A BILL TO BE ENTITLED
AN ACT to improve the quality and accountability of the public health system by strengthening the public health INFRASTRUCTURE, to improve public health outcomes and reduce health disparities by the development of state and local comprehensive public health plans, and to improve the public health workforce by enhancing COLLABORATION with public and private sector entities and imposing performance standards for public health practice.
Whereas, North Carolina has a rich local public health heritage and wishes to continue that heritage by strengthening the State's public health infrastructure;
Whereas, the public health system must respond to: new serious public health emergencies, significant changes in population, decreasing funding, and significant variations in public health protection between counties and regions;
Whereas, the mission of protecting and promoting the health of the public can most efficiently and effectively be addressed through the coordinated efforts of State and local public health agencies, the collaboration of the public and private sectors within the public health system, and the consolidation of local public health agencies;
Whereas, a consensus for establishing, prioritizing and implementing essential public health services and functions can be achieved through locally developed and coordinated health plans that provide the foundation for a comprehensive statewide public health plan; and
Whereas, the public and private sectors can demonstrate public accountability and provide high quality services through accreditation, certification, credentialing, and the implementation of performance standards; Now, therefore,
The General Assembly of North Carolina enacts:
SECTION 1.  G.S. 130A‑1.1 is repealed.
SECTION 2.  G.S. 130A‑2 reads as rewritten:
"§ 130A‑2.  Definitions.
The following definitions shall apply throughout this Chapter unless otherwise specified:
(1)	"Commission" means the Commission for Health Services.
(1a)	"Communicable condition" means the state of being infected with a communicable agent but without symptoms.
(1b)	"Communicable disease" means an illness due to an infectious agent or its toxic products which is transmitted directly or indirectly to a person from an infected person or animal through the agency of an intermediate animal, host, or vector, or through the inanimate environment.
(2)	"Department" means the Department of Health and Human Services.
(2a)	"Essential public health services and functions" means those services and functions listed in G.S. 130A-1.3.
(3)	"Imminent hazard" means a situation that is likely to cause an immediate threat to human life, an immediate threat of serious physical injury, an immediate threat of serious adverse health effects, or a serious risk of irreparable damage to the environment if no immediate action is taken.
(3a)	"Isolation authority" means the authority to issue an order to limit the freedom of movement or action of a person or animal with a communicable disease or communicable condition for the period of communicability to prevent the direct or indirect conveyance of the infectious agent from the person or animal to other persons or animals who are susceptible or who may spread the agent to others.
(4)	"Local board of health" means a district board of health or a public health authority board or a county board of health.
(5)	"Local health department" means a district health department or a public health authority or a county health department.
(6)	"Local health director" means the administrative head of a local health department appointed pursuant to this Chapter.
(6aa)	"Local public health agency" means a local health director, a local board of health, and a local health department.
(6a)	"Outbreak" means an occurrence of a case or cases of a disease in a locale in excess of the usual number of cases of the disease.
(7)	"Person" means an individual, corporation, company, association, partnership, unit of local government or other legal entity.
(7a)	"Private sector partner" means nongovernmental persons, including community organizations, contractors, educational institutions, health care facilities, health insurers, private businesses, media, nonprofit organizations, and volunteers, that provide essential public health services and functions or work to improve public health outcomes in collaboration with the State or a local public health agency and are identified in the local public health plans in accordance with G.S. 130A-2.7.
(7b)	"Public health" means assuring the conditions in which the population can be healthy. The term includes population-based or individual efforts primarily aimed at the prevention of injury, disease, or premature mortality or the promotion of health in the community, such as assessing the health needs and status of the community through public health surveillance and epidemiological research, developing public health policy, and responding to public health needs and emergencies.
(7c)	"Public health agency" means a federal, tribal, State, or local public health agency.
(7d)	"Public health infrastructure" means the competencies and resources that enable public health agencies, in collaboration with other components of the public health system, to provide essential public health services and functions throughout the State.
(7e)	"Public health system" means State and local public health agencies and their public and private sector partners.
(7f)	"Public health workforce" means State and local public health agents and other persons working within the public health system to provide essential public health services and functions in the State.
