Senate Budget and Fiscal Review Subcommittee No. 3 on Health and Human Services

Number three on healthy human services will begin. Good morning, everyone. Little later start than usual so that means everyone's going to have 5 seconds to present on all their items so we can get out here at a good decent time. Time has not been my friend for the past couple of weeks. I made it like 30 seconds before boarding started last week. We're okay though. Learned my lesson. I have later flight tonight so it's okay.

All right, so today we're only going to be doing one department. Even though it's just one, we have a lot to cover in the next couple of hours. A lot of great things that I'm looking forward to dive into. We're going to be reviewing our Department of Public Health and we're going to kick off with an overview. It's an informational hearing. Our Director is going to be giving us the State of the State's health presentation. I welcome the administration to come up to the well. I welcome LAO and Department of Finance to join us. So we can start with our overview. Issue number one on Department of Public Health. Hello, Director Tomas.

Good morning. Dr. Tomás Aragón, Director of CDPH. And we're going to have Brandon Nunes who's going to give the overview of the budget and then I'll give the State of the Public Health Report.

Perfect.

Good morning. Brandon Nunes, I'm the Chief Deputy Director for Operations here at the department. So following the rule of quickly. For our department, for Governor's Budget 24-25 we have a total budget request of 5 billion, 815 million of that coming from our General Fund, 2.2 billion coming from federal funds and then another 2 billion coming from roughly 50 different special fund sources that help support over 200 different programs within the department. Because your agenda lays out very well the programs within the department, I'll kind of just go into a high level overview of our budget for this year.

For this year, our department does have some proposals that address the budget deficit, specifically in the area of some General Fund savings items, some fund shifts and then some General Fund loans. On the first area of General Fund savings, and all these we're going to be talking about in more detail today. So I'll just give you a high level but we have a $900,000 General Fund reduction beginning in current year and ongoing.

These are for savings associated with now hosting the COVID-19 website within our department's infrastructure rather than the separate COVID-19 website. We'll have that again, we'll be discussing that. A $1.71 million one-time savings in the current year for General Fund. These are anticipated savings just related to our disease surveillance IT systems. These are kind of natural savings that we think we'll have in the current year. And then 3.1 million General Fund again one time in the current year for climate and health surveillance program.

Anticipated savings that we again foresee in the current year for that program. Related to fund shifts, there were a couple of proposals that happened in last year's budget that we're going to be shifting to different funding sources. The first one is in our center for healthcare quality. There was $4 million provided to us in General Fund for skilled nursing facility staffing audits. We're going to be shifting that to the special Fund within that program and as well as within current year and budget year.

There was 9.7 million that's proposed to be shipped from the General Fund to Prop 56 tobacco funds, specifically to support our clinical dental rotations. And then finally on the General Fund loan front, there is a loan from our AIDS Drug Assistance program, a $500 million loan from that fund to the General Fund that still leaves a roughly 100 and some odd million dollars, 78, thank you, million reserve in the fund. So we don't anticipate any program impacts there.

But again, that's on the agenda a little bit in further detail. With that, then we have some just miscellaneous adjustments that we normally make to our different estimates as well as our tobacco revenue accounts in Prop 56 and 99. Again, that we'll be discussing today. It's a very high level overview. Again, we got a lot of detail on some of these others, and I can pass it over to the state of the state if you like or take questions.

No, Chief Deputy, we'll go over into each item.

Thank you so much, Director.

Sounds great.

Okay. Good morning, chair. I'm Dr. Thomas Aragon, state public health officer and Director of the California Department of Public Health. It's an honor to be here today to present the State of Public Health in California. At CDPH, our mission is to advance the health and well being of California's diverse people and communities with the vision that all Californians enjoy healthy communities with thriving families and individuals. Public health is our collective effort to promote and protect and improve health of all communities in California.

This year, CDPH submitted the inaugural State of Public Health report highlighting key public health indicators, health disparities, and leading causes of morbidity and mortality. This report serves as a foundational tool for monitoring population health, informing public health action, and promoting shared accountability. Our approach to safeguarding and enhancing health in California is guided by four pillars in public health. First, ecological social environments. This pillar centers on the connections between individuals, their families, and social circles, as well as their interaction with their neighborhood and environment.

Second, the life course perspective. This pillar acknowledges that health is influenced by experiences throughout one's life and the lives of past generations. Third, equity and health equity. This pillar focuses on creating fair and just conditions where everyone has the opportunity to achieve optimal health free from discrimination and racism. Fourth, prevention focus. This pillar prioritizes primary prevention, particularly intervening early to address potential health problems before they arise. Over the past 20 years, the health and well being of Californians have improved.

These achievements are due in part to our collective public health prevention strategies and investments. Life expectancy increased over this period with declines in mortality from ischemic heart disease, stroke, lung cancer, chronic obstructive pulmonary disease, prostate cancer, and breast cancer. Our tobacco prevention efforts led to a 59% reduction in lung cancer death rates, and we boast the second lowest smoking rates in the nation. Similarly, public health and medicine contributed to a 60% decline in ischemic heart disease deaths.

Interventions included promoting healthy eating, physical activity, and access to quality health care. California's infant mortality rates rank among the lowest in the country, driven by maternal and child health programs that include nutritional support, genetic disease screening, home visiting, and WIC programs. Despite important gains, there are long term increases in deaths due to Alzheimer's disease, hypertensive heart disease, and drug overdoses, and racial, ethnic, and Socio Geographic Disparities persist across these and other leading causes of death.

The COVID-19 pandemic presented unprecedented challenges, with life expectancy falling for the first time in 20 years. The pandemic underscored and amplified longstanding racial, ethnic, and socioeographic health inequities. Our COVID-19 response mitigated the health, social, and economic impacts of the pandemic. As a result, COVID impact has shifted from high rates of hospitalizations and deaths to a less severe endemic status we have today. As we navigate the post pandemic recovery, we remain focused on protecting the highest risk communities and patients.

Looking at this from a life course approach informs our prevention strategies. I will walk you through a few of the stages of the life course, highlighting those areas. First, we're going to start with early stages of life. A healthy start in life is crucial for long term well being. Factors such as prenatal care, access to health care, economic, housing, and food security, and positive social connections influence health outcomes. Adversity and health disparities early in life drive unequal health outcomes throughout life.

Although California has some of the lowest infant and pregnancy related mortality rates in the nation, Black infants and families experience significant disparities in perinatal outcomes. In 2022, the mortality rate was three times higher for Black children and nearly two times higher for Latino children compared to White children. Infant mortality rates are also significantly higher in neighborhoods with higher rates of poverty, although their rate is improving. Black women were three to seven times more likely to die from pregnancy related causes.

Structural and interpersonal racism is a key driver of these disparities, impacting neighborhood conditions, chronic stress and access to respectful care. Disparities are also observed in adverse childhood experiences, which are linked to negative health outcomes throughout the life course. Native American, Pacific Islander, Black, and LGBTQ plus communities experience more aces than other groups. From 2016 to 2020, California's youth experienced an increase in depression or anxiety symptoms from 7% to almost 12%.

LGBTQ plus students reported experiencing depression or anxiety symptoms at levels twice as high as heterosexual, identifying students about 63% versus 26%. As we move along the life course, young adults and adults ages 25 to 44 are facing a significant burden of injury related deaths, mental health struggles, and interpersonal violence. For Californians aged 25 to 44, the leading causes of death in 2022 were from drug overdoses, alcohol related deaths, traffic injuries, suicide, and homicide.

Young adults had the highest rates of mental health related emergency visits and hospitalizations, with Black young adults experiencing significantly higher rates. Young adults aged 18 to 34 experience the highest prevalence of poor mental health and depression. Young adults also experience the highest rates of homicide deaths. Black males experience homicide rates eight times greater than the overall population, with homicide being their leading cause of death. Among Black young adult males, firearms accounted for 72% of all homicides.

Communities with the highest levels of violence face secondary trauma from exposure to violence, such as hearing gunshots and walking to school or work near sites where violent events have occurred. Suicide and self harm are major preventable public health outcomes that have emotional community impacts. The highest suicide rates were in Native Americans and white individuals, while older adults aged 85 and older had the highest rates of suicide. Recent trends reflect concerning increases among youth and young adults.

Firearms are the most common means of suicide, with rural communities in northern regions experiencing the highest mortality rates. The prevalence of mental health conditions is higher among LGBTQ plus adults, with gay and bisexual adult males two to three times more likely to experience a serious mental health condition than straight males. LGBTQ plus individuals experience more social stigma, discrimination, lower quality of health care, which impacts their mental health and general health well being. As we move along the life course to older adults 55 and older, chronic diseases are the major burden. Cardiovascular disease, including stroke, is the leading cause of death in California. Risk factors are more common in lower income communities and communities of color. These communities face barriers to regular physical activity, healthy food access, gainful employment, and quality education. Although death rates have generally declined, cancer remains a significant cause of death, claiming over 60,000 deaths in California in 2022. Alzheimer's disease was the leading cause of death for adults older than 85 years old. So what are we doing?

At CDPH we promote community based interventions at the earliest stages of life, and we promote prevention and upstream strategies to improve social drivers of health and equity. Addressing growing behavioral health challenges is a top priority. We're integrating behavioral health into our public health strategies, focusing on prevention, resiliency and equity. More than 50 different programs at CDPH are working to improve behavioral health outcomes, including our offices of school health, substance addiction and prevention, and suicide prevention.

Under Cal HHS, the California Children and Youth Behavioral Health Initiative, CDPH is leading community based suicide prevention media and outreach campaign. We have a public health campaign co designed with youth to reduce stigma around behavioral health and to increase health seeking behavior and wellness support. The Youth Suicide Reporting and Crisis Response Pilot program is testing models where youth suicide and attempted suicide events lead to a rapid and comprehensive local community response.

Additional initiatives in behavioral health prevention include Governor Newsom's master plan for tackling the fentanyl and opioid crisis, including a one stop resource website, Opioids.CA.gov. We also have the innovative California Reducing Disparities Project, which is using community defined evidence practices to promote and improve mental health.

And of course, our landmark future public health investment, initiated by the Governor and legislature in 2021, is a pivotal step in strengthening our public health infrastructure, developing our workforce, promoting community health, and developing for future and preparing for future emergencies and threats. We will use this report to see collaboration opportunities to work towards equitable outcomes. Californians are enjoying major improvements in health and well being over the past 20 years. California continues to boldly address the emerging public health challenges.

I look forward to working with you to achieve our shared vision to protect and improve the health and well being for all Californians. Thank you for your leadership and partnership in these efforts. At this time I can take some questions. And then we were going to address the questions three through six that were in the packet that had to do with the SOGI data audit.

Because three through six is going to take a little bit more, let's do some questions regarding the state of the state's public health right now, my first question is regarding the numbers you gave. In 2022 60,000 deaths related to cancer. Later on, at the end of this hearing, we're going to be hearing regarding cancer registry. I'd like to ask, since I have you right here right now, the concerns we're having in having the system go dark. What happens if we no longer are able to collect this data?

Yeah, so the cancer registry is an incredibly important population health registry that collects detailed information about every cancer diagnosis in California. We've had this for the longest time, and because California is so big, everything that we do contributes also to the knowledge we have around cancer in the country. So one of the challenges that we've had connects to our tobacco. I mentioned that tobacco has gone down, lung cancer have gone down, and some of the revenue streams from that has gone down.

So we have had to backfill the budget in previous years looking for money within CDPH, and we do need to find a longer term solution because the cancer registry is an important area. I don't know, Brandon, if you have anything else before.

Department of Finance, are we at risk of losing federal funds if we don't find a way to keep the system going?

Good morning, Madam Chair. Nick Mills, Department of Finance. Don't have that information available with me, but I can work with your staff to provide a response at a later date.

And I know, Director, you mentioned we're a large state, but it seems like we might be the only state across the nation that's been struggling to. Been unable to keep it going as strong as possible.

No. We've been able to backfill the previous budget deficits using internal money within CDPH. We have to figure out a longer term solution for this because, as I mentioned, for example, cancer goes down, or impacts, for example, from tobacco go down, we have to find other revenue streams. I agree with that.

Would you like to add something to that?

No. And I know that we have a team that's available to kind of go into some of the details of the federal funds and the matching responsibilities and the like and some of the later agenda, but nothing additional to add.

My second question is regarding, I would say maybe the groups of zero to five year olds. California ranks 46 out of 50 in the nation in regards to access for the well being of a child between the ages of zero to five. How are we looking at this in terms of data collecting the behavioral health that could be really decreasing in this youth, in this future generation as we're seeing? Because I think last year we were 42nd and we've dropped down four places more. How are we addressing this potential public health issue with this generation?

Yeah, so zero to five is a critical period for neurodevelopment of children. And so if you think about where kids spend most of their time, it's not in a healthcare setting, it's at home, it's in the community. And so we now know a lot more about adverse childhood experiences. And we're working closely with the Surgeon General, Diana Ramos, who's been leading the effort around aces awareness and also primary care screening for aces in the clinical setting.

So the clinical setting is one area, but it's really in the community. How do we raise awareness around adverse childhood experiences, the impact that has on children's brain development? Because those years are critical. They change your brain, behavior and biology for years to come. And so that's part of what we do at CDPH. Our Center for Family Health has the WIC program. We have home visiting maternal, child and adolescent health. So there's a lot of effort, but there's absolutely more that we want to be able to do.

Absolutely. It feels like we're going backwards in terms of the it. And for also my understanding, this is my first address for the state. Well, second address for the State of the public's health. What comes after these? You put together these numbers. Do recommendations then go out to the different programs under CDPH to perhaps implement some of recommendations or prevent any further negative impacts in what you're finding?

Yeah. So we use this both to help our strategic planning, understanding what the highest burdens of morbidity and mortality are for the population. It also allows us to monitor for emerging trends. And then the other important thing is to get this information out there, because it takes all of state approach to address these issues, because ultimately we have to improve the quality of life, social determinants of health.

And public health doesn't control that, but we can provide the data and the guidance and the science to help other sectors improve those conditions where people grow up. California, on average, does better than most states, but there's certain areas where the disparities continue to exist. One area where I would say that we're very different from other states is that public health is very intentional in embracing behavioral health as an important component of our strategy, focusing on primary prevention.

A lot of behavioral health is very focused on severe mental illness, which is incredibly important. But we want to figure out how can we work with communities and partners to do more primary prevention around behavioral health outcomes?

Okay, colleagues, to my right, colleagues to my left.

Thank you, Madam Chair. I just have one follow up question. The chair mentioned that we fell from 34th to 39th. Okay, I'm sorry. 42 to 46.

Remind me of what specific data point that was.

In a response to this. When she pulls that up, I guess my question is that how much money did we spend? And then we still fell. And the reason why I'm only asking is because I think that being a business owner, you bring different worldviews to this body. Everybody has their own life experiences. When we use something in the business world and invest a significant amount of dollars, we change it if it doesn't work. So if we have fell in, what was the subject matter?

So two weeks ago, LA Times came out with this report, and we, between 0 and 5 year olds, I just had it right here. Fell to 46 in terms of being able to get a well child visit. - holistically, ensuring that we're meeting those developmental milestones, behavioral.

Yeah, that's a good question. I don't have the answer to that specifically. That's probably going to be monitored in the departments that monitor health care. But yes, in terms of childhood visits, I don't have the answer to that. We'll have to get back to you.

So as CDPH as a whole, when you look at that, we're all about access to health care. Specifically, I think my colleague over to my right, because of the rural hospital situation that we have, and we want people to have access to health care, but if they're not getting access to health care, because for whatever the reason is, the hospitals aren't making the appointments. And just like the chair just referenced, we're dropping from 46th to 49th in the nation about getting wellness visits, even to start.

I realize that may not be under your purview, but it should something that we should look at, because we all want to see access to health care, we're investing a significant amount of money to make that happen. But yet my constituents aren't having access to adequate access to good health care. So I appreciate you guys looking into that, maybe getting back to us, and maybe it's not right at your level, but maybe a level underneath you or so I would appreciate that. Thank you, Madam Chair.

And I recognize that, and I know this is more of collecting and just public health as a whole. And I was trying to find some connection to that as how we're looking at this, because I look at this issue as a public health issue. A huge proportion of our young kids potentially falling behind.

We agree with you. You can think of access not just to health services, but all services. It might be around housing, food insecurity, social determinants of health. You want to have access to all of those. And then there are other conditions that happen that you want to promote. So we completely agree with you. That's an area that in this age, I had this conversation just last week with an epidemiologist that studies this specific ages, zero to 10.

And that's actually one of the more challenging areas for us to get data. We get data when people touch systems. So when people touch a service system or they're in school or when they're born or when they visit a Doctor, we get data. But it's sort of this in between.

Because they're not visiting doctors.

Yes, exactly.

So I think it's a really big focus area that we should really somehow pivot towards because, again, we're just falling further back on this population.

Well, it is on my radar because of the conversation I had last week. And we can follow up with that because I know there is a team in maternal, child and adolescent health that's specifically working on how do we figure out what's happening in that age group, because it's harder to measure until people go to, they hit, for example, kindergarten.

Senator Eggman.

Thank you for being here. Dr. Aragon. So the Senator from Kern County and I sit on the Rules Committee, and one of the boards that is getting filled is the, what's it called? Maintain health care costs, health care affordability. Thank you very much. Yeah, there's a loss. Health care affordability. And we're interviewing the doctors and the one physician said, and I use the analogy of highways. Because we have severe hospital shortages in the valley especially, but that we're not going to get healthier by more hospital beds.

And if we're trying to contain our costs, we have to focus way more on the public health side and make sure we have a healthy population because that helps decrease costs. At the end of the day, you don't want people in hospitals. You want them to be healthy. So can you tell me a little bit about the 100 million hence was right for the future of public health and how you see us being able to compensate for the lack of hospital beds by producing a healthier population?

So we do have a whole presentation just on future public health. I don't know if we want to. I think it's issue two. It's issue two. So we do have a team that will summarize for you in detail, look at your public health.

Then I'll ask again later.

Okay, Senator Grove.

Thank you. You just expanded your authority based on your comment that you made about surrounding people with wraparound services. Basically is the brief term for it. Housing, things like that, affordable housing, food security, all of those things. I guess my question to you is that, which again, is not under your purview, but we have an insurance crisis in the State of California and I have a group of habitat humanity, hundreds of houses that are available at a low cost for low income families, but they can't secure a mortgage because they can't get insurance. And you have to have insurance to back your mortgage.

So I think even though you're with CDPH, you have a huge problem because you're going to have to bring in different agencies or different departments to be able to help solve this problem. And I think Dr. Ghaly and you and you guys have the ability to do that because if you're talking about the whole health of the person, there are major problems going on with our state regarding to housing. With the skilled nursing facilities, you guys in 2020 when we had COVID said one midnight overstay and you could stay at a skilled nursing facility, and now you're requiring that falls off because we don't have the COVID rules anymore.

