safety Code,
Chapter 32, Subchapter D
• Directs DSHS to establish Centers of Excellence for Fetal
Diagnosis and Therapy
• Designate one or more health care entities or programs in Texas,
including institutions of higher education
• Perinatal Advisory Council to make recommendations for
designation rules
• Members of the Centers of Excellence for Fetal Diagnosis and
Therapy subcommittee have been appointed. First subcommittee
meeting was held on 9/1/16
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Maternal and Child Health
• Healthy Texas Babies
• Breastfeeding and Lactation Support
• Maternal Mortality and Morbidity Task Force
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Birth Rate in Texas and US
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Infant Mortality Rates
(United States & Texas, 2005-2014)
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Ethnic Disparities in Infant Mortality
(Texas, 2005-2013)
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Percent of Infants Born Preterm
(United States & Texas, 2005 – 2014)
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Ethnic Disparities in Preterm Births
(Texas, 2005-2014)
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A High Human Cost of Prematurity
• Low birth weight
• Underdeveloped organs or organ systems
• Increased morbidity
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Breathing problems, including respiratory distress syndrome
Life-threatening infections
• Increased risk of disability
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Cerebral palsy, blindness, and deafness
Chronic lung disease
Learning and developmental disabilities
• Increased mortality
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Premature birth is the number 1 killer of newborns
Increased early childhood and late childhood mortality
• Significant impact on the family
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Medicaid Costs
Preterm Births/Low Birth Weight
• Approximately 53% of all Texas births (213,253) paid by Medicaid
• Over $3.5 billion per year for birth and delivery-related services for
moms and infants in the first year of life
• Medicaid newborn average costs
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Prematurity/low birth weight complications
Full-term birth
$ 109,220
$
572
• In FY2015, Medicaid paid over $402 million for newborns with
prematurity and low birth weight
• Care delivered in the neonatal intensive care unit (NICU) is now the
costliest episode of medical care for the non-elderly population
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Healthy Texas Babies
• Fosters coordinated efforts by stakeholders to improve the
health of babies in Texas
• Five program components
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Someday Starts Now
Professional Education
Support of Local Perinatal Coalitions
Preconception Peer Educator Training
Support of the Texas Collaborative for Healthy Mothers and Babies
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Someday Starts Now
• Public health awareness campaign to improve preconception health,
and ultimately, birth outcomes
• Websites with public health messaging and tools
• Life Planning Tool — assists women with planning their reproductive
future and discussing their plans with their provider
• Birth Planning Tool — assists women in planning for the delivery of their
baby and discussing her preferences with her provider
• Key Message
• If there’s a baby in your future, today matters
• Stop smoking, eat right and exercise, and do something about your stress
• Whether you’re a man or a woman, your health today matters to the baby
you might have… someday
www.somedaystartsnow.com
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Breastfeeding and Lactation
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Exclusive breastfeeding for the first 6 months of the baby’s life is the goal
Texas has reached public health targets for breastfeeding initiation, but falls
behind targets for exclusivity and duration
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Healthy People 2020 targets are 81.9% for ever breastfed and 25.5% infants
exclusively breastfed through 6 months
83.3% of Texas infants born in 2012 were ever breastfed, but Only 21.0% exclusively
breastfed through 6 months
Multi-pronged approach to achieve the goal
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Baby Friendly Hospitals
• As of June 2016, 14.8% of Texas live births occurred in an accredited in Baby-Friendly
facilities, surpassing Healthy People 2020 goal of 8.1 %
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Mother Friendly Worksites
• 2,300 worksites as of August 2016 (~1,000 % increase since 1996-2009)
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Additional Breastfeeding Initiatives
• Hospital-based (Texas Ten Step Program)
• Community-based (Child Care Provider Training)
• Environmental and Social Support (Every Ounce Counts – PSA)
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Maternal Mortality and Morbidity
Task Force
• Senate Bill 495 (83R)
• Created a multidisciplinary task force to study maternal mortality
and morbidity cases in Texas
• Charges
• Review maternal death cases
• Study statewide trends in pregnancy-related deaths and severe
maternal morbidity
• Make recommendations to help reduce incidence of maternal
mortality and severe maternal morbidity
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Maternal Mortality and Morbidity
Task Force
• Findings
• Mental health (perinatal/post-partum depression) and substance use disorders play a
significant role in maternal death and contribute to severe maternal morbidity
• Repeated missed opportunities to screen for and refer women to treatment for
mental health and substance use disorders
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• A majority of maternal deaths occur later than 60 days after delivery
Recommendations
• Increase screening for, and referral to, behavioral health services
• Increase access to health services during the year after delivery and throughout the
interconception period
• Next Steps
• Joint report by DSHS and the Task Force due to the Governor on September 1, 2016
• http://dshs.texas.gov/Legislative/Reports-2016.aspx
• DSHS and the Task Force will continue the review of maternal death cases,
analysis, and make recommendations for prevention of maternal mortality and
morbidity
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ZIKA UPDATE
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Zika - Situational Perspective
Global
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Outbreaks are
occurring in many
countries
Zika is expected to
be much less
widespread in the
U.S. than in Brazil
or Puerto Rico
Socioeconomics has
impacted the spread
of Zika (access to
screens, AC, insect
repellent, integrated
vector management)
