San Diego County is the second most populous county in the State, with an estimated population of 3.3 million residents as of January 2018. San Diego County’s Health and Human Services Agency (Health Agency) is responsible for providing a variety of health and social services to county residents, including public health, child welfare, and behavioral health services. San Diego County’s Code of Administrative Ordinances requires the Health Agency to administer programs through its departments, divisions, and geographic service regions in a manner that integrates the administration and delivery of services to assure effectiveness, efficiency, accessibility, and quality. For this audit, we reviewed whether the Health Agency had adequate levels of public health nurses (PHNs) to appropriately serve county residents.
The Health Agency does not consistently use available information, such as case assignment data, to measure PHN efficiency and help assess its PHN staffing assignments. For instance, the Health Agency does not require its managers to monitor each PHN’s caseload. Our review of caseload information for the Health Care Program for Children in Foster Care (Foster Care) and the California Children’s Services program (Children’s Services) revealed that the average caseload per PHN exceeded state benchmarks for both programs for the three fiscal years we reviewed. For instance, in 2017, the average caseload per PHN in the Foster Care program was 255, which exceeds the state benchmark of 200. We also observed notable differences in Foster Care PHN caseloads among the Health Agency’s six regions. In 2017 the Foster Care PHN covering cases in the East region averaged 295 cases, almost 100 cases more than the 197 average Foster Care caseload in the South region. The Health Agency also does not require managers to use a case complexity measure to assess or distribute caseloads in Foster Care or Children’s Services. A case complexity measure would allow managers to assess levels of client need and anticipate the amount of work that cases of differing complexity might involve when making PHN caseload assignments. For instance, such a measure could help Foster Care assess whether variations in regional PHN caseloads are reasonable on the basis of varying amounts of work particular Foster Care cases require.
San Diego County experienced an outbreak of hepatitis A in 2017, which the Health Agency detected in March 2017 and for which it declared a local public health emergency in September 2017. According to its after action report, San Diego County implemented its draft Public Health Personnel and Infrastructure Surge Capacity Plan (surge plan) to respond to the outbreak. Specifically, the report stated that the Health Agency used the surge plan’s protocols to use both its own PHNs and to engage and train 158 temporary nursing staff to augment its vaccination efforts. Billing summaries show that these temporary nurses worked nearly 6,800 hours during the outbreak response. Although the Health Agency appears to have followed its surge plan during the hepatitis A outbreak, the plan was still in draft form until June 2018. Neither the after action report nor the 2017/2018 San Diego County Grand Jury (grand jury) report, which assessed the county’s performance in responding to the hepatitis A outbreak, identified concerns related to the Health Agency’s use of its PHNs in response to the outbreak.
To hire new PHN staff, the Health Agency uses San Diego County’s civil service practices and procedures, filling its vacancies from a list established through the county’s certification process. The county has had a full list of qualified candidates for the PHN classification. For example, from March 2017 through November 2017, the Health Agency received 142 applications for PHN positions, of which 107 applicants qualified and were placed on the list and from which the Health Agency hired 13 PHNs. We also reviewed the Health Agency’s financial resources and did not find impediments that would prevent it from filling its currently authorized PHN positions. State and federal government agencies provide the primary funding for the programs that staff PHNs; the county matches these funds with realignment money from the State.
To better ensure and demonstrate that it efficiently meets the public health needs of at‑risk county residents and that it employs the appropriate number of PHNs in the right locations to address those needs, the Health Agency should measure and assess PHN efficiency.
The Health Agency disagreed with our recommendation that it develop and implement PHN efficiency measures. Beginning here, we provide our perspective on the Health Agency’s response to our report.