Princess Health and Kenton County's approval of a needle exchange inches Northern Kentucky, hit the hardest by heroin, toward getting one. Princessiccia

Princess Health and Kenton County's approval of a needle exchange inches Northern Kentucky, hit the hardest by heroin, toward getting one. Princessiccia

county government county health boards county health departments health departments hepatitis c heroin HIV legislation local government needle exchanges public health

Gusty 16:40 Add Comment

The Kenton County Fiscal Court unanimously approved a mobile needle exchange program March 29, which moves the City of Covington's needle exchange program one step closer to fruition, Terry DeMio reports for the Cincinnati Enquirer.

The Fiscal Court's approval was one of several conditions required by the City of Covington to allow its exchange to move forward. Covington's plan also requires two other counties in the Northern Kentucky Health District to adopt exchanges (only Grant County has); limits access to only resident's of the district's four counties; and would move the exchange to St. Elizabeth Healthcare hospital.

In addition, it requires a one-for-one needle exchange and a mandate that all participants must be tested for hepatitis C, hepatitis B, HIV, and, where applicable, pregnancy. This condition is likely not legal and is being investigated by the Northern Kentucky's Health Board's legal counsel, DeMio reports.

Kenton County's plan differs from Covington's in that it mandates only the offering of these tests, DeMio reports.

Both plans will require the Kenton County Board of Health's approval.

Needle-exchange programs were authorized by the state anti-heroin law passed in 2015, and require both local approval and funding. They are meant to slow the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among intravenous drug users. Northern Kentucky has been hit the hardest in the state by heroin and its hepatitis C rates have been reported at 19 times the national rate.

The needle exchange would be funded by $250,000 from the R.C. Durr Foundation, and the health department would use its staff and already available testing to further pay for the exchange, DeMio reports.

The Fiscal Court also approved exploring the idea of building a community-wide addiction treatment center on the county jail grounds; putting $25,000 toward a heroin helpline; and approved a resolution to encourage the Northern Kentucky Board of Health to create a high-quality prevention and education program for the community.

The Northern Kentucky Area Development District has already put out proposals for the heroin helpline, DeMio notes. And County Judge-Executive Kris Knochelmann told him that Boone and Campbell counties were willing to consider putting $25,000 each toward it, and that St. Elizabeth had promised $75,000 toward its operation.

The other needle exchanges in the state that are either operating or have been approved are in Louisville and Lexington and in the counties of Pendleton, Carter, Elliott, Franklin, Grant and Jessamine.

Princess Health and Boyd, Clark counties approve needle exchanges; Boyd's is a limited, one-for one; Covington's proposed limits draw objections. Princessiccia

Princess Health and Boyd, Clark counties approve needle exchanges; Boyd's is a limited, one-for one; Covington's proposed limits draw objections. Princessiccia

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Gusty 16:00 Add Comment

By Melissa Patrick
Kentucky Health News

Clark and Boyd counties are the ninth and 10th Kentucky counties to approve a needle-exchange program, and Madison and Anderson counties are talking about it. Meanwhile, the city of Covington has approved an exchange with conditions that don't match its health department's plan, and one of the conditions might not even be legal.

Needle exchanges were approved under the state's anti-heroin law passed in 2015, and require both local approval and funding. They are meant to slow the spread of HIV and the hepatitis C virus (HCV), which are commonly spread by the sharing of needles among intravenous drug users.

Clark County Health Director Scott Lockard noted that the federal Centers for Disease Control and Prevention has "identified 54 counties in Kentucky as being vulnerable to rapid dissemination of HIV or HCV infection among persons who inject drugs. Of the top 25 most vulnerable counties in the nation 16 of them are in our state."

Clark County

On March 23, the Clark County Fiscal Court approved on a 4-2 vote a needle exchange that will start on or before June 1, but the program will need re-authorization in January, Greg Kocher reports for the Lexington Herald-Leader.

"Both the Fiscal Court and the [Winchester] City Commission inserted a sunset clause in the orders requiring the health department to present data on our program in January 2017 in order to get re-authorization for a longer time period," Lockard told Kentucky Health News in an e-mail.

He noted that the CDC identified nearby Wolfe County as the most vulnerable county in the nation to rapid dissemination of HIV and HCV among drug users, with adjoining Powell and Estill counties 15th and 25th, respectively.

"Residents from all three of these counties frequently come to Clark County for medical services from our provider community and the health department," he said. "More must be done in the area of prevention if we are to avoid a situation similar to what Scott County, Indiana, encountered."

That county, about 30 miles north of Louisville, has drawn national attention for its high rates of HIV and hepatitis C, mostly caused by intravenous drug users who share needles. According to published reports, "from November 2014 to mid-June 2015, the Indiana county of 24,200 reported 170 HIV cases. It reported 130 new cases of hepatitis C in 2014," noted Bill Robinson of The Richmond Register.