And now they have to stay in a skilled nursing facility for 30 midnight stays, which takes up a bed in the skilled nursing facilities for people who really need them that may be able to be discharged in a few days back to their family, but they have to stay for 30 days on a requirement without that COVID rule that has now fallen off. So I think that, I didn't realize that you guys had expanded.

I mean, your role really gets larger because to treat the whole person, you do have to address those things. Food security. You need water to grow food. I represent the top three food producing counties in the world. When you think about all those things that we have to do for wraparound services. And I appreciate your report. Again, this is only my second one being on this Committee, I believe with Madam Chair. But I appreciate your report.

But there are serious health issues facing Californians and a majority of it is because of things that are happening outside your purview that are causing homelessness. Right. How do you treat the whole person when people are only allowed to treat the wound that comes in, but they can't treat the mental health that's causing them to poke their arm, you know what I mean? Or whatever that causes the wound.

So I think that you're going to expanding your territory based on the own information that you just provided. You're going to have to partner with a lot of different agencies to try to solve this problem. And I think you guys can do it. I have confidence, Dr. Ghaly has shown confidence in some of the stuff that he's worked with me on. I wish you the best of luck.

Thank you so much. And I do want to just really do a shout out. Of course, we're part of the HHS family, so there's 12 departments, and we're one of them. And we work really closely together under Dr. Ghaly.

Thank you so much. We can now move on to question number three.

Okay.

All right. Good morning, Madam Chair, Members of the Committee, and guests. I am Dana Moore, pronoun she/her. I'm the Deputy Director for the Center for Health Statistics and Informatics. I'm the state registrar of vital records and vital Statistics, and I am also the acting chief data officer for the Department. I'm joined today by my colleague and subject matter expert, Jason, and he'll introduce himself.

Hi, good afternoon. Good morning. Still. My name is Jason Tesher. I am the manager of the gender Health Equity section inside of the Office of Health Equity at CDPH.

We want to thank you today for the opportunity to speak with you and address your inquiries regarding the California State Auditor's findings and recommendations for the collection of sexual orientation and gender identity public health data. We do share your vision and desire to improve the lives of the LGBTQ plus Californians through ameliorating what data we collect, how we collect it, how we report it, and how we display it. As you know, CDPH understands the value of data that is equitable, accurate, and inclusive.

Our programs also value data collected in a manner that is safe for the LGBTQ plus community and done in a way that balances both the fidelity of the scientific method and privacy laws with the flexibility of community input for data that is continuously relevant to them. When looking at adding soji data to forms that already collect demographic data, such as race and ethnicity, our CDPH SOGI workgroup sees soji data as being community driven, whereas race and ethnicity data are institutionally driven.

People are used to answering static, discrete, and often overly broad non representative or outdated race and ethnicity data. SOGI data, however, is fluid, complex, and will always be changing with each generation or influenced in Shorter epochs than other standardized data. Voluntary data collection is complex, particularly when the source of collection is within the healthcare system.

We share the concerns that a lack of understanding of the importance of collecting this data by providers, patients, and program participants significantly impacts the usefulness of data that we can report to the public. Cultural and linguistic differences, conflation of sex and gender identity, perceived lack of relevance of sexual identity all lead to a high proportion of missing data. At every point where data is collected and data flows, data loss can occur. This comes in the form of loss in translation answers of unknown and non response.

To that end, using the recommendations from the audit and feedback from our partners at local health jurisdictions and in the community, as well as reviewing the very latest information and research from the California Health Interview survey, state and national organizations, and other experts. It is CDPH's intent and public health's role to provide technical assistance and guidance on policies and best practices in response to the 2023 state audit findings, CDPH has been working diligently to address the findings and recommendations of the auditors.

The CDPH SOGI data work group that convened in 2022 is continuing their work, incorporating feedback from local health jurisdictions and community organizations into an updated set of data collection standards, and is well underway with recommendations for SOGI data visualization standards. My team and I present a monthly report to CDPH Executive staff on the progress of meeting all of the SOGI data collection audit recommendations.

Our teams are on track to meet the following milestones and key results that are fully inclusive of and will meet the audit recommendations by the dates as follows. Gaining directorate approval of Soji Workgroup data best practices and standards by October 2023 that is complete through the SOGI workgroup. Develop a SOGI data collection reference document for local health jurisdictions and others outside of CDPH. With the addition of developing best practice standards for display by August 2024, our team is on track and this is still in progress.

Develop processes for our county's communicable disease programs that are not using Cal ready, including compliance with SOGI data reporting requirements, by March 2026. This is in progress and on track. Ensure Cal ready users and public health programs can extract SOGI data for all reportable diseases in Cal ready through the Cal ready data distribution portal by April 2024. This is almost complete through the SOGI workgroup. Create processes, policies, and procedures for standardized form review and monitoring.

This includes legislatively mandated forms and standards for data collection by September 2024, the team is in progress and on track. The one area of opportunity that has been delayed is being able to ensure that Cal ready and the future disease surveillance system can receive SOGI data from local health jurisdictions. The goal was to achieve this by July 2026. The milestone and audit recommendation is, of course, incumbent upon funding. CDPH does not have the funding needed to meet this recommendation.

However, our teams are actively in the process of identifying funding opportunities and sources and are open to exploring different alternatives and avenues for funding. Question four so CDPH continues to reevaluate the forms that were brought up in the audit. A key lesson learned in the process of evaluating the forms and addressing the audit recommendation for the 105 identified was that it actually shouldn't be assumed that the 105 forms aren't collecting SOGI data.

The audit list has nonaplicable responses, which shouldn't be assumed to mean the forms do not collect SOGI data. For example, the behavioral risk factor surveillance system has na in the audit list, but we found it actually does collect SOGI data. Many of the non applicable in the auditor list are federally mandated forms listed as A. Federally mandated forms may still be collecting SOGI data for some forms, though, it does not make sense to collect SOGI data.

For example, the perinatal hepatitis C report is listed as no, but the form for children two to 36 months who cannot self report their status. However, the form has no demographic information on the mother, clearly an opportunity. CDPH is taking this information and is now asking all of our programs who have forms listed as N/A, so therefore we're exempt as to whether or not they collect Soji data.

The team will then add SOGI questions to those forms that are missing it, as well as evaluating the rest of the forms in the departments that are relevant. I will now hand it over to Jason.

Thank you. Good morning again, Chairperson and Committee Members. From our maternal, child and adolescent health programs to our Office of AIDS and Injury violence prevention programs and gender health Equity section programs, CDPH administers a wide variety of programs that focus specifically on LGBTQ plus communities. We work in partnership with local health jurisdictions and LGBTQ plus community based nonprofits to facilitate ongoing communications in real time on issues impacting specific populations.

In addition, Ceph partners with and funds well respected LGBTQ plus research institutions like UCLA's Williams Institute, UC Santa Barbara's Social and Health Equity Lab, and the Fenway Institute in Boston. CDPH uses these close partnerships to help us forecast issues and address long standing systemic barriers experienced by LGBTQ plus Californians. CDPH uses existing research to inform the design of programs authorized by the Legislature to address inequities experienced by vulnerable subpopulations. In recognition that LGBTQ plus communities are not a monolith and each requires customized interventions.

The California Department of Public Health's gender Health Equity section, for example, administers public health programs approved and funded by the Legislature focused on LGBTQ health inequities. While the overall priorities are conveyed by the Legislature, we use the most recent LGBTQ plus health studies and community feedback to design funding programs that focus on the most vulnerable populations, including transgender, gender nonconforming, and intersex Californians and LBTQ women who face systemic and unique barriers in access to care.

The Gender health equity section is currently funding research focused on assessing barriers to gender affirming care and hormones for transgender and nonbinary Latin-A youth. We're funding research assessing surgical disparities and the impact of gender minority stress on suboptimal outcomes among TGI patients.

We're funding needs assessments of black, indigenous and indigenous persons of color in LBTQ women and Trans identified BIPOC persons in Southern California and the San Gabriel Valley, LBTQ Health in the eastern Sierra, and experiences of LBTQ and transgender men and women with child protective services. These research topics were all driven by local CBOs and research institutions who serve LGBTQ plus persons and researchers with decades of experience.

We listened and funded gaps in knowledge that will both help communities address local inequities and inform our future recommendations to improve LGBTQ plus health. In collaboration with LGBTQ plus CBOs across the state, the gender health Equity section also funds a set of strategies to build the capacity of healthcare providers to deliver culturally and linguistically appropriate healthcare services to their LBTQ plus patients.

The goal is for funded partners to enhance the capacity of providers, resulting in better quality and quantity of SOGI data reported to CDPH through LHJs. These programs are small scale at this time, and as we evaluate their effectiveness, CDPH expects that they will provide data driven direction for future investments in this area. In addition, CAPH's Office of AIDS leads coordination of state programs, services, and activities related to HIV and AIDS and provides for the needs of impacted Californians.

The Office of AIDS Statewide Planning Body, in collaboration with our STD Control branch and the California Planning Group, includes community Members and stakeholders, with a majority identifying as LGBTQ plus persons impacted by the HIV syndemic and operates as a planning and advisory body to advise the Office of AIDS and the STT control branch on Community needs and gaps.

Again, CEPH's strong community partnerships, partnerships with research institutions and with local health jurisdictions offer us an insight that we use to identify and address public health issues that specifically impact LGBTQ communities.

Thank you, Jason. Gaps in SOGI data collection are the result of several challenges we face integrating many systems and industries that collect and report SOGI data. However, CDPH has identified multiple opportunities to expand SOGI data collection, which includes, but are not limited to: the following looking at models a model to help guide local efforts to increase Soji data collection. It may include a statewide protocol and guidance for local adaptation,

looking at our data systems of course, alignment of data systems gives the opportunity to ensure accuracy and completeness of SOJI data, which is related to public health data modernization communications, consistent messaging from CDPH to communicate SOGI mandates, and ongoing technical assistance by CDPH to support local health jurisdiction staff to understand what is required.

Resources significant resources make changes to EHRs and ELR data systems train and educate the public providers and laboratories and develop cultural and linguistic translations and facilitate coordination to resolve barriers to transmitting data across platforms. Feedback loops CDPH will conduct and share Soji data analysis with local health jurisdictions, so a feedback loop can help identify gaps in local Soji data collection.

Use of new technologies to expand the collection of self reporting data development of connections with health information exchanges to directly query medical records to fill in missing demographic information, expansion of electronic case reporting, and development of technologies to link information across multiple systems at the individual level so that demographic data can be shared and then validated across systems.

Engagement with organizations that set national data standards to advocate for the inclusion of SOGI data fields in data streams for electronic case reporting, syndromeic surveillance, and other national data collection systems, implementing the virtual Training Academy, a collaboration between the University of California, Los Angeles and San Francisco, along with CDPH to provide education, training, and support to frontline staff, communicating requirements to local health jurisdictions and other critical partners, and lastly providing informational updates during regular meetings and all opportunities of communication with local health jurisdictions and CBOs.

The SOGI data Workgroup is planning to survey every program in CDPH as to what forms they use, irrespective of whether they were identified in the audit or not, whether they are following our most recent recommendations for best practices for SOGI collection reasons if they are not, and a plan to add SOGI questions if they are not.

Again, Jason and I thank you for the opportunity to share our progress on meeting the requirements of the audit, and of course, we share your vision and are welcome to further discussion.

Thank you. Will, does Elio have any comments on this issue?

Will Owens with the Legislative Analyst Office. Nothing to add this time but available for questions.

Thank you, Dana, correct?

That is correct.

Dana, I wanted to go back to in one of the earlier talking points, you started talking about some of the forms that had N/A went back and realized that they did actually ask that question. And then you have asked that every single form that came back with N/A to be re reviewed. Is there a timeline of when we can anticipate hearing feedback on which one of those, in fact, do have that question?

I don't have immediate timeline with me, but I can connect with our SOG work group and get back to you with that.

Great. Thank you. My other question is regarding the ones that do have that question embedded in the form. It seems it appears that 24 of them came back with they do have the question. However, seven of them did not collect the complete data. So I know we're encountering some barriers where it's not on the form. Now, part two is it is on the form, but not the full information is being collected. Can you break it down?

What we're exactly asking, is it across the same in all 58 counties and providers, does one form ask more SOGI information than the other one?

So this goes back to our SOGI work group, where when we're evaluating forms and developing the best practices or recommendations. So this comes from feedback from our local jurisdictions and community based organizations so that there is a broader and more appropriate range of questions as opposed to incongruent questions. Are there other pieces from the work group that you would have to add?

No, I don't think so at this point.

Okay.

Because of the one that didn't come back with a full completion of data. One of them in particular is completely connected to the LGBTQ plus community, is the adult HIV and AIDS case report form. I think at that minimum, should have our full data on it. So I'm wondering maybe if you could go a little bit more further as to. I get the first part right, the second part, if it's on there, why are we not collecting all of it?

That is a good question. I'll have to work with our HIV team to get a little more information on that.

Okay. And then also, my overarching question is, it's been around for a while. The working group started 2022. 2022. We're almost two years in. At what point have we learned everything we need to learn to move forward with this?

That's a good question. I think as we move forward, we've had a lot of lessons learned. As I mentioned, we found out that there are actually a lot of surveys and forms that actually did collect SOGI data. We're finding opportunities that weren't even evaluated as a form where we can add SOGI data while we can go by the letter of the law and the letter of the audit and meet all of the recommendations? I don't think we'll truly ever be finished.

As I mentioned earlier, race and ethnicity are institutionally driven data points. SOGI data, as we see it and as the work group sees it, is truly driven by the community and is adapted depending on different parts of the community. So we will constantly be in a quality improvement process, connecting with the community, reevaluating data, ensuring it's representative, and that it's actually meaningful data so that we can intervene. Are the interventions appropriate, and are they working?

Is it still the mindset of CDPH that the way the language within the Bill reads is that it does not require, but rather permits in some of these forms to collect SOGI information.

So sorry, what's the question?

Is it still the mentality, the understanding of CDPH, that the way the Department is reading the statue is that the verbiage only allows, permits, some of these forms to collect this data, rather than requiring to collect this data.

So ultimately, our vision is to maximize the collection of soji data wherever possible, permitting that it doesn't violate federal or state law or privacy laws. The idea is to, again, look at as many forms, as many opportunities where we connect with the community, where we connect with healthcare and figure out how to integrate that.

From my understanding, could you break down why privacy laws weren't be, and I just don't know personally be a factor for this information and not for race?

Privacy laws vary depending on the data sets is ultimately what it comes down to. So, for example, I work in vital records and vital stats. We have privacy laws around birth data that are incredibly different than HIV data. Some privacy laws allow for unidirectional, so we can get data, but we are not bi directional. We may not be able to give data.

So it really depends on the type of data and the type of and level of privacy that is being protective of that data set, whether it's individual or record level data versus population health data.

Do we have an understanding of what certain privacy laws are in place that are preventing us from collecting this data?

I would have to work with our privacy attorney. We do know the laws, and again, it varies by data set and data program, but that's something we can get to you.

Anybody else?

I also have my hat as the LGBTQ caucus chair, and so it is a frequent topic of discussion, Department of Public Health, both with the adapt program as well as this. So I guess just how does the Caucus, is there a way the caucus can work more collaboratively with you to be able to. Because it's been an ongoing source of frustration. The data hasn't been coming. So are there ways we can partner with you in better ways to be able know probably lessen the frustration for all of us?

That's a good question. I think an opportunity as we go through and evaluate our Soji data and best practices and recommendations, I think of, for example, the Cal HHS Jedi Council, Justice Equity, diversity and Inclusion Council, which is a group that we would partner with at a policy level to get feedback from. So the caucus could also be an opportunity to hear what our recommendations are as representatives of the community providing feedback. I think that would be a good way to do that.

Okay, maybe we can come for an update?

That would be great. Thank you so much.

I do appreciate that you appreciate our good questions, but I appreciate a better answer to our good questions.

Always happy to do more research and bring it back.

Thank you so much. Thank you for this presentation. We're going to. One last question here.

Thank you, Madam Chair. I'm just going to follow up on that. Is there different statutory regulations or different rules for that data to be given to us so that data comes to us based on whether it's HIV information or, as you mentioned earlier in your comments, birth rate information or birth information?

Yes. So there are different statutory and regulatory requirements and privacy laws that vary depending on the part of the health and safety code. And, for example, like vital records, we have federal laws that also protect the privacy of individuals. I am uncertain about HIV data, but again, it is variation across the health and safety code that provides for each data type.

But the problem that we have as legislators, and of course, like my colleague from Stockton mentioned, and also the chair, is like, we're looking for data. Right. And we want to know why you can't provide it. So if it's legislative, tell us it's legislative, and I'm sure everybody will work to fix that. If it's cooperation of partnering with other organizations, like the justice organization that you mentioned or the LGBT caucus, then tell us, and I'm sure that we will make that happen.

So what is the reason you can't provide us that data? I'll be a little bit more direct than my colleagues, who are so polite.

Much appreciated. There is much of it that is legislative.

Much of it is legislative, yes. So, like the chair, Madam Chair, who read that statement that California Department of Public Health is saying that it's permissive. What's permissive but not what required?

So if we change that to word, instead of it being permissive for you to provide that regulation and required you to do that, then you would be required to give us that, even though we were trying to be kind in the legislation and say, we'd like you to give us this so that we can make good policy decisions, but you're choosing not to. So now we need to require you to do it.

I would say that we're not choosing not to, but requirement definitely has a more powerful language to be able to help us with partners that we get third party and second party data from.

Great words, requirement.

Senator Grove, I'm not always nice in this Subcommitee, I promise. Other departments can attest to that. Thank you so much. But I just want to actually just summarize, I'm very interested in getting the timelines for when we're going to be reviewing all those forms that have the N/A. And then what was my other part? Just any privacy laws that are impacting our ability to collect that data. And then if you could report you send that up to us, that'd be really helpful.

Absolutely. As a Member of the community, I appreciate the work that's being done here.

Thank you. Okay, we're going to move on to our issue number two. Issue number two, the future of public health. Our investments in the state and local public health is going to be in a little of a panel forum discussion. The Department is going to be welcomed by representatives from other counties and orgs we might need. Let's see one more. Okay, now I'm going to take the advice from Senator Roth.

I'm going to have you pronounce and introduce yourself so that I may not butcher your names. I like your style. Sir, we're going to have Sarah. I can pronounce Sarah.

Both Sarah.

Just kidding. The Department who is representing. We're going to have CDPH go first.

