Meeting to order at 9 a.m.

on Thursday, February 26th for the district board of health.

And it's going to be a great meeting.

I can just feel it in the air.

And it's warm and it's not snowing.

So we're we're going to celebrate that as well.

Like to go ahead and call uh roll call, please.

Umbrella.

Okay.

Dr.

Duarte?

Here.

Dr.

Denko is not present, and Devin Reese is not present.

We do have a quorum.

Thank you so much.

I'd like to ask Dr.

Marte if he were due the pledge of the motions, please.

It's to the flag of the United States of America.

And to the Republic for which it stands.

Indivisible liberty justice for all.

Comments heard under this item will be limited to three minutes per person.

It may pertain to matters both on and off the board agenda.

Time may not be allocated to other speakers.

Comments are to be made to the board as a whole, and virtual public comment can be taken when facilities are available.

Speaker's viewpoint will not be restricted, however, reasonable restrictions may be imposed upon the time, place, and manner of speech.

Irrelevant statements, unduly repetitious statements, and personal attacks that would objectively untagonize or incite others are examples of speech that may be reasonably familiar.

Warnings about disruptive conduct or comments may or may not be given prior to the more certain disruptions of a public meeting or criminal access to find under NRS, which may result in prosecution inappropriate cases.

Um which was forwarded to the board members and is listed to the record.

And we do have one request for public comment.

Um I'd like to call out Jamar May.

You're welcome to use the podium.

My name is Jamar May.

I'm a culinary entrepreneurship at Chucky Meadows Committee and a business management student at the University of Nevada Reno.

I'm also the founder of Mars Mobile Mungeys.

The original Mars Mobile Mungi's sidewalk stand model was developed as a practical learning step, a way to gain real-world learning experience before investing the significant capital required for a full trailer build-up.

As a student studying both business management and culinary entrepreneurship, my goal has always been to build responsibility, gain experience, and scale appropriately.

Senate Bill 92 establishes sites, sidewalk food vending as lawful regulated business activity in Nevada.

The statute defines a sidewalk vendor as someone selling food upon a public sidewalk from a convenience.

Including without limitation, a push cart, stand display, title-driven cart wagon showcase or rack.

The word stand is explicitly included.

My original concept was intentionally designed as a controlled limited risk sidewalk stand aligned with N NPH food safety and equipment standards, not a pushcart and not a full mobile food trailer.

The design was conceptual and proposed a simple structured setup consisting of two tables under a tent, a portable steam table that have been dedicated solely to maintaining holding temperatures for precooked meats and canned nacho cheese with a portable griddle position outside of the tent and used strictly for hot finishing.

All primary food preparation would have occurred at a permitted commissary kitchen.

The setup also included a generator to safely power the steam table and lighting.

A stand-based pathway was not presented as viable.

I recognize how fortunate I am to be able to take that route.

But many aspiring small business business owners cannot afford the capital required for a full trailer build out.

Senate Bill 92 was to reduce unnecessary regulatory barriers while still maintaining appropriate food safety standards.

So my question is simple.

I really I respectfully request clarification on how an NPH interprets stand on our Senate Bill 92 and how local implementation aligns with that law.

Thank you for your time in our service too.

Your service to our community.

Thank you.

And I hope that uh staff has your information as they can follow up.

Um I have sent out my email to a few people.

But uh but thank you.

Thank you.

Chair.902.

Oh, great.

It's okay.

I can hear you.

Can you hear me?

Yes.

Hello.

Any other public comment?

No.

Thank you.

We'll move now to the approval of the agenda.

Motion.

We have a motion by Mr.

Driscoll.

You have second.

Second.

Second by Mr.

Anderson.

Any further session?

And all those in favor, sign up by saying aye.

Aye.

Aye.

Unanimously.

Thank you.

Sorry.

Couldn't resist saying that.

Um we'll move on to the approval of January 22nd, 2026.

And that's if anybody has any changes.

We have uh motion by um Mr.

Brown.

Second by Mr.

Drill for discussion.

Hearing none, all those in favor signify by saying aye.

Aye.

Any opposed?

Motion carries unanimously.

We'll move now to item six.

And so today I think everyone has their schedule and their creative uh thinking caps on, and just ready to this the best treat yet ever experienced.

Um, certainly um the focus of health and looking at community needs, looking at staff needs, looking at financial and and the strategies to accomplish um navigating the best possible solutions we can offer are always welcome.

But just as a reminder, we are working at a you know 30,000 foot level.

And so um just want to, and I'm sure that we all uh Miss Olson will help us remind us of that as we sometimes travel in the weeds, but I certainly appreciate that.

But in order to make this a memorable experience, I am going to ask that we have a little icebreaker, and everyone's gonna participate.

Everyone or two over oh, yes, everyone has to participate.

Oh, yes.

So here's what it is.

I'm gonna have you think about what you ever received as either personal or professional advice that you have found to be impactful either in your personal or professional career.

So we'll do the Jeopardy do we give a minute or two because there's no preparation for this, and I apologize that um I'm springing this on, but I hope that you can share with us what that message or message is.

We're given to you, and it can be at any time in your life.

So it looks like they have an already doing that.

We'll just go around the room.

So Eric, I'm gonna start with you.

Yeah, you were gonna start with my gosh.

Um did you feel that?

I did.

Yeah.

Do you want me to shake it up and we'll go on the other side?

Oh, that's okay.

Okay, I'll jump in.

I what strikes me, just I'm very present in this work right now.

So um uh Katie Simon, Katie Singlong, many of us know her, of course, is very impactful mentor of mine.

And so she always said to me, in any process that you want to run for run effectively and impactfully, it always starts with who has the D, who has the decision making authority and role.

And whenever we miss that, we miss we we sort of don't clarify that the processes go off the rails, and the change doesn't happen.

So that stuck with me.

Let's go back and forth.

Becca bounced right your way.

I was gonna say, uh, this was advice given to me by my father.

Uh he said, anytime there is a problem and you bring it to someone, always have a few solutions as well.

That's awesome.

Thank you.

Okay, back to me.

Umce told me um we were talking about.

But before he would, you know, I'd always ask him for feedback.

And this one particular time it was a big situation, and he said, Can I give you feedback?

And I just noticed in that moment it was a pretty big situation, and I try and do that with my staff.

But can I give you feedback?

So just asking for permission.

Sometimes people aren't ready for it just yet.

And so that really stuck with me.

Thanks for sharing.

Or bouncing.

Um, so mine came from my mother who was a public school teacher for many, many years.

I mean, she used to give graduation commencement addresses, but in one of those um addresses she talked about um taking care of your own corner of the world before you can take care of others.

Um, so that was really meaningful to me, like making sure I'm taking care of myself and taking care of my corner of the world before I can go out and do the work of taking care of others in the community.

That's awesome.

Yeah.

Um, I think that the the themes that always come back to me are the it's actually my stepfather who was an administrator for a number of years with the school district, um, talked about those universal truths that have been around for millennia, like truth and justice and beneficence and dignity and like those things that are held true through every generation.

And I think that I always try to hold to those things that I um I try to hold those values dear to me and never betray those things.

So that's a good lesson.

Francisco.

Um you asked the question, I thought of several things, but uh one that I've heard pretty consistently through my life, whether it be sports or my career is focus your energy on what you have control over, and that's your attitude and your very true.

Um my dad has been a really good mentor to me ever since I was a little kid, and he has always given me really good advice in school, which actually applies to me when I started working.

Um, I actually have two.

So one is he always said it's not how long you work, it's how efficient you work.

Um, I think he said that to get me to go to bed.

Um that actually does work in a work environment.

If you can find a way to work more efficiently, do that.

Um, the second thing he also always said to me was um if you sweat more when you're preparing, then you'll bleed less when you go to war.

Wow.

That's profound.

Um, so I also was thinking of a few, um, but I think the one that hits home the uh most right now for me is that attitude is the difference between an adventure and being overwhelmed, right?

So approaching how you approach if you can approach something with optimism and as a challenge, it becomes an adventure.

The situation doesn't change, but your approach to it does.

Awesome.

Thanks.

Nancy.

Uh what comes to mind and what I kind of want to points saw earlier in my career, I had a mentor.

You know, I was trying to decide, well, should I really apply for this position?

He said, make them tell you no.

So it's a good way to approach something, you know, say if you never ask, the answer is always no, right?

So make them tell you no, which leads into being curious.

And every situation, ask the questions.

That's listening and being curious at that point.

You also have to ask those questions to maybe it's a no, but you should always still ask those questions, understand what's the whole process, what's everything it goes into.

Awesome.

So we're gonna go back over here.

I see you.

You can't duck.

I see you ducking.

Um when I graduated high school, what I shared with the class um in my speech was um a quote that I had heard was the most interesting people I know didn't know at 22 what they wanted to do with their lives, and some of the most interesting 40-year-olds I know still don't.

And you can always switch, even when you're in your 40s, in your 50s, it doesn't matter.

Um whatever you do, don't congratulate yourself too much or berate yourself either.

Your choices are half chance, and so are everybody else's.

That's awesome.

How old were you when you found them all back?

I was 18.

Oh, good graduating high school.

That was a quote that I heard, and I want I shared thanks for sharing.

I really can't think of anything off the top of my head.

Um you make it up, we'll never know.

Um thinking just always, you know, put your best foot forward and uh the example and your best.

Thank you.

Well, you know, my career's mainly been in public safety.

And um years ago, I asked uh a fire chief that was outgoing fire chief, you know, what he was very successful in my eyes, in our community's eyes.

I said, What did it?

How did you do this?

And he says, you know, never forget to surround yourself with people that's more.

So it's worked.

Happy to have you here, so we have smart person.

Ironically, it's almost the exact same.

Well, seriously, it was my father-in-law when I was a young manager.

He said, Don't be afraid to hire and promote people that you know are smarter than you and more talented than you, because it's easy to be a good leader when you are surrounded by good employees.

You're here.

Even though I seem to know more science.

He reminded me over lunch one day that it's relationships that heal.

How beautiful.

Daniel, no.

Take what you get and make it work.

Sometimes you have to move the horizon to do that.

That's beautiful.

Dr.

Danko.

Thank you.

Uh, what beautiful uh insight from everybody.

It's really nice to hear that.

I think uh for me, uh all the good ones are taken.

No, I'm just kidding.

Um what I what I thought through uh right from the beginning is be kind.

Uh kindness heals, and you really never know what people are going through.

And I think that's true for me in my personal life, but also very true for me in my professional life.

I've spent about 20 years working in hospitals where a lot of bad things happen in hospitals and miracles come out of hospitals too.

But behind those miracles and those success stories are really tough struggles and journeys.

And a lot of the time people share stories with me that the regular outside world doesn't know.

Sometimes the workplace doesn't know, sometimes even the friends don't know.

It's hard to be vulnerable in those places.

So just know you don't know what people struggle with, and kindness can heal, a smile can heal.

Somebody who might be angry or irate, which happens in all of our jobs all the time, might be just somebody who's struggling that much harder.

Thank you, Peter.

Thanks for sharing.

I became a manager at a pretty young age, so that realized a lot of things I didn't know.

And so I spent time researching and taking classes in a theme that came through, especially being in the public forward businesses that I was in my entire life, was to act to me.

And then before you have next to make sure that you're actually letting it sit in and have it go forward so that you're reacting properly instead of just thinking about returns.

Anyone in the audience want to share?

All right.

Oh, great.

Good morning, everybody.

Sorry, I'm not uh in person today, not feeling as well, but I think two things stick out in my mind.

The first was when I had my first child, a uh legendary TS employee, Paul Burr said he had like four daughters, I believe.

The first was when I had my first child, a uh legendary TS employee, Paul Burr said he had like four daughters, I believe, and he said, even though they thought he was probably the dumbest person on earth, he always just said just love them, just love them.

So I think from a parenting advice, I think that's a big one.

The other one my dad taught me was just about honesty.

When I was 16 years old, I was selling a truck, and the rear end was almost going out, and he was content on telling the the buyer like hey, just so you know it's got a rear end that's going out pretty soon.

And I was so mad, I was like, Dad, why would you tell them we're not gonna get as much money?

And uh ended up selling it for less than what we asked for, but the rear end went out probably like two weeks after we sold it, and that kind of just opened my eyes that if you're honest and upfront with people, you're gonna avoid a lot of different problems down the road.

Thank you.

Thank you.

That's good advice.

Anyone else that I'm missing?

Second chance?

Okay.

Well, I have a couple too, and a lot actually were shared.

So what an inspirational way to start off today.

But um, for me, um I was at the legislature, and I was a lot younger than I am now, and a young lady by the name of Carol Villardo asked me if I wanted to have a smoke.

I don't smoke.

Um, but we all know that she smoked.

It was about uh 1 a.m.

in the morning, and we went under the lamp post in front of the legislature.

She put her hands on my shoulder and she said, I would I was dealing with some um, you know, because at the legislature is always a lot of happiness and a lot of so the particular um legislation that um I was moving through, um, you know, had some some interesting twists and turns and she put her hand on first.

I knew it was interesting because she asked me if I want to smoke, and she doesn't have to smoke.

So she again put her hands on my shoulders and she looked at me and she said, Do you realize that what you have done has not ever been done here?

And at least as long as however long she has been there.

And I'm just gonna give you some advice, and the advice is continue to always do your research, always know the facts, look at all the sides, but always have the courage to do the right thing for the right reasons, and you can put your head down on the pilly and know that you're helping in this case all the folks that you're trying to help.