According to Lockard, Clark County's program will use a patient negotiation model, which does not require a one-to-one needle exchange, during the initial visit, but will try to get close to a one-for-one model on subsequent visits.

"We will educate participants that they need to return needles to get needles," he said.

Boyd County

The Boyd County Fiscal Court voted 4-1 March 15 to approve a one-to-one needle exchange for one year, Lana Bellamy reports for The Daily Independent. 

The Ashland City Commission had already given its approval for the exchange, which may begin as early as July. Bellamy reports that the program will be paid for by special taxing districts, and all of the fiscal court members voiced concerns about the sustainability of the funding.

Ashland-Boyd County Health Department Director Maria Hardy told the court that syringes typically cost about 97 cents each, but the health department will be able to buy needles from a distributor for 9 cents each, Bellamy writes.

The Boyd County program will assign tracking numbers to its participants to protect their identities and allow a maximum of 40 needles to be exchanged each week.

County Commissioner John Greer, the only member to vote against the resolution, said he was concerned the program would encourage drug abuse and Sheriff Bobby Jack Woods agreed, Bellamy reports. This is a common concern among opponents of needle exchange programs, though evidence-based studies have proven otherwise.

Covington

During the same week, the City of Covington approved a needle-exchange program, but with conditions that could kill the program, Terry DeMio reports for The Cincinnati Enquirer.

The conditions are that all participants be tested for hepatitis C, hepatitis B, HIV, and, where applicable, pregnancy. That could be illegal, DeMio reports.

A Northern Kentucky Health Board spokeswoman told DeMio that they believe that they cannot require anyone to undergo any medical procedures, but said they were checking with legal counsel. Other health and harm-reduction officials told DeMio that this requirement is not legal, and that such a condition would likely prevent a program from getting off the ground.

"The Covington commission's resolution includes other conditions that differ from the health board's model program, too, and would require passage from the Kenton County Fiscal Court and the Board of Health before it's approved," DeMio writes.

These conditions include a requirement that two other counties in the Northern Kentucky Health District also adopt a needle-exchange program (only Grant County has); restrict use of the program residents of the district's four counties; and moving the exchange to St. Elizabeth Healthcare hospital.

The city also wants a one-for-one exchange, Michael Monks reports for The River City News.

The health department says its plan is "need-based," not one-for-one, because studies show that is the best way to reduce the risk of community exposure and spread of HIV and HCV. This is the main goal of the program, although needle-exchange programs also provide HIV and HCV testing and access to drug treatment.

The health department's plan is to initially provide clients with the number of syringes they would use in a week, along with a safe container for their return with instruction to return the used needles for new ones. Participants who don't return dirty needles after three trips would not receive new syringes, DeMio reports.

The department has been trying to establish needle-exchange programs in the district since the law passed one year ago. The Kenton County Fiscal Court is expected to discuss a needle exchange plan March 29, DeMio reports.

Dr. Lynne Saddler, the health department's director, told the Enquirer "that the Covington resolution was a start and that more discussion is planned by the health department."

Other counties

Madison County Health Department officials are also worried about becoming another Scott County, Indiana, as they face an epidemic of heroin use in their county, Bill Robinson reports for The Richmond Register.

Thus they have begun the process of educating their public officials, Robinson writes. Public Health Director Nancy Crewe presented her detailed findings to support a needle exchange at a quarterly joint meeting of the county Fiscal Court, Richmond City Commission and Berea City Council, noting that they were just beginning the long process of educating the public.

A needle exchange program was also brought up at the March meeting of the Anderson County Fiscal Court meeting, and was met with some disparaging remarks, Ben Carson reports for The Anderson News.

"What jackass thought of that idea?" asked Magistrate David Montgomery. "We might as well give them the dope, too."

Despite these comments, Montgomery did volunteer to be on a committee to explore a needle exchange program along with members of the health board, Lawrenceburg City Council, law enforcement, EMS and county jailer.

Robinson also reports that the Bourbon County Fiscal Court has voted to reject an exchange.

The other needle exchanges in the state that are either operating or have been approved are in Louisville and Lexington and in the counties of Pendleton, Carter, Elliott, Franklin, Grant, and Jessamine.

Princess Health and Princess Health andState Supreme Court says county boards of health cannot enact smoking bans by regulation.Princessiccia

Princess Health and Princess Health andState Supreme Court says county boards of health cannot enact smoking bans by regulation.Princessiccia

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Gusty 19:10 Add Comment

By Al Cross
Kentucky Health News

County health boards in Kentucky do not have the power to ban smoking in public places, the Kentucky Supreme Court ruled without dissent Thursday.