Hi, I'll introduce myself. I'm Julie Nagasako. I'm the Deputy Director of the office of Policy and Planning. I have two colleagues from CDPH with me.

Good morning. My name is Amy Zhang. I am the community equity branch manager. For the Office of Health Equity.

All right, so I think Amy's going to lead us off addressing the first question, and then I'll address the remaining questions related to the future of public health and workforce investment.

The Office of Health Equity. We have been working with agency to obtain the $1.6 million for the retrospective analysis, and we will be contracting with the University of California of San Francisco to conduct the work, and that interagency agreement will be beginning July 1, 2024. We are also working on hiring a retrospective analyst who will be conducting the work to support UCSF, and this position is for two years.

So thank you, chair and Members of the Committee. I'm now going to provide an overview related to the future of public health investment. I'm sharing this update on behalf of many CDPH programs which are supported, so there's quite a bit of information to cover. The purpose of the landmark future of public health investment is to strengthen and transform California's public health system, addressing critical gaps in core infrastructure.

This initiative focuses on growing a skilled representative and well supported workforce, improving systems preparedness and resilience, contributing to equity, and protecting and improving the health of communities throughout the state. Most significantly, in the first two years, these resources have enabled an important expansion of the public health workforce, the heart of our public health system. CDPH and local health jurisdictions have hired over 1200 new public health staff statewide, over 300 at the state level and over 900 at the local level.

These objectives of the future of public health initiative are achieved by addressing priorities within the foundational public health services that are critical to strengthening and sustaining our state's public health infrastructure. I'll share a few updates and highlights from each of these foundational public health service areas in some of the related projects. The first is workforce.

The foundational public health service area for workforce development, recruitment, and retention includes $57.9 million to increase staffing capacity through 270 positions, 226 of which have currently been hired to provide support to both program and operational activities, improving capacity, range of expertise, and lived experience reflected across our Department. Key projects have also focused on workforce development, including increasing our HR staffing, launching a new hiring system, expanding marketing and pipeline efforts to promote careers in public health.

CDPH has also developed a new public health core competencies system, modular public health trainings, and a career management program to help support the professional development and retention of public health professionals in state service. CDPH has also established new structures, including our Office of Policy and Planning, which supports priority initiatives across the Department, and our new regional public health office to support local health jurisdictions with key projects and bi directional coordination in the area of emergency preparedness and response.

This foundational public health service area includes 77 positions and $27.6 million. The primary staff classifications in this area are emergency services coordinators, program managers, research scientists, analysts, health program specialists, managers, research data specialists, and public health medical officer roles. At this time, 40 positions have been hired with additional roles in active recruitment. One key preparedness initiative is a 24/7 intelligence hub to integrate new and existing data streams to proactively detect emerging threats.

This hub is in active development with a focus on data architecture, redesigning existing processes for proactive integration and recruitment of dedicated staffing. The 24/7 intelligence hub is related to syndromic surveillance or biosense efforts, in that inputs from that developing syndromic surveillance capacity will be one of the data streams integrated into the intelligence structure.

It is distinctly different in that it will also analyze data from other sources such as EMS data, hospital census data, state threat assessment center, and many others, to create comprehensive reports about current and emerging threats to California's public health. CDPH has also expanded planning, training, exercise, and evaluation capabilities.

Examples over the past year include initiating a review and update of the CDPH emergency operations response plan input, including reviewing and revising the emergency support function eight public health and medical annex to the state emergency plan participating in regional medical countermeasure exercises and national disaster system medical system exercises. Staff support through future of public health also contributed to conducting hotwashes or debriefs and the development of after action reports for incidents where CDPH participated.

Planning teams also developed threat specific response guides and playbooks, including extreme heat, Wildfire and Wildfire smoke winter storms, as well as work on initiatives for nuclear radiologic threat and Ebola, Marburg, and special pathogens. Planning efforts CDPH is actively working on a regional disaster health Representative program. Regional meetings have been held with public health officials, regional disaster mental health specialists, and mental and health operational area coordinators to identify goals for integration into regional networks.

With recruitment for these regional roles currently underway, CDPH has also established a dedicated recovery unit, which was deployed to work collaboratively with Cal OES partners on the recovery for winter storms and tropical Storm Hillary. This team initiated the development of a public health medical recovery framework and community resilience plan and identified gap areas for focus, such as disaster behavioral health.

The foundational service area for preparedness also includes investments in state laboratory emergency response support, hiring key staff in technical laboratory classifications to support preparedness and response activities, including testing for pathogens and outbreaks in the area of information technology, data science, and informatics. The future of public health investment includes a focus on improving health technology infrastructure in critical areas to support IT systems and solutions for addressing emerging threats, for example, expansion of coverage for the California birth Defects monitoring program.

Other activities in support of this foundational service area are addressed under the separate budget allocation information technology, data science and informatics framework for a 21st century public health system, which included $54.8 million to support foundational strategic planning, data sharing, upskilling of our IT workforce, establishing a framework for modernization of our IT platforms, data interoperability, and cloud infrastructure. This investment included 33 positions. At this time, 28 positions have been hired.

In addition to critical personnel, these resources support software licensing, professional service contracts in order to accomplish proactive support for rapid data analysis with real time insights, automated file transfer, reducing duplication, and leveraging our resources for common investments for the future. Separately from future of public health,

the disease surveillance, readiness, response, recovery, and maintenance of IT operations is another key investment contributing to public health infrastructure, which included a total of 133 positions in 22,23 and 144 positions in 23,24 to support maintenance and operations of multiple IT systems, including those established during the COVID-19 pandemic in the area of communications and public education included 4.5 million to achieve a communication strategy to reach California's diverse population, with an emphasis on increasing digital, linguistically and culturally responsive communications on public health prevention and emerging issues, the Office of Communications has hired 25 of its 26 new positions in roles including digital communication, social media strategy, health program specialists, and bilingual information officers.

Resources have also supported web development tools and media studio enhancements. The creation of these new staff roles and resources have improved public health communications capabilities by expanding proactive outreach efforts and engagement through experts that represent diverse populations, including rural and other underserved geographic regions, as well as improved capacity for dissemination of toolkits, videos, and social media across a variety of channels.

For example, CDPH developed the California's opioid Response website, which was produced internally in less than a month through support of an FOPH position rather than an extended and more costly process through a consulted contract.

Additional examples of messaging and communication tools developed in a linguistically and culturally competent manner and tailored to specific populations include outreach messaging to reach rural agricultural workers this spring on valley fever awareness and prevention a social media toolkit on extreme cold, including information on safe generator use in preparation for winter storm season many campaigns and toolkits to address respiratory virus and COVID prevention, health education materials on topics such as tuberculosis control, xylozine wound treatment, youth suicide prevention, and Alzheimer's disease, as well as resource materials on recent measles outbreaks and STD increases.

In the area of community partnership, there were five positions and $2.9 million to develop a community partnership strategy and plan with a dedicated team of community engagement personnel. CDPH has hired a black health equity specialist, tribal health equity specialist, rural health equity specialist, community engagement specialist, and manager. These positions and resources have strengthened relationships with community partners by building robust partnerships with populations experiencing some of the greatest health disparities.

These positions have established population focused advisory groups, including a lived experience advisory board for people experiencing homelessness, a black health equity advisory board, and tribal health equity advisory board. These groups strengthen our relationship with partners by drastically increasing the frequency, intensity, and specificity of our bi directional engagement. CDPH is also working with key partners to co create a bridge to partnerships blueprint to ensure that CDPH develops governmental infrastructure that can convene and sustain community partnerships.

The main purpose of community partnerships is to establish a collaborative network that can be mobilized quickly and effectively support California's state and local governmental public health efforts to address community health needs. CDPH is supporting all 61 local health jurisdictions in joint efforts to grow their equity competencies with a virtual equity toolkit, which includes dozens of resources for practitioners, including competencies to support extending the reach of governmental public health via trusted community partners.

CDPH is also deepening cross sector partnerships with continuums of care and homeless systems of care to improve health outcomes for persons experiencing homelessness throughout the state. The 6th area of the foundational services is community health improvement. All of these workforce and system improvements contribute to the broader goal of community health improvement, with 6.1 million focused on additional strategies to advance life course equity and prevention and strengthening partnerships across health systems, health plans, and local communities.

To support community health investment, CDPH has implemented an initiative to develop a financing strategy planning guide that outlines various opportunities for public health system to maximize existing revenue streams, and opportunities to align with healthcare system partners, as well as a local health Department playbook tool that provides an assessment of the current funding for core public health functions that can be used to assess gaps in funding and capacity needed to adequately implement governmental public health.

Another key community health improvement priority is the CDPH Behavioral Health Planning initiative. CDPH is engaged in a departmentwide effort to address the current behavioral health crisis in California. This initiative involves cross cutting planning, engaging over 50 CDPH programs, addressing behavioral health, and a landscape analysis of partner initiatives to inform the development of a prevention framework for behavioral health. CDPH has leveraged future public health resources to expand capacity and behavioral health across the Department.

For example, the maternal, child and Adolescent Health Division established a new community resilience and support section implementing an initiative focused on improving and protecting mental health for the MCAH statewide workforce and populations while integrating primary prevention and a life course approach. Additional dedicated staffing was also added or expanded for multiple existing behavioral health programs, including in the areas of injury and violence prevention, safe schools, substance and addiction prevention programs.

Community health improvement is also advanced by enhancements to the state health assessment and improvement planning functions, including the inaugural State of Public Health report released this year. I'll now share a short overview of CDPH's Administration of the local assistance funding under future of public health. CDPH Administration of this funding is facilitated by the newly established regional public health office.

Funding is distributed to each jurisdiction using an allocation methodology, which includes a focus on reducing health disparities with a base grant of $350,000 for each jurisdiction, with the remaining balance of appropriation provided to LHJs proportionally under a formula of 50% population size, 25% based on population in poverty, and 25% based on proportion of black, African American, Latinx, or Native Hawaiian Pacific Islander. Population. Requirements include that at least 70% of funds must be dedicated to the support of hiring permanent staff.

LHJs have made strong progress on hiring. Over 900 positions have been filled in jurisdictions across the state, reflecting 74% of planned hires. Ultimately, future public health will be adding over 1200 positions to the local public health system. Highlights so far include 90 epidemiologists, 100 public health physicians and nurses, 140 community health workers. Additionally, over 500 staff have been hired in roles that include a focus on addressing health disparities and equity.

Staff are focused in many program areas, including chronic disease, infectious disease Administration, public health labs, finance, environmental health, family health, and preparedness with the staffing priorities based on the needs of each local health jurisdiction. Jurisdictions are also required to submit a three year public health work plan informed by their local priorities, including their community health assessment and improvement plan and strategic plan.

These work plans include an evaluation approach, metrics, staffing plan, and public health focus describing how the public health issues to be addressed are elevated from their community health assessment process and align with their local health improvement plans and state health improvement plan. The plans specify strategies for action based on the foundational public health services. They also describe how LHJs will achieve key requirements such as 24/7 healthcare officer coverage. The first three year work plans were due and fully approved by December 2023.

100% of local health jurisdictions have all successfully submitted and now have approved work plans and spend plans for evaluation. Local health jurisdictions also conduct an annual self assessment of capacity based on the foundational public health services. The first self assessment rolled out fall winter 2324 to establish baseline capacity, and the next will be conducted in June 2024 to assess changes after the initial implementation of future of public health funds. The future of public health implementation framework supports both alignment and flexibility.

Just a few examples of the diversity of local work in action include everything from collaborations to expand immunization coverage for children and farm workers, community education on dementia care, and fall prevention quality improvement to decrease outbreaks in skilled nursing facilities, a new genomic episequencing team identifying hepatitis a outbreaks, improvements to fiscal and billing processes, addressing public health reaccreditation requirements, or building a new public health laboratory facility.

The availability of sustainable, noncategorical funding in public health infrastructure enables local health jurisdictions to address issues that are relevant and meaningful to their unique community needs while also contributing to collective impact and addressing key gaps in the public health system. Additional public health workforce investments, such as the California Public Health Equity and readiness opportunity or hero initiative, effectively complement the Future Public Health Infrastructure Initiative.

A few highlights of current implementation reflect strong participation, often at double the rates of prior year levels, in these important programs to prepare public health professionals in key roles, 56 California epidemiologic Investigation service, or Cal EIS Fellows were trained with a goal of training 100 fellows by 2029. 59 public health microbiologists trainees and 18 lab Aspire Fellows, which are being trained as future public health lab directors, have been trained during the first years of this program and additionally, the California Pathways into public health or pathways initiative provides training, support, and hands on work experience to community college and University students who are studying public health related disciplines.

Through this program, students are offered an opportunity to work at local health departments across the state and receive training, professional development, and paid wages. Two cohorts of fellowships have placed 87 fellows at 37 local health jurisdictions across the state, many of whom went on to accept positions at California local health departments.

For each cohort, more than 90% of participants come from historically underrepresented and diverse backgrounds, including first generation college students, ability to speak English plus another language belonging to a racial ethnic minority group, LGBTQ plus identity living with a disability, or those whose highest level of school completion is a high school diploma or GED. A high percentage of fellows are placed in either their home county or a nearby county to reduce relocations and increase the potential for alumni retainment in LHD positions in their community.

I know this has been a lot of information and is still a very high level update of the accomplishments to date and plans going forward for the future of public health. We plan to keep the Legislature updated about milestones with this important investment. This investment would not have been possible without the collaboration and support of the Assembly and Senate budget committees and staff. And we're truly grateful for that ongoing partnership. We'd be happy to address any questions and continue in discussion. Thank you so much.

Thank you so much. I just have one question here regarding the communications public education to promote healthy behavior. The reason why I'm asking is because the Director mentioned that stroke is leading in deaths across California. Are we doing any outreach communication around stroke?

I'm certain that we are. I would love to be able to get more detailed information when we are doing health education initiatives for CDPH, it happens both through our programs. So we have programs that focus on various chronic diseases, including stroke, and then our communications apparatus that helps with social media and campaigns. So be happy to get information about what we're doing in terms of education on stroke.

Thank you, Senator Eggman.

Thank you. And thank you for that overview, although it's hard to follow so much.

I know, I'm sorry.

I just want to go back to the hiring we're doing in the investing in mental health and the plans. Everyone submitted a plan, their work plan, and who reviews those plans, and then how do we use that as a measurement going forward? And are all the plans, do they have similar data that we can measure across?

Yes. So our regional public health office, which is one of the new initiatives, established as a structure within the Department, they provide the administrative oversight for those plans. So they'll be reviewing all of them. They are all collecting consistent information so that we can have comparison and be able to look at the impact of what are the issue areas, what are the types of the different classifications that are being added to public health workforce and what are the strategies that are being employed.

So those work plans were finalized in December. We're preparing a summary of that, which is going to be publicly available later this month. Okay.

And then there'll be ongoing reviews?

Yes, absolutely. So there's also a quarterly that we also receive, in addition to those three year work plans, quarterly work plan and spending plan monitoring that we do, we also have, through the regional public health office hours available for consultation with local health jurisdictions, both to follow up on questions, but primarily to see what we can do to provide support and how we can learn from the efforts underway at the local health jurisdictions. Thank you.

Seeing nothing further on our end, we're going to move over to our local health officers or representatives. Now kicking us off is the County of Madera. Sara.

Good afternoon. I'm the Madera County public health Director. It's my pleasure to be here today to share with you the impact of the future of public health investment in Madera County the Madera County Department of Public Health includes communicable disease mitigation and clinics, a public health laboratory, immunization, emergency preparedness, children's medical services, maternal child adolescent health, home visitation, WIC and community wellness programs such as tobacco and calfresh.

Madera County receives an annual allocation of just over 1.2 million in future public health. With those dollars at work, our department is better prepared for an emergency and better equipped to improve population health. In addition to investments in communicable disease, we are implementing interventions designed to identify and address chronic conditions and connect people with primary care so when the next virus emerges, our population is healthier and better able to avoid acute illness.

We focused our future of public health funding in Madera exclusively on staffing. Much of Madera's first future public health work plan focuses on key plans required by public health accreditation and by the funding requirements. Madera was accredited in February of 2023, so we were due for the next round of these plans. So our community health assessment was published in 2023 and we are working on publishing our strategic plan and community health assessment in 2024, this spring.

We hired permanent staff to be able to complete these plans, and the team included a second epidemiologist for a department. We have never before had a second epidemiologist in Madera, so that's super exciting. So this expanded our capacity, really revolutionized our ability to an approach to our community health assessment in this round, having that extra capacity, and has certainly contributed to the quality of our health improvement planning. In our community health assessment in this round, I just really want to highlight how we have partnered with community based organizations

We were in just Little Madera County, 160,000 population. We did primary data collection in collaboration with four community based organizations collecting nearly 1700 surveys, 11 different focus groups from different geographic areas and targeting different populations, and 21 key informant interviews. Based on that, we worked with our coalition, which is called Live Well Madera County.

That data, as well as the expertise and experience across that coalition, which includes community based organizations, other agencies and leaders across the community and residents, to be able to identify key priorities for our community. In selecting those goals, the partnership was really the common practice that had been well established long before COVID but was certainly tested during COVID. And so we continually interacted with those community based organizations and with those partners in identifying what the key priorities were for Madera County.

We landed on diabetes and heart disease, domestic violence and child abuse, substance use disorder, and access to care. And as example of how we have begun implementing on those efforts. Access to health care is a particular need in Central California, as you all know, and Madeira County having lost our hospital. But what's often lost in the highlight of the hospital kind of tragedy and disparity that has resulted is that our healthcare system in Central California was always a problem, a big problem.

And when we look at the data, each of our healthcare providers is serving between 45% and 50% more patients per provider in comparison to the rest of the state. And so it's really something that we're working regionally to address. And we're currently working with Senator Caballero and Assembly Member Soria on a proposal to increase medical rates so that we can work upstream and keep people out of the hospital.

But with the investment in our epidemiology and that team that's really being able to lead that effort around our child owner chip, we're able to tackle data projects that we've never been able to. We're looking at a regional gap assessment around that healthcare continuum. We are also in the process of developing our new strategic plan. It includes extensive assessment, internal and external, and the first time we've ever done equity assessment in our department, and a department wide equity training.

And that's being incorporated into the goals of our strategic plan. I want to highlight just a couple other temporary things that we were able to do that were teams that were temporary staffing that we were able to convert to permanent staffing after COVID using future public health.

But if you could start wrapping up as well, please. Thank you.