(7g)	"Public sector partner" means international, federal, tribal, or other State or local governments and their public health agencies that provide essential public health services and functions or work to improve public health outcomes with a State or local public health agency.
(7h)	"Quarantine authority" means the authority to issue an order to limit the freedom of movement or action of persons or animals which have been exposed to or are reasonably suspected of having been exposed to a communicable disease or communicable condition for a period of time as may be necessary to prevent the spread of that disease. Quarantine authority also means the authority to issue an order to limit access by any person or animal to an area or facility that may be contaminated with an infectious agent. The term also means the authority to issue an order to limit the freedom of movement or action of persons who have not received immunizations against a communicable disease when the State Health Director or a local health director determines that the immunizations are required to control an outbreak of that disease.
(8)	"Secretary" means the Secretary of Health and Human Services.
(8a)	"State public health agency" means the Commission for Health Services, the Department of Health and Human Services, and the Department of Environment and Natural Resources to the extent that the Department of Environment and Natural Resources has jurisdiction to protect the public's health.
(8b)	"Tribe" means the same as the term 'Indian Tribe' in 25 U.S.C. § 450b(e), section 4(e) of the Indian Self-Determination and Education Assistance Act, Pub. L. 93-638, as amended.
(8c)	"Tribal public health agency" means any program or organization operated by a tribe or tribal organization, including boards, agencies, commissions, or offices, that principally acts or is responsible to protect or preserve the public's health and shall include the health programs of any tribal organization that carries out essential public health services and functions or otherwise acts to protect or preserve the public health.
(8d)	"Tribal organization" means the same as the term in 25 U.S.C. § 450b(l), section 4(l) of the Indian Self-Determination and Education Assistance Act, Pub. L. 93-638, as amended.
(9)	"Unit of local government" means a county, city, consolidated city‑county, sanitary district or other local political subdivision, authority or agency of local government.
(10)	"Vital records" means birth, death, fetal death, marriage, annulment and divorce records registered under the provisions of Article 4 of this Chapter."
SECTION 3.  Part 1 of Article 1 of Chapter 130A is amended by adding the following new sections to read:
"§ 130A-2.1. Mission statement.
(a)	The policy of the State is to protect and promote the health of the public to the greatest extent possible through the public health system while respecting individual rights to bodily integrity, health information privacy, nondiscrimination, due process, and other legally protected interests.
(b)	The mission of the State and local public health agencies is to provide leadership and protect and promote the public's health by:
(1)	Providing essential public health services and functions as provided in G.S. 130A-1.3.
(2)	Encouraging collaboration among public and private sector partners in the public health system. 
(3)	Seeking adequate funding to provide essential public health services and functions and to accomplish public health goals from public or private sources.
(c)	Nothing in this section shall be construed to require the State or local public health agencies or an individual or agency within the public health system to provide specific health services or to implement unfunded programs.
"§ 130A-2.2. Responsibilities of State and local governments; private sector collaboration.
(a)	The State and counties are responsible for assuring that the public health system accomplishes the mission of public health.
(b)	State and local public health agencies shall collaborate with public and private sector partners within the public health system to provide essential public health services and functions listed in G.S. 130A-33-55. 
(d)	State or local public health agencies may contract with contractors or other private sector partners for the purpose of providing essential health services and functions directly through these private sector entities if:
(1)	The contractor has the potential to improve public health outcomes without causing harm to individuals or the public health system.
(2)	Privatized services are fully and regularly monitored by the contracting public health agency or others within the public health system. Nothing is this subdivision shall be construed to require private sector entities to be monitored by other public agencies providing services within the public health system. The State public health agency shall devise, in consultation with others within the public health system, evaluation criteria to be used in conducting performance reviews of any private sector partner that provides privatized services or functions.
(3)	Privatized services or functions are subject to other federal, State, or local laws.
"§ 130A-2.3. Essential public health services and functions.
(a)	State and local public health agencies, in collaboration with public and private sector partners, shall provide the following essential public health services and functions:
(1)	Monitor health status to identify and solve community health problems.
(2)	Diagnose and investigate health problems and health hazards in the community.
(3)	Inform people about health issues.
(4)	Develop policies and plans that support individual and community health efforts.
(5)	Enforce laws and regulations that protect health and ensure safety.