The decision was a stiff blow to health officials who see smoking as the primary factor in making Kentucky one of the least healthy states, and have sought state and local smoking bans to limit exposure to second-hand smoke. It struck down a ban in Bullitt County and presumably will do likewise for those enacted by the Clark, Madison and Woodford county health boards, which joined the case. (Click on map for larger version)

Justice Bill Cunningham, who wrote the decision, noted that the U.S. surgeon general has found "many of the chemicals inhaled through second-hand smoke are known carcinogens" and "that even short-term exposure to second-hand smoke can result in serious health consequences. In 2009-10, overall second-hand smoke exposure by Kentucky adults was 51.4 percent, with 30 percent reporting exposure in the workplace and 32.8 percent reporting exposure in public places. Given such dismal data, it is understandable that many health-care professionals and government officials have sought to curtail the prevalence of this noxious fume. Promoting a smoke-free society is a reasonable goal grounded in sound research. However, when promotion becomes enactment, even the most virtuous causes must also be grounded in law."

Health boards enacting bans have relied on a 1954 state law that gives them to power to adopt regulations "necessary to protect the health of the people." To find that law as "sufficient grounding for the regulation," Cunningham wrote, the court would have to construe the law "as delegating the totality of the Commonwealth's police power to the health boards. Nothing would remain to be ceded by the General Assembly, including the critical legislative charge of distinguishing virtue from vice."

Cunningham said such a ruling would "promote an overly broad delegation of legislative sovereignty," in violation of the state constitution. He said the authorization of regulations was limited, and was based that view on what he called the law's legislative history. In 1954, he wrote, "It would have been
commonplace for members of the General Assembly to indulge in a cigarette or cigar in their offices, committee rooms, or even on the floors of the House and Senate chambers. Most likely, the . . . legislation was debated and voted in chambers fogged with a haze of smoke."

Thursday's decision overturned a 2-1 ruling of a Court of Appeals panel that relied partly on the 1984 Supreme Court decision that upheld a Jefferson County regulation on lead paint. Cunningham said that was based on a law that "specifically addressed lead poisoning and expressly authorized and encouraged action at the local level," and "There is no similar statutory mandate" in state law for smoking bans.

Cunningham also noted that most of the Jefferson County board is appointed by local officials, while health boards in other counties are appointed by the state health secretary "and not by duly elected representatives. When regulating controversial issues traditionally within the province of state or local legislative entities, this structure is constitutionally problematic in that it does not comport with traditional notions of representative government." In this case, the Bullitt County Fiscal Court filed a lawsuit challenging the health board's authority.

The appeals court, in rejecting the fiscal court's case and overturning the local circuit court, also relied on a 1967 decision upholding a local health board's regulation of private sewage disposal systems. Cunningham said that decision was strongly based on earlier cases on the topic, and in contrast, there is no "well-established line of authority regarding the need for administrative regulation of smoking and second-hand smoke."

Finally, Cunningham said legal precedents in Kentucky say that "Where reasonable doubt exists concerning the proper scope of an administrative agency's authority, it should be resolved against the agency," and "An increase in the aggregate power of administrative agencies over the recent decades, if left unchecked, invites the ascendance of a fourth branch of government�the regulatory state."

Princess Health and Three Kentucky health departments in first group up for national accreditation; requires local health assessment, improvement plan.Princessiccia

Princess Health and Three Kentucky health departments in first group up for national accreditation; requires local health assessment, improvement plan.Princessiccia

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Gusty 14:41 Add Comment

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.

Princess Health and Some Christian Co. health board members balk at director's idea of using $100,000 of $2.4 million reserve for recreational trail.Princessiccia

Princess Health and Some Christian Co. health board members balk at director's idea of using $100,000 of $2.4 million reserve for recreational trail.Princessiccia

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Gusty 09:20 Add Comment

The director of the Christian County Health Department urged its board to give $100,000 from reserves to fund a rail-to-trail project to provide residents with new opportunities for exercise.

Coverting old railroad beds to recreation trails could help improve Christian County's infrastructure to promote healthy living, which is needed because a study last year ranked Christian County 116th out of Kentucky's 120 counties in this area, said Health Department Director Mark Pyle.

The department has $2.4 million in reserve, but several board members opposed the idea, citing a budget shortfall this fiscal year, financial troubles with the school-nurse program and delays in Medicaid reimbursements, reports Nick Tabor of the Kentucky New Era.

The City of Hopkinsville hopes to raise $400,000 for the first phase of the trail project. A recreational trail would initiate a culture change and residents should have public resources equal to those of other regions, Mayor Dan Kemp told Taylor.

Pyle told Tabor the trail would help the health department accomplish its goal of advancing public health, and the reserve money isn't there for sitting on. He said he believes the board will agree to using the money for the project at its next meeting, April 22, after considering funding priorities.

The New Era endorsed the health department's contribution as a good investment in local health, which by law is the health board's responsibility. For a PDF of the editorial and the news story, click here.