So for me, I really held that to um a very dear place in my heart because sometimes when you were having to make decisions, um, not ever knowing that I'd be in the position I'm in, you have to have the courage to do what's right always and know that it's the right thing, even if it's not necessarily so um living that um is is not always easy, and then I'll just end it with one thing that I've always shared, um, especially in public speaking, which I guess is like right up there with the most um nerve-wracking thing to ever do, right?

Is to public speak, and uh I always remember where people uh really famous people like Pavarati was asked one time, do you ever get nervous speaking or singing or going and and and he said of course I do.

Um, but the difference is is that I always have butterflies, and the difference is I try and make the butterflies fly in formation, and I never forgot that.

So today I hope we can make the butterflies in terms of what we're trying to do.

Fly information, have this really powerful opportunity to make a difference in our community, share all the hard work that you guys do, and we're blessed to have each and everyone's not open that's here, but it's part of the entire team.

So thank you for the opportunity.

Thanks to everybody for sharing.

Last time, third.

All right.

Well, I'll move now to um turning this over.

It's gonna be facilitated by um Olsen.

Thank you so much with On Strategy for helping to guide us through today, and thank you.

Before we jump in, um, Mr.

Kingsley, any opening remarks from your chair, and then I'll I'll do the agenda or the discussion stage setting.

At this time, just mirroring those same uh points.

Thank you, but also thank you for the staff and the time that we put into this, the preparation.

Um thoroughly gone over this, and thank you, Eric.

Also, as well as being an advisor to us and helping us through this process.

This is always one of our super goals in a sense of the amount of work that goes into this, and as we're prepared for this, we're like Chandorilla said, we want to do our research.

We want to come here, we want to be able to forward, change our horizons where we need to change them, and impact for our community.

So again, thank you for all the staff for the time put into this and for the board and your support that we have.

So thank you very much.

Let's jump in.

Okay.

Awesome.

So our conversation and discussion flow uh is outlined uh above.

It's also in the slides you have in front of you or the handouts you have in front of you.

Just a couple of quick ground rules.

Uh taking the advice that I I just shared today.

Actually, looking for direction and sentiment from the board based on uh a bunch of different um input, if you will, which is again a set of of information from the community, from staff, from our financial situation, and triangulating that a bit to get the sentiment about where we want to go with the organization over the next three years.

This sets off the conversation that will refresh our strat plan.

So we'll talk a little bit process-wise about that in just a minute.

Um, but that's the that's the kind of the point in time of where we are.

What's fighting against us is we could be here all day easily.

We can be here all week easily.

There's a lot to talk about.

There always is.

So just know that good looks like great looks like the the general sentiment from the board about what might be on our, as I like to call it, strategic agenda for the next three years.

What are those those areas of focus that we might want to kind of essentially like pull out of the whirlwind the font size, however you want to think about it and the analogy, so that when we refresh the strap plan, we're able to align the resources as well as the intention of the organization, potentially around some of those areas that we're gonna hear about today.

You know, and I think in the work that we've all done together for many years, and in this capacity and other capacities, we never really walk out of these meetings with a dramatic C change.

Um that's just not how it's just not how it gets done, it's just not appropriate, actually.

So it is the essence and the nuance of where we might want to shift a little bit, or again, where we what what we might want to pull out of the whirlwind uh to put energy around and resources around over the next three years.

So just know that's what we're I'm looking for.

It's going to feel undone on purpose.

We we are not voting on um or taking action on the specific priorities in the strat plan today.

We will take the conversation from today and come back to the board after staff work around what the refresh strat looks like.

So and I am saying refresh, we are not looking to start from scratch.

That's not where this organization is right now.

That's not the that's not what that's not what we heard from the board.

That's also not what we heard from staff.

So um, so just again, just kind of know that.

The other thing that I think is really powerful about what we have today that not we don't always have in these processes, is very good uh a direction and feedback from the needs of our community.

That is the the cha and the chip.

And the the deck, of course, was there the the packet was sent out in advance because there's a lot of information.

We have asked for the team to present again a little bit more around the so what we do not need to read all the slides together.

We're you know, as professionals we know that it's also really hard to not do.

So please know that our intention is to is to ask our our discussion leaders to get to the so what.

So um, with that in mind, we're looking for a bit of 50-50 uh presentation conversation.

With that, I will also set the stage on how much time that we have for said area uh of discussion and uh or that that topic as the as the case may be.

And if it's the board's pleasure, we'll stay there longer.

Just know we're eating into time somewhere else.

So the way we're styled is as follows.

We're just gonna do a quick uh high point on on the strategic direction and just how this process works.

We are going to then jam into the the CHA and the chip, which which is really the essence of what is the community, uh what is it?

What are the community needs?

Very very data-based, very um solid process.

It's again great data.

Uh we'll talk then about health equity.

So again, some some information on that, workforce planning, which is really around staffing needs, and then we will talk about the uh health of the organization sustainability.

We do need to take action on the budget that is being uh proposed, so please know that.

And then also we are looking, we are looking for guidance on what we are calling the financial guiding principles.

We will get there.

Um, we'll get there towards the end of the conversation, but I also don't want to shortchange that.

So time-wise, I'm I'm trying to get us there.

So and then the board discussion is gonna happen throughout, but of course um we will I will hopefully be pulling together what some of the strategic areas of focus are looking like from our conversation, and we'll we'll see that at the end.

So um, some kind of keeping roof sheet on the side.

Um, I also don't have flip charts, I will be putting it up as a slide so folks online can see, but also so we all can see this room as well.

So um yeah.

Here we go.

So with that in mind, um Kingsley is gonna walk us through, I'll start us, and then you're gonna go carry on.

Just a quick couple, just a couple of slides on on the direction, like how do we actually do the priority setting for the mission?

Our mission that we developed a handful of years ago.

We are not necessarily as a team recommending changing that.

It does guide uh the engines of of what's uh of NPH is up to.

Can I ask someone to read it for us just to ground us?

Anybody feeling like speaking it into thank you to improve and protect our communities, quality of life, and increase equitable opportunities for better health.

The words are really intentional.

Uh a lot of intent built into the mission statement.

Again, crushed it maybe four years ago.

Okay, that feels less old.

Uh good.

So uh any, yeah, any any anything to say about it, Ray, just as our our leader of this um process.

Uh we took a lot of time to refine our mission about four years ago with our mission.

We also came up with a set of values.

Um, you'll notice with NG, we don't necessarily have a vision statement, but we really want to live by a set of values.

Um, and and we use our mission to kind of guide the direction that we're headed.

So when we talk about great strat plans, um, there's there needs to be directionality somewhere, the directionality uh in the NPH strap plan and the strategic priorities.

Um this is the framework of our uh framework of our plan.

Everything cascades from this, everything aligns to it.

I love butterflies flying information.

This is what we're intending to align towards.

Um the intention here would be uh this is what we're starting with.

Our conversation today is going to uh start to uh show what might emerge maybe differently.

There's many levels of the plan, of course.

We may keep exactly these and change some things below it.

Uh, we'll see just how it emerges.

But we have we have six strategic priorities, again, also very intentional, um, healthy lives, healthy environment, uh, local culture of health, impactful partnerships, organizational capacity, and financial stability.

Underneath all of those are uh aligned um outcomes, KPIs, and actions down to the divisional and team levels.

So there's there's a lot of a lot of depth around the way in which this plan guides.

So very a lot of hard work over many years uh to kind of get all of the infrastructure in place.

Uh is it is does it work perfectly?

Plans don't work perfectly.

They are plans, they are intentions, uh straight jackets.

Um, but they these do need to reflect what's important to the organization.

So this is our starting point.

I just wanted to anchor us there.

Then Mr.

Kingsley, maybe I want to speak to the the process by which we we we build our plan.

Yeah.

So speaking from the current strategic priorities, which are wonderful.

They have a lot of depth to them, but they're also easy to get behind.

That's something that I think many of us that we can go home sometimes with our heads on the pillows and say that we impact within our community.

That's sometimes way of working in public health.

We want to continue that, carry that forward.

So our strategic plan inputs, so looking for our next three years, and then continuing what our current strategic priorities are, but how do we continue to develop and uh and assemble those pieces?

You know, as we need to as put forward for us.

So as we develop the next three uh three year strategic plan, uh we ground it in multiple inputs to ensure it was both data-driven and operationally realistic.

So we back we began with the community health assessment data to our priorities and the needs of the community.

We incorporate board input to reflect governance direction and policy priorities.

We've also invested in doing a foundational uh services analysis uh to assess system capacity and service alignment.

Uh we also evaluate priority considerations to ensure focus and feasibility.

Finally, through leadership workshops, we apply professional judgment, in line programs and resources with what is most relevant and sustainable.

So together these inputs ensure the strategic plan is evidence-based and positioned for impact over the next three years.

Give us a little sense on the absolutely.

So how this is traditionally worked is we provide information here at the retreat so that the board can give us uh their perspective on what they would also like us to focus on in the next three years or in the next year.

And so once we are aligned on the board's priorities, um, my team goes back and we work with our divisions to actually put all of those ideas into play.

And so we're working together to put an action plan together.

Um talk about the performance uh reports that we I provide quarterly, because we're gonna get to a slide that talks about that, but everybody gets to see quarterly what our progress is, and we like to keep the board updated on what your priorities are through those quarterly progress reports.

So we'll do a retreat, I'll go back to our divisions, we'll do workshops if you will.

We'll make sure that all of our outcomes are uplifting those priorities that everybody has agreed upon, and then we'll execute those through our performance management system, and I'll come back to the quarterly to provide those to you.

And for this specific, we would expect the the strat plan to come back to the board for approval sometime in August.

Yep, in August.

And any clarifications coming out of today will come back and write to what we schedule for meeting, just again in time and and all of that.

Okay, awesome.

So foundational public health services.

So many years ago, again, we wanted to create the foundation of our public health is and the standard that we uh live in within uh within the nation and resembling other public health initiatives throughout uh not only our community through our state and our nation.

So foundational public health services are basic programs and capabilities every local health department needs in order to keep community safe and healthy.

That includes things like tracking health data, responding to outbreaks and emergencies, ensuring safe food and water, preventing chronic disease, supporting uh maternal and child health, and having the right staff systems and communication in place to do the work effectively.

As a public health agency by aligning our plan to these core services, we make sure we've we're investing in the essentials, using our resources wisely and building a department that is strong and sustainable.

And so this is always uh a goalpost that helps us that we align with and always help us go back when we need to find that horizon again where we are, look at our values, look at our mission, also our services that we deliver, they are core and allows us to be able to understand what our mission is based on these public health services.

Great.

So, over just uh overview on board reports what we supply to the on a monthly basis to the board.

Um for we have our monthly divisional reports that we provide.

Um we'll also uh have some meetings set up with the board so we can also go more into depth if there's another process or if there's more information or data.

If we've gone through, we like to provide this monthly day, not only a narrative but also data for you, so a comparable or be able to know any trends.

But we're uh always looking as uh our monthly division reports where we're at, but also if there's any improvement there or any process to the uh we gladly take direction on that.

That's something we want to feel that are you informed?

Are you the correct information that is it digestible and is it actionable?

Um we have our quarterly reports and uh purpose is really to uh be able to compare the our performance management targets that we've set together and moving forward, and then also we have the new district uh snapshot.

So we as we are moving forward, we have our snapshots, but also the capacity of informatics and how we put forward uh information to streamline that says had some great success.

So uh there's always opportunities to improve this and provide the information you need to make uh to have the research and the data there to make uh those decisions that impact our communities.

So um, any questions on this for board reports or anything that the board would like to see?

I know if you're saying board reports, but does some of this information share with public?

I know that um the amount of media uh channels that you use are vast and consistent, and I I will be honest, I don't look at every single thing.

I wish I could, but I just can't.

So I'm just wondering, especially on the um the district snapshot and the portly results.

Do those is that type of information get shared publicly?

So in different forms.

So one, they're all public record, yeah, but did they get lost?

So we also take the the monthly divisional reports, and that is so that every six months when I go to each of the districts when I go to each of the jurisdictions, it's based off these reports, so it's kind of a secondary kind of summary of hey, here's the past six months, and previously we have also I've also brought uh the district snapshot, and sometimes that's simpler when coming, so that's another aspect of doing that.

But I do believe as we've seen success, like with our uh respiratory dashboard, for example.

Uh we have one of the questions like how can we make this digestible and tractable that somebody from the community can just sign on and instantly see that information and it's actualized per month, those things.

So I think there's some development there.

So another way, how do we make it more easily accessible to the community?

So, yes, direct answer, it's available to community, but can we do better on making it digestible and easier to access?

I think that's that's a great point.

So directors, any insights on that?

Why we have this here.

Is there anything?

So we do you know, have encouraged our staff as well in their meetings that when these monthly division reports are out that they review them, but also understand what's going on in other divisions.

Um we will find the media does go through them, especially when it's important, but sometimes they breeze over it on those points.

And I think when our directors come up present to the board, they're really taking that one snapshot that we put that's most relevant to you hitting that moment at that point.

So just as a follow-up, I think um some of the partners that are connected in deeper ways that aligned with the particular information, and I was wondering if we share the problems as well.

We don't want everyone to bombard them, but that is a good way.

I think also with each of our staff has those wonderful connections out there, and so they can make it more meaningful and go and have a way to receive feedback cooperative systemic school processes.

Hey, Chad, could I could I say something real quick?

Yeah, Scott.

Uh Scott Arks are our communications manager for NPH for the record.

We also chair will have our data publications and reports page on our website.

Uh, you can you can access it off the the home page.

Uh it has all of our reports that we have, including the chip, the CHOP, the strategic plan, our health equity plan report, all of our major reports that are all public facing can be found there, as well as some archive stuff.