(6)	Link individuals to needed personal health services and facilitate the provision of health care when not otherwise available.
(7)	Monitor and ensure the competency of the public health workforce.
(8)	Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
(9)	Conduct research to identify new insights and innovative solutions to health problems.
(10)	Promote the availability and accessibility of quality health care services through health care facilities or providers.
(11)	When not otherwise available through the private sector, collaborate with other public sector partners to promote the availability of and access to preventive and primary health care, including acute and episodic care, prenatal and postpartum care, child health, family planning, school health, chronic disease preventions, child and adult immunization, dental health, nutrition, and health education and promotion services.
(b)	The essential public health services and functions listed in subsection (a) of this section shall not be construed to limit or restrict the powers and duties of the Commission, the Department, or the Department of Environment and Natural Resources as otherwise conferred by State law.
"§ 130A-2.4. Public health infrastructure.
(a)	The Secretary shall coordinate State and local public health agencies and their public and private sector partners to do the following to strengthen and maintain stability of the public health infrastructure:
(1)	Identify and provide leadership for the provision of essential public health services and functions;
(2) 	Develop management standards for the public health system and workforce that are tied to improvements in public health outcomes or other measures;
(3)	Develop and provide effective training for members of the public health workforce that is focused on performance-based standards;
(4)	Evaluate performance management standards and training efforts within the public health system; and
(5)	Comprehensively plan and set priorities for the efficient and effective accomplishment of essential public health services and functions.
(b)	In performing the duties set forth in subsection (a) of this section, State and local public health agencies and their public and private sector partners shall consult with and utilize national guidelines, initiatives, programs, and recommendations relating to improvements in public health infrastructure that are consistent with accomplishing the mission of public health in the State.
"§ 130A-2.5.  Public health workforce.
(a)	The State public health agency shall manage the public health workforce performance related to public health infrastructure and capacity, processes, and outcomes at the State and local levels. The State public health agency shall establish and implement performance standards, measures, and processes for quality or performance improvement that are accessible, affordable, and nonpunitive. These include the following:
(1)	Performance measurement standards for the public health system. – Consistent with the National Public Health Performance Standards Program, the State public health agency shall adopt and administer performance measurements within the public health system as a means of improving the quality of State and local public health practice and improving system accountability.
(2)	Accreditation of local public health agencies. – The State public health agency shall adopt and administer a mandatory accreditation program for local public health agencies. The accreditation program shall be based on criteria developed by the State public health agency that focus on the ability of agencies to provide essential public health services and functions.
(3)	Certification or credentialing for the public health workforce. – Consistent with any national system of public health workforce certification or credentialing, the State public health agency shall adopt and administer public health workforce certification or credentialing programs for members of the public health workforce. These programs shall be designed to develop knowledge, skills, and abilities in relevant and contemporary public health practice areas and must be based on:
a.	Basic, core, or technical competencies for public health workers; or
b.	Professional codes for public health professionals.
(b)	The State public health agency shall, directly or in conjunction with educational institutions or others within the public health system, make available or assure effective programs, continuing education, or other tools for training public health agents and others within the public health workforce.
(c)	The State public health agency may require individuals within the public health system to meet minimal training requirements to assist the individual in providing essential public health services and functions.
(d)	The State public health agency may provide incentives to meet performance management or training requirements, including:
(1)	Organizational accountability awards.
(2)	Accreditation recognition for public health agencies or their contractors or volunteers.
(3)	Certification or credentialing titles or recognition for individuals.
(4)	Other career development initiatives, including financial benefits.
(e)	The State public health agency shall:
(1)	Adopt a framework for the evaluation of the performance of the local public health agency workforce.
(2)	Develop standards to consistently evaluate the effectiveness and delivery of training programs, continuation education, and other tools.
(3)	Consistently evaluate performance management and training programs, continuing education, and other tools pursuant to these frameworks or standards.
"§ 130A-2.6. Comprehensive public health plan.