Princess Health and How to take local action to improve health at the local level is outlined at Frankfort conference.Princessiccia

Princess Health and How to take local action to improve health at the local level is outlined at Frankfort conference.Princessiccia

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Gusty 14:51 Add Comment

By Tara Kaprowy
Kentucky Health News

A recipe for how to improve health at the local level in Kentucky was the capstone of a day-long seminar in Frankfort Monday, with experts stressing that partnerships are key and funding will remain tight.

Communities must mobilize, prioritize, "effectivize" their actions, publicize and evaluate, measure and report performance, Trudi Matthews, director of policy and public relations at HealthBridge, summed up at the end of the Kentucky Health Quality Collaborative Conference.

The gathering was hosted by Kentucky Voices for Health in partnership with the Friedell Committee for Health System Transformation. "No single actor or set of stakeholders can solve what's wrong," Matthews said. "We really need to think across silos. We really have to collaborate."

When it comes to funding, governments "have made it very clear they will not increase the number of dollars that will be put into health care," said keynote speaker Dr. Robert Graham, national program director for Aligning Forces for Quality. "We're in a perfect storm," agreed Sue Thomas-Cox, branch manager for chronic disease prevention at the Kentucky Department for Public Health. "Federal, state and local governments don't have enough money . . . so we must work together."

Luckily, health care happens at the local level, Graham said, with hospitals and clinics unique to communities, health insurance agents locally based and consumers grounded in their communities. While there is "no particular model for how to get (change) started," Graham said, the first step is getting all stakeholders � purchasers, insurance agents, providers, consumers, faith-based organizations � around the same table. "You've got to make sure there is a balance of interests," he said. 

Also key are local boards of health and health departments, whose members and staff are charged with safeguarding the health of the people of a county, under state law, and have the advantage of being "relatively untainted by the illness-for-dollars disease," pointed out Dr. Forrest Calico, a rural health consultant and longtime worker in the field.

Health departments must ensure they don't spread themselves too thin, said Dr. Steve Davis, acting commissioner for the Department for Public Health. "One of the biggest reasons why we have not moved the health needle in Kentucky is we need to be an inch wide and a mile deep," he said. Communities need to "come up with five or six things and let's hammer, hammer, hammer it," he said. Of those priorities, Davis pointed out the importance of tackling chronic disease: "That's what's killing our brethren and eating our financial lunch." For adults, he would like to see an increase in breast, cervical, colon and lung cancer screening, as well an increase in immunization rates especially for flu and pneumonia.

For children, Davis has six priorities: reduce preterm and low-birthrate babies; improve injury-prevention programs; decrease tobacco use; reduce obesity; increase immunization rates; and improve oral health.

To get more accomplished, health departments need to team up with local organizations to avoid duplication of services, which Davis said accounts for $300 billion in unnecessary spending nationwide. He added the goal is to make "1 plus 1 equal 3," with health departments needing to adopt a "do or assure" philosophy.

But there are challenges in health departments, with some local health board members failing to "roll up their sleeves," Davis said. "You can go in with nothing in your head and leave with nothing in your head," agreed Henry Bertram, chair of the Pendleton County and Three Rivers District Board of Health.

A survey of health departments showed just 46 percent of local boards of health have a vision for the next three years to improve the health status of their community and just 44 percent say they are tracking compliance for the 10 essential services they are charged with providing. And the real numbers might be worse, because the survey was voluntary.

While about half of the state's health departments are committed to working toward achieving national accreditation, only three departments � Franklin, Northern Kentucky and Three Rivers District � have actually applied for it. 

Also crucial for communities is using data to identify priorities, take action and measure performance, whether using county-specific numbers at www.kentuckyhealthfacts.org or using national data.

"We don't want to get stuck in analysis paralysis," but communities can use the data as "a story you can use as leverage," said Jan O'Neill, community engagement specialist for County Health Rankings & Roadmaps. The County Health Rankings evaluate the morbidity and mortality rates for nearly every county in the country and rank them within a state.  The rankings can act as a motivator for counties interested in effecting health changes, but "We have to be aware of their limitations" given their margins of error, especially for small counties, pointed out Al Cross, director of the Institute for Rural Journalism and Community Issues. 

O'Neill spoke of San Bernadino County in California, which used its low ranking to spur change. The county focused on its built environment, pressing hard for Walk or Wheel to School programs, community gardens and a kids community health center. O'Neill pointed out the changes are about more than infrastructure. "It's the relationships," she said. "It's the human capital ... It's many not all doing it all, but bringing what you do best. That's what mobilizing looks like."

Jodi Mitchell, executive director for Kentucky Voices for Health, said she is "starting to see a tide of change" already in Kentucky. What's important is to keep momentum building and, equally vital, ensure people are willing to participate. "If you're not at the table," she said, "you're on the menu."

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