Um we do plan on kind of optimizing that page a little bit to make it a little bit more graphic heavy instead of just links, and I think once we get this in a better position past this meeting, I think you'll see some some more visual elements uh that are available to the public.

Thank you.

Thanks.

You you are always on it.

Um honestly, thanks for all you do, by the way.

Yes, I think one of the things that's very important, and I've been lived in the public realm for a long time where staff reports are very important.

I think the staff here I think they write their staff reports well.

You write it in the language that's understandable by anybody who reasonably is interested, and that's really difficult to do because we live in the world of words, medical words and technical words and rules and regs and acronyms, and so I compliment the work that we do because someone can sit down and they can get through it without having to go to a dictionary or having to call and ask for further clarification, and we're really pretty good about starting the day in the Z.

And if there's any verification needed, I have found that as particular member that I ask a question that the person's written the staff report very quickly has an answer.

Very quickly has an answer.

So it's not stuff in the cloud being crazy.

It's actually document that can be used archived.

So thank you very much.

Thanks.

Okay.

I believe on the next slide we actually went into that question.

So that's good.

And overall, just to reiterate, is the oh no, if you put the question out.

Is the board getting information needed to govern it?

So I just have any other thoughts on that that we can do.

See any more effective.

Thank you very much.

We'll move on then.

Let's jump into the first of four, essentially like data stage setting.

Three years, if you will.

Uh, which all culminate in the notion of like what the needs might be from the various different areas that we're talking about.

So Kelly is going to walk us through where would you like me to stand?

Okay.

You're comfortable with that?

That would be that's fine.

Yeah.

Fantastic.

So Kelly's gonna walk us through the chip in the chat.

There's quite a bit of information here, as we're all well aware.

We've got about 30 to 40 minutes in total for uh Kelly's high-level points as well as the conversation.

So just like and we're expecting it to be in the record, of course, too.

So that's great.

Great.

Thank you.

So thank you very much for having me be here today.

I am an epidemiologist and statistician by training, so I absolutely love talking about data.

I love collecting data, and I like using data to empower decision making, evidence-based decision making.

So before we get started, I always give this cautionary tale that when we are talking about data, we're really talking about it from a population health lens.

And so, what this means is individuals contribute to these data points, but these data points likewise are the lens that we use to actually understand the impact on individuals.

So it is dynamic, it's ever changing, and I'll go into how we collect this data and then really what those results are and where we would like to go from here, looking at the results that we have.

Um, so uh essentially we do have a very robust steering committee.

This steering committee is full of representatives that play active roles and leadership roles or engagement roles within our population, educational roles, and they are key development key players and provide that agency of our communities to really direct the entire process as we go through and design the data collection, look at the data, make sure that we are representing all of the populations you want to represent, and likewise informing the Washa County community of the effective different health and well-being components that impact them.

So our agenda is pretty simplified for today.

We are going to go through what our actual community health rankings are.

We'll give you a very brief snapshot of what they look like so you can orient yourself.

Then we'll go into what data actually feeds into this prioritization technique.

We'll explain what that technique is, how that methodology influences how we come out with these uh rankings, essential rankings of our health and well-being issues, and then we'll give you a very brief snapshot of the top four priorities that we have.

However, I do want to refer you to a, I believe it's a handout that was emailed and might be in front of you.

It is a summary sheet for lack of a better word.

It is a tenant executive summary that does provide a more in-depth look at all ranking topics, what feeds into them, and some of the basic outputs and results that we have for all those topics.

For the sake of time, we're going to focus on the top four that were an output of this entire process.

So, what are these rankings?

As you can see here, we have eight high-level topics in general, but every single topic has these subtopics.

And you'll notice that many of these are not mutually exclusive, meaning although we have these topics that fit under this higher heading, many of these are interconnected.

And we recognize that even though we are talking about prioritization, it really is ultimately a circle where no one stands alone and no individual health, whether it's medical or non-medical drivers of health actually exist in a silo.

So we always give that disclaimer as we talk that we do know that these are complex topics that we're trying to look at in really a not necessarily simplistic way, but in a way that we can understand it and then make sure that we develop these measurable impacts and plans to make sure that we are able to focus on these gaps and services and systematic issues.

So what does our pyramid look like?

So this is simply a visual representation of our rankings.

And so at the top, the highest priority that came out of our ranking methodology is mental health that is followed by second access to health services, economic stability, and so on and so forth.

So we're going to give you a little bit of detail in each of these.

But the thing about data is that it's essentially as much as we work on active data collection and capturing community voice, we know that as soon as you capture that data and analyze it, it's already in the past.

It's essentially this time stamp of data that shows what is happening in the snapshot of a community, and we'll talk about how we considered that and community voice into the actual ranking methodology.

So what actually goes into this very complex.

There's almost 500,000 people in Washoe County.

How do we actually represent everyone?

How do we collect data from massive secondary data sets?

How do we focus on a very short time frame to capture the input of our community members and figure out how we synthesize all of this into a meaningful, a meaningful document and guidance for planning.

So we have what we typically call primary data and secondary data.

Primary data is simply data that we collected directly from Washoe County community members.

This is a joint endeavor with renowned health.

They've been absolutely wonderful partners with us and also bringing in a new service perspective to us about how we can all work together to improve our community.

So primary data includes things that I'll go into greater detail on, but that's focus groups, and formant interviews, and a community survey.

So this is in a way a mixture of what we call qualitative data and quantitative data.

Now, secondary data is data that's already been systematically gathered.

So these data either exists through different agencies and different points in the county, different state and federal offices, and essentially other existing data sources.

We will go into how complex both of these data sets can be and how we essentially go about categorizing it in a way that can actually be absorbed and something that can be accessible not just to you, but anyone that's interested in the job when it is ultimately published.

So primary data.

So primary data has essentially focus groups and key informant interviews, and then a community health survey.

So focus groups and key informant interviews are essentially narratives that we perform the NATO analysis on.

So what this means is focus groups, we had 15 in total, about 75 minutes each and five to 10 participants each.

And they're really conversations that we guide and want to have the community members actively participate and talk to each other and talk to us and really give this narrative of what it means to have the different qualities and components of a healthy community.

What actually qualities exist, what components exist, and what are the barriers to having a healthy community?

And so there are about 110 participants in total.

And from these narratives, we really extract these themes.

And I'll show you what those themes are from this analysis as we go into our different rankings.

And this is a way for us to not just understand, we can take quantitative data, we can take these secondary data sources that exist for different purposes.

And what we really want to get them is the perceptions of the community groups.

And so what they are actually experiencing, how they actually feel about different health issues that can be in alignment with different data sources, or it might be something new and emerging, their worries for the future, how they're feeling right now, how the different environments that they exist in, whether that's a workforce environment, whether that's their neighborhood, how all that comes together for their various perceptions and what they see as potentially merging conditions within the community.

For CAM formant interviews, again, it's essentially semi-structured interviews.

It's 19 subject matter experts.

So essentially, we give this semi-guided interview where they provide and give their feedback on what they see as these high level systematic issues that affect the individuals in our community.

So they help us really extract priority populations, system level barriers, system level gaps, but also potentially system level strengths and how those strengths are playing into this complex circle that we have of all these influences affecting how our community lives.

Now, the community health survey had about 694 participants, and we're really looking at the magnitude of these community health topics.

So this is pretty easy for many people to understand.

We ask as much as pious as much as possible non-biased questions, where we simply try to fill in gaps identified by the steering committee, things that we they have thought we don't have enough data on, where maybe we need to focus and ask very pointed questions.

We often use something called a Likert scales to ask, you know, whether they strongly agree or strongly disagree, and we have different phases within that agreement that we can look and see how people actually view various components and various quantitative data.

So we do point blank one point and ask them, can you please rank your top priorities?

So give us your first, second, and third.

And then we also worked with our steering committee to fill in some of those blanks.

So that could be anything from, for instance, our steering committee said we really don't have any good pointed perceptions on reproductive health.

So we asked some reproductive health questions.

There was also a lot of interest in active living and safety and how safety can affect active living.

That could be anything from bike lanes and what motivates people to go out and exercise and what might be a barrier to them going out and exercising.

So all of these analyses, all of these themes will be published ultimately in a very comprehensive CHA.

But what we're going to give today is a snapshot of how all this went into the rankings and hopefully help you all understand those priorities and really use that for that evidence-based decision making.

So out of primary data, we also have secondary data.

So secondary data is pretty complex.

Essentially, we have almost 350 secondary data indicators that come from over 50 data sources.

So we work with the Conduent Healthy Community Institute, Healthy Communities Institute, and they essentially take a wide range of data sources.

Now, these data sources are vetted data sources.

They have valid methodologies for their surveys for their data collection.

They understand the data source, they regularly publish, whether that's yearly or monthly, so we know that these are reliable indicators.

They publish those methodologies as well.

So we know if the data can be compared to previous years, how there might be changes, and we also look at that geographic level.

So we are the county, we are Washoe County.

So essentially, we the secondary data are a score, a numeric score that is assigned to each indicator, and it considers Washoe County and a particular indicator such as the incidence of lung cancer amongst a specific age group.

And it looks at what that incidence of lung cancer is in persons age 18 and over in Washoe County.

And then it looks at comparative numbers for the state, for the for other US counties, nationwide, healthy people 2023 targets, and the trend over time.

Is the trend going up?

Is it going down?

What are we actually looking at?

It combines all of this into this numeric score, where typically a higher score is equal to poorer outcomes, essentially.

So I will show you what that looks like.

As I stated, there are almost 350 in total.

So there is a snapshot today, but there are some reference documents that are available and ultimately all almost 350 will be available and they are categorized themselves into higher level topics.

Okay.

So this is just a list of everyone that contributes.

Some are local, some are national, some are state.

So it really is a very robust centralized database that is always growing and is maintained on a regular basis.

Okay.

So now we're going to go into the ranking methodology.

So this is called the handlon method.

So essentially it is a structured way of assigning numeric scores to make objective decision making in public health.

It is a prioritization technique.

And so it essentially works where the steering committee and these experts came together together and they look at the list of health problems.

They really look at what we've done in previous CHAWAS.

What are these health problems?

How do we categorize them?

How do we understand them?

Then we do the active data collection, which again is that primary and secondary data.

Then we assign this numeric score, often called a weight.

And then that weight ultimately combines into this high level ranking that will go in today.

And so again, this is a summary of what this data analysis looks like, how we synthesize these pieces of data.

So primary data has these three components right here.

You have secondary data, which is about the 350 indicators.

That feeds into what are the significant health needs.

And then those significant health needs are prioritized for community action.

So when we talk about weighing, this is something that we took a lot of consideration into what the community voice looks like.

That's the primary data collection.

So primary data collection doesn't necessarily have these 350 indicators, but this is where we came together.

We did this survey that was in English and Spanish and promoted both by renowned health media teams and NPH media teams.

We made sure that we had these locks that we were, you know, make that we were adamantly getting Washoe County community members to contribute.

We have these focus groups.

So you have these key informant interviews.

That really is a community voice.

And that's something the steering committee brought up.

They said we really cannot necessarily rely just on this retrospective historical data that's in secondary data indicators.

We really want to know where there are gaps and these emerging issues.

And that's what primary data can help us fulfill.

We are actually actively talking to the community members that live here and these key witnesses essentially to what is happening in the health and well-being of our community.

Then we essentially go through and assign a weight.

This is very similar to how you might remember from school.

They'll talk about curves and academic curves and essentially how to look at what you are collecting.

And then you essentially make sure that you have these adjustments to capture the weight of the outcomes that you are looking at.

And so you will notice that secondary data in total has a weight of three, but these three primary data sources have a weight of five.

They're essentially weighed a little bit more due to the amount of time, effort, and knowing that these are our Washoe County community members contributing to these rankings.

And so again, just as a snapshot, we simply are constrained by time.

All these are important, and all these feed into each other, and they all influence each other from top to bottom, bottom to top.

I encourage you to think of it more as a circle, but understanding that we do have this systematic ranking technique, and that is what came out as the final rankings from number one being mental health to essentially number eight.

And we're just going to focus on the top four for time today, but you do have more information on all of them available to you.

So number one is mental health.

So the top table is simply a way for you to see the summary of each individual score, because we do score within the primary and secondary data.

And then all this comes down to that essential, think of it as that grading on a curve, but essentially putting this all together and comparing them across each other to see what comes out as the highest rank.

So that's mental health.

So what does this mean?

Well, as I stated in the community survey, we have a lot of data, all those analyses will eventually be available, but we asked the community members, 694 of them participated.

What is your top priority?

18% said mental health is their number one priority.

18% said it's their second priority, and 14% said it would be their third priority.

And so this is just a snapshot of how else this primary data collection contributes to this particular community survey rank.

We asked things like how often do you need how often do you get the help you need from others when you're feeling sad, worried, or need someone to talk to?

And we essentially look at that quantifiable data.

We can actually assign how many said never, um, how many said almost never, and how many said sometimes.

And unfortunately, 33% said it was sometimes that they don't that they get the help they need, which doesn't mean they always get the help that they need.

Then we have focus groups.

So focus groups identified these high-level key themes, the lack of mental health services and providers and social and community connection being key critical components of maintaining mental health and what of influences mental health.

So these select themes include things like mental health options, there are general mental health concerns, feeling alone and disconnected, youth mental health.

That came up quite a bit.

I'll show you some quotes in a few seconds.

And then also the stigma around mental health and how that can actually be a barrier and how we might overcome these stigmas to make mental health accessible and actually empower people to seek these services.

So of the interviews, very similar.