We added an informatics team, which was deployed first to make our testing and vaccination smooth and able to collect all the data that you're interested in. For sure. SOGI data and all of the other great data that really helps us with workflows and efficiencies. We hired and deployed a bilingual mobile health team that was initiated for testing and vaccination, but is now being deployed across a whole host of issues and mobilized to do wellness checks in addition to other communicable diseases, and is now the central hub of one stop shops of many, many agencies and other partners. We were just in Fairmead, a tiny community that struggles with transportation. We brought all of the 20 agencies and partners to them. And that mobile health team is that anchor.

Our communications team, we were able to sustain after COVID, which has just been so huge in reaching important communities through everything from social media, video, radio, all of those things. And we maintain that team. Final thoughts are we just really appreciate honestly how this has revolutionized our department. I can't emphasize enough how different our department looks from before future public health and what it looks like now. And I just really applaud the forethought of the administration and the legislation in putting this funding in place for public health.

Thank you so much. Moving towards Riverside County Public Health Director.

Good afternoon, chair and members. My name is Kim Saruwatari. I'm the director of public health for Riverside County and the immediate past President of the County Health Executives Association of California, or CHEAC. Thank you for having me here today.

I was going to talk about some of the programs we have, but Sara covered those. We all have similar programs in our public health departments. So I'll jump right into the future of public health piece. So COVID clearly highlighted the impacts of decades of disinvestment in public health infrastructure, and the investments that were made prior to and during COVID were categorical, disease specific, and time limited.

These funding challenges made and continue to make it difficult to have a workforce that is cross trained and capable of responding to emergencies like wildfires, floods, or a worldwide pandemic. And this is why the future public health funding is so critical to maintaining our public health workforce. The funding is flexible and ongoing so we can hire the positions we need to support our most vulnerable communities and accomplish the work laid out in our community health improvement plans, also known as our CHIP.

I'm happy to report that we're making great strides in improving our public health infrastructure and our ability to efficiently respond to emergencies. We're not where we need to be, of course, but we're headed in the right direction. And much of that is due to this $200 million of funding through future of public health to local health departments. In Riverside County, we receive almost $12 million of funding per year, which has allowed us to hire both new positions and transition positions that we hired during COVID into permanent. In total, we're funding 107 positions, or 78.5 FTEs, with future public health funding to improve our capacity and communicable disease response, chronic disease and community health, including climate change, data modernization, reporting and analysis, emergency response, laboratory capacity, outreach and education, particularly to our most underresourced communities.

We've hired nurses, microbiologists, epidemiologists, communicable disease specialists, community health workers, health educators, accountants, analysts, couriers and others, all with the goal of serving our community, improving the overall health of our residents, and enhancing our response capabilities. As of today, we filled 104 of the 107 positions, or 97.2% of the 78.5 FTEs supported by the future of public health funding, and the three remaining positions are in active recruitment. With these additional staff in place, we're starting to see results.

Our outreach teams attended 610 events and 17,249 community members received health education in connection to public health and other resources. We developed an expanded disease surveillance team to enhance disease detection and reporting, and as of today, approximately 99% of our tier one diseases are investigated within the required 24 hour time frame. Previously, that was 80% to 85%. We created immunizations, mobile teams, and during preteen vaccine week and school enrollment, we offered 48 clinics and administered 8,431 total doses of vaccine to 7,197 unique patients.

In addition to the staffing support, 30% of the future of public health dollars can be used to support equipment, supplies, travel and professional services. So in Riverside County, we use these funds to provide training to staff, purchase equipment to enhance our IT infrastructure and data storage capacity, implement a lean performance improvement process across the department, and contract with the city to conduct wastewater surveillance to further enhance our disease detection capabilities.

I do want to acknowledge that on a statewide level, it took some time to get these funds into place, to get them accepted through each of our boards of supervisors, and to hire the staff. So as a result, there probably is a small amount of money left unspent and we would propose repurposing that through a proposal we're calling PNA-PATH.

PNA-PATH would support local health department work in developing their community health assessments and their community health improvement plans that are now being synchronized with the new state requirement having a synchronized cycle of assessment. So I'd like to end my comments today by thanking the committee for their support of governmental public health. The future of public health investment is improving public health infrastructure, and by doing that, we're saving lives, improving communities, and extending healthy living. Thank you so much for your time today.

Thank you. Just a quick question. When you said that you're putting a request to repurpose some of that funding to your Board of Supervisors or you're asking the State Department?

We're actually working with CDPH.

Okay, thank you so much. Moving on to our next panelist, a deputy health officer from Santa Clara County.

Thank you. Good afternoon, Madam Chair and Members. I'm Dr. Sarah Redmond, deputy health officer for the County of Santa Clara and director of our Infectious Disease and Response Branch. I'm here also on behalf of both the county and the county Health Executives Association of California and the Health Officers Association of California with a specific ask that we sustain funding for the Cal Connect system along with support for core resources for local public health capacity, such as the future for public health funding.

So I had a unique role during the COVID pandemic with Santa Clara County, directly leading elements of our core public health response, including our contact tracing and our outbreak investigation work. So I remember acutely the painful early days when we in Santa Clara County were redirecting nearly every resource we had to both perform these core public health activities and try to build our own system for the data that we needed and the work we needed.

But we still didn't have the system we need to track even the relatively few cases of COVID we had at that point. We struggled to create our own systems on paper or in individual Microsoft Excel spreadsheets, and found we ultimately couldn't do it ourselves without a statewide coordinated response.

Then I remember what a game changer CalConnect was when it finally came along and allowed us the ability to track vital public health data, assign work in a timely fashion, reach out virtually via soft phone or text, automate components of what we were doing, and share information across jurisdictions. And ultimately, I have no doubt that the calconnect system saved lives, especially when case rates then increased by orders of magnitude. And we simply couldn't have kept up without something so streamlined.

CalConnect's efficiency and capabilities let us redirect saved resources to other efforts like vaccination. It meant we could overlay advanced algorithms and interact with other databases, which helped us do things like identify which cases and contacts were vaccinated, or predict which cases would need a call from someone who spoke Spanish, or streamline the reports that were coming in from schools and other agencies. It meant we could finally work across jurisdiction for shared investigation and avoid duplicating efforts across the state.

It meant we had a modern system to let us analyze our investigation data to assess quality and highlight new key findings to guide policy decisions. We could update the information we collected or the resources we were offering almost overnight, even when we were peaked at a staff of about 1000 staff and volunteers utilizing the system.

For example, we recognized early that through our analysis that became capable in Calconnect that we were undercollecting and incompletely collecting SOGI data, and allowed us to use the system to deploy a training that increased staff's ability to do so and therefore have meaningful findings with respect to these data. And most importantly, we could do much more rapidly offer life saving interventions.

And I even remember a couple of occasions where our staff had to call 911 and bring emergency medical assistance to offer life saving care to a patient they reached through CalConnect, and without the rapid case processing and assignment system that allowed it, we never would have reached those cases in time.

Now this build wasn't easy to go from nothing to the functionalities in CalConnect I just described took months, in some case years, and included not only the significant investment at the state level through federal funding, but at the local level to offer input, test changes, and train our staff, which we would have to find resources to recreate if the system lapsed.

But now that we have it, we've come to rely on it completely, not just for COVID, but for MPOCs, for Ebola and Marburg threats, and right now using it to support measles investigations. We also know that syphilis and tuberculosis are growing threats not only in the state, but especially in Santa Clara, where we are seeing the highest rate of congenital syphilis in generations and a 20% increase in TB cases in just the last year.

And CalConnect is now poised to be ready to support us with both of those investigations in again a game changing way because the system is so adaptable and well designed for what we do in public health. There may even be other future uses for noninfectious diseases such as lead poisoning, which is of interest to us in Santa Clara County.

So my ask specifically today is that the legislature please redirect unexpended CDPH state operation funds from the 2022 and 2023 Budget act in order to sustain and continue CalConnect. This may include funds that were dedicated to disease surveillance, readiness, response, recovery, and maintenance of it, or state future of public health funds. We also ask that the legislature and administration explore federal enhanced laboratory capacity, or ELC funding that can be dedicated for continuing the system. Without sustaining CalConnect, I fear we risk taking a major step backwards and undoing years of progress we made in disease investigation during the pandemic. So thank you for your attention to this issue, and I'll be happy to answer any additional questions.

Thank you so much. Moving on to our next panelist, managing Director of policy, California CPEHN.

Good morning, Madam Chair, and members, Ronald Coleman Baeza, managing director of policy for the California Pan Ethnic Health Network, CPEHN. CPEHN is a statewide policy advocacy organization that works closely in partnership with communities of color to advance health equity. CPEHN has historically advanced policy advocacy focused on prevention within public health, but our deeper public health policy portfolio was developed as a result of the community needs that became apparent the moment the pandemic began.

CPEHN has been frustrated with the lack of investment towards public health in our communities. We understand that public health at all levels of government has been underfunded, which has resulted in general under preparedness to respond to any public health emergency. However, with the limited dollars that have been available, we also know that historically systemic and institutional racism has strongly contributed to the lack of attention, funding, and engagement broadly across our communities of color. For far too long, our communities have just been ignored.

It actually wasn't just COVID-19 that was a public health crisis. Racism and the impacts and effects of racism are also a public health crisis, and California continues to fall short at acknowledging that or establishing targeted mechanism focused on racial equity for specific populations. From the start of the pandemic, there was often no seamless mechanism to do outreach and education related to COVID-19 to all communities.

Language access standards were completely ignored, contract tracing was completely limited or nonexistent, and many local public health departments had no way to link with CBOs who could support these efforts. Communities of color struggled to get the accurate information needed to protect themselves and their families, despite the well documented risk that they were most being impacted by COVID-19 lack of data or inadequate data collection methods often obscured consequential health outcomes and disparities for many communities, including indigenous and many Asian American, Native Hawaiian, and Pacific Islander communities.

Disparities within these communities often go unreported or are subsumed under General categories that could be better understood if disaggregated. As a result, we don't have a full picture of the way disparities inequities are truly playing out in our communities. We do know that race itself does not lead to these differences.

Rather, systemic racism in healthcare and throughout society are the driver of these disparate health outcomes for communities of colors, and these disparities are often intersectional due to overlapping effects of systemic discrimination of sex, gender identity, sexual orientation, or even disability status, as we heard from CDPH. Given the deep structural inequities across counties and around the state, it is not surprising that the disparities we see in health outcomes were generally mirrored in COVID-19 infection rates, related morbidity, and mortality.

This was also evident in the hiccups connected with the rollout of vaccines to communities until CPEHN and partners stepped in to push the state on vaccine equity to ensure vaccines were going to the communities that needed them the most because of transmission and impacts. CPEHN recognizes that the state and local government were struggling to do what they can, but the infrastructure they were working off of already didn't focus on the most pressing needs for communities of color.

Many public health departments didn't have strong relationships with diverse communities before the pandemic, and again, it was very difficult, if not nearly impossible, for them to do that in the midst of the pandemic. It took CPEHN two to three months to actually sit down and get a meeting with CDPH in the pandemic. Many organizations also cited lack of trust with public health departments due to lack of engagement and lack of representation within local governments.

As a result, CBOs were the ones to step up for their communities. CBOs employ staff from their communities. They serve those communities and are trusted to get out accurate and reliable information in a culturally competent way. In language, CBOs often use traumainformed approach to help ease the burdens as an approach to delivering services, often meeting people where they are.

This included CBOs using team based care models, sometimes working with providers or mental health professionals, while often organizing and hosting mobile COVID-19 testing and vaccination sites around the state. CBOs were responsible for keeping communities socially connected and engaged. We saw from Roots Community Health center hosted weekly briefings to raise awareness of the COVID-19 impacts in Black communities.

In Los Angeles, a collaborative of Asian American, Native Hawaiian and Pacific Islander residents used their CHWs to conduct outreach and education to connect residents with rental and food assistant critically needed due to lost wages, while they also established COVID-19 and vaccination sites. We also saw Mixteca Indígena community organizing project MICOP use its radio station, which reaches tens of thousands of indigenous language speakers across California, to disseminate information about COVID-19.

We also saw good moves from local public health and counties who did move in the right direction to work to center equity, develop coalitions and task forces to actually work in partnership with CBOs. But more needs to be done. As a result of what played out during the pandemic, we know exactly what needs to happen to ensure our public health system works seamlessly. We should be investing funding and resources to CBOs.

We should be investing funding to clinics, CBOs, and tribes to strengthen their role as vital partners to meeting community needs. CPM partners proposed the Health Equity and Racial Justice Fund, which would have done just that would have created a grant program within CDPH to deliver grants to communities to move community projects at their direction, particularly on health equity and racial justice. We should also be actively engaging community partners and organizations. There should be strong connections to workforce development, particularly through CHWs.

We were pleased to see the Medi Cal benefit establish them, but CHW reimbursement rates are abhorrently low, making it hard for the program to get off the ground. State and local governments should also build capacity and partnerships with government institutions and community stakeholders on community strategies such as active listening, cultural humility, cultural linguistic competency, acknowledging past wrongs and failures and techniques to build relationships and community. The one thing that is going to be crucially important moving forward is making sure that we can involve community in the conversations around public health. Community participating budgeting is absolutely essential. Thank you.

Thank you so much, sir. I definitely agree. I led a team in a nonprofit in my district on mobile clinics, on community health workers reaching and knocking on doors in my district. So I agree with you 100% on that. In fact, I was a little staffer back then, and on my own I would hold weekly calls with different CBOs just to give information because we all know it was just convoluted and just everyone was just very confused during that time. So thank you very much. Our last panelist is President and CEO of Public Health Institute.

Good afternoon, Chair Menjivar and members of the committee. My name is Melissa Stafford Jones and I am the President and CEO of the Public Health Institute. PHI advances well being and health equity with communities in California, across the country, at the federal level, and in countries around the world.

For 60 years, PHI has served as a convener, collaborator, and implementing partner with the State of California, local health jurisdictions and communities, as well as the Federal Government. In our role as a thought leader, a catalyst, a trusted partner, and an intermediary, our work includes program design, implementation, grant making, data infrastructure and analysis, and research and evaluation. Thank you for the opportunity to speak to you today about this critical work happening to build public health infrastructure through the future of public health.

Addressing inequities and focusing on root causes are central, as we all know, to the field of public health. We make the most powerful impacts by focusing on prevention and on creating the conditions for health and well being, particularly for the most underserved. I wanted to highlight today three strategies to consider as we continue to advance the work of the future of public health. First, continuing to strengthen the public health ecosystem and partnership.

When we think of public health, I think there's a value in recognizing that it is an ecosystem that includes governmental public health at the national, state and local levels, as well as community based organizations and services and communities themselves. Each part of the system has particular roles, capabilities and strengths that can be deployed in our collective efforts.

For example, the future of public health effort on local community planning processes that really engage the community and integrate them into that work, I think is a reflection of this ecosystem approach that we think is critical, and building infrastructure and sustaining investment for each part of that system and for those component parts to work together in partnership is critical. When each part of the system has the infrastructure, appropriate resources, workforce and capabilities it needs, we can best improve health and equity for Californians.

Second, we would suggest really prioritizing the role of communities and in a particular way. The future public health pillars include a vital focus on community partnership and community health improvement, which we heard about, as essential components of public health infrastructure. Advancing equity necessarily involves shifting power, including to communities, which is also critical to rebuild trust in the public health ecosystem.

We saw during COVID as we just heard from my colleague, the effectiveness of investing and focusing on efforts at the community level through trusted community based organizations and partners. For example, PHI together toward health worked closely with 548 CBOs to reach more than 27 million of our most underserved Californians. Their trusted messenger model connected just shy of 1 million community members to vaccines and supported more than 250,000 with workforce development opportunities.

Working in close partnership with trusted CBOs and community led organizations in concert with governmental public health is vital to achieving our public health goals. Our recommendation is that future public health investments should prioritize infrastructure for authentic, meaningful community partnership that is ongoing and sustainably funded, and not only in response to a particular emerging issue or a particular priority.

And we heard some examples, I think, of perhaps the way we are starting to move in that direction, and we would really encourage this development of infrastructure investment and prioritization of community engagement in the work of public health. Third and last is focusing on integrating public health into the overall health system. I've been very fortunate to work across multiple systems, including safety net healthcare and financing at the community level in terms of different services and sports and at all levels of government.

And so I really appreciate California's leadership right now in the ways in which we are trying to think about how public health and the social determinants of health and the healthcare system can be more integrated. And I want to really emphasize that as a recommendation, a priority. And I think Senator Eggman's comments earlier around the connection between hospitals and public health was really important in this space.

We have a tremendous opportunity in California to integrate public health and healthcare, to support and resource the public health system with the healthcare delivery and financing system, particularly in Medi-Cal, given the emphasis of CalAIM, and on really thinking about social determinants of health, community supports and prevention. And you may have seen earlier this week, actually, a national coalition of hospitals, physicians, health plans and Kaiser Permanente announced a new effort to advance the vision of better health by collaborating with and supporting public health. Bringing public health more explicitly into the vision and structures for healthcare delivery and financing would strengthen California's efforts to increase early and upfront prevention.

Give us your final thoughts.

Yes. At the individual and community level, connect the dots between public health and health care and build intentional cross sector strategies for reducing health disparities. Thank you for the opportunity to speak today.

LAO, Will, if you have anything to add to this.

Can you hear me? All right, great. So Will Owens with the Legislative Analyst Office. So we have nothing in particular to add to the future of public health, but I think there were a couple of notes from some of the panelists on potential future General Fund supplements. All that to say, given the budget condition, the legislature we would recommend weigh those against other legislative priorities.

That being said, our office has worked to identify a number of one time and temporary spending items that the legislature may wish to consider and would need to work with to then provide for these General Fund other additional General Fund augmentations. That being said, we're available and ready to work with the committee to assist in identifying those. Thank you.

Well, before you leave anything off the top of your head that you are on your list of those one time within this space.

Yes, one moment. Sorry.

That'd be helpful. I think. I've also been trying to really pin on how much we have on the CYBHI funding left.

Yeah, absolutely. Not only is there kind of current funding that has been carried over, but there is right now planned future Children Youth Behavioral Health Initiative. funding for the budget year and beyond that will go to CDPH, and we can help identify and work with the Committee on those.

Thank you, Department of Finance. Would you like to add anything? You can shake your head no if there's nothing. Okay. You don't have to walk over here. Okay, I have three questions. Well, one comment. I just first want to say, I mean, this is what happens when we really invest in workforce, right? I think we've been saying this for a long time. This is just proof of how much I've heard the numbers that you shared. We're almost close to, like 95% on almost every single one that we've invested in.

Really close. It's like one or couple left. Right. So not bad investment. Two questions I have is, I forgot who mentioned diabetes, and it reminded me, and I wish the Director was still here. Diabetes is such a huge problem in the Latino community, the BIPOC community as a whole, and it continues to rise and it comes up in every conversation that I have in my district with any clinics, counties, DPH, CDPH, what are we doing around just the increase of diabetes and high blood pressure in our BIPOC communities?

