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San Diego County’s Health and Human Services Agency
It Cannot Demonstrate That It Employs the Appropriate Number of Public Health Nurses to Efficiently Serve Its Residents

Report Number: 2017-124

Public Health Services Branches

Maternal, Child, and Family Health Services Branch—works to promote health and protect and support pregnant women, children, families, and communities. The branch administers the Health Care Program for Children in Foster Care (Foster Care), among others.

California Children’s Services Branch (Children's Services)—provides funding for treatment of children with certain physical limitations and chronic health conditions or diseases, and authorizes and pays for specific medical services and equipment provided by Children’s Services‑approved specialists. Children’s Services is a countywide program funded by state, county, and federal funds, as well as fees paid by parents.

Epidemiology and Immunization Services Branch—works to identify, investigate, register, and evaluate communicable, reportable, and emerging diseases and conditions to protect the health of the community.

Tuberculosis Control and Refugee Health Branch—works to detect, control, and prevent the spread of tuberculosis through treatment, case management, and contact investigation, and provides refugee health program services.

HIV, STD, and Hepatitis Branch—helps assure the development and delivery of prevention and treatment services for the human immunodeficiency virus (HIV) and sexually transmitted diseases (STDs), particularly in communities disproportionately affected by HIV and STDs.

Public Health Preparedness and Response Branch—coordinates with emergency management agencies, community organizations, medical providers, prehospital provider agencies (fire/emergency medical services), hospitals, clinics, skilled nursing facilities, businesses, and other partners to develop public health and disaster preparedness through dissemination of risk assessments, trainings, and public health guidance.

Public Health Services Administration Branch—provides program direction and administrative support to all Public Health Services program areas. The branch is also responsible for coordinating a unified response from the Public Health Services division when information is requested agencywide.

Source: Health Agency’s fact sheets and website.



Public health nursing is a practice within the nursing profession that focuses on promoting and protecting the health of a population by working to prevent disease and support at‑risk populations. At‑risk populations (clients) can include foster youth; children with specific physical limitations, chronic health conditions, or diseases; first‑time low‑income mothers; and persons who have tested positive for conditions such as tuberculosis. Public health nurses (PHNs) also respond to public health emergencies and other immediate public health needs as they arise, which can involve such actions as providing vaccinations during disease outbreaks.

San Diego County’s Health and Human Services Agency

The Department of Finance estimates that as of January 2018, San Diego County had 3.3 million residents, making it the second most populous of California’s 58 counties, behind only Los Angeles County. According to its website and operational plan, 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 child welfare, public health, and behavioral health services. The Health Agency is governed by the county chief administrative officer and board of supervisors, and is headed by a director who oversees its 6,000‑plus staff, including 192 PHN positions. This equals roughly one PHN position per 17,000 residents.

The Health Agency comprises six programmatic departments, one of which is Public Health Services. According to its website, Public Health Services works to prevent epidemics, the spread of disease, and injuries; protect against environmental hazards; promote and encourage healthy behaviors; and respond to disasters to help communities and assure health services throughout the county. The Health Agency assigns 71 of its PHN positions (37 percent of its total 192) to Public Health Services. The text box describes the branches within Public Health Services. Public Health Services also assigns 105 PHN positions (55 percent) to facilities within its six regions. Figure 1 depicts these regions.

Figure 1
San Diego County Has Six Public Health Regions

Figure 1 is a map of San Diego County's six public health regions.

Source: Health Agency’s website.

Each of the Health Agency’s six regions has at least one public health center, which usually hosts a health clinic and a variety of public health services, including those staffed by PHNs. The Health Agency assigns its remaining 16 PHN positions (8 percent) to Aging and Independence Services and the Medical Care Services Division. Figure 2 illustrates the Health Agency’s relevant organizational structure.

Figure 2
The Health Agency Assigns Its PHNs Across Multiple Regions and Programmatic Departments

Figure 2 is an organizational chart that shows the Health Agency assigns its PHNs across multiple regions and programmatic departments.

Source: Analysis of the Health Agency’s organizational charts and human resources data.

Notes: Other than the six regions, this organizational chart includes only those Health Agency programmatic departments that contain PHNs. The Health Agency’s other programmatic departments are Self‑Sufficiency Services, Behavioral Health Services, Child Welfare Services, and Housing and Community Development Services.