Something that was a high-level theme that came up is mental health concerns across the lifespan.

And we saw many of the same themes come out in that analysis, not just how many options we have, the stigmas that still exist around it, these mental health overall concerns, youth mental health and substance use.

And so just to give you some select quotes, because again, themes are essentially taking an analyses from these high-level narratives, but we do want to represent this voice.

Basically, a key informant interview quote was we're seeing more youth in crisis than ever, but the problems haven't grown to grown to meet the need.

Adults are cracking under the weight of cost, caregiving, and crisis.

By the time they show up, they're already overwhelmed.

And our mental health system is reactive.

People have to get really sick before they get help.

And please consider these quotes as we continue down, particularly for second, third, and fourth rankings, because you will see how different components that come up here weight of cost, caregiving, crisis, the fact that it's reactive, not proactive, how that influences health behavior and preventive services.

So all of these do feed into each other, and we have mental health at the top, and really it is influenced and also a contributor to a lot of the other topics that we will continue to see.

So, what does the secondary data look like?

So the secondary data, this is a snapshot where you can see that it is categorized under mental health and mental disorders.

I don't think I have a laser on here.

So hopefully it's available for you to see, but we just want to bring a snapshot that again, red typically means worse outcomes.

So, number one here is a score of 2.18.

The highest score you can have is three.

And you can see it's intentional injury, suicide mortality rate.

It gives the units, so that's death per 100,000 population.

And in this particular metric, we do have comparative numbers.

So unfortunately, you can see here, just as an example, Washoe County has a rate of 24.3 deaths per 100,000 population.

The target for healthy people is half that.

So we are double what the actual target is in reducing the intentional injury by suicide.

We are also higher than the state of Nevada, and we are also higher than the United States.

So you can see also, unfortunately, the trend is still going up.

And so this is a way for us to synthesize data into a single numeric score.

And as you can see, there are sometimes missing components depending on the actual metric.

That is not necessarily a bad thing.

It's essentially coming down to is there an exact measure that would make it comparable?

If it does not exist, it might exist in a different form, but if it's not directly comparable and measuring the same thing, we don't necessarily want to compare and represent that other Nevada figure unless it exists in that comparable, um, that comparable measure.

It needs to be pretty pretty close to measuring the exact same thing for it to count on the same line of our secondary data indicators.

So I won't spend as much time explaining this as we go forward.

I just want you to be aware that there are many components.

Um, it can be difficult to tease out, but there's a lot that is in here.

And also again, some of these can overlap in other areas.

You see adolescence on here, you see age, you see various components that again do represent some of these other areas that we'll be talking about.

So access to health services.

So again, this table, just a snapshot for you to see how it ranked individually in all these other various primary and secondary data components.

Um, this was pretty consistent.

Um, it was number one for the community survey rank.

And essentially we asked them to rank what they're number one problem that they saw, or number one priority, excuse me, that they saw in our community affecting their health.

They said 34% said it is the first priority, is access to health services.

16% said it's our second priority, 11% said it is their third priority.

So we asked various questions to tease that out.

What makes it hard for you to get health care?

Unfortunately, we have quite a few.

Um, these are not mutually exclusive, so they can take more than one.

People felt that insurance doesn't pay for what they need.

They can make appointments, and if they have insurance, the co-pays too much.

We don't have enough doctors, we don't have enough specialties.

There's not enough doctors taking new patients.

All of these feed into what access health services mean to them.

This is only one question.

There are more questions.

This is just a representation of how people felt when we teased out the various priorities that they gave us.

Focus groups said the same thing.

It's the lack of healthcare providers.

It's the challenges accessing health information.

It comes down to health literacies, information actually able to be consumed effectively.

Are they able to understand chronic disease management?

How do we improve our ability to be more inclusive of individuals and their understanding of their health?

The select themes.

Again, medical provider shortage, the high costs, communicable disease prevention, everything from caregiver shortage, medical misdiagnosis, lack of medical supplies.

And so again, some of these themes and examples we'll talk about later, but you can see that all this really comes down to can you access a doctor and what goes into you accessing a doctor when you need that health?

That can be preventive and that can be essentially chronic diseases or chronic management of health.

And so key informant interviews, same thing.

You have provider shortages, system gaps.

How do you navigate the system?

It's very complex.

You're navigating insurance.

You're trying to understand the different providers and specialties available to you.

And also the lack of health information and outreach.

How do we effectively help individuals navigate these systems and also navigate their own health care and empower them for their own health care?

So these themes come into medical, dental, and vision provider shortage, caregiver support and the shortages around caregiver support.

This is a big deal for individuals that are undergoing cancer treatment.

I know that, especially at like Texas Children's Hospital Hospital, it is often and well known and published that a parent that has a child that has cancer has to go into rigorous treatment.

They often have to have one parent that is not working in order for them to get access to the treatments that they need because it is so time consuming, requires so much attention.

It's lack of health information, technology limitations, language access and health misinformation and health disinformation.

Where are people getting their health information?

Who do they trust and how do we build that trust?

So, some key quotes.

We don't have enough professionals who understand the cultures they're serving.

We don't have enough providers in almost every specialty, even for basic care wait times are months.

And those times can be critical to improving the health of individuals that are suffering from chronic or acute conditions.

Dental and vision care are almost impossible to get quickly, especially for people on Medicaid.

So secondary data, this comes into oral health, STI, healthcare access quality, who has a routine checkup, who actually has health insurance, who can't see a doctor, maybe a breakdown of why they're unable to afford or see a doctor, children with health insurance.

How do you actually make the time and actually make sure that even if health services are available, that they are accessible and they're accessible to the people that need it.

And so this also comes down to number three, which is economic stability.

So again, you can see some of these rankings here.

What is interesting, I just want to point out that is something that I think is we keep a close eye on it in terms of data.

And this is something that I think is always important to recognize.

Secondary data is often a little bit more out of line with what primary data is telling us, which to me is interesting because we went through why we value primary data.

This is what our community is saying they feel.

This is what our community is saying they are living right now.

Secondary data is a wealth of components in really getting into those nitty-gritty details, but we do prioritize what is happening right now when we're collecting these data for our community.

And so 13% said it is their first priority, 9% second, third, 13.

And then we asked again, it is a multi-select, these are not mutually exclusive.

So people can have multiple issues affecting their ability to pay for services in the last 12 months.

And unfortunately, shelter, housing, housing instability is number one.

Medical, which feeds into number two is number two.

That's followed by credit card payments and also things like fund things to do, utility bills, and car transportation, education, student loans.

So again, we have these high-level categories, but we know that everything comes together in a circle.

Focus group said cost of living and community food sources.

And those select themes come down to cost of living, lack of housing, housing and instability often leads to unsafe neighborhoods, lack of time, lack of program funding, lack of supportive housing, these supportive safety net services, these warm wraparound services, lack of educational opportunities, financial illiteracy and job availability.

So key informant interviews, housing instability, high cost of living.

That comes down to insurance costs, prescription costs, the medical insurance dissatisfaction or inaccessibility, and how that also is linked to rental assistance, distance.

That can come down to transportation as well, and the lack of housing and supportive housing.

Housing is a biggest stress for stressor.

If your housing isn't stable, nothing else is.

It's not that people don't care about health.

They just have to choose between rent and medication.

Supportive housing is a huge gap.

People fall through the cracks because there's nowhere stable for them to recover.

Economic stability.

So this is a snapshot of a measure of economy through secondary data indicators.

But we also do have many other indicators that are also under here, such as education, community, so on and so forth.

Again, it's a very robust document.

And this is going to be published.

All these indicators will be available when we publish the job.

So last but not least, my apologies.

That should say health risk behaviors and early detection.

So again, quite interesting.

The community said that it is extremely high as a priority for them.

So they said it is what 14% said it was their first or second priority, actually, 14% across the board.

So it is very consistent in people saying this is important to them.

So we asked, how often did you or someone in your household get food from the food bay, pantry, free distribution site?

Because it comes down to nutrition, healthy eating, active living.

So we had about 11% say a few times.

We do have a percentage that also go once a month or once or twice a year or once a week.

And so we do ask these questions about how services are being utilized if they are available in the community.

Focus groups, concerns of managing chronic illness.

So those themes are unhealthy food choices, technology misuse, fall concerns, injury prevention, genetics, infectious disease monitoring, chronic illness.

Essentially, one of the quotes that we had was there are insufficient programs to prevent the health issues before they start.

And that is very complex and all-encompassing, meaning healthcare system navigation and health management.

If people are trying to prevent and stay healthy, do they have access to screenings?

Do they have a primary care doctor?

Can they go into their primary care doctor?

Do they have an appropriate referral process?

Are there dissatisfaction in that referral process, lack of preventive programs, lack of women's health, lack of sexual health, technology?

This is a big one that keeps coming up.

And I think that that is telling to us about how technology is playing into health, not just in how people live, but also how people utilize it for health care and health language barriers.

So transportation, you can't get to appointments, you're not staying healthy.

People don't know where to start.

Services exist, but unless you're in the system, you don't know what's available.

A lot of families don't understand their diagnosis and medications as information isn't in their language or explained clearly.

We had an interesting situation that really shows the robustness of health risk behaviors and detection.

We had a case that essentially had a GI illness and they are in a sensitive occupation.

This is called steck.

It's just a strain of E.

coli.

But they essentially have to have two negative tests consecutively, at least 24 hours apart before they can be cleared to return to work.

So number one, this is a case, meaning we missed a prevention opportunity.

Number two, they are excluded from work because of the risk of transmitting the infection.

So not only do we miss the prevention, but we had to exclude an individual.

And this individual, there's typically no treatment for STEC, you clear it on your own, was testing positive for weeks.

That is very unusual.

And that became an alarming concern as our investigators were talking and trying to help this individual.

That means they don't have necessarily an income.

They might not have access to insurance.

They might not qualify for temp disability insurance.

How are they going to pay their bills?

How are they going to access food?

And so in this particular case, when looking at it from a whole health perspective, we worked and essentially had our infectious disease consultant look into cutting-edge literature to see if there is an ability for us to work with him to have a novel treatment that could be available to this person to help them clear this infection and basically get back up to work.

So I like that example because it happened not only recently, but it really talks into these behaviors and how we assess risk, not just to ourselves but to others, but essentially how important prevention is.

But if we don't have prevention, then really what that impact is if people are getting sick or have other issues affecting their morbidity and or unfortunately leading to mortality.

We talk about that in statistics and epidemiology.

What are the actual years of life lost?

And what are the years of quality of life that are lost because of different conditions that affect us from all these different environmental factors?

So secondary data, this one is extremely robust.

We talk about things like immunizations.

We talk about nutrition, healthy eating.

As I said earlier, fall preventory, injury.

That could be anything from safety on bicycles to walking paths to how we program our stoplights and make transportation safer, safe, uh safer, active living, different physical activity accessibility, cancer, heart disease, all of these can come down to chronic management coupled with prevention and these risk behaviors that influence and also help us stop these from progressing further.

And so these are our other four.

I know I'm going fast, but I do want to be mindful of time.

We do have, of course, a lot more information.

It is not that these aren't important or part of the cycle themselves, but we are just simply working on those priorities because those are what priorities our methodology produce.

So this is a snapshot.

Again, I do encourage you to just consider how all these pieces of data come together in the ranking.

The asterisk does mean that there was a tie, a numeric tie, even as we combined all these various components.

So again, it's both a complex process, but also trying to get these results that we can absorb and use.

And to leave on a positive note, after throwing a lot of bad news at all of you, um, so we don't live in utopia.

Um, we do know that there are always ways for us to really focus on that altruism and working together and improving our partnerships and doing the good work that we do with our critical partners.

Um, again, strong shout out to Renowned Health.

They've been a great partner in us for streamlining these activities and having really one strong cohesive, comprehensive CHA.

And these are what people liked.

Um, we this is a snapshot.

This is not all encompassing.

People said our healthcare system does have many good elements.

People are dedicated, they want to keep helping improve access for families.

We have strong partnerships.

We want to work together, and we've managed to maintain this strong sense of community, even though our community is dynamic, it's growing, and we know that that comes with challenges.

People want to step up into these challenges.

And they liked various themes that were identified through these interviews and through the survey.

They love our outdoor access, community gardens, the natural environment, the climate and weather.

Think about how that affects active living, plentiful food options, community gardens again, mutual aid groups, food banking services, that nutritional wellness.

Are people eating enough?

Are they getting nutritious food?

And also this social interconnectedness that people keep bringing up as being important to their mental health.

What are the good components of that?

The good work environment, good social interactions, cultural diversity, and recreational opportunities.

So it is a mark of how well all of you, how well many people in our community have come together to really improve these wraparound services and build social connectedness and come together to solve these problems together.

And people do recognize that and they do put that into our CHAP.

And again, that is not the only ones that we have.

So there will be more finally published.

And so, as always, this cannot exist without the individuals that make up our population in Washoe County.

It really is a special thanks to their participation, their continued participation.

And those are always our hoopy surfers.

We are here for them to help them.

We live and represent this community as well.

And we do want people to absolutely live their best life.

And so that's essentially it for today.

Wow, thanks.

We're all back.

I'm glad we don't have a quiz, but you were giving us a quiz right now.

Um I do know, and I know that there's a second part to this, but I do know that we have a public comment for this item.

You want to have the public comment now after the child reverse result?

Do you want to wait?

Yes.

Yes, I thought it might be appropriate to Carrie Kelly from Renowned.

Okay, great.

Thank you.

Hi, good morning.

Thank you all so much for having me.

My name is Carrie Kelly, and I represent Renowned Health, Northern Nevada's leading not-for-profit healthcare network and Nevada's first integrated academic health system and the region's only level two trauma center.