Well, in Madera County, we're really looking at the more upstream measures. So I was the one who mentioned diabetes and heart disease as one of our priorities. And one of the things in our Committee health improvement plan is our coalition made a commitment to really focusing our efforts upstream. There are lots of programs, like Diabetes Prevention Program, for instance, that are expanding, and we have that capacity in our Department. We're continuing to provide individual patients with care to be able to prevent it.

But until we address the upstream factors of our ecosystem around healthy eating and physical activity is going to continue to be an issue across our population, and especially our Hispanic, BIPOC populations and communities that don't have the same opportunities. They're living with a grocery store that's more like a convenience store. And their neighborhoods are not safe to be able to get outside. Active transportation is not an option. And so those are areas which we're leaning in.

So we, for example, engage our residents in walk audits of their neighborhoods, and we work with the city to be able to fix intersections so kids can walk to school. And we're consistently adding additional opportunities for people to access fruits and vegetables, gardening projects. And we're in the process right now of planning a community garden.

I mean, that reminds me of the CalFresh pilot program. Right? Adding additional refunds for fruits and vegetables.

Vouchers for farmers markets. Exactly.

Would you like to add something to that?

Yeah, through the Chair. On behalf of Santa Clara County. I think just as Ms. Bosse was describing for Madera, what we've found is while we need to be partnering closely with our healthcare delivery partners in identifying pre diabetes, ensuring people have the treatment and preventive services they need, these kinds of cross cutting upstream factors, do you have a safe place to exercise? Do you understand and have access to the food that will help prevent diabetes?

Do we have policies that make those foods and safe activities affordable to you? The kinds of cross cutting staff we need to do that was almost impossible prior to Future of Public Health because we often needed somebody who could only focus on food because there was a food related funding stream. Could only focus on transportation because there was a transportation related funding stream.

Now that we're able to hire cross cutting staff who may be able to manage contracts in any of those areas or gain their own expertise in any of those areas, we're able to much more easily have those holistic conversations with the communities impacted and then bring them whichever piece is most pressing to them and most important, .

Our public health is taking us toward the streets. I know someone mentioned also mobile teams. I know that it is really literally the future of public health. What is our investment in expanding this countywide, statewide?

So, Madam Chair, I did mention mobile teams in my comments, and we've actually kind of reshaped the way we've done public health. Traditionally, public health disease investigations involved a lot of field work and going into community now, we really are looking in depth across all of our programs.

And so two examples I would offer for you are immunization teams, where we're actually looking at things like healthy places index data, where we see the most under resourced communities, overlaying that with where we know our immunization rates are low, and then going into communities, community centers, schools, churches, places where people naturally gather and offering vaccines so that we can try to raise vaccination rates.

And while we're there, also bringing WIC staff and maternal child adolescent health staff, so we can get people enrolled in home visitation programs or other voucher programs, so that they can get services they need in the communities they live in. And then the other one that I mentioned briefly in my comments was our equity mobile teams. And so we have teams of about four people from public health, and we've pulled in other county departments.

And so they are actually embedded in the community, known by the communities, by our community based organizations, our faith based community folks, so that they also serve as a resource to connect people to services and help them navigate what is sometimes a bureaucracy right, to get the services they need. So I think that future of public health funding has really helped shift us to think that way about taking services into the community, and particularly into those underresourced communities that need them the most.

We're doing a similar thing in Madera County, and I just want to highlight how difficult it is to do that coordinated, holistic, mobile kind of effort using categorical funding streams because of the requirements. How do you chop up those individual people into different funding pots? And so, because future public health is so flexible, we're able to put that core team together, and then we can bring in those individuals from the other categorical funds to supplement that.

So before this, you couldn't do that.

It was very, very difficult. It was basically a funding nightmare on the back end, and we were constantly figuring out, how do we actually weave that into the scopes of work when the scope of trying to fit a round peg in a square hole.

Okay, colleagues, any further questions? Senator Roth.

Thank you, Madam Chair. I'm just curious, particularly for the representative from a participant from the Central Valley, we've tried our best here to improve the overall health of our population by colleagues expanding Medi-Cal in a rather dramatic way. Unfortunately, at least, it's my perception that for many communities, and certainly certain segments of those communities, the initial point of entry into our healthcare system has been our hospital emergency departments.

And in the Central Valley, where - the land of challenged hospitals, I think I would say - are we making any headway in terms of redirecting the population to our clinic system? We've been talking about mobile services, and, of course, that's wonderful. But we have a system of clinics in the state and other office based delivery systems, other than the Emergency Department, that haven't been utilized quite as heavily as the Emergency Department. Are we making progress in redirecting our population to the clinics early and often to try to catch people before they need emergency services. Is that a fair question?

Yes, it is a fair question. Within the infrastructure that we have available, we're making as much progress as we can. So I can say in Madera County, they don't have an Emergency Department, so they're forced to now learn when it's appropriate to use urgent care. But our mobile team, one of the core things that we do is we do wellness checks, and we provide the services that are about public health.

But the reason we're doing wellness check is we're wanting to identify if they have high blood sugar or high blood pressure and get them connected and help them understand, like, who is your Medi-Cal provider? Do you know how to get a hold of them? Do you know how to schedule an appointment and getting them connected, enrolled, if they're not enrolled in Medi-Cal, such things.

But we still have an infrastructure that is inadequate for actually providing for primary care, because we have about 50% more patients per provider than the rest of the State of California. So the wait times to be able to see your primary care provider, how much time that provider has with each patient, to be able to truly listen to them, understand culturally, linguistically, everything that they have going on, to be able to identify and address social determinant hurdles for being able to follow through on treatment plans.

All of those things are very difficult in an overwhelmed system. That's why we are wanting to do a pilot in the Central California around augmenting Medi-Cal to see if we can make an investment upstream in managed Medi-Cal, attract more workforce, and see if we can address that infrastructure.

Well, we're certainly going to have to do something. I mean, even urgent care is not really the place to start. I mean, we ought to be at FQHCs and other clinics that are on the ground, designed for visits to catch issues before they become illnesses or otherwise, that require urgent treatment or Emergency Department treatment.

And I'd be interested in knowing what this Legislature and certainly the Budget Committee can do, hopefully in better times, to try to help expand and develop the clinic operation, Medi-Cal or otherwise, in places like the Central Valley, because the hospital situation is a very, very difficult one to resolve, and hopefully we'll come up with some solutions.

But the bottom line is, as my colleague to my right indicated, the goal is to keep people healthy, out of the Emergency Department for sure, and out of the hospital certainly, as well. So this is public health, and I guess that is public health, right? Keeping people healthy. So I'd be interested in hearing from you during the course of my remaining time, however short that is, as to how we can help you, help us, and help the residents of your communities. Thank you, Madam Chair.

And to prepare you for your future. To prepare you for your future.

I may not have a future, Madam Chair, but thank you for thinking about it.

Thank you for your presentation today and all the work you do. I'm a huge fan of public health and could ask questions all day, but in the interest of time and the Chair's flight, I'll be brief. But I also want to say that that's your real champion right here for the MCO tax and being able to get more money with Medi-Cal. Again, I could ask a thousand questions, but just I think the issue that we keep talking about is around we have to keep people out of the hospital.

And so I guess, as we just had a hearing yesterday on CalAIM and funding some of the social determinants of health, and how, if anything, will you see that impacting your work and the ability of your local systems to resource their plans so that they can be able to contract and provide for a lot of those social determinants of health types of services? I'm interested in from the public health directors, if you have any thoughts.

Thank you, Senator Eggman, for that question. I think it absolutely will give us an opportunity to really look upstream. And so these benefits, like many of my colleagues mentioned, the community health workers. So in Riverside County, we're looking at creating a community health worker hub in partnership with our community based organizations so that we can expand community health workers throughout all of our public health programs, but also with our hospitals, with our clinic systems, so that we can make sure that we're connecting to services we're getting upstream. We're addressing the other issues that are outside of the traditional healthcare sphere, like housing, like other social services, right.

So that we can look at health holistically, because we know that all of those things impact health outcomes at the end of the day. So I think CalAIM provides us with a really unique opportunity to start looking at upstream interventions and resourcing those interventions through things like community health workers, enhanced care management teams, those different programs.

I'll add, for Santa Clara County, one of the things we'd appreciated about components of CalAIM is the opportunity to work closely with our Medi-Cal managed care plans on the community needs assessments, the community health assessments.

What I have noticed, though, is just that initial lift to bring us both to the same place, to bring us together, develop some of the memorandum of understanding that are useful to get us on the same page and urge those managed care plans to take the right steps to, just as public health has for many years, listen to the community to drive what solutions will address upstream social determinants of health. That work is not traditionally resourced in public health either.

This is a new ask, and unlike many of the other components of CalAIM that come with a CalPATH funding mechanism to support them, that hasn't been the case for public health. So we are looking forward to that opportunity to work that much more closely with our managed care plans and ensure that they are able to lift out of public health some of these direct service activities that will ultimately make their members healthier. But we are still continuing to search for the resources to be able to engage in that early work.

I just want to highlight quickly that CalAIM is continuing to highlight the inequities across the state, that those communities that have a really robust ecosystem for public health are able to capitalize on the opportunities of CalAIM in a more effective way.

Our urban centers and populous areas, but small counties, Central California, the rural north, Inland Empire, continue to struggle to be able to find all the appropriate vendors. We don't have the same infrastructure and sophistication to be able to access the supports that are supposed to help with equity. So in some ways it magnifies the inequity and sometimes amplifies it.

What's our solution?

Do we see improvements in that now that we have the chicken and the egg, right?

It is the chicken and the egg. What I'd say is that what I've noticed is we have tried to create statewide, formulaic approaches to equity. And when we do that, we use examples of places where it's working really well to use a formula, and those are typically places in which you don't see quite as much equity from a statewide perspective.

And so we're going to have to do some very targeted infusion of funding and strategy in those geographic areas, which is difficult to do when you have such a large state and not try and fix a problem that is inherently about differences by rolling out something that is uniform across the state.

Yeah, when we think about it, it's analogous to the food ecosystem, right? When we talk about diabetes and hypertension, all those things, and we know there's not easy access to fresh fruits and groceries and maybe just a corner market. It's the same thing when you're talking about trying to hire community health workers or work with nonprofits and CBOs. They don't exist in the neighborhoods or in the region? Yeah.

Would you like to scratch up another question from your 1000?

No. Again, I appreciate your work and I appreciate your scrappiness in finding where there could be some money that you can snatch too.

Thank you so much for joining us today. I really appreciate your insight. We're moving now on to issue number three, where we'll be talking about the maintenance and operation support for Sapphire System.

Good afternoon. Good afternoon. Adrian Barraza, Assistant Deputy Director with the Center for Infectious Diseases. I'll start with an overview of the BCP, and then there were two questions that were submitted that I'll go into. So again, starting with a brief overview, the California Department of Public Health requests 26.9 million General Fund and 24/25 for MNO support for the surveillance and public health information reporting and exchange, or the Sapphire System.

The Sapphire System is a gateway for receiving electronic lab data and electronic case reporting at CDPH. This data exchange evolved out of a previous statewide IT platform, the California COVID reporting system, which was developed in 2020 to increase statewide capacity to manage extremely high volumes of COVID-19 laboratory data in pandemic response when the prior gateway was not able to handle the volume.

Sapphire functionality allows for receiving public health data for all reportable conditions, not just COVID-19 including infectious diseases such as tuberculosis, measles, HIV, syphilis and Mpox. Previous budget acts have funded the Sapphire System up to the 23/24 fiscal year, and additional expenditure authority is needed to continue operation of the sapphire system in 24/25.

Continued MNO of the Sapphire System is needed to maintain a timely and accurate statewide health information exchange system for effective public health surveillance and disease outbreak response, as well as comply with federal health information data technology requirements. And if helpful, I can go through the questions at this time. Perfect. So the first question, the requested maintenance and operations resources are only for 24/25. What is the plan for ongoing maintenance and operations of these systems?

So let me first say Sapphire is an essential system that CDPH uses to collect public health data on all reportable diseases, and so to that end, it is an integral part of our IT portfolio. The budget year MNO appropriation request from the BCP aligns with the current contract term date, and we'll have to revisit the out year considerations and work internally to do that. Your next question - what would be the consequences of allowing the contract for maintenance and operations for Sapphire to expire?

Maintenance and operations for the sapphire system is crucial to support California's continued public health response by supporting laboratory and case reporting for over 80 other reportable conditions including influenza, RSV, COVID-19, tuberculosis, measle, HIV, syphilis, Mpox, and many others. This enables California to have better quality, timelier, and more complete surveillance for infectious disease and facilitates more rapid and robust response to current and future infectious disease outbreaks and emergencies.

Without funding for Sapphire, CDPH and LHJs will need to stop some data streams and revert to less robust tools for laboratory reporting, which will dramatically slow CDPH and LHJ ability to receive timely reports of notifiable diseases and significantly hamper capacity to prevent, respond to, and manage emerging disease outbreaks. It should be noted that these tools failed during the COVID-19 pandemic and likely could not effectively manage current data reporting needs. And if there are any other questions, I'm happy to answer those.

Department of Finance, do you have something to add?

Nothing further to add. Thank you.

LAO.

Nothing further to add. Available for questions.

I don't have any questions on this. We're going to hold the item open. Move to issue number four. Talk about information technology savings and reversions.

Good afternoon, I'm John Roussel. I'm the CIO for CDPH. I finally get to speak.

There you go. For some reason I was like, are you with Will? LAO?

I am not. I'm with California Department of Public Health. But he just likes to sit next to me so. Speaking on the two technology savings issues. The first one is COVID website. After June 2024, the COVID-19 ca.gov URL will be redirected to the CDPH hosted site. Communication has been provided to the Governor's office and local health jurisdictions for the migration to a CDPH site. We worked with the Governor's office, who provided us with approvals for this move. We expect minimal to no user experience changes, and potentially the greatest change would be site layout arrangement would be slightly different. Any questions on that one?

LAO? Any comment?

Just given the budget situation, we generally find this proposal reasonable.

We're going to hold the item open. We're going to move on to issue number five. We're talking about AIDS Drug Assistant Program, also known as the ADAP program.

Hello, my name is. Can you hear me? Okay, good. My name is ... I will be giving the overview of ADAP and some brief changes. So for the current year, the 23/24 Budget Act included ADAP local assistance funding of 398,000,000. The revised current year 23/24 budget is 353.9 million, which is a decrease of 44.1 million when compared to the 23/24 Budget Act. The decrease is driven primarily by lower medication expenditures and medical out of pocket expenditures than previously estimated.

And then for budget year, the proposed ADAP local assistance funding year is 366,000,000 with no state General Fund appropriation, which is a decrease of 32.1 million when compared to the 23/24 Budget Act. The decrease is driven primarily by the same factors, lower medication expenditures and a medical out of pocket expenditures, than previously estimated. I will pass it Adrian.

If there aren't any other questions on the estimate, I understand there was a question submitted regarding the adapt rebate loan that I believe Department of Finance will be fielding.

So the 24/25 Governor's Budget includes a budgetary loan of $500 million from the ADAP Fund to the General Fund from resources not currently projected to be used for operational or programmatic purposes. You asked about two loans. To mention the previous loan of $400 million was authorized in fiscal year 23/24. There is a loan before that of $100 million that was authorized in fiscal year 20/21 and paid back in fiscal year 21/22.

A few key points to note about both the $500 and $400 million loans. So the budget proposes uses of funds from available idle fund reserves. The loan does not cut any authorized expenditures and we do not anticipate these loans to disrupt any services, as the Department mentioned earlier in the hearing. And the ADAP Fund has a remaining reserve.

After accounting for the proposed loan, there is a projected fund balance at the end of current year of $670,000,000 and at the end of 24/25 of $177,000,000. The loans can be returned when needed for critical program activities per language in the Control Section 13.40 in the Budget Act, and just a few notes about repayment.

So the state is obligated, of course, to repay all of these loans and the repayment dates for all of the loans will be assessed based on program needs, availability of funds, and competing priorities through the annual budget process. Authorized spending revenues and reserves will be taken into consideration and the language in Control Section 13.40 ensures that the funds must be returned when there is a need for the funds to support operations authorized under the ADAP Fund in the Budget Act in a given year.

When that need is identified in the annual budget process, repayment will be made. Moreover, to address the question about undermining the ADAP program, Finance is working with the Department to ensure that the timing of loan fund disbursements and repayment during the term of the loans will be structured to meet their cash flow needs.

Well, any comments on this? Okay, a couple of comments on this and I'll start with the most recent comments you talked about on repayment. The language in there seems a little loose. What if the program has a need next year or in two years and we're still dealing with this kind of budget deficit? What capacity are we going to be in to be able to pay back that loan?

My understanding is the control section, the control section language holds. So if there is a need to spend those funds for activities that are authorized in the Budget Act, then those funds would need to be returned. And of course, in that annual budget process, we're assessing what is approved in the ADAP Fund.

Because we'll be close to $1 billion loan from this fund. And advocates are very worried about this. You shared two other previous year loans. Was there a loan in the recession? Because we're getting some word that during this recession there was a loan and it actually impacted programs during that time, which is one of the reasons that it's sounding the alarm for a lot of advocates moving forward. Is that correct or is the information in front of you only on loan history from the past two years?

That is the information that I have on previous loans. If you're interested in further back than that, I can look into that.

If you could please look at the recession year. And either confirm or contradict that that loan impacted the programs during that time. I'm really interested in seeing how we can just further ensure follow up if it looks like the loans undermine financial stability of the program.

Matt Aguilera for Finance yeah, just to add one thing, in this program area, the annual revenues are fairly consistent with the spend out of this pot and the money we're talking about is out of the Reserve. So I think on the natural, all other things being equal, we would expect that trend to continue. But as my counterpart mentioned, we'll continue to evaluate the revenue, collections, spend and everything through our annual budget review.

As we continue to utilize this fund, as we are doing with a lot of funds, right. To pull out and balance the budget, advocates within this group are looking to utilize some of the reserves for other investments. Have we taken a look in how we can use the fund in this, the dollars in this fund to further invest in other big programs related to the categories under ADAP?

I would say that the reserves are still available in the fund would be things you know folks could reasonably consider and still authorize the loans that are in the budget before you.

Okay. Senator Eggman.

Yeah, I just. To again, I love Public Health, but then as a Chair of the LGBT caucus, you're the Department where I get the most complaints about both with this program as well as with the SOGI issues that we talked about before. So do we know when we're sweeping it to the general pot, then what those funds are being used for?

They would just be used for our overall General Fund state priorities. So General Fund Dollars don't have a specific linkage.