* As of August 31, 2016
** As of September 6, 2016
U. S.
U.S. States*
• Travel-associated cases: 2,686
• Locally acquired vector-born cases:
35
• Laboratory acquired cases: 1
• Total: 2,722
Texas
• 160 confirmed cases directly or indirectly
travel-related**
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• Sexually transmitted: 23
U.S. Territories
• Travel-associated cases: 51
• Locally acquired vector-born cases:
14,059
• Total: 14,110
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No local mosquito transmission in Texas
to-date
6 cases was pregnant
2 cases were infants infected before birth
1 case was sexually transmitted
Will likely experience small flare-ups of
local transmission by mosquitoes at
some point
Some areas are at higher risk (North
Texas, Rio Grande Valley, Gulf Coast)
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Zika - Current Texas Situation
• As of September 6, 2016, Texas had 160 reported cases of
Zika.
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Bell (5)
Bexar (10)
Brazos (2)
Collin (5)
Dallas (34)
Denton (4)
El Paso (2)
Ellis (1)
Fort Bend (7)
Frio (1)
Gray (1)
Galveston (3)
Grayson (1)
Greg (1)
Hamilton (1)
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Harris (45)
Jefferson (2)
Lubbock (1)
Matagorda (1)
Medina (1)
Midland (1)
Montgomery (1)
Palo Pinto (1)
Randall (1)
Tarrant (18)
Travis (3)
Val Verde (1)
Walker (1)
Williamson (4)
Wise (1)
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Texas Zika Plan
• DSHS has finalized an updated version for the state response plan for
Zika.
• Distributed to local health departments and posted on www.TexasZika.org
• Original draft was updated based on community input, emerging
information, and feedback from experts
• Plan divided into three levels of response
• Level 1: Prior to local mosquito transmission
• Level 2: Potential case of local transmission
• Level 3: Sustained local transmission
• Plan format
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Communications/Public Health and Medical Information
Mosquito Surveillance and Control
Human Surveillance
Command, Control, and Coordination
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Texas Zika Actions
• Strategies used to protect our most vulnerable Texans must
make scientific and public health sense.
• Areas of focus to ensure we are doing everything we can right
now to delay and prevent Zika.
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Communicate Precautions
Articulate Outlook
Expect Local Transmission
Define Area
Prevention – Now and Later
Describe Response Plan to Public
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Texas Zika Actions
Communicate Precautions
• Communicate and educate clearly about prevention and recruit
community volunteers to help amplify messages:
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Create barriers against mosquito bites (repellent, clothes)
Create barriers in human habitats (screens, AC)
Deny breeding habitats (standing water, larvicide)
Spraying adulticide
• Most expensive and least effective
• Attacks last and hardest link in the transmission chain
• DSHS has initiated several communication, education, and awareness
activities:
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www.Texaszika.org
Public awareness campaign
Webinars and educational opportunities
Guidance document for schools and daycares
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Texas Zika Actions
Articulate Outlook
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Articulate the Zika outlook, and what our response is going to look like
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Be on top of evolving information and make honest estimations about expectations
and plans for response
Expect small pockets of cases in limited clusters rather than widespread
transmission – response will be precision strikes in defined areas
People may be alarmed if they do not see the response they expect
Openness and candor now, builds trust
Specifically, the response to local transmission will include
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Prompt communication of status and response plan
Redoubled prevention efforts
Guidance to local health care providers
Targeted integrated vector management within 150 meters of instances of vector
transmission
Targeted community outreach and education across entire area
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Texas Zika Actions
Expect Local Transmission
• Be on high alert and act fast when local transmission occurs
• Work together to analyze and respond to evidence of possible local
transmission (symptom onset, travel history, mosquito exposure, lab
results)
• Ensure consensus between local, state, and federal entities about whether
local transmission has occurred
• Characterizing a case as local transmission will be collaborative
• Because of the potential to cause great public concern, must work together to
minimize confusion and anxiety
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Texas Zika Activities
Define Area
• Have ability to precisely define the area of recommended testing for
pregnant women if local transmission occurs
• Define area in close coordination with local and federal partners.
• Likely an area of at least one mile in diameter centered on a public
landmark or intersection to preserve privacy of known cases
• Must be able to provide testing to all pregnant women who spend
significant time in this defined area
• Be on alert for signs of tests outstripping capacity
• The area may grow or shrink depending on how events unfold
• There may be smaller, more targeted vector control efforts within this area
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Texas Zika Activities
Countermeasures
• Know and use our universal Zika countermeasures
• The tools we have to prevent Zika are the same one we have to
combat it when it arrives
• Priorities for prevention and response should be based on an
assessment of each community’s risk profile
• Factors that increase risk include
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Low public awareness of threat and prevention
Lack of access to barriers
Lack of barriers in structures
Presence of breeding habitats close by
Lower socioeconomic status
• Greatest Challenge: The Call to Action
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CLOSING REMARKS
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Partners in the Public Health System
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THANK YOU
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