And I wanted to talk a little bit about this amazing collaboration that has happened with this current CHA.

We are doing it joint, 50-50 as far as the report.

Um, renowned has also done a community health assessment over the last 15 years.

So we're able to do this process together.

So we're committed to bringing the best possible care to our community.

And our vision is clear to inspire better health for everyone we serve.

The community health assessment is one of the most important ways that we advance that vision in partnership with Northern Nevada Public Health.

This assessment has been a deeply collaborative process between our two parties and our partners in our community.

We know that when community organizations work in alignment towards shared goals, we achieve stronger coordination, reduce duplication, and ultimately improve health outcomes for the populations we serve.

This shared approach ensures alignment between public health strategy, healthcare delivery, and community investment.

It enables us to prioritize prevention, reduce disparities, and make meaningful progress on the issues that matter most to Washop County.

Sustainable community level change happens through collaboration, shared accountability, and long-term commitment.

Renowned Health is proud to stand alongside Northern Nevada Public Health in using community health assessment data not simply as a report, but as a coordinated call to action to build a healthier community for all.

Thank you all for being part of the process.

Thank you so much.

I was gonna ask us.

I completely agree that.

But I don't know what your pleasure is.

Yeah, it's a good question.

So I was also processing that as well.

So Rayona has a couple of summative slides that will help anchor this conversation.

Then I think potentially we should take a break because we might need to adjust, and then we need to hear from the board.

Resonating.

So give me a minute to just um we'll have Ray kind of put a put a bow on this.

We'll take a 10 minute break, and then we'll come back and have conversation about what or so carefully.

Thank you.

All right, so what do we do with all of this data?

We turn it into the community health plan.

Annually, you typically see me up at um the podium in chambers talking about our chip is what we refer to it as it's our point to um basically be accountable to the board on how are we making progress on all this data that we shared with you and what the community's needs are.

So Kelly went into the process.

How do we collect different data points so that we're looking at every need to understand what health actually looks like here in Washoe County?

We can send it into a chip because this translate all this translates all of the data into an actionable and a measure that we can work with our partners to move the needle into improving health outcomes.

And we do this uh through coordinated conversation around what our priorities are.

So, in a minute, I'm gonna share with you what those rankings are before we get to that point.

Um, we start to transition from the CHA to the CHIP by having a community forum.

We had our community forum a couple weeks ago, and we invite all of our community partners to start reacting and taking a look at all of the data.

So, what Kelly was presenting was really around secondary and primary data, but then we turn, we turn around and we say, okay, partners, this is what our community said.

Now, how are we going to start addressing the community needs that our community is asking us to prioritize?

And so we do this through a variety of ways, but we start having conversations around what are your priorities and what are you hearing through the external your external networks?

So we have five criteria that we asked our partners to weigh in on.

And these things are opportunity, urgency, capacity, leverage, and momentum.

And the reason why these things matter is if you're looking just at the secondary data, sometimes our partners, as well as renowned health and NPH, we don't always have the resources to necessarily go after that very specific topic that they're looking for, but we we know that it might be urgent.

So this gives us a couple of options, and it could be maybe we invest more resources into that topic area, where maybe we are um, you know, or maybe we're tabling that to prioritize something different.

So, starting from the top, opportunity is just asking is there opportunity in the community to address this need that our community is talking about?

Urgency just means is it urgent?

Do we need to prioritize this above all of the other topics that we have?

We recognize that all of these things are very important to our community, but we can also do so much, and we want to be very efficient with our time and our resources.

Can we all work together?

And can we are we ready to leverage our resources to address this topic?

So can we work together?

And then momentum.

They're pretty broad.

Um, so where can we put a fine point and start making some improvements here in our board?

Should we take a quick break and then come back and I'd like to come back around is get the the board's comments and feedback on what we just heard, and where you where you're thinking the energy might have this applied to organization.

Maybe we take ten minutes till ten forty to that work.

And recalibrate it on we are on item are gonna table item number eight to look at it number nine just going um in front of the board in March.

So having said that, we'll come back and stay in item number seven and look at offering an opportunity to have a discussion about the job and the information that we're correct?

That's exactly right.

So um amazing presentation.

I'm not sure where Kelly just went.

I think oxygen should be available.

So it's always so much information, and then we always have to balance like providing the context and then enough time to get into the conversation.

So the request of the of of several of the board members uh was to make sure we have an opportunity to have a conversation about this.

One of the most important things we need from today is of the needs of the community, what is NPH's role and how do we think about these uh prioritized areas as we're teeing up our priorities for the next three years?

Um so we're gonna open up the space for conversation a little bit more deeply, and then I know the board has questions.

Um, and staff, you know, team that directors also probably have opinions as well.

So this is the opportunity to say first more city, it's really deep work.

So what um we probably have about 20 or pretty much, and we we will uh talk about more of these that we need to get to.

So we use it.

So going back to what Eric uh said at the beginning of our morning, this retreat is special in the sense that we don't always get to see a community health assessment.

Every three years we conduct a community health assessment.

It takes a lot of time, it's very comprehensive.

We're trying to look at every corner of our community to understand what is that purview of community health and where as NP, where's our role?

Where do we lean in to improve health outcomes?

And so it's special because all of these different data points are giving us an opportunity to look at outcomes to determine where do we put our energy and our resources for these the next three years.

What is your perception and where you feel we need to lean in?

And then we come to the board and then we ask you all, as well as our division directors, where do we have the capacity, where is our role to address what we're seeing here up on the screen.

So starting from the very top, right?

We've got mental health, access to health care, etc.

And I think just uh I'd get a little bit of a bridge.

So as we sit with that question, um, let's uh let's get clarifying questions and um and then we'll go with the conversation.

Mine actually goes back to the survey group.

I believe you said 694 of participants in that.

I was just wondering the number of how do we go about getting those folks involved in the survey.

I I guess I was just more wanting to see demographics.

Were they from all of Washoe County?

What what was the makeup of socioeconomic everything?

So that's it.

I'm gonna ask Kelly to come up and speak.

So that's a good question.

Um, and for the for simplicity's sake today, because we knew we were under um that general time constraint.

We've removed the initial breakdown where we looked at the education, we looked at age groups, gender, um, so on and so forth.

So I do have those pieces of data that are available, don't have all the ends and percentages memorized.

But one thing that we talked about extensively, Nancy and I, during this community survey and our approach and how lessons learned would influence our approach moving forward, which is it's not a truly randomized survey.

So I actually um just out of curiosity, we did a very very simple statistical analysis to see are we actually is the survey truly representative of the demographic spread that we see in Washoe County because we know that in the past not being truly randomized, um knowing there are harder to reach populations, and that can be very labor intensive of how you then purposely oversample certain populations.

So we talked about that and we ran the stats, and I could easily give you um if there's a follow-up, I just don't have the numbers in front of me, but I believe it was gender was statistically different from what we want to capture in the community.

We were overrepresented on women and we were underrepresented on men, and then certain demographic groups were also challenging um by race and ethnicity.

I think ethnicity, so Latino and Latina were I think they were actually matching, they weren't statistically different from the population, um, but there were some demographics.

So there are a few key racial groups that we would want to to better represent moving forward in that survey.

But our teams did do a good job of promoting it on the media um and trying to figure out strategies to really get as high of a participation rate as possible.

Okay, thank you for that.

We do have some of that data.

I don't have it in front of me.

Um, and we did have a slide that had all that detailed.

We simply removed it um just for this presentation.

But yes.

Yes, understood.

Thank you.

So this priority list we're using on how we're gonna assign the assets that we have, and how we're gonna sort.

Why is this list?

It's the member list different than the pyramid you showed us through.

So the the rankings and priorities that we do are essentially fed in by these data sources.

So there are um, for instance, in the primary data, there's hundreds of participants from Washoe County from the community giving their information to us.

And so that information is done by the handline method, which takes into those different feeds to do these prioritization rankings, which I believe from the exercise that was done.

This is from the community forum exercise, which was post us telling them what the data is showing of the priorities based off of these different community components, but it's also a different sample of the community that is actively present and sees the presentation and then gets their own feedback into that presentation, correct?

So for clarification, we have two prioritized lists, they're in different order.

We need to work from a list of which list are we using using this one or you use in the headlock?

Is it not that just to say it in what I thought I think I understood was we asked the community, the community came back with the pyramid, and then you engage the community partners against those attributes around what can what's doable?

So I think it's a is a step that um that applies, it's the next step from the from the community to community partners applying against those criteria that then refine the priority list.

Thank you.

It's like kind of so yeah, I think a way to look at this is like the size and severity of the size and severity of these different health and well-being components are the CHA rankings, but then you essentially work with the community to talk about feasibility, the and how we can actually do quick and or long-term achievements to influence these different topics.

So pleasure, do you have anything?

Sorry.

Well, that's okay.

Pleasure of the board though.

So the the the slide after this is the the last step of the prioritization.

We could go back to the pyramid if that was easier, but okay, we'll go with the okay.

Sorry.

Can I ask a question?

I was just wondering, and and I may have missed it when you were talking about the stakeholders and the different folks that we were involving in the community.

Did we have housing authority?

Did we have educational um participants?

Um, and even like economic, you know, EDON and stuff like that, those were all a part of the group.

So for a community forum, we reached out for about a month um to ask our community partners to come and join us at the table around the community health assessment with renowned health help.

Um, they also did their own outreach to make sure that we were inviting their partners to this forum.

So when we say community partners, we're talking about everybody from business to academia to nonprofits to housing.

Um you name it, they were there in the room.

So our MCOs were there.

Also shared the very first slide was our steering committee.

We're also vetting all of our indicators through our CHA steering committee to ensure that we are looking at the right data sources, and we're doing this, making sure that we have housing representatives, academia, um, you know, physicians, we're trying to make sure that our uh scope is comprehensive so that again we are looking at community health as a whole and not just through one lens.

So we're doing it through a variety of factors and each step in this process.

Dr.

Mark, do you have anything?

Brown, do you have anything?

Thank you for clarifying everything on community partners, public safety, law enforcement.

I see every time I see violence prevention and crime, or we stepping into the wrong world, but uh see that there, thank you.

Uh quick comment.

So um both very comprehensive processes and what you're seeing the two rankings.

Um, the CHA itself is what uh Dr.

Watkins presented, is that it it took us six months in partnership with Swedenow where the comprehensive secondary data primary data came together, and that uh along with our Surrey Committee came out with the prioritized rankings.

Then we went for the community forum of a almost like a dot mocracy, where people in the community on where they have capacity to make a change.

So that's why it looks different.

Is there where they're focused on where they think the change should meet versus the other one is our strict data um collaboration and our strict uh conglomeration of everything together, and that took six months to complete, which is the uh rankings that you saw.

Thanks for clarification.

Dr.

Danko, do you have anything?

I'm okay, thank you so much for asking.

Um I wasn't sure what you said, but if you have anything, you're welcome to share.

If you have any questions, comments.

Oh no, I said uh nothing, nothing from my side.

Thank you for asking.

Okay, thank you.

I have a couple things.

First of all, thank you, Dr.

Watkins.

I I'm serious, like the succinctness and the depth of information you covered in such a short period of time was amazing.

And on all and kudos to everyone, renowned everyone who helped, because we're just seeing we're just seeing the end result of it.

All of the data that gets fed into that and all of the meetings and hours and hours of the contributions that have been made should be recognized and are greatly appreciated.

Having said that, I did have a couple questions as well about the steering committee, because as an example, um just throwing out when you're looking at things and thinking about all of this, and then and I may again not taking away from renowned, renowned is actually a percent partner in this.

So thank you to renowned.

Thank you.

Is um even including Dr.

Amy Hein Suther with NACO, and and I don't see her on this, and I think that that is really missing uh an opportunity, especially because um of NACO's um not only Nevada NACO, but National NATO and representing the 69 counties across the United States of America.

Having said that, I do think that there is also opportunities with the CHA to help drive and blur these silo lines, and here's where I'm going.

I would love to see, and if you've already done this, I I will apologize that I'm just not aware, but I think the um the uh district board of health should be very aware of what's happening in the sequential intercept model.

The sequential intercept model is touching almost every single one of these points, every single one, with whichever list we want to use.

And I think understanding how the sequential intercept model and the CHA can help drive that, and I think a lot of people don't, and and I is everyone familiar with sequential intercept model.

Okay.

Uh look, oh, there we go.

Brianna, do you want to take it?

So um I think I don't know if if maybe everybody knows about the sequential intercept model, but um, to kind of shorten it up, our sequential intercept model is actually uh supported by our last community health improvement plan as well as um the work of the behavioral health system.

So the sequential intercept model is the idea that we are intervening with those who interface with the juvenile uh system and making sure that they get the intervention that they need before they get to a point in which um maybe an organization should not be intervening with people.

So it's to try and give them earlier support at an earlier time period in which they interface with the system.

Is that I'd also extend it to not just youth, I'd extend it to everyone in our community.

And mental health is a major major contributing factor, and seeing how the sequential intercept model and taking this CHA data and sharing that with the folks that are supporting the sequential intercept model.

But I think the board, it would behoove all of us to have a presentation about the sequential intercept model and really looking at prevention and identifying prevention long before it goes to uh jail-based solution, which is not the solution.

That is not where we should be essentially trying to look at treatment, if you will.

So I will stay off the sequential intercept model, as you can tell.

I feel like I should get a tattoo, a sim tattoo.

If you see me get a sim text, so you know what stands for sequential intercept model.

I think having um Judge Walker speak at that is something I'd highly recommend.