Okay. Because I think the Legislature would like to be a little bit more involved with that. Right. So again, we're talking about up to $1.0 billion now that's been borrowed. And this money was, I understand it's a nice pot that the Administration sees. Like we're going to have some of that. But I think we just heard from the last panel. Right. The really intense needs that exist in the public health environment.

So I would just like to say that continuing to make the same borrow from the same pot, it is very upsetting for the community and for those of us who to represent that community. So I think we'll continue to have some conversations about that. I mean, it's not just a slush fund for the Administration to use when times are hard. Right? I mean, that money is there for a reason, for purposes.

Especially with recent STI, further increases that we're seeing in the state as well. I mean, this goes hand in hand in preventing even further STI cases. I just, you know, I guess I want to hear a little bit more about how we're addressing the advocates' concerns. I feel like I can't walk away from this Committee where I can go back to the advocates and say something that's going to ease some of that concern.

Yeah. I think just from a budget balancing perspective, one of the reasons we look to reserves is because that's the relative lesser of two evils as compared to making program reductions that otherwise may be necessary or possibly raising taxes. So these are just some of our difficult choices that we're having to make through our budget deliberations.

On average, annually, how much goes into the fund, the Reserve Fund. So we have, after we take out the, if we, sorry, if we take out the $500 million, we'll be left with $176,000,000.

So annually there are about $259,000,000 of - excvuse me -$325,000,000 of revenue annually, average, just averaging.

Between fiscal year or calendar year.

This is averaging between past year, current year and budget year. So between those three years, if you look at the fund condition statement, it's taking an average.

So would you say that by the end of this year that 176 could jump up to, if you're at 400 million?

I would say that it's roughly in the $300 million range. The incoming and the spend from this area. Just rough figures.

Okay, thank you so much.

Okay, thank you. Found the numbers. No further questions on our end. We're going to hold the item open. We're going to move on to issue number six. And six can be really short because this item is eligible to be for early action. Welcome.

Good afternoon. Okay, my name is Maria Ochoa, one of the Assistant Deputy Directors in the Center for Healthy Communities, and so I will be given an overview of the clinical dental rotations and trailer bill.

So the Budget Act of 2022 appropriated a 10 million in a one time investment for CDPH Office of Oral Health, in consultation with the California Dental Association, California dental schools, and other stakeholders to support the establishment of a community based clinical education rotation for dental students in their final year or dental residents. The 2024-25 Governor's Budget proposes to shift 9.7 million of this investment from the General Fund to the Proposition 56 State Dental Program Account to address the budget shortfall.

The 2022 Budget Act included programmatic and provisional language that once stated that funds were available for encumbrance or expenditure until June 30, 2027, provided a public contract exemption, established program eligibility criteria, and specified reporting requirements. Because Prop 56 is not subject to an appropriation in the Budget Act, statutory changes to the Health and Safety Code are added to maintain the programmatic requirements that were established in the provisional language in the 2022 Budget Act. And I can get to the questions.

Okay, so the first question was, after accounting for the use of the unexpended fund balance in the State Dental Account, is the Office of Oral Health still receiving the 30 million allocation required by statute? And the answer is yes, they are still receiving the 30 million. And does this fund shift offset some of that required allocation? And no, the shift does not offset the allocation. And then what is the remaining fund balance in the State Dental Account? And the remaining fund balance is 3.5 million.

Are you with Department of Finance?

I'm with the California Department of Public Health.

So then, Department of Finance, two questions here. The same question on the previous fund. Does it get funded annually? Is 3.5 million what we're going to have for a while? The remaining balance.

3.5 million is the ending balance at the end of fiscal year 24-25. Future years in the special fund would be determined by available Proposition 56 revenue.

And so the reason why I'm asking is because I'm wondering, two weeks ago we talked about the Specialty Dental Program. And I know that's a higher price tag, but I'm wondering if we can look at this fund to offset some of the delayed costs in that program. Are we looking at utilizing this fund for other programs that are being delayed in the dental space?

That's currently not included in the Governor's Budget, but we could take that back.

Appreciate that. Any additional comment? We're going to hold the item open. We're going to move on to issue number seven, syndromic surveillance.

Good afternoon again. I'll provide an overview of the trailer bill language and then jump into the two questions that were submitted. So California currently does not have a comprehensive, statewide, near real time capability to identify and analyze emerging public health threats. California is currently behind other states in adopting syndromic surveillance. 24% of hospitals with emergency departments in California submit data to BioSense through local arrangements, compared to 78% of hospitals with emergency departments across the United States.

Our proposed plan is to stand up a statewide syndromic surveillance system in California, or a program rather, in California, to enhance real time, widespread monitoring of public health. This translates to more informed, rapid, and targeted public health action for disease control and prevention and heightened situational awareness to facilitate more effective, prepared, and responsive public health strategies and policy development. CDPH will stand up a statewide syndromic surveillance program and become the California State Administrator for the BioSense platform.

The BioSense platform is a free, cloud based computing environment hosted by CDC's National Syndromic Surveillance Program. This system collects, analyzes, and shares electronic patient encounter data received from emergency departments within 24 hours of a patient's initial encounter. The proposed TBL gives CDPH the explicit authority to collect syndromic surveillance data and require hospitals with emergency departments to submit the data to the syndromic surveillance system.

Then your first question, please describe the specific privacy provisions that are barriers to the implementation of the syndromic surveillance system that require, notwithstanding all California privacy laws. And so the syndromic surveillance data in California would be governed by the Information Privacy Practices Act. The IPA does not allow CDPH to share personally identifiable information with the federal government unless required by law. Therefore, any sharing with the CDC must be done notwithstanding this section of the IPA.

And we understand that there's also been concern with the current language and the trailer bill, and so we are going to be replacing the notwithstanding any other privacy of the law language with notwithstanding the Information Practices Act, and then would welcome the Legislature as well to weigh in on that language. And then for your second question, would any other entities besides general care hospitals with emergency departments be required to report data to the system? The answer is no.

Other entities could be added to the system through regulation in the future, if the data are needed to address public health needs. And then I'm happy to answer any other questions you may have.

Department Finance, any further comments?

Nothing further to add at this time.

No additional comments.

Thank you. I appreciate you adding those remarks at the end because that was one thing we were going to ask if you could just, on the May Revise, come back with better language to better accomplish what you're seeking in the privacy section. So thank you so much for that. I have just a question on my curiosity regarding the support the emergency responses. What does that look like? How do we support emergency responses?

Right. So I think it would be helpful to maybe provide just a quick overview of how syndromic surveillance works with traditional surveillance to help kind of inform public health policy and prevention and interventions. So current surveillance in California really focuses on reportable conditions and confirmed diagnosis via labs with individuals. Syndromic surveillance provides rapid, preliminary information on specific diseases, as well as information on syndromes that might not have a clear cause, like respiratory and gastrointestinal illness increases or outbreaks, climate related health outcomes.

So emergency department visits due to heat or cold weather illness, poor air quality, also with mental health condition trends, so opioid overdoses or suicide attempts and other emergency or emerging diseases, rather. Syndromic surveillance can supplement traditional surveillance methods because it allows us to monitor conditions and detect trends rapidly before diagnosis are confirmed. Current traditional surveillance and syndromic surveillance are complementary in understanding and responding to public health threats.

So, for example, does this mean if hospital A is getting, just recently in the last hour, got 200 patients walk in with whatever, a rash, one specific kind of rash. They all have the same symptoms. This would be collected here? You'd be getting that live in the moment data for a potential outbreak?

So I'm actually going to ask my colleague, Dr. James Watt to go ahead and respond.

Oh, doctor, for sure. Yeah. He'll know.

Hi, I'm James Watt. I'm the other Assistant Deputy Director in the Center for Infectious Diseases. The short answer to your question is, that's just about it. It might not be live, but it's much more quick than the current systems that we have.

Okay. Near real time. Okay. Perfect. So that's, I just want to make sure I was understanding this program correctly. Thank you so much. Appreciate that, doctor. We're going to hold the item open, move on to issue number eight. Regarding the Office of Probation Gambling Community Based Organization Grants.

Okay. CDPH is requesting an increase of $200,000 in the Gambling Addiction Program Fund to expand services and provide community grants to expand prevention and treatment services to priority populations. This BCP would support the Office of Problem Gambling in reaching priority populations by providing grants to and partnering with community based organizations. The RFA would outline specific criteria for the CBOs to follow, including reporting and evaluation activities.

CDPH anticipates the initial funding cycle to be three years and anticipates awarding approximately 50,000 per year to four CBOs, each resulting in a total of 200,000 per year in funding. Evaluations would be conducted at the end of each grant period by existing staff and will inform program design and priority populations. CBOs have experience in working with and outreach to their communities.

Outcomes expected in the first five years of funding, a 10% increase in awareness of problem gambling and appropriate treatment services among priority populations, 15% increase in the use of helpline services among priority populations, and a 15% increase in access to treatment services by priority populations. This would strengthen and expand OPG's prevention, education, and treatment activities, and it would also align with OPG's strategic plan and meet OPG's goals of effectively delivering problem gambling education, prevention, and treatment services to California's most impacted and highest risk communities.

Thank you. Will, any additional comment?

No concerns with this proposal.

Okay. Once again, your proposal. Right? Okay, we're going to hold the item open. We're going to move on to issue number nine on Climate and Health Surveillance Program reversion.

Good afternoon. It's afternoon now, right?

Yes, ma'am.

Madam Chair and Members, I'm Ana Bolanos and I am the Assistant Deputy Director with the Office of Health Equity at the California Department of Public Health. I can start with addressing your questions.

Please proceed.

Approximately 3.1 million is being reverted on a one time basis in fiscal year 23-24 to the state General Fund as a budget solution from the overall ongoing 10 million annual allocation for surveillance of climate change related conditions such as heat related illness.

The program builds of the broader syndromic surveillance program discussed earlier and provides training to emergency departments and local health jurisdictions on climate related conditions and also develops broader surveillance methods to monitor climate change related health conditions, such as studies on the mental health impacts of climate change, tools that track factors and vulnerability indicators for health impacts of climate change, and novel early intervention methods such as Internet searches and 911 call data.

This savings is due to anticipated savings from the information technology contract funds that will not be spent this fiscal year. The contracts will be executed in fiscal year 2024 and ongoing to develop climate and health visualization platforms. For your second question, you wanted to know about the difference, right, between the syndromic surveillance and other ones. This program addresses syndromic surveillance for climate change related conditions and also broader surveillance or detection and monitoring of climate change related health conditions.

The syndromic surveillance portion is different from the Department's other syndromic surveillance efforts in that emergency departments will be trained to detect and report climate change related health outcomes, understand data on climate change related conditions, and plan to collaborate with others to act on the data to prevent further illness, injury, or death.

This interactive dashboards will be developed specific to climate change related conditions such as heat related illness, wildfire smoke related respiratory conditions, West Nile virus, waterborne diseases such as febrile foodborne salmonella or E. coli, dustborne Valley fever, and mental health impacts. These dashboards will be tailored to user sectors such as CDPH, local health jurisdictions, and the general public. The broader surveillance for climate related conditions goes beyond syndromic surveillance.

It detects and monitors climate change related health conditions, such as population level surveys, including the Behavioral Risk Factor Surveillance Survey and the California Health Interview Survey, studies on the mental health impacts of climate change, tools that track risk factors, adaptive capacity, and vulnerability indicators for health impacts of climate change at the census tract levels. Studies combining environmental and meteorological data with health data to detect the climate influence on health conditions now casting our near real time estimates of heat related deaths in the state using historical patterns of preliminary death counts and final death counts to overcome reporting lags in death certification, estimating the economic burden of the various health impacts of climate change in California, as well as providing cost benefit analyses on the health effects of alternative climate actions and novel early detection methods for climate related conditions such as Internet searches and 911 call data.

The health impacts of climate change are widely considered to be the greatest health threats of the 21st century. Queries of BioSense exist for climate related conditions of heat related illness and respiratory conditions exacerbated by wildfire smoke. Other queries must be developed. Furthermore, data alone do not interpret themselves, let alone develop recommendations, programs, and policies to prevent and reduce the conditions detected in the data.

The cases of conditions themselves must be combined with environmental and meteorological data to elucidate the degree of climate influence on the conditions. And then modeling tools develop to project and plan for future harm based on various greenhouse gas emission scenarios. Resources and positions are necessary to develop interactive dashboards specific to climate change related conditions such as heat related illness, wildfire smoke related respiratory conditions, West Nile virus, waterborne diseases such as febrile foodborne salmonella.

As we mentioned earlier, E. coli, dustborne Valley fever, and mental health impacts tailored to user sectors such as CDPH, local health jurisdictions, and the general public. In addition, resources and positions are necessary to detect and monitor climate change related health conditions through surveillance methods beyond syndromic surveillance, such as population level surveys, including Behavioral Risk Factor Survey and the California Health Interview Survey.

Studies on the mental health impacts of climate change, tools that track and communicate risk factors, adaptive capacity, and vulnerability indicators for health impacts of climate change at the census, stratified by race and ethnicity. Again, now casting are the near real time estimates of heat related deaths using historical patterns of preliminary death counts and final death counts to overcome reporting lags in death certification.

Estimating the economic burden of various health impacts of climate change in California, as well as providing cost benefit analyses on the health effects of alternative climate actions. The investigating, initiating, and maintaining novel early detection methods for climate related conditions, such as Internet searches and 911 call data.

Finally, resources and positions are necessary to train departments to detect and report climate change related health outcomes through this program and to train local health departments to access and understand data on climate change related conditions and plan to collaborate with others to act on the data to prevent further illness, injury, or death.

Thank you. Will, would you like to add anything to this? Would you like to add anything, Department of Finance?

Nick Mills, Department of Finance. Just to reiterate something that Director Bolanos said earlier, this is a one time reduction and we don't anticipate that this will impact program operations.

Thank you so much, Nick. We're going to hold this item open. Thank you so much. We're going to now move on to issue number 10.

Thank you.

Be talking about the WIC Program, Women, Infants and Children.

Hi, good afternoon. Christine Sullivan from Department of Public Health, WIC Program. Issue number 10, we had a couple of questions. First, addressing the caseload and expenditure changes. WIC participation in California and nationally has been increasing slightly over the past few years. In our budget estimate, the current year revised estimate is 993,000 participants per month, which is a very slight increase over our previous estimate for the current year. And the estimate is right in line with our actual numbers.

In February of last month, we served 995,000 individuals in California. The budget year estimate is just over 1 million participants per month, which is a 4% increase over the current year. Food costs have also been increasing due to inflation and this slight increase in participation, and I'm very happy to report that last weekend Congress approved and the President signed a budget for the Department of Agriculture that included an increase for the WIC program due to this increasing participation in food costs.

We are awaiting information from the USDA on what the funding levels will be for California and should be able to include that in the May Revision. The budget continues to support the increase for the Fruit and Vegetable Benefit as well. For your second question about our program reach, which is the percentage of individuals serve compared to the eligibles, in USDA's most recent report, looking at 2021 data, California served 67% of our eligible individuals and our rate has been increasing over the past five years.

The national average look of 2021 was 51% and the national average and the rates of other large states have either been flat or decreasing over previous years. We are the only large state with an increasing program reach rate, and of the 50 states, we are second overall only to Vermont.

Will, any comments?

Nothing to add on this issue. Thank you.

Nick?

Nothing further to add nothing further to add.

Thank you so much. I had finally the honor about a month and a half ago to visit my first ever WIC site in my district, and I loved everybody there. The books they had that they were giving away, the courses they showed me about breastfeeding and their rooms and so forth. I'm always really appreciative of the people invested in our children and families. So obviously I'm really excited for the federal government.

Yes, we're very excited.

Yeah, that's great. Usually those words don't come out of my mouth where I'm thanking them for something wonderful that they're doing. But I'm glad that in the May Revise we're going to see an increase in rates. Nothing? We're going to hold the item open and move on to issue number 11.

All right, number 11 is WIC modernization. It's an initiative by the US Department of Agriculture to reach and retain more families, advance equity in the WIC program, and improve program delivery so that more families can redeem more of their food benefits. Our budget change proposal separates the priorities into two categories. First, modernizing technology and service delivery at the local level, and second, improving the shopping experience by implementing online shopping, or also called online ordering.

Under the first category, the additional staff resources will develop and implement new education and training practices that optimize the latest technologies, including E-learning and strategies for remote service delivery and support communications and outreach efforts to reach and retain families. Investing in efforts at the state level will ensure that WIC local agency staff receive the support they need to serve families and that modernization efforts are effective and equitable across the state.

In the second category for online ordering, online shopping, it's a way to allow participants to order and pay for WIC foods online using their WIC benefits and either pick up the groceries at the store or have them delivered. It can improve access and convenience of the program and reduce stigma. The additional staff resources will prepare for the upcoming changes, engage with stakeholders and program partners, revise state regulations, manage any new vendors, identify data measures, and conduct program monitoring and evaluation.

To address your second question, we expect that our current brick and mortar stores will fulfill online orders, at least in the first phase or first few years of online ordering. WIC families could order online and pick up in the parking lot of their neighborhood store, avoiding walking store aisles with young children. Delivery may be an option, depending on the individual store and or what USDA allows in their final federal regulations, which are expected to come out next year.

We don't know yet if USDA would permit stores that do not have a brick and mortar option. As part of preparing for these changes and for our state regulation changes, we would discuss our plans and ideas with stakeholders and consider what USDA learns through their pilots, what they put into their final regulations. In addition, because we need to revise state regulations, there will be a public process for reviewing and providing feedback on our plans. But we would have discussions with stakeholders prior to that process.

Just to clarify, it sounds like we haven't gotten federal guidelines on if we're going to allow places like Amazon to be eligible because potentially they might not have... Well, they do have some brick and mortars. But is that what I'm understanding? So that won't really hurt our local brick and mortars?

Correct. So the federal government has released their preliminary regulations. There was a lot of public comment. We had hoped that the final regulations would come out this year, but the revised estimate from USDA is that it would take another, at least another year before they'd know. We don't currently authorize Amazon. And so in California, we would like to start with our current vendors, our current authorized stores, so that we are just implementing one type of change at a time.

Are those the 170 new Internet vendors that the Department, SMAs would be eligible?

So Internet vendors, so that's kind of a bureaucratic issue there. So what USD, what we expect USDA will say is, for example store, I'll pick Safeway, for example. They are an authorized vendor right now. Every single Safeway location is considered a separate vendor. If they add an Internet face, that would count as another number of vendors for us. So it's a different vendor contract for us to manage.

It increases the total number of vendors that we have, and we have to do onsite visits and do monitoring visits for a percentage of our total. So if a store, like a currently authorized grocery store, adds Internet options that could definitely increase the number of our total count of stores.