(a)	The State public health agency shall develop a comprehensive public health plan ("Plan") that assesses and sets priorities for the State public health system. The State public health agency shall develop the Plan in consultation with representatives from its public and private sector partners and in consideration of local public health plans submitted in accordance with G.S. 130A-2.7. The Plan may rely on existing or available surveillance data or other formation available to the State public health agency, as well as national guidelines or recommendations concerning public health outcomes and improvements. The Plan shall cover five years and shall be reviewed annually. Future Plans shall be developed every five years. The Plan shall include the following:  
(1)	Identification and quantification of existing public health problems, disparities, or threats at the State and local levels.
(2)	Identification of areas needing greater resource allocation to effectively combat public health threats or decrease disparities in the provision of essential public health services and functions.
(3)	Goals for targeting essential public health services and functions to address prioritized public health problems, disparities, or threats through program development, implementation, and evaluation and specific recommendations, strategies, and schedules for meeting these goals.
(4)	Identification of specific at-risk populations targeted, including criteria for identifying targeted populations.
(5)	Goals for increasing the efficiency and effectiveness of the public health system and specific recommendations, strategies and schedules for meeting these goals.
(6)	Strategies for coordinating service delivery within the public health system.
(7)	Measurable indicators of effectiveness and success.
(8)	Identification of public and private sector partners.
(b)	The State public health agency shall submit a copy of the comprehensive State public health plan required under this section annually to the Governor and the General Assembly upon its convening or reconvening, including any recommendations for legislative amendments.
"§ 130A-2.7.  Local public health plans.(a)	Every county, through its local public health agency, shall provide for the development, review, and approval of a local public health plan consistent with the comprehensive State public health plan required under G.S. 130A-5.4. The local public health plan shall address how the local public health agency will coordinate with the State public health agency and others within the public health system to accomplish goal and priorities identified in the comprehensive State public health plan. The local public health plan shall cover five years and shall be reviewed annually. Future plans shall be developed every five years. In addition to the items listed in G.S. 130A-5.4, the local public health plan shall include the following:
(1)	Description of the demographics and health indicators of the population being served by the local public health agency.
(2)	Description of the numbers and types of professionals in the local public health workforce.
(3)	Description of the local public health workforce training needs.
(4)	Description of how the local public health agency is accountable to the public in ensuring the provision of essential public health services and functions.
(5)	Description of how the local public health agency provides the necessary leadership to ensure that public health services are managed, monitored, and are of the highest quality possible. 
(6)	Description of how the local public health agency manages its finances and accounts for expenditures of State, local, and all other sources of revenue. 
(7)	Identification of public and private sector partners.
(8)	Other matters determined by the Secretary to be necessary to effectively and efficiently provide essential public health services and functions by a local public health agency.
(b)	The local public health plan shall be approved and submitted to the Secretary no later than July 1, 2004. 
(c)	The State public health agency shall provide technical assistance to local public health agencies that request assistance and shall otherwise work with local public health agencies to generate the plan."
SECTION 4.  G.S. 130A‑5 reads as rewritten:
"§ 130A‑5.  Duties of the Secretary.
The Secretary shall have the authority:
(1)	To enforce the State health laws and the rules of the Commission;
(2)	To investigate the causes of epidemics and of infectious, communicable and other diseases affecting the public health in order to control and prevent these diseases; to provide, under the rules of the Commission, for the prevention, detection, reporting and control of communicable, infectious or any other diseases or health hazards considered harmful to the public health; to obtain, notwithstanding the provisions of G.S. 8‑53, a copy or a summary of pertinent portions of privileged patient medical records deemed necessary for investigating a disease or health hazard that may present a clear danger to the public health. Records shall be identified as necessary by joint agreement of a Department physician and the patient's attending physician. However, if the Department is unable to contact the attending physician after reasonable attempts to do so, or if the Department determines that contacting all attending physicians of patients involved in an investigation would be impractical or would unreasonably delay the inquiry and thereby endanger the public health, the records shall be identified as necessary by joint agreement of a Department physician and the health care facility's chief of staff. For a facility with no chief of staff, the facility's chief administrator may consent to the Department's review of the records. Any person, authorized to have or handle such records, providing copies or summaries of privileged patient medical records pursuant to this subdivision shall be immune from civil or criminal liability that might otherwise be incurred or imposed based upon invasion of privacy or breach of physician‑patient confidentiality arising out of the furnishing of or agreement to furnish;
(3)	To develop and carry out  the comprehensive State public health plan pursuant to G.S. 130A-33-58. The Commission is authorized to adopt rules to carry out the Plan. 