The other thing that I'd like to share is I do think the CHAD blurring lines.

I think the CHA, and uh when is the results coming out?

I think our goal right now is to have the at least final draft by June, but we plan on publishing pretty shortly after that.

That's our tentative timeline right now.

Is there gonna be like a community forum or anything to actually talk?

Because imagine going through even if this, even if Scott, who does a great job with uh social media and all three of the channels sends that out, they're gonna need you, Dr.

Watkins, to come.

But I do think um, even chunking it out because it is so big, and I think maybe chunking it out and trying to share what um factors are because I'm sure that this touches everyone in one way, shape, or form, whether it's the mental health or whether it's the violence prevention and crime and everywhere in between.

So I would just like to offer that as a suggestion and recommendation for consideration.

I think that's great because the CHA itself is hundreds of pages, it's a lot of information for people to synthesize, and that's something that is typically uh at least I can speak um for my program.

We very much so talk about community engagement and how we continually have those feedback loops, not just with our partners and internally, but also how the community is able to understand and see how it impacts them and give their input.

So I think it's something we always try to maintain in focus.

And honestly, I know that time is always a factor, and everyone's balancing a lot.

Um but the reality is you know, maybe you could do the CHA tour and go to the EDON board meeting and go to those folks who are part of our.

I mean, I'm just picking Evan, you know, you said Edo, because I was thinking too, and housing.

It touches every single aspect in our community, not just and so maybe there's an opportunity to think about really how they then can think about how they can be the solution as well.

I think it also ties into the financial aspect of the budget and how that can be leveraged.

So resources could be leveraged and stretched to accommodate as much as we possibly can in various ways.

So I wanted to run that out as well.

The last thing on my notes, I had more, but I'm going to restrict it to this last conference.

I was writing a lot.

As I was watching you not even take a breath, like you are amazing.

I was in that 20, well, I don't know if I was in 20 minutes, but I tried to keep it.

Um I just returned from uh DC attending a uh a National Association of Counties legislative conference, and the um current administration's director of health and human services uh was a guest speaker and really gave a lot of stats, a lot of stats.

And one of the things that I think that Cha fits into even that is looking at, for instance, um the um health threat of children as an example.

There are, I believe there are five states right now legislatively that have adopted, just have adopted, not been mandated to have like the WIPR WIC program not include um so as an example, and they're seeing results of not having sugar be a part of unfortunately due to the economic factors that come into play with those recipients of WIP as an example, not just picking on WIC, but I just think those two are also important, and so I wanted to throw that out because there could be some even legislative opportunities to help that maybe we can bring some of these things down and not always be the leading your imitators on red were in some cases.

I don't have to tell you, we're sometimes more than double not only Nevada, but the national average.

That should that should give everyone pause, and what should we be doing?

The last thing I'll say, and I'm gonna call um the president of the Washington County School District and many other folks in other school districts because they're also looking at grants to help with nutritional nutritional programs and really mandating so it all ties in, doesn't it?

And we're here for the community, and so I wanted to throw that in as an example that you might not be aware of some of this.

So there you go.

Thank you so much.

Anyone else have anything?

Oh, Dr.

Awarte.

Yeah, I was just gonna comment that uh the mental health ties into the substance abuse health risk and violence prevention and crime.

Yeah, so those are all tied to that, and the other is the economic stability.

People are homeless uh or don't have the resources to take care of themselves, we have all of this fallout that comes down to the two.

I think you're gonna find it very interesting.

Well, I mean, there's just lots of models that inform us and and they help us understand complex data sets.

But I I think just seeing the mental health thing to be just tied together a whole bunch of other things, and the economic stability ties in most of the others.

So I think uh this is a pretty good alignment of what we would be looking at.

I I would just extend that to the board.

You know, we're looking at these priorities to hear from you.

Where do you feel that our role as NPH should be?

Do you agree with this that we have?

Um, you know, we we try and be very intentional with our chip.

We know that we can't address all of the eight themes, and so we try and be intentional by addressing the first four.

That doesn't mean that we aren't going to address you know health risk and early detection the other things.

We can absolutely do that, but our chip is really focused on the top four so that we can leverage our impact with our community partners and resources so that we are attentional time that we have over the next three years to actually see health.

So kind of a general question from the standpoint of this is what the community says that they believe are the issues and what the services they'd like to see us perform.

How does this relate to what we're actually doing as the health department and the services that we're providing to the community?

Is there a conflict between what we're really doing versus what they think they want?

Yeah, so try and balance that, right?

So we understand that our role as NNPH, we are likely not going to provide therapy for mental health services, right?

But we can support mental health in other capacities like we can provide an investment to say we know that this is going to change public health infrastructure.

They're going to give, let's say, the SIM, you know, resources, and maybe be the convener of that conversation to ensure that we're addressing mental health.

That is to the extent that an in we're not going to start doing outpatient therapy because that's quite not our role, right?

We can address transportation.

Transportation has come up a lot in our community survey.

You know, people cannot get access to health care because there's lack of transportation, specifically out in our valley areas.

We are not going to become the next RTC, right?

We are going to invest in the transportation system.

We might be able to say, okay, we need to do a little bit more thinking about what bus lines are put in, you know, out in our valleys or maybe in some of those areas that surround county so that people can come into the city to get access to health care.

But we certainly are not the next RTC.

That's where we draw.

So we try and strike a balance between if mental health is prioritized by the community.

How do we be thoughtful about an NPH's role in addressing this, but stay out of the lane of providing those direct services like therapy?

We could be the convener, absolutely.

And that goes a long way.

I mean, you think about the crisis response system.

NPA was the container of that conversation.

We now have a crisis stabilization center four years later.

That was an NPH's role is the can.

I think the other the other value here to address your question is that it informs outside agencies of where they need to be looking, directing.

So you're talking about bringing people in, but they're building emergency rooms out in the periphery so that people don't have to travel long distances.

So the services are more available in their community.

So this is not just about what informs us as public health uh uh board, but also uh informs our stakeholders, the partners of the community about where they need to be looking and where they maybe.

So I think that's the other value of the community health.

Yeah, and and if I may, just to add, I think that wraps the bow about what I was trying to say.

That's what the child's for that I mean that that then allows not the responsibility of public health to execute and deliver, but to actually provide the framework that the data helps to drive this is what the not only the community says, this is actually a priority, and then those folks to your point on the crisis stabilization center or the sim model or others.

So it allows it allows essentially those that are in that space to actually have even more uh resources and data so they can write the grant, or they can actually look at what they need to adjust in order to meet whatever the particular criteria is.

That's why I think the CHATOR, I'm just calling the child tour, it would be really really great.

Because then you're just having Dr.

Watkins go out and just share this information to those bodies who are delivering it, not that it's on health to execute.

And who knows?

Who knows what that benefit might be to our community as a whole?

And to that point, just to maybe tag on to that and see where we might bring this conversation today, uh, with the the direction, I think it would be very helpful for staff is did these these four those four rising to the top from from where you sit as well, or if you like to see something else highlighted, so to speak.

And then I think the tools that the team has to facilitate and come back with an actual plan is the foundational public health services informed direct service.

That is the role of this organization, and then supporting or secondary through convening or other such means for things that are not that are up here but that are not necessarily direct because of uh responsibilities or quite frankly uh affordable uh with the the resourcing that the organization has.

But I think those are the kind of the guidelines I do believe that exist in order to help make sense of direct versus supportive uh or secondary service, if you will, or secondary convening, etc.

Um, but I think what matters is these four are the ones that rose to the top from the process.

Does the board concur with that, or would you like to see anything else bolded?

If I if I may, I I I thought that having the maternal child health at the bottom of the priorities was a problem.

And so I'm glad to see that in the transformation and with adding additional input, you were able to raise it up to four because I see single mothers struggling to earn an income, they can't nurture their children.

This relates to behavioral health, health problems, getting in trouble with the law, uh, all these things, the gangs, all this stuff stems out of these kind of stressors.

And so I think moving the maternal child health to a higher priority level makes a lot of sense.

It ties together with all of this, the mental health, the economic stability, the access to health care, all of those things are tied together.

And I from my 15-year perspective as a physician, tying these things and working all of them as kind of a unit problem is gonna yield the best results and and and the and the best uh stability over time.

And I think that the with all of the stressors that people are experiencing, um, it's it's really it really drives a lot of the problems that we see.

Yeah, sorry.

I wanted to ask Dr.

Banco just because Dr.

Danko, do you have anything that you'd like to add?

Um the top four are being asked.

I'm I'm sure you can see everything okay.

Oh yes, I can see everything just fine.

Uh no, I don't have anything to add at this point.

Thank you.

Mr.

Anderson.

Can you help me understand the relationship to the CHA versus the CHIP?

And I mean, I know they're linked, but could you help me better understand this?

Never mind, she answered yes.

So the CHA is the collective data, and so we do that through collect secondary data.

So that's all of the indicators that Kelly talked about.

There's also a data synthesis pack that you have in front of you, some of those data indicators.

So we're looking at health outcomes, and then we're also gathering primary data, which is going out into the community focus groups and surveys and key interviews to understand from our community all of these themes, all of these data indicators, your health outcomes.

Where do you feel agencies like Northern Nevada Public Health, renowned health who are bringing our community together to improve public health outcomes?

Where do you feel you need the most help to improve your quality of life here in Washoe County?

That is the CHA.

We transition data into action through the community health plan.

And so our community health improvement plan is just taking that data saying this is what we are prioritizing as a community, focusing on these top four priorities, and this is how we are very specifically going to measure health outcomes and improve health outcomes through very targeted initiatives like the SIM crisis response, the crisis response system, um, the 520 healthy washow program that addresses physical activity and nutrition, um, mama care kits for maternal and child health.

We talk about those very specific interventions with our community partners to uplift the priorities that you see supports.

So that is what the chip is for.

Just to add on that, it's always a good example.

So previously we had the last year's CHA.

The only difference between the last CHA that we saw is economic stability came on here.

That's priority that our community came out.

I know the reasons what's occurring.

So that's the addition.

So previously, three years prior, same thing.

We developed CHA with the community, and then we developed the chip from that.

So previous chip that uh that Riona has brought to you periodically, is we invested in the SIMs.

Uh we invested in a we shared uh cost of one employee to help in the name of that, and what program was that for mental health?

So um so the office of the county manager's office, they have a behavioral health program, and so we are helping to manage the crisis response system through an employee who is managing that process.

So we are contributing, we are one agency that contributes to thinking ship that structure is 5050, the food access program out there in the community healthy corners, those are things that previously came out of that previous CHA, and then we made what's the priority we're getting in the community that's where we invested over the last two years.

Okay, awesome.

Thank you.

I appreciate helping me understand.

I I knew they were linked, but but I appreciate you going a little bit further.

So any other comments from the board about uh us the the larger group taking forward these four as we're moving into the next three-year planning cycle.

Sounds like we have support generally speaking.

Nope, nope, I just want to make sure that everybody's added their thoughts.

The clarifying question in the standpoint that within the top four, there are some things we specifically do.

There's others that we would advocate.

What keeps us from straying away from the advocacy role that we're supposed to have and not dipping our toes into something more shouldn't because it's like a resource.

How do we control that?

And that's a good question.

So we have the foundational services that really keep us aligned for services.

And we really have to use that framework.

Can we resource this or not?

And it's NP as NPH, you know, the convener, we can say they can't necessarily tape on this, but we identify a partner in our community to address this issue.

And then we'll we still put it in our community health and we still report on it so that you all know how progress looks like.

But we usually identify another partner to be able to do that work if we are not resourcing that.

I think just echoing that.

So that was one of I think slide eight or something.

Uh toward the beginning, but those are the five areas, if I'm if I'm not mistaken, correct, that are those foundational public health services, which is where everything starts from correct a core service perspective.

A few of those are directly aligned up here if not.

So if again, if if the board is supportive of that, then the team will take take this back and use the foundation of public health services as core programming, and then understand the other things would be through convening or advocating.

To add to that, you know, so the CHAD SHIP is core for us.

That is a requirement.

All public health across the nation do chosen chips so we can inform our community.

Adjacent systems come out that we do not directly address, but we are part of those systems.

So it's where can we make an impact in the system to overall improve our community, but we don't have to invest in it or put our resources into it, and it's really that collaboration and communication strive for.

Yeah, just to clarify some of the other items.

This is the prioritized community needs, is how I see it.

The reality is we could probably take some of even five, six, seven, and eight and talk about what uh there's compliance that actually may be statutorily required for some of those items.

So I'm not looking at it from that perspective.

I'm looking at it with all the data, how it was compiled, both primary and secondary, all the hundreds of hours, not thousands of hours to contributed to this coming out to the top four.

So I think separating that to your point about not bleeding in or having um you know creep into getting into an area.

Um I think it's it's actually clear with the organization on what that should have.

So yeah, just like to kind of go off with what Mr.

Tristle was pointing out.

And I'm I'm just wondering, do we routinely check ourselves to make sure that we haven't inadvertently run down pass where actually a community partner is better suited, better financially, logistically, whatever, better suited for that niche and so we come every three months, correct?

So I come every year to share with you the annual report health improvement plan, and we discuss all of the the initiatives that are included in the work, and then also when we're having all of our community committee meetings, I'm also taking a look at our say does this align with what we do as an NPH.

We're not resourced to do that thing, again, we're convening with other partners to make sure that they take on that role.

So there are a lot of times where we're just a we're just a partner and we're just making sure that people are coming to the table to understand that we're all operating using the same data set to measure health outcomes, but we're not taking on that crisis response.

I think is a really good example of that.

We are not resourced center and all of the different factors.