As of December 31, 2017, the Health Agency had 192 authorized PHN positions, 163 of which it had filled. Twenty (69 percent) of its 29 vacancies were in the North Coastal, East, and Central regions and the Public Health Preparedness and Response Branch. Data from the Health Agency indicate that as of June 12, 2018, the Health Agency had filled five of those 20 PHN vacancies and was in the process of filling seven others. The data also indicate that the Health Agency reclassified or was in the process of reclassifying five PHN positions and was waiting to fill one position until it filled a corresponding supervisory position. The remaining two PHN positions were vacated in May and June 2018.

Funding for the Health Agency’s PHN‑Staffed Programs

According to Health Agency data, many of its programs that employ PHNs receive a blend of federal, state, and county funding. Realignment revenues, which are funds collected by the State and distributed to counties for specific purposes based on a formula, account for a large portion of the Health Agency’s spending on programs that employ PHNs.

The county’s adopted operational plan for fiscal years 2017–18 and 2018–19 reports that in fiscal year 2017–18, the Health Agency’s total budget was $1.9 billion. Of this, nearly $144 million was for Public Health Services. Table 1 breaks out the Health Agency’s funding over the past three fiscal years for programs that employ PHNs.

Table 1
The Health Agency Derives the Majority of Its Funding for Programs With PHNs From Federal and Realignment Sources
(Dollars in Millions)
2014–15 2015–16 2016–17
PHN positions
[budgeted, full‑time equivalents (FTEs)]*
179 180 177
Federal funds $27.6 $30.5 $32.9
Realignment funds 28.4 29.4 28.5
State funds 11.8 12.3 13.0
County funds 11.4 10.9 12.1
Miscellaneous funds§ 1.8 1.4 1.4
Total funds for programs with PHNsll $81.0 $84.4 $87.8

Source: Unaudited financial information provided by the Health Agency’s Financial and Support Services Division’s assistant finance director.

* PHN positions is the number of budgeted FTE PHNs that the Health Agency was authorized over the course of the year. It does not reflect point‑in‑time counts, as we depict in other graphics.

Realignment funds refers to state funds distributed to county governments for public health and social services.

County funds refers to general‑purpose revenue and use of fund balance.

§ Miscellaneous funds refers to funds from First 5 for programs such as Lactation and Childhood Obesity, from Medi-Cal payments for tuberculosis services, and from fees charged for services including STD and immunization fees.

ll The Health Agency did not provide budgetary information for the 16 PHNs under the Aging and Independence Services programmatic department. According to the Health Agency’s Financial and Support Services Division’s assistant finance director, the majority of Aging and Independence Services’ budget is for In-Home Support Services, and including those funds would distort the overall picture for public health funding. Totals may not equal the sum of funds above due to rounding.

San Diego County’s Recent Hepatitis A Outbreak

During 2017 San Diego County experienced an outbreak of hepatitis A, which, according to the Health Agency’s website, resulted in at least 590 cases, 405 hospitalizations, and 20 deaths as of July 12, 2018. Hepatitis A is a highly contagious liver infection that is spread person to person and via fecally contaminated material. In San Diego County the outbreak primarily affected people who were homeless or using illicit drugs.

According to the county’s May 2018 after action report, the county detected the hepatitis A virus outbreak in early March 2017, with cases traced back to late November 2016. The after action report also indicated that in March 2017 the Health Agency began redirecting its PHNs from their regular duties to administer vaccinations. On September 1, 2017, the Health Agency declared a local health emergency. In October 2017 the Governor declared a state of emergency for all of California and ordered that all measures necessary should be taken to obtain hepatitis A vaccines.

As we discuss here and here, we found that 92 PHNs worked overtime as part of the hepatitis A response, and that the county hired temporary nursing staff as well as contracted with hospitals and fire departments to counteract the outbreak. Although its board of supervisors lifted San Diego County’s emergency on January 23, 2018, the State’s emergency remained in place as of May 2018. Figure 3 illustrates the timeline of the hepatitis A outbreak.

Figure 3
New Cases During San Diego County’s Hepatitis A Outbreak Peaked in August 2017

Figure 3 is a graph that illustrates the timeline of the number of new cases and the key events associated with the hepatitis A outbreak.

Source: Analysis of San Diego County’s after action report and the 2017/2018 San Diego County Grand Jury report on the hepatitis A outbreak, both issued in May 2018.

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