(4)	To make sanitary and health investigations and inspections;
(5)	To investigate occupational health hazards and occupational diseases and to make recommendations for the elimination of the hazards and diseases. The Secretary shall work with the Industrial Commission and shall file sufficient reports with the Industrial Commission to enable it to carry out all of the provisions of the Workers' Compensation Act with respect to occupational disease.
(6)	To receive donations of money, securities, equipment, supplies, realty or any other property of any kind or description which shall be used by the Department for the purpose of carrying out its public health programs;
(7)	To acquire by purchase, devise or otherwise in the name of the Department equipment, supplies and other property, real or personal, necessary to carry out the public health programs;
(8)	To use the official seal of the Department. Copies of documents in the possession of the Department may be authenticated with the seal of the Department, attested by the signature or a facsimile of the signature of the Secretary, and when authenticated shall have the same evidentiary value as the originals;
(9)	To disseminate information to the general public on all matters pertaining to public health; to purchase, print, publish, and distribute free, or at cost, documents, reports, bulletins and health informational materials. Money collected from the distribution of these materials shall remain in the Department to be used to replace the materials;
(10)	To be the health advisor of the State and to advise State officials in regard to the location, sanitary construction and health management of all State institutions; to direct the attention of the State to health matters which affect the industries, property, health and lives of the people of the State; to inspect at least annually State institutions and facilities; to make a report as to the health conditions of these institutions or facilities with suggestions and recommendations to the appropriate State agencies. It shall be the duty of the persons in immediate charge of these institutions or facilities to furnish all assistance necessary for a thorough inspection;
(11)	To establish a schedule of fees based on income to be paid by a recipient for services provided by Migrant Health Clinics and Development Evaluation Centers;
(12)	To establish fees for the sale of specimen containers, vaccines and other biologicals. The fees shall not exceed the actual cost of such items, plus transportation costs;
(13)	To establish a fee to cover costs of responding to requests by employers for industrial hygiene consultation services and occupational consultation services. The fee shall not exceed two hundred dollars ($200.00) per on site inspection; 
(14)	To establish a fee for companion animal certificate of examination forms to be distributed, upon request, by the Department to licensed veterinarians. The fee shall not exceed the cost of the form and shipping costs; 
(15)	Conduct performance management and training programs and evaluations to improve the public health system and workforce; and
(16)	Systematically review, on at least an annual basis, the public health system to recommend modifications in its structure or other features to improve public health outcomes."
SECTION 5.  The Department of Health and Human Services shall do the following to prepare for the development and implementation of the comprehensive State public health plan and the local public health plans:
(1)	Develop the State comprehensive public health plan in accordance with G.S. 130A‑5.2 not later than January 1, 2005.
(2)	Review all rules currently in effect and adopted by the Commission for Health Services and the Secretary and identify rules that are inconsistent with this act.
(3)	Review all oversight and monitoring functions currently implemented by the Department with respect to the public health system to determine the effectiveness of the activities on achieving the intent of the act; and improve the oversight and monitoring functions and activities, if necessary; identify areas where additional training is needed and provide it.
(4)	Develop service standards, outcomes, and financing strategies necessary to implement this act.
(5)	Develop format and required content for local public health plans.
(6)	Develop a method for Departmental evaluation of local public health plans.
(7)	Develop contractual agreements for the provision of technical assistance by the Department to local public health agencies in the development of local public health plans.
(8)	Report to the Joint Legislative Health Care Oversight Committee on the Department's readiness to implement public health infrastructure reform no later than October 1, 2003.
(9)	Develop a consolidation plan that will result in no less than 10 and no more than 20 local public health agencies by January 1, 2005.
SECTION 6.  There is appropriated from the General Fund to the Department of Health and Human Services the sum of one million dollars ($1,000,000) for the 2003-2004 fiscal year. These funds shall be used to create incentives for counties to consolidate public health services into multicounty district health departments.
SECTION 7.  Section 6 of this act becomes effective July 1, 2003. The remainder of this act is effective when it becomes law.