The 980 system that was for another partner, but we absolutely were the convener to make sure that all of those stakeholders were in the room to determine how that system was going to operate here in Washoe County.

That was our role, but we're certainly not going to be in the crisis center.

Transition into finance as we're moving in their budget and one of the five financial principles I've listed today is 500k.

We use the document that we use to invest in these systems, not over for us to do, but it's a discretionary board for us to take that and invest in those systems so we can make an impact in addition to working with our partners and all those points.

So that is public yeah, that is one of our financial principles I'll be discussing on today.

So we want to do that, you know, and uh talk more in depth, but then we do more budget, but also affects what is our capacity and then the ability to really are paying for our fund.

Yeah.

We did that was nice.

Thank you for thank you for the time on that conversation.

And again, we could have all afterget about it, probably.

It's that rich.

Um, but that's really good direction.

That's what from that topic.

The two other topics that I just flipped through, we'll come back to another board meeting.

And we're gonna close item seven and now remember we're tabling eight.

Looking at having um item number nine back in March.

So now we're on item number.

Just to frame it up, we are looking or hoping to take action on this item, so just knowing what we're on that.

Okay.

Okay, okay, everybody.

Uh, so I've got a full slide deck inside of the attachments.

Um, this is a truncated version.

I'll go through it really quick and just highlight those things that I think are the most relevant areas.

Uh, starting with our orange charge.

So we've got 194.99 positions at the moment.

Uh, we're at about 165 that are currently filled.

Uh, we've been managing our vacancies as a way to deal with our budget.

Um, and as I go through this, I'll give you the punchline in advance that our expenditures are uh increasing faster than our revenues, and we're gonna have to address this over the next couple of budget periods.

Um, and I'll explain some of the details as we get into this.

Uh so just as kind of a general overview, this is the fiscal structure for our revenues.

So there's a good chunk of what we get that comes from grants that's been changing over the last handful of years fairly dramatically.

Uh, we've got state funding that's sort of a new source of revenue for us that seems to be relatively stable.

We have ease from environmental health services and air quality management as some clinical services, and then we also get a county transfer.

So on the expenditure side, same thing, there's about four things that are particularly relevant to us.

Um, we'll keep saying this over and over again that salaries, benefits overhead are compromised about 90% of our budget at this point.

Um, most of the other things that exist within the budget, we have some flexibility within to make adjustments, um, and that falls within services and supplies category, but salary benefit overhead are the major drivers of our budget.

Uh, this is the source and use.

So, this is our reflective budget for the close of fiscal year 26 as well as seven, and then there's an above base ask for the county that shows uh an additional million dollar ask in transferred to increase our total transfer to an 11.5 million for um uh funds.

Um, know that this reflects worst-case scenario.

This makes an assumption that our entire spent out, so we have authority and we don't necessarily spend that authority in each one of those areas.

So this is reflective of the full authority that we have this moment on the revenue and expenditure side.

So we know that there are places where the revenues may be understated, there's places where the expenditures may be overstated, there are some unique features inside of the budget that I can get into on some of the later slides of the way that we booked the public health funds that came from the state this time.

But um, the general trends are showing us to that salary benefit overhead issue that um most of the jurisdictions are dealing with at this time.

So this is just a summary of the base requests that we have that we put this into the financial system, and we've asked the county for an additional one million dollars to address our shortfalls at the moment.

Uh, this is a reflection of our full revenues, and I'll get into the details of this.

Um, it's kind of a strange period to choose from 2019 through 2027, but I chose this because 2019 is the last budget that we have that doesn't have COVID and ARPA fund.

So the little dance in the intervening years with the total revenues is showing that we've had a number of lots of money that were put into our budget to deal with both COVID and ARPA activities.

So getting into some of the specifics.

So this is revenue.

Uh, the vast majority of this is federal grants.

So some of those federal grants come straight to us from the federal government, others flow through the state to us.

Um, but overall, between 2019 COVID time up to 2027.

We've had about a 24% increase in those grants.

So those grants have increased in dollar amount over time.

Uh, but I'll show you when we get the expenditure side that are expended increased by about 60 plus percent over that period of time.

So the grants aren't keeping pace with the cost of the services that we provide.

Um, and again, that dance in there between 21 and 26 is reflective of all four funding that occurred over.

So this is licensed permits charges for services.

So some of this is in air quality, some of this is in environmental services, and some of this is inside of the clinical areas.

Uh so we've got some increases 2019 to 2027, uh 41%.

Uh come up each year by CPI in the intervening years that we don't do a full fee study, and we do a full fee study every five years.

Uh, there was one year around 2023 that we decided to forego CPI because we had so much cash on hand, and that CPI was about 8%.

So if we take the full CPI over that period of time, we would have brought in about 49% increase of revenues over that period of time, but still not quite keeping pace with our expenditures.

Uh, this is the general fund transfer, same period 2019 through 2027.

Uh for 2027, this reflects the 1 million dollar increased ask in the above phase.

So over that period of time, our intergovernmental our transfer from the county has increased by 21%.

So this is the expenditure side.

Uh, same things.

This is an overview of 2019 to 2027.

Uh the dark red is the salaries, the middle is the benefits, uh and the the light blue is the overhead, and then the pink would represent our services and supplies, and then the dark blue at the top is really just reflective of capital, which is always tied to some revenue source that we brought in.

So those salaries and wages over that period of time have increased by 71%.

Um, this is the thing that's driving the cost within the department.

Uh, it's I know that it's uh becoming a recurring theme that we'll talk about government at the state level and the local level and even the federal level.

This is uh pretty uh common that inflationary pressures are hitting us.

The other side already increased salaries.

Uh, same on the benefit side.

Um, we've seen a 75% increase in benefits over that period of time.

Some of this is reflective of OPEB and COVID pandemic created some fascinating things that have been uh seems to be leveling out over a period of time, and probably over the next couple of years the dust will settle on it, but it's trending the same way that salaries are trending of 70 plus percent increase from that pre-COVID time to this moment in time.

This is the overhead.

This is what we pay back to the county for the services that they provide us.

This is technology, this is the manager's office, this is human resources, and over that period of time it's increased by 132 percent.

Uh, this and I'm gonna put a caveat in there that this is an estimate based on best possible information.

I have more information.

Um, we were we assume it's going to go up by 15%.

In this case, it went up by 11.2 percent.

So there's a minor adjustment that I need to make in this chart, but it's uh gonna be a material for the that 131, 132 percent.

This is our services and supplies.

So when you take all of the other activities out, when we take the salaries, the benefits of the overhead out, this is what's left.

This is uh the fuel that we put in our cars, this is the biologicals that we produce for the clinic.

This is all of the activities that we do on an eight-to-day basis.

We've had an 11% decrease in our services and supplies as we're compensating for these increases in salaries, benefits, and overhead.

Uh so this one it's there's a little bit of sawtooth in here, and I'll explain this a little bit.

Um, so this same period 2019 through 2027, and then some projections going out to 2030 uh over the course of COVID when people were billing towards those grants.

We were banking money into our health fund, and that fund continued to increase over time.

Uh eventually we ended up with about in 2024, we had about a 2.8 million dollar shortfall.

We created some deficiencies, we backed off on positions, we tightened up the ship as tight as we could.

Uh, that reflection into 2025 if you take out the SOT2.

So, what's happened with the period, the 128,000 is that we got SB 118, which is the first time that the state invested in public health activities.

That revenue was booked in 2025 and it can be expended out into 2026.

So the revenue is reflected in 25, and the and about 1.7 million of that will be reflected in 26.

So there's an underrepresentation in 25 and an overrepresentation in 26.

But if you look at the general trend, we're going backwards by roughly $2 million a year, which shows that impact of the salary benefit overhead.

So that's the place, even though we're compensating on the revenue side for the CPI increases, um the expenditure side is uh moving faster than the revenue side is a reflection.

Fund balance.

So it was just showing the the money that we banked over the period of COVID.

So prior to COVID, we were sitting around seven or eight year of the health fund that continued to increase as we were billing to grants and the health fund inflated over a period of time.

Now we're using some of those funds to compensate for the shortfalls that we're dealing with.

And that shortfall you can see is following that same trend of roughly two million dollars a year, salary benefits overhead that uh we're trying to figure out how to compensate for at this moment in time, uh, showing that we'll hit our uh minimum reserve somewhere around 2027, 2028, depending on how revenues come in and depending on how many expenditures we can control.

But somewhere over the course of that 12, 24 months is the point where uh we're gonna have to have serious conversations about how we address long-term sustainability for the department.

Um I won't go through all this.

Um, I can dive into it if anybody's interested in particular areas, some of the assumptions that I made over the course of this.

Um I think the Federal is definitely straightforward.

Uh the only thing that will side again is salary benefit overhead are those things that we can pull over the department and they're impacting our risks, same things.

I won't read all of this to you.

I know our time is precious, but uh if you have specific questions, I'm happy to get into the nuances of the risks that we have over the next couple of years.

And I believe that's it.

Thank you.

Have any questions?

Like to add anything or first say thank you to the board as well as our county partners, those jurisdictions on the umth with our budgets over the past year.

Um, and we'll continue to do monthly with uh county budget uh staff, and so they need a wonderful support to us on being able to address uh and help to really fine-tune our budget and our risk and overall uh components of it.

And then um this is this is to understand too that this isn't just us, we understand all our communities and across the nation and local budgets are facing this, and so we're the best partner as we can on that.

And we'll always go move forward basing on data and our course services and what's priority for the community.

Yes, we have to trim up some.

Um, but you know, it's always we don't want it to be the sky is falling.

We understand that um we've been here before, and we're here today.

So the same thing point.

We are still here today, and we plan to be here next year and the following years, and you'll find uh where we do what continuing to protect and deliver our mission to our community.

So look forward to being partners with you on these points.

When we look at our numbers, but um that slow incremental process, I believe, as we work through this with our partners and the county and addressing those points to continue.

And uh it's modest, but it is a good uh good point that we worked with the county and uh million above the base, and uh we continue working on them and continue monthly access with them in order to address as we have questions.

Anyone have questions?

Do you have any questions in the budgeting information you're showing?

It's assumed that our friends at the county are going to inject uh funds needed to get us to where we need to be.

Is that I mean, out of all the the slides that we looked at, that's that's what we're counting on.

I I think that we are having ongoing discussions about what that means and where it's going to land.

Uh we've been having those discussions for a couple of years.

Uh, we're doing what we can at this moment.

To me, that million dollars represents a good faith effort that says that we need time to see the dust settle inside of the COVID and the corporate funding and see what the trend really looks like.

Uh, this budget is really complex to see when you start getting into the difference of hit and how they offset some of the expenditures.

But I think that that million dollars really does reflect us working in good faith with the county to say, yes, we need to open up our books, we need to look at the details and identify those places that uh we need to be made whole.

I think that some of this is tied to the federal conversations as well.

That I think that we're reflecting the toughest correct environment from public health perspective that I've seen in 22 years.

Um, so it really is uh are we going to make changes to those programs that are grant funded historically, or are we going to start pressing some of the infrastructures and look at it looking at different ways to approach those activities?

So it's going to be, I imagine, some combination of those activities.

I have a question, just in terms of um the projections that you know how in that preparation, um, I wonder if there's an opportunity, and this a long time, so it's really just asking to look at a priority-based budget to look at what are the compliance requirements, looked at what is this is what we need to do, and this is what we don't have to do, and looking at that in a priority way with compliance being driver in preparing as we move down this um path of uncertainty, because as you've mentioned, it's not just actually us, it's not just the state, it's the entire nation.

And so um, I think just in in planning accordingly and adjusting accordingly, I wonder if we could think about having opportunities of more discussions as we plan and forecast, and then what does that look like?

So that when the decisions that may um come before the board, that we're well prepared for understanding why we are here, even though you will know because you're well informed and you do this, and and thank you for putting all this together.

I think um going through a planned process and path will help because I don't think that people the expectation of delivering to the community is not aligned with what we're required to do versus what we're required and we do, and so I think there as we travel down that there's also an education opportunity as well in the event that some tough decisions have to be made.

So instead of having it, like I said, um for a decision in a planned way on an agenda that we have uh a plan and a process to get that, and if if something finds we find the money tree, or you know, like uh then that can be adjusted too, but I do think priority take priority-based um from a compliance standpoint is is really a critical.

I'm saying what I'm saying at Washoe County as well, so I'm not just reserving it to just um this position that I'm honored to serve on, but um, I I would welcome that opportunity that is available.

Absolutely.

And having briefings, I'll just add one thing, and I hate I think having briefings because in a business meeting we're very constrained, and um, I think having briefings to understand the depth of it will help all of us to better support all the great work that's done here.

Absolutely.

I appreciate the feedback, and I think that have a priority matrix that we put together, and I think that we can tie those pieces into the budget.

So I think that's likely our next steps.

Thank you.

I appreciate anything else, Mr.

Dressel.

With your permission, before we finalize and decide what we're gonna do about the budget, if we can just jump ahead to the next agenda item, the very first proposed principle.

It is suggesting if we were to approve these proposed principles that are ending fund balance would be at least 17%.

This budget that we're gonna be asked to make a decision on is only 13.9 percent.

So I guess I would like to understand since we're having this proposal of what we'd like to do, and then we have the reality.

How are we going to tie those together if we're to approve the proposed principles under this budget?

So on that point, yes.

So taking there's uh the county has set their priority for cash out balance of 10% to 17%.

So we chose the high end of the 70%, and this can be amended today, but we chose the high end similar to take the example of COVID, so or our protest outbreak right now, or if we have another outbreak.