Okay.

Even though it might be physically the same brick and mortar, one is a walk in and do it this way, and one is do your transaction online. That one place might count actually as two.

With that in mind, it seems then when somebody seems really low.

So we don't know yet if, for example, I couldn't tell you how many Safeway locations we have. But having an Internet face to Safeway, that might count as one instead of 100.

Okay.

Don't quite know yet what USDA will do.

Can you talk to me about fraud protections when it comes to the delivery services? I know we heard regarding some vendors who already have that in place for the rest of their customers that if a delivery, say from Saver or a Vons delivers and the food is one item is missing, delivery person stole it, XYZ, are those protections going to apply for WIC customers as well?

So delivery is really a big issue in and of itself. What we don't expect, it's possible, but we don't expect that WIC funds would be able to pay for delivery. So it could be something outside of the scope of the WIC program. Though there could certainly be an option. It could be possible that a store might waive delivery fees. So we're trying to really focus on the actual online ordering piece right now. And then there's a lot of different pickup.

So this is just for curbside pickup?

Curbside pickup. We expect that might be a big piece of our online ordering. Now. It could be that an individual would use their own cash, their own money to pay for a delivery if the store does that. There have been some of our WIC authorized stores during the COVID pandemic that piloted something where it wasn't actually ordering and paying for the food products yet. It was just curbside transactions, so to speak. So there was no delivery option there.

So it's possible that delivery might become part of this, but it probably wouldn't be allowed with WIC dollars. Certainly might change when the federal regulations come out, but it's really just about the online ordering, and curbside pickup is kind of our biggest focus really, which is why we expect the current authorized brick and mortar stores to be the ones fulfilling the orders.

Okay. And then two questions from that. My goodness. Oh yes, you said that the federal regulations are going to be coming out in another year. Do we have then, with that in mind, a potential timeline of when WIC participants will be able to start this new modernization?

So we have drafted a timeline there. So in our budget change proposal and also in our trailer bill request. So the trailer bill request we put in so that we can expedite the state regulation process. So we have current health and safety code statute that allows us to do what's called a bulletin process. It's really an expedited state regulation process for a few categories of what we would put into state regulation.

So, for example, the foods that we authorize in the WIC program. That was put in place in 2012, and we've been using it many, many times since then, successfully working with stakeholders, making changes to vendor authorization criteria, the foods that we authorize. And so we are requesting to add another scenario where we could use that same expedited process so that we could do these state regulations through a little bit faster process. So it will probably still be a couple years out before we could go through.

We need to get the federal regs, know exactly what they're going to do, and then we would go through our own process, really looking at those federal regs, talking with our stakeholders in 2025, and then propose our state regulations and have that public comment process. But that state reg public comment process would be faster than if we did not have this exemption to the APA.

And finally, are we being sensitive with the geographic in terms of perhaps not every single brick and mortar right now that accepts WIC is going to be able to do the online. That could potentially create a barrier for some. I know it's curbside. Not everyone has a vehicle, especially when we're talking about this kind of demographic. That we're going to be sensitive, that there will be some online options in each geographic area.

Yes. So we've had a lot of discussions internally about that. We've had some stores that have volunteered. If we want to do a pilot, we're happy to do it. And we thought, well, we don't want to just have it be very limited to some areas. We want to be very proactive and careful and thoughtful about how we make sure that we don't lose ground on equity, certainly by doing these types of changes.

The whole purpose of this is to provide low income families with the same options that everybody else has. And so we want to do that in a very, very thoughtful and careful way. It's really important to us to serve families well and not lose any ground that we've been making on supporting equity.

Thank you. Thank you so much. We're going to hold. Will, did I ask you for a comment?

No, but we have none. But happy to answer any questions.

Nick.

Nothing further to add.

Thank you so much. We're going to hold this item open. Move on to issue number 12, Genetic Disease Screening Program.

Good afternoon. I'm Leslie Gaffney, the Acting Deputy Director at the Center for Family Health, which oversees the Genetic Disease Screening Program. GDSP is adjusting their current budget this year downward by $20 million in expenditures and $24 million in revenue. That's attributed to both the ongoing decrease in the birth rate as well as the loss of exclusivity for the Prenatal Screening Program.

That happened as a result of a lawsuit that we lost when we went live with cfDNA screening in September 22, and the lawsuit was brought by laboratories that were not participating in the state program. And so that was resolved in December. And we have lost exclusivity permanently. So we have seen about a 20% decrease since the beginning of screening. Prior to the loss of exclusivity, we were screening 72% of births, and we're now screening 52% of births.

And then for budget year, we expect to see a net decrease of just over $6 million compared to the current year. That decrease is again attributed to the lower caseload and the lower uptake of prenatal screening, as well as a reduction of the $7.4 million one time funding you gave us last year to do a move of our data to this cloud platform and some adjustments upward of $1.2 million increase in contract rates and a $4.4 million increase for screening costs for two newborn screening disorders that are being added this summer.

So for budget year, the revenue projections will see an increase of $6.2 million. And those are attributed to fee increase that are coming. We will begin screening for sex chromosome aneuploidies as part of the Prenatal Screening Program on April 1, in a couple of weeks. and then July 1, we will be raising the fee to account for that. It's easier to do it at the beginning of the fiscal year. And that will raise the fee $112, and it will be $344.

$112 up from 211, right?

232 to 344. It will be starting July 1. And then newborn screening is adding two disorders this summer, mucopolysaccharidosis type two and Guanidinoacetate methyltransferase deficiency.

Good for you on pronouncing that.

I practiced. And we will be raising the newborn screening fee $15 from 211 to 226.

Who pays for that?

Insurance, Medi-Cal. And generally if insurance doesn't pay it's the hospitals. Because we bill hospitals directly, and then the hospitals are getting the feedback through their insurance coverage. So this year we should have a fund balance of about 10% and next year we project it to be 9%.

Thank you. Will, any comment on this?

Nothing further to add.

Nick.

Nothing further to add.

Thank you so much. We're going to hold the item open. We're going to move on to issue number 13. Issue number 13 is on the Center for Healthcare Quality estimate. We're going to have a small panel discussion on this. Here in the Subcommitee Number 3, we requested panelists to come discuss the department's enforcement of a 2019 statue, SB 227. I ask that only the people who are on the panel to please come to the well. If you will be speaking, please come to the well.

You will have an opportunity to provide public comment after. I ask for the Department representative to be here, the representative from SEIU Local 121RN, and a representative from California Hospital Association. If we're all here, great. I ask the Department to please kick us off.

Good afternoon. Monica Nelson, Acting Chief of the Internal Operations Division at the Center for Health Care Quality. We have for issue 13. Would you like me to just go straight to the questions? Very good. For issue number one, please provide a brief overview of the Center for Health Care Quality, including regulatory responsibilities, organizational structure, funding, and performance. The Center for Health Care Quality is responsible for regulatory oversight of licensed healthcare facilities and healthcare professionals to assess the safety, effectiveness, and healthcare quality for all Californians.

The Center fulfills this role by conducting periodic inspections and complaint investigations at healthcare facilities and provider agencies to determine compliance with applicable state and federal laws and regulations. The program is organized into 14 district offices and includes a partnership with Los Angeles County, which operates under a contract with the Center. CHCQ licenses and certifies over 14,000 healthcare facilities and agencies in California in 30 different licensure and certification categories.

In addition, CHCQ oversees the certification of nurse assistants, home health aides, hemodialysis technicians, and the licensing of nursing home administrators. The center also hosts the Healthcare-Associated Infection Program, which oversees the prevention, surveillance, and reporting of healthcare associated infections and antimicrobial resistance in California's hospitals and other healthcare facilities.

The majority of CHCQ is funded by the State Department of Public Health Licensing and Certification Program Fund, 3098, which is supported by licensing fees collected from the California Department of Public Health regulated health facilities and providers throughout California. The US Department of Health and Human Services, Centers for Medicare and Medicaid Services awards federal grant monies to the Center to certify that facilities accepting Medicare and Medicaid payments meet federal requirements.

Additional funding includes reimbursements associated with interagency agreements with the Department of Healthcare Services and General Fund, which support survey activities in state owned and operated facilities. You'd like me to go into issue number two? Please provide an update on the LNC Program's vacancy rate, particularly for the VN classification and efforts to improve vacancy rates. As of February 2024, the vacancy rate is 14.3% for the health facility evaluator nurses, which is an increase of 10.6% points since the beginning of the COVID-19 pandemic in February 2020.

This increase is due in part to newly authorized positions, but also because of increased retirements and separations. CHCQ is currently utilizing social media platforms such as Indeed, LinkedIn to attract and increase engagement with potential candidates, walking them through the complex state hiring process and the nature of the surveyor role. CHCQ's recruitment teams started attending in person job first to engage with local candidates at hard to recruit locations. We are also promoting all internal employment opportunities with CHCQ staff via email blasts to create vacancy awareness.

Finally, CHCQ has an onboarding program as well to welcome new hires and introduce them to CDPH's culture, mission and values. These onboarding meetings help new hires to feel engaged, integrated, and part of a team. To close, CHCQ continues to reassess and monitor our vacancy rate, recruitment progress, and more. Focusing on this area, CHCQ has been reaching out to other states to understand how they are addressing similar issues, which includes their workforce composition, in particular their use of individuals of other professional disciplines.

All right, moving on to number three, please provide an update on the most current timeliness metrics for investigation of complaints and entity reported incidents. As of quarter one of 2023-24, CHCQ completed 93% of long term health care facility complaints within 60 days of receipt. This represents a 30% improvement in the timeliness of long term care complaints since quarter four of 2021-22. As of January 2024, CHCQ has completed 97.6% of backlog long term care complaints that existed as of April 1, 2021.

CHCQ has redirected resources to address these open complaints with a goal of eliminating the backlog by the end of fiscal year 2023-24. In terms of general performance, CHCQ continues to prioritize not only backlog, but also the resumption of recertification under licensing surveys across numerous facility types statewide. Thank you.

I'm going to have you kick us off with the panel discussion, so you can move over to number four.

Thank you so much. My name is Cassie Dunham. I'm the Deputy Director for Center for Health Care Quality, and I'd like to take the opportunity to address this very important issue. CHCQ recognizes the importance of maintaining sufficient staff resources in healthcare settings and their role in protecting safety and quality of care, in particular among general acute care hospitals, which are the subject of SB 227. The Center takes allegations of staffing noncompliance very seriously and appropriately assigns top priority to investigations for inadequate staffing.

Additionally, CHCQ has continued to raise awareness of staffing ratio requirements to hospitals and Hospital Association members in an effort to also prevent future violations, as well as offering ongoing direction and informed training to surveyors across our organization. Implementation of directives and updated policy direction has resulted in numerous penalties being issued to hospitals and revisions to databases and publicly available dashboards are underway to increase transparency in this area.

In addition, CHCQ has established a recurring meeting with stakeholders to address questions and understand experiences or concerns from representative perspectives. The Center is also actively evaluating existing processes and exploring options for leaning approval steps to reduce the time between investigations and the issuance of related penalties. I'm happy to continue to question five. In terms of unannounced inspections that may have occurred since a September all facility letters that our center has issued.

Yes, in fact, all complaint investigations and periodic inspections are completed and performed by CHCQ as unannounced visits. The Center has substantiated violations of staffing ratio requirements since September and has issued penalties to hospitals for noncompliance. So we'll speak a little bit more detail in terms of penalties that have been issued and the frequency of exemption criteria being met by facilities. So yes, there have been cases where evidence has led to a determination of exemption from penalties.

However, based on the preliminary data that we were able to gather for today, these exemptions have become far more infrequent compared to occurrences that may have happened during the declared public health emergency. Additionally, in some cases, multiple violations are identified during an investigation and result in multiple findings being cited, but constitute a single penalty. As a result, drawing conclusions of complaint volume to penalties issued is not expected to provide a direct comparison.

And again, based on that preliminary data, we were able to gather approximately 75% of the complaints that we've received and an investigation has been completed specifically related to staffing ratio noncompliance have been substantiated with some additional investigations that are still pending and then others that are actively underway. To date, roughly 70% of those determinations, those substantiated determinations, have or will result in a penalty. Of course, as we continue to adjudicate those cases that number may grow once those additional cases are completed.

Thank you. Before we go on to the panelists, just some questions. You mentioned the reoccurring meeting with stakeholders. Who makes up that group?

Members from SEIU and parties from my team, including myself.

Okay. And then do we have a number of how many complaints we received since--

I would want to validate again, we pulled some preliminary data using allegation counts and then mirrored those with the complaint cases that we were able to put together. So I'd like to validate that. Happy to share detailed data following today's hearing.

And I know the pandemic put a halt on these investigations and follow-up. And then in September 2023, the Department did send out that letter, and I know you shared with me some data since September 2023, but what about the year that this statute was first was implemented, in 2019 for that full calendar year? How did we do that year?

To my knowledge, there was still some development underway as far as how we were going to approach that. I don't have data today to share, but I'm happy to go back and look at anything that might have been put in place or cited in 2019.

Would you say that perhaps that year was used to ramp up this program and in fact we've only been able to investigate since September 2023?

Potentially.

Okay.

Yeah.

And then can you tell me more about the barriers that exist in the time it takes to investigate and how we're further reducing that time?

Sure. As Monica, my colleague, had mentioned, we're really focusing on trying to reduce our vacancy rate, bring in additional disciplines, look at ways that we can maximize the efficiency of our teams and how we deploy them out to facilities. You heard her mention we have 14,000 facilities and a number of priorities that we need to respond to. Oftentimes, we will gather numerous complaints together and bring those to make the most out of a visit. So that may be one approach. Certainly setting prioritize, and readjusting.

And then a number of the hospitals across our state are accredited through a federally-approved accrediting organization and there are opportunities where we can leverage their authority to perform some other investigations on lower priority things, which can then, in turn, free up some more of our staff to be able to be responsive to both state priorities, such as nurse-patient ratio issues or other high priority things that have a risk to patient safety. So our approach is continually modifying and adjusting and prioritizing to be responsive.

Okay. And then my last question before we move on to the next panelist is speaking regarding the single violations and that sometimes they all constitute as--even though there's a lot. All single. Can you speak more on how you're judging this and how they're not stacking on top of each other?

So the statute does, in terms of stacking, that the first violation would be a lower level penalty, and then they increase on the repeated. Correct. But the statute also recognizes that where multiple violations are discovered during an investigation, it does constitute a single penalty. So in those cases, when we do find that, if we get an allegation, I'll use an example. We investigate a staffing ratio issue at a hospital, and we find that three different units are out of ratio. That's technically three deficiencies on our part tied to one complaint and one investigation. And so in those cases, it would not then translate to three penalties.

Thank you for that clarification.

It would be just one. Yes, of course.

Senator Roth.

I mean, refresh my recollection. Did the penalty start in 2019?

It was the 2019-20 session when the statute was passed. And then, of course, subsequent 2020, early 2020, there was a shift to be responsive to the issues around Covid-19 and staffing issues and--

I understand this but--

The staffing ratios have been in effect since 19--

Yes.

Many years.

99. So was there no penalty attached to violations of those ratios?

There was no penalty attached to that unless it rose to an adverse event or an immediate jeopardy issue, which has separate criteria, of course.

It's hard for me--obviously, there's a lot of consternation about whether, in fact, complaints have been investigated, whether they've been investigated timely, whether action, any action was taken, whether action was timely, and whether penalties were assessed at all or assessed properly. I've long been a proponent of--I mean, I've supported staffing ratios. I've also been a proponent of allowing hospitals to have off-ramps in cases where the staffing ratios were breached due to inadvertent, whatever the inadvertency is--someone calling off sick without a proper notice, somebody just not showing up without the proper notice.

And I'm sure there are other examples that we can come up with where it would probably be inappropriate to assess a penalty against a hospital, but on the other hand, if hospitals are not staffing appropriately, and there's a pattern of that, and that results in a breach of the staffing ratios, then something should happen, obviously. It's hard to ask questions.

Is there a report that's available that lists by complaint or a series of complaints, even if the facilities aren't named? The complaint, the type of complaint, the action taken, the timeline of the action from complaint to finalization, and the penalties that were either assessed or not?

The report doesn't currently exist, but again, our work with our stakeholders is moving towards not only having a report developed, a reporting system and tracking system implemented, but then also integrating that into a public-facing dashboard so that that transparency is available and folks can continue to track what the progress is or the frequency of penalties being issued.

Well, it's sort of hard to conduct oversight if we don't have the data.

Sure. We can pull the data. We can pull the data.

Is this the first time that anybody's requested that data?

Recently there's been a request for that data, and so we're able to populate that.

And the reason I'm concerned is, of course, I've spent a lot of time--six years, to be exact--on the Budget Subcommittee, not this one dealing with IT projects, software, data collection, and the like in this building and in the state, and it seems to take for-absolute-ever to design a system. And so if we're waiting for a system design in order to get data, we're probably going to be--none of us will be here. Certainly not me.

And during that time, those of us who are charged with oversight won't really be in a position to conduct appropriate oversight. And of course, this is a health care delivery system issue and we're talking about patients and safety of patients and performance and all the rest. I'd like to see some data, but I'm not the Chair of this Committee. I'm just giving you my perspective.

I don't speak for my Chair, but if somebody has to put on a green eye shade and take a pencil, I think we probably ought to be doing that because we need to know what's going on because we get a lot of complaints. We get complaints from our constituents, we get complaints from patients about care issues, and then we get complaints from constituents who work in hospitals about the fact that they report situations and nothing seems to happen.

And that may or may not be true, but we need to be in a position to respond. I apologize for not having--oh, I guess I did have a question buried in there, and you did answer it, so thank you for answering my question, and I apologize for the speech.

Of course.

Thank you, Madam Chair.

And if I may, I think that the benefit is that we're advanced in our development. We already have a number of data metrics that are published publicly on our center website. So we have the framework there. It's just coding the system to pull the data. So hopefully we can produce a public-facing dashboard before you're not part of the team here.

You'll have to move rather quickly.

Okay.

What's going to be on that platform?

So haven't fully defined that yet, but that is part of the conversations that we're having with our stakeholder group as to what information is appropriate, what information that they would like to see, what is publicly meaningful to people. We want to make sure that the data is consumable by folks and that it's easy to understand and get a picture of the enforcement activities that are underway. So again, we have the framework. It's a matter of defining and making sure that our system pulls the correct data and then publishing it in a way that is, again, digestible by folks.

On page 42 of the wonderful description that Mr. Scott here put together, it speaks on the ratios for each different type of unit. Do we have an idea on which unit we get most complaints from? Is it our intensive care, labor and delivery, neonatal care, step-down?

I would need to go back and relook at the data. I know that telemetry came up when I was briefly looking at the data last night. ICU briefly came up for context. Those are for the deficiencies that we've cited. In terms of complaints, we would have to actually pull allegation data and see if it was that specific in the complaint to identify a particular unit.

But coding-wise, in the way that we write the deficiency, we should be able to produce a breakdown to give an idea where we're seeing more frequent occurrences of nurse-patient ratio violations unit by unit.

Thank you so much. Senator Roth.

And will that data report, first of all, is it simply prospective or is it going to have a look back to the time when the staffing ratios were actually put in place?

So going back prior to 2007, the Department of--Department of Health Care Services and Department of Public Health were one department. So anything post-2007, potentially we could go back to. But prior to that, accessing data in an archive, prior to the existence of our Department, I think would be.

So at least we can expect data from 2007 on?

I would think so, yes.

And will the data report that you're able to provide us, will it provide--obviously not patient data--but will it provide the name of the institution that we're focusing on?

It could provide--yes--the facility name.

That would be helpful.

Okay.

Thank you, Madam Chair.

We're going to move on to our next panelists representing SEIU Local 121RN.

Thank you. My name is Joyce Powell. I'm an emergency room nurse of 25 years at Providence St. Joseph's Medical Center in Burbank. I'm currently the Secretary Treasurer of SEIU 121RN. I want to thank you all for giving nurses the opportunity to speak on this very important issue that impacts us and the patients that we care for. We're also joined by UNAC today who have joined us in our campaign to ensure that life-saving nurse-to-patient ratios are upheld.

When I was here last year with SEIU California, I talked to this Committee about SB 227, a law that mandates fines for hospitals that repeatedly violate California's nurse-to-patient ratios. That law was not being enforced. Since the emergency order was lifted over a year ago, there are still only a handful of fines that have been issued, leaving most complaints ignored and not accounted for and has resulted in chronic understaffing.

The fines under SB 227 are meant to act as a deterrent to hospitals that repeatedly violate the law, but hospital administrators know that there's no real consequences or accountability when they violate the law. Hospital administrators often refer to our ratios as guidelines, not laws that need to be followed. Our members have issued hundreds of complaints about ratio violations, and nurses across the state have submitted many more. Responses to our complaints often take months, even cases where the complaints included patient death or demonstrate that patients lives may have been at risk.

Sometimes we never hear back at all. Our nurses are witnessing a lack of transparency and accountability in the process, which has resulted in nurses leaving the bedside. We have seen too many of our patients' care be put into jeopardy due to unsafe staffing. I want to thank Joss Siete here that he and his family are here today.

The Siete Family experienced a nightmare after visiting an ER, one all too familiar for our nurses. According to the lawsuit that his family has brought against West Hills Hospital in LA, a repeated pattern of understaffing turned Joss's emergency room visit into a life of dependency on machines and caretakers. Many complaints of working out of ratio are substantiated, yet they too often do not result in fines as the law requires. CDPH did issue one nursing ratio-specific fine at one of our members' hospital.

Los Robles Regional Medical Center received a fine in March of 2023. This fine was based on investigations that turned up 116 incidents of departments' nurses going out of ratio, affecting 470 RN shifts in June and July of 2022. Only one of the 116 incidents were fined. The investigation concluded the failure of short staffing resulted to staff quitting, care assessments not being done, placing patients at harm's way of poor quality care, unmet medical and patient care needs.

Those impacts weren't unique to the special two-month window at that one hospital. They are true of hundreds of other times our nurses have been out of ratio in the last two years as substantiated by CDPH. As an emergency room nurse of many years, I know and accept a certain level of uncertainty, even chaos. It's the nature of the job. My fellow nurses and I are ready for the challenge, but we need to know that there'll be enough staff to do our job safely.

Unsafe staffing is a problem that results in real patient harm, and it's driving nurses who want to provide compassionate care away from the bedside. We call on CDPH to be part of the solution by enforcing the law.

Thank you so much. We're going to now move on to our California Hospital Association representative.

Good afternoon. Vanessa Gonzalez with the California Hospital Association. Appreciate the opportunity to share with you how hospitals work hard to be in compliance with nurse staffing ratios, as well as some of the challenges that arise in being fully compliant at all times as is required. Let me begin by saying that hospitals are the backbone of--I'm sorry--nurses are the backbone of our hospitals, and without a doubt, hospitals would not be able to operate without nurses.

Additionally, patient safety is a hospital's top priority, and for more than a decade, hospitals have worked hard to meet ratio requirements and are doing everything within their power to hire and retain enough nurses to be able to meet those staffing ratios at all times. California nurses are the highest paid in the nation, and in addition to paying top wages, California hospitals offer comprehensive benefits and programs on a day-to-day basis.

Hospitals employ many strategies to stay within ratio, including scheduling extra nurses in anticipation of nurses calling in sick or other circumstances arising, offering premium pay and bonuses for nurses who pick up additional shifts on top of overtime, implementing an in-house float pool and backup pools to help cover shifts, paying high rates for travel nurses to help stay in ratio. Hospitals take staffing ratios very seriously and work hard to be compliant.

However, there are challenges outside of the hospital's control that make it difficult to comply at all times. As you know, California is in the middle of a health care workforce crisis. A recent study by UCSF showed that California had a deficit of 40,000 registered nurses, and that number has likely grown. In addition to nursing shortages, there are also other reasons a hospital may not have enough nurses to comply with the ratio requirements at all times. Unexpected issues arise.

Sometimes a nurse may call in sick or they may be traffic, an issue back at home that they might be late to work, and in those instances, the hospital will work to make sure that there's another nurse that's able to cover that time. So there could be ten, 15 minutes that the hospital is out of ratio due to an unforeseen circumstance. In addition to unexpected issues from the nursing side, there's also challenges that arise from the patient side.

For example, there could be a patient that is ready to be discharged, ready to go to their next level of care. If it's a skilled nursing facility, for example, they may not have a spot for that patient, so the patient ends up having to stay in the hospital for longer than expected. There could be another emergency situation where there was an unexpected flow of patients, like a big car accident, and there may not be enough nurses to be able to stay in ratio at all times.

Like I've mentioned, the regulations do apply at all times and are very strict. So that means that if a nurse needs to go to the bathroom or even just step off the floor to make a personal phone call for just a few minutes, there must be a backup nurse available to cover that time. And because of some of these challenges that arise outside of the hospital's control, there is some flexibility for these unforeseen circumstances.

And as is noted in the hearing agenda, there are some flexibilities and a hospital would have to demonstrate that all three of the following were met, that any fluctuation in the required staffing levels was unpredictable and uncontrollable, prompt efforts were made to maintain the required staffing levels, and that the hospital immediately used and exhausted the hospital's on-call list of nurses and the charged nurses.

But outside of those three circumstances, nurse staffing ratios must be met at all times and hospitals work hard to be compliant with those ratios. So with that, happy to answer any questions, and appreciate the time. Thank you.

Thank you so much. You know, we can be here all day to talk about all the work that hospital is doing, departments, CHCQ is doing to investigate this, but I mean, I hear it. I have family and friends. I have a little cousin about to be a nurse. Like, I'm hearing it day in, day out, that nurses are one: leaving bedside at rates we've never seen before; two: just being burnt out, breaks not being taken.

I've been part of this world where sometimes you can't take your break. Legislators, sometimes we can't take our break. But when we go through a period of calling these heroes and sheroes, APM were clapping for everybody during the pandemic and then seeing that, transferring to now, not supporting them, and so having anecdotal stories on this, there has to be some--a gap. Something's missing if we're still having nurses talk about these issues.

So it's going to be very hard to get to the root of this in this conversation, but one thing that came to mind is when we investigate, what is the percentage of hospitals getting that exemption compared to a fine?

I don't have that data with me, but would be happy to include that with the additional data that we're providing.

Thank you. Is there anyone in the background with you, in the background, in the audience here that can provide some information related to that? I just felt like that information would be really helpful during this discussion.

Not today, but I would venture to guess less than ten percent based on the preliminary numbers that I saw yesterday, and again, as we've moved out of the declared public health emergency circumstances for hospitals--and I certainly can't speak for the hospitals--circumstances, I think, have shifted in terms of planning around what staffing may usually look like or anticipating increases that may have a seasonal relationship to flu or RSV that we're seeing.

But in terms of giving a definitive number on the percentage of cases that do result in an exemption, I would feel much more comfortable validating that data and giving you factual numbers.

Does your investigation include hiring efforts by hospitals? Are there postings for nursing or what does that investigation look like?

So I believe, as the representative from CHA mentioned, measures that they've taken to address staffing issues, and often that is calling additional folks that are on-call, relying on registry to bring in temporary staff and then certain--

Is that just the word? We're just asking that question--is it just based on the word of the hospitals?

No, there's verification. Anything that we do, we verify. The processing of an investigation includes observation interviews to verify what we are seeing, and then reviewing documentation to also support what our findings are.

Okay. And then, Jen?

Joyce.

Joyce. I should know this constituent of mine. I should apologize. Can you give me some of your experience and other nurses regarding if one of your colleagues calls out sick, is that a dramatic impact? Are we talking about that kind of impact on the staffing issues or are we talking of a greater scheme of we're just super understaffed or is it due just by call outs?

I think that I would push back on the understaffing, that there's a shortage of nurses. I think there's a shortage of nurses that are unwilling to work in the unsafe environment, right? That puts us and our patients in harm. The BRN reports that 30 percent of new grads leave the profession within two years because of the environment that the hospitals have created.

So it's the environment. So to answer your question, yes. Even one nurse puts you under strain, but we're seeing more than one nurse, right? We're seeing holes in our schedules that are there for the week. They're approved schedules with holes in them. And then we also see flexing off, right?

Well, the census is not here, so we're going to flex them off. I would argue that it means send them home. We send them home. There's not the census, so we're going to send them home. There's not enough patients to fill those beds. But I would argue that you don't know. We don't send our firemen home. Why are we sending our nurses home? We need to have them there.

Firefighters.

Correct.

Women too.

Correct. I stand corrected. Yeah.

You know, I know stuff happens, but the fact that a nurse has to go to the restroom or take a break to me isn't a reason to fall out of ratio because that's been a legal requirement in the State of California for a long time. And if we're an employer, we need to plan on relieving individuals who are in the workplace when they're entitled to be relieved.

And it's a regular recurring thing, twice a day for rest breaks and once a day for meal periods unless you have a longer shift. So I would certainly expect hospitals to plan for that, which would mean probably keeping one or more staff members on the shift in order to provide the relief.

So I'm anxious to see the report and I'm hoping it goes into detail and to see whether there's a pattern in practice in certain hospitals or hospital systems of not staffing up to cover the legal requirements that we impose in California. That to me--other things are acceptable, but that to me probably falls in the unacceptable category. I am interested in seeing what the report reflects with respect to surge staffing.

So you staff for a particular expectation of patient census during a day, and the patients' census suddenly falls off and you send nurses home, and then five hours later, you find out that your census has climbed, but you don't have enough nurses to meet the staffing ratios. I suspect if that happens and it's unexpected and there's not a pattern of practice, maybe we provide a pass to the hospital that guessed wrong.

But I'd be fascinated to see if it's a pattern where in a given point in time in a year, in October or flu season, maybe your census drops off but you know that after people get off work, your census pops back up but you don't plan for that. You let your staff go to save some money between two in the afternoon and 6:00 p.m., and then when the surge hits, you don't have staff. To me, that would falls into the unacceptable category.

So once again, I think it's going to be very, very helpful to have a detailed report, Ma'am, from your organization, as to the nature of the complaints by hospital or system so we can sort of track these things and see if someone's playing games with us. Because up here, some of us have been talking about staffing ratios, in my case for 12 years and in my colleague's case probably for longer.

And I just don't understand why we keep talking about it and why we keep getting the level of complaints that we get in our district offices and in our Capitol offices about this. So no criticism of CHA. I just think we need to figure this thing out, and if we're not staffing to meet the legal requirements and it's not unexpected or inadvertent, then we need to be taking some action. Thank you for allowing me to speechify, Madam Chair.

Senator Eggman. Oh, go ahead. Vanessa.

Yeah, thank you, Senator, and I think on the first point--apologies if I maybe misspoke--but what I meant to say is that the staffing ratios have to be met at all times, and so even in cases where there's a nurse that needs to go to the bathroom and absolutely agree, they should be able to take their breaks and step off the floor. And so hospitals do plan for that and have nurses ready to cover that time off.

But I know CDPH also sent their facilities letter in September of last year, also clarifying that something like a flu season is not considered unexpected, and we've advised our members to ensure that they're preparing for that in advance.

Thank you.

Thank you, and I'll try not to speechify, and I'm sorry. I've missed earlier part of the conversation, but just to concur with what General Roth says, we've been asking, talking about this for a very long time, and I would just reiterate the idea that there weren't a lot of budget issues in public health, but we wanted to talk with you more about oversight. And it seems like there's been a couple episodes, a couple of times that we've asked for data and it's not been forthcoming.

So I would just really stress that we need to be able to see the data to analyze--we can hear anecdotes from everybody forever, and we know that real harm occurs sometimes for all kinds of reasons. So I would just like to reiterate, we need the data. I mean, staffing ratios are there for a reason. I understand why and how it's difficult, but we're creative folks and should be able to figure out a path.

In the small period that I did clinical work, I remember this phrase called the 'magic question' that you would ask a patient: in a perfect world, what if? And I want to ask that magic question to the three representatives here. In a perfect world, what would be needed to make--and even for CHA--to help you meet those ratios, to better be able to investigate adequately and move forward, and then for you to feel safe in these environments?

I think from CHA's perspective, what we hear the most from our members is nursing workforce shortages. So how we can look at increasing the pipeline. I know CHA in particular has been doing a lot of work in trying to increase that pipeline, trying to make sure we're having adequate amount of nurses going through nursing school and getting licensed and working in our hospital. So I would say increasing that nursing pipeline is a big issue for CHA.

Well, if CHA wants to do any loan repayments for nurses, let me know. Department.

I think our solutions are there in terms of our ability to complete the investigations. I think right now, the volume that we're seeing certainly creates a competing demand with other intakes that we have that also are of the utmost priority. Again, we see the critical nature of ensuring that nurse to patient ratio staffing levels are abided by and that those are consistent across all hospitals. So I don't know that there's a particular need for CHCQ in terms of being able to get out and investigate those.

I think in some cases, the nature of the process of the investigation may take more time in terms of if there's a need for us to interview a particular party, speak to a particular nurse, understand what their policy is, or looking at particular census at any given time to establish whether that ratio was met. So that can delay things, but otherwise, I think that we have what we need. Just getting through the process, I think, is probably something that.

And again, we're looking at trying to lean that process out, not just with the investigation, but then also any subsequent penalties that might be issued to ensure that we're not delaying the efficacy of that penalty to remedy the actual issue.

And does CHCQ have dedicated staff just to this issue, or is the staff also doing nothing?

No, our staff are assigned investigations across 31 different facility types. Some have specialties in hospitals, and we try to funnel that staff where the expertise is. But universally, our staff need to be cross trained. That's right.

Okay, Joyce.

If I had to say, I would say transparency. I think that nurses have gone over and above trying to bring the deficiencies about understaffing out. But we don't hear back. And from experience, when CDPH comes out, they generally come out with the chief nursing officer or the risk management. They do not speak to the nurses. They collect their data and the nurses are not part of that. So I think transparency moving forward would help, at least with the moral distress that nurses have. That would be my solution, was transparency when we put in these forms.

Could you quickly respond to that? Are we not talking to the rank and file?

That is part of the process. So depending on what information is discovered or in order to make a determination, the process is and may be talking to Administration. But we would expect that they would also be talking to nurses that may have been on shift on a particular day that's related to the complaint or that may be able to validate some information that we're discovering during the investigative process.

Excuse me if I ask this, you talked about, and we've been talking about the data and so forth, do we have a timeline when we can expect this to be more transparent, public?

In terms of producing and publishing the web page? I would like to say probably within three months. Happy to give an update once we have a better evaluation. But again, the framework is there. At this point, it is identifying particular categories within our licensing database to isolate those particular penalties so that it can then be automatically published to the public page and then doing the same, creating that subcategory to identify and isolate the data within our enforcement system to be able to track those deficiencies. Right now, when we're pulling data, we have to code it manually. So we just need to overcome that and then we can move towards publishment.

I would ask, since we're still going to be in our subcommitteeing hearings, if you could come back in 3, 4 months and just give us an update on that. Great. Thank you. Senator Roth.

I just have two questions. Trying to make them questions this time. Do you have a set of guidelines or I would call them requirements for investigators who were conducting this type of investigation out in the field?

There are guidelines for how to conduct the investigation. It is consistent across all allegations and all deficiencies, both at the federal investigation level on our behalf of CMS, and then, of course, the same for the state investigation.

And are the guidelines fairly detailed to the extent that it instructs investigators in terms of categories, who to contact and in what order?

That typically is established as a surveyor is moving through the investigative process. Again, there needs to be some level of flexibility if we prescribe; you interview these two people, if we notice that there's an expansion of that violation, or we suspect that there may be a violation in another area, surveyors are allowed that flexibility to then expand and they may engage in interviews with different individuals.

They may branch off to another area, because, again, when we are on site and we are investigating, they're paying attention to everything and not just limiting the scope of what may have drawn them into a facility and instead making sure that they're doing a complete assessment of anything that might come to their attention. So there's a guideline, but they're not strict guardrails to limit how they may approach the investigation.

Well, as a former federal investigator, I was just trying to address the questions that were raised by the lady to my left. I think that would be interesting to take a look at the guidelines that you have in place for your surveyors. That's right. We're in healthcare, the surveyors that go out to deal with these sorts of complaints. And then my other question has to goes to funding for your operation.

Do you have the authority to assess the cost of the investigation against those healthcare institutions that where you find a violation, whether or not a penalty is assessed?

So currently, the penalties would be the only revenue or the only fee that would be assessed to a facility that we're investigating for a ratio.

That may be widely divergent from the cost of your actual investigation. So the question is, obviously, you can assess a penalty, but apparently some don't feel the penalties have been very high. Do you have the authority to assess the cost of your investigation regardless of whether you assess a penalty and regardless of the penalty assessed?

So currently, those costs of any of the work that our program conducts in terms of investigations or expenses, inspections, is folded into our larger methodology, which generates the fees to support our organization and the work that we do. So essentially, the cost of an investigation for a staff ratio or any other complaint would be redistributed out to the facility category or the facility population. So in this case, these are investigations of hospitals.

Hospitals across the state would share in that cost as an overhead for the operations of our program. They're not distinctly charged back to the facility that was under investigation.