So for the first year of 2020, we voted over more than 50 million dollars to maintain COVID, right?

So it's always keeping a little bit extra cash on hand to do that.

So we took the high end of it.

It doesn't mean that that's it sets a principle, and so being lower than that, I think it goes to speak what uh Chair Andrew said is that we have to make some vice chair chairs.

Don't don't put me in that position.

Uh it said that you know, it's just that we may have to make some decisions, so that helps us inform.

We have that principle.

We know we're now below 17 percent, so we need to apply our principles, get back to that as close as we can.

That makes me may mean some hard decisions.

So that just helps guide the board as well as us as we're preparing finance to say that okay, we are now below 17 percent.

We need to address this.

We're at this, we're we're at this point that we we need to recognize that and we need to uh find those solutions.

I have a five.

What's the statutory requirement for fund balance?

It's by policy, it's 10 to 17 percent.

It's what it's 10 to 17 percent.

There's a range, right?

There's a range, um, and and I yes, so there's a range from 10 to 17, and so we're within that range statutor, and so um, I'm going to stay within the scope of the authority.

This agenda item or moving, and I'm looking at the attorney.

I try and not have the attorney just share, you know, wonderful things about how her day's going versus saying that I'm I'm leading into an agenda item that's not um we're not at.

So um, I think there's an opportunity when we get to next agenda item to talk about what that says, and you know, unless we want to pause this, ask the ask for legal counsel if we can move to pause this, come back, look at the guiding principles first, then we'll close that and then go back.

That would be my recommendation of facilitating this meeting is staying within the compliance of the rules for the record.

You can take your agenda items out of order, just please um be clear on the record which item you're considering.

Yes, so I'm getting the feeling unless there's something that we could table this item for the moment, open up discussion on the next agenda item, take the appropriate action, and then come back to item number 10.

If that pleases the board, that's what I'm going to suppose.

Nope.

You don't need a motion to do that.

I'm just if someone had a problem with it, then we could have adjust, but it sounds like we're going to move now.

We're gonna just for the record, we are going to pause or suspend.

I don't know what the legal term would be.

Um what would you say?

Council defer until a subsequent item after 11.

We'd like to take the items out of order.

We take the items out of order, item number 10 until after after we're through with items.

So we're gonna open up item number 11.

So having said that, Dr.

Kinsley, you are up for the presentation, discussion, and acceptance of the Northern Nevada Public Health Guiding Financial Principles to align the board on long-term sustainability, responsible stewardship, investment strategy, and mission aligned resource allocation.

So we bring before you today five uh guiding principles.

Um principles that allow us to be able to the direction of the board that also help us when we are developing and matching our budget, make sure we're in line with my mission, but with uh the board's perspectives and as well as principles of how we uh use our uh our budget.

Uh so these five points uh before you, and I believe at your discretion if you'd like to talk about each one, or I could go through and just go ahead and give a perspective on each of the five or divide them up.

So I'd just like to take your direction on on um on that on how to discuss it.

I I would um just in the spirit of uh everyone being prepared to come to this meeting.

If anybody has any specific questions at this point for any of these five items, Dr.

Danko, do you have any questions?

Um I do not have any questions at this time.

Thank you.

Great.

So um I actually have already shared this um with Dr.

Kinsley in a briefing that I had, so I'll just fully trans be transparent and sure with everyone.

I believe that um principles are certainly wonderful, but policies have what I would call uh a direct place.

Um, and and item number one is not a principle in my opinion, it is a policy, and I believe that that policy should be agendized.

I believe we should have a range, the statutory falls within what's already in law, and to make it at least 17.

I know we could get into semantics, but 10 to 17 is the range.

And so, from my perspective, that just my perspective, I will you know, follow the uh vote that we'll be taking as the board.

I would like to recommend that item number one be put on an agenda for a policy of 10 to 17 that falls aligned with the compliance that we're required to fulfill.

And for me, I think the rest of the other um two, three, four, and five, um, I think are fine for a principle, but that was the comment I felt to share with them.

Maybe just as a context on this too, for background as well, is the the notion about uh teeing up some guidelines for decision making prior to potentially moving some of these into actual policy to see if they to try them all before memorializing them.

The first one's a uh is a bit outside of that commentary because it is a current policy and requirement.

So yeah, and that's why I brought it up because it is a policy, um, in my opinion.

I I also think that as we're moving through these guiding principles, that as I already mentioned in the item that's now been um deferred, I'm not gonna talk about in depth, is that um we need to look at priority-based budgeting, and we need to look at the compliance, those are the financial guiding principles as we're moving forward.

That should that, in my opinion, should be included in here, especially given that principles do have that um agility to um to move as needed, um, certainly coming before the board, but not with the the depth of uh policy.

So I I would like to see an additional.

So one item number one would go to a policy agenda.

That's my recommendation, adding another item that would um look at guiding uh priority based with compliance being added.

I would like to add go ahead, sorry.

Go ahead.

I think I was just gonna tag in on that.

I think number four is the intent, the spirit of number four kind of starts to go in that direction, but but I'll I'll leave that for so I would say yeah, and on some of these two, you know, I want to be transparent with them too.

That we're not, you know, we're putting these one principles so they guide us, will they guide us towards policies and as Eric outlined, filling you know, filling them out.

So just some challenges like what's the real world, what does this mean to translate to?

So, number two, when we go 100% cost recovery, this is where public comment will come in and say that well, you know, two years ago when I was a restaurant, I paid $600 for my fee for the year.

It's now 1200 a year.

And so that's that's what it translate transparent rights, right?

And especially when you go CPI.

So we affect small businesses.

We expect the economy of our of uh of our community as a whole.

We do perhaps create some barriers, but at the same time, it's 100% cost recovery is a is a valid target for us.

And that's why we put in there too that we're at least every five years, we're doing an independent study.

So they wanted to just want us to be us saying, hey, this is the fee we think it should be.

We're having the independent study come in to verify that.

And so we're always trying to best align that, but it does put constraints on our community.

I just want to be transparent about that.

Next is the end, an NPH shall dedicate 500,000.

So this is where we have previously with our previous chip.

We dedicated 500,000 to invest in our community.

We did it into mental health, we did it into food sources.

When you get into budgetary crisis, this is kind of like having building a new capital project, you know, and our community will say, Well, should this not be invested in your services over a billing?

You know, so we do get into that.

So there is perhaps a point in there that we have to do we cut back that 500,000.

Do we do we taper it down?

Do we put a limit on it?

But this is just a beginning principle to that that we have to address.

We have you know our staff will say that you know when we go into priority-based budgeting, which we have have have aligned on those points.

Um, there'll be there'll be hard points on there, and staff would it will be hard for staff to say that we're going to continue invest in an adjacent mental health system over our core function.

So there's challenges there, right?

We have to recognize as a board of the reality of it.

Same thing.

So you go into what our core services is, uh, that sets us there, and that guides us, but that also means when we do our priority basing, those things that are that are priority based will are challenging.

So one is in example, mosquitoes, right?

That's it's it's down on the bottom.

Um, suicide prevention is down on the bottom.

You know, these are priority bases that perhaps we will no longer be able, we will pause investing in until we are better situated to be able to reinvest back into those.

So that means those are sometimes those are decisions that we will have to face on those ones.

So this is just being and then um uh we already number five is already there, we practice that uh on a monthly basis, but it's just also how the board receives information.

Those I just wanted to be transparent on all these points and realize there, but what does that translate times sometimes into the real world but um and this is something that we have spoken about, especially number three with the 500,000 spoken in that with our directors?

Uh we're in alignment on it, understanding that there will become a point that we will would have to pull back on, which is challenging, and it is an investment to systems and truly makes an impact in our community.

So it's that uh it's the capital project versus uh reality of our services.

So these are these are great principles, but we do feel that because we are in constraint right now, we need principles to make sure that we're moving forward correctly.

And what we need from today's conversation, we don't necessarily need action, but we do we are seeking direction.

Um and I'm also watching the clock a little.

I don't know if or is it an extra 15 minutes, but um we do need to come back to that item that we so vice chair.

So you don't need action on these, do not need action, but we would like feedback.

We would like feedback.

Okay, seriously.

So Dr.

Kennedy for your just conversation just having about the 500,000 for the chip.

Seems to me that the language and the principal for this line should be May instead of shell.

The other one's shells appropriate because that's gonna be there.

But this one, because if you're already looking at at some point saying, well, maybe we need to adjust it, well, then we should change the language because otherwise, this is telling you you start there and everything else.

Okay, okay.

Great point.

Thank you.

That's an excellent point.

Shalom May are two different terms.

So we do we all have stories.

We could go around the room and do an icebreaker on how this meeting shall and May.

Um the only thing I would just add is in closing, unless someone else has something else is as we move to now item three saying uh May, dedicate or any of the other items that may have an impact to the community.

I think we need to get in front of that in a community.

Scott does an excellent job, and I think we need to think about how we spend the time sharing that it's not that we don't care about suicide prevention or we don't care about the impact of mosquito abatement or any whatever the particular item is, but I do think it's important because I do in talking to constituents, it's very clear when ever whatever the body it is, there are legal requirements that you have to fulfill.

And if you can't stretch that dollar, we have to do those, and so sometimes the others may not, especially on the 100% cost recovery.

I think educating on why that is um is important.

So that's all I would add is having an community engagement piece that's attached to some of those impacts that happen budget.

So any other comments.

So I got a question.

It's a clarification of number one.

Um so it's between 17% for an ending fund balance, correct?

Between 10 and 17.

Yeah, 10 to 17.

So we're actually gonna say just for this fiscal year, 17% is the top, or are we looking towards the future on that?

Well, I'm asking for it to come back as a policy, and I'm asking for it to read just as it is required, and that's a 10 to 17 percent.

We're required by the help is required by law essentially by statute.

So, yeah, exactly.

So I feel like that's what we need to go.

Okay, so this year we would fall under it because it's 10 to 17.

Sure, but it's already statutory there.

We just go 17 up all white.

Yeah, okay.

Slice in a dice in here.

I don't know.

Yes, it's a recommendation of our district health officers of staff to go to 17.

We should do it.

Right, except it's at least 17.

So now we're gonna get into semantics.

Yeah, gotcha.

So we'll see what happens on the agenda agendized item.

Hearing no other discussion on this.

I'm gonna close item number 11.

We're gonna move back to item number 10 for the record.

I'm opening back 10.

Do we have any further discussion on item 10?

Comments, any additional questions.

We don't have any.

This is an actionable item and would entertain a motion at this time.

I would move that we accept the proposed budget as presented by staff.

And I'll second, I'll go ahead.

Um Mr.

Brown will second.

Um, any further discussion?

Hearing none, all those in favor signify by saying aye.

Aye.

Any opposed?

Motion carries unanimously.

Thank you so much.

We'll move now to item number 12, which is public comment under this item.

We'll be limited to three minutes.

May pertain to matters both on and off the board.

Time may not be applicable to other speakers.

Comments are to be made to the whole virtual public comment.

However, restrictions may be imposed on the time, place, and manner of speech.

Irrelevant statements and delay repetitious statements and personal attacks that would objectively antagonize or incite others or examples and speech that may be reasonably limited.

This board carries out the business of Northern Nevada Public and its citizens during its meetings.

The presiding officer may order a person removed if the person's conduct or statements disrupt the order of safety of the meeting.

Warnings about disruptive conduct or comments may or may not be given prior to removal.

Furthermore, certain disruptions of a public meeting or criminal acts is defined under NRS, which may result in prosecution inappropriate pieces.

And we do not have any requests for public comments.

Go ahead and close public comment and open up item 13.

Any board comments.

Dr.

Danko, sorry.

Thank you.

Dr.

Danko, do you have any comments?

Yeah.

I think Mr.

Anderson.

Uh the only thing I want to say is thank you to all the staff, everyone that's been involved with that, all of the topics that we've covered today, uh, including the budget, which is not uh funding topic we need discussing right at this time, but just want to say thank you for all time energy effort that you've done.

I was going to uh say that, so we might actually meet our one minute.

I just wanted to say thank you so much to everyone.

Putting all of this together is a lot of work, and um, we recognize and appreciate everything that we do uh and helping our community and help educate everyone, especially as we go down these paths that may not be as nice as we would like them.

There are gonna be challenges, and I think everyone recognizes that.

I certainly want to thank you, Miss Olson, for your facilitation and all your hard work as well.

And I don't know if you have any closing comments.

I certainly appreciate you.

Only flowing, thank you.

Closing comments would be we were looking for like 30,000 foot direction from where we should be focusing for the next you know three years ish.

Community needs, budget, focus there.

That's super helpful.

And we we purposely are leaving it undone, so it feels undone because we just need the opportunity to take the take the feedback back and then process it through.

Um but we heard all of your comments.

We have documentation of the requested follow-up as well.

So thank you as always very insightful.

And um, and then we'll uh we'll get to work, and I'll pass it to Dr.

Kingsley for wrap us up.

And just read your main on those points.

I want to say thank you for the board for that 30,000 view, and sometimes the 10,000 view and thousand that you provide to us and help us provide the direction and get staff and um and the contributions that they make to our community and asking back that we have grateful and careful for our federal partners or state partners.

Again, you made these points before, but we were opposed to continue to grow and you break things.

Well, I'm gonna close it out with someone who uh shared with me during the break that uh something that was shared to the person, and that was every time you say, and I'm gonna close it by this way every time you share something with someone, smile.

Wasn't that beautiful?

So I'm not gonna say who that was, but honestly, so I say from our hearts, right to all of yours, have a wonderful day.

Thank you so much.

This meeting is closed at 1202.