To: Honorable Mayor and Members of Town Council
Through: David L. Corliss, Town Manager
From: Matt Gohl, Special Projects Manager
Title
Discussion/Direction: Public Health Department
Body
______________________________________________________________________
Executive Summary
The following discussion is in response to the Town Council request for information regarding formation of a municipal health department. Colorado Revised Statutes require the formation of public health agencies in counties, districts or municipalities. There are currently no municipally operated health departments in Colorado that do not also comprise county operations (i.e. Broomfield, Denver). Castle Rock, and all of Douglas County, are part of the Tri-County Health Department, which also serves Adams and Arapahoe counties.
As the Douglas County Commission reviews the issue of a Douglas County Health Department in the coming weeks, County staff informs Town staff that the current direction to establish a separate Douglas County health department will proceed, with likely full implementation targeted for January 1, 2023. Existing agreements for funding in 2021 and 2022 cannot be removed, there are significant transitions for State and Federal funding for health departments that must occur and it is functionally and statutorily necessary to have this transition for establishing a new Board of Health, staffing, facilities and related items.
A primary benefit of forming a municipal health department for Castle Rock is that it provides a Town-specific approach to public health for Town residents. Castle Rock would be able to gain limited local control by representing its public health needs separately from other municipalities and counties within the TCHD service area. Despite this independence, a Town of Castle Rock health department would remain under the authority of the Colorado Department of Public Health and Environment (CDPHE). This can be seen in the recent COVID pandemic response. County and district health departments are permitted to apply more stringent restrictions than the State, but cannot be less restrictive without approval from CDPHE. While gaining some local control, a municipally operated health department would not be exempt from State orders and variances would still require State approval. Colorado’s structure for public health agencies has placed responsibility with appointed public health professionals rather than elected officials, which proponents of this structure indicate keeps public health decisions from becoming political matters.
Public health agencies can be separate from, or combined with, human services departments that offer financial assistance programs, adult protection services for at-risk adults and more. Public health services for Castle Rock residents are provided by TCHD while human services programs are offered through Douglas County. The following discussion pertains only to public health services and impacts of withdrawing from TCHD to form a municipal health department. The following discussion is comprised of three sections:
• Statutory Overview: Provides background on the formation and modification of public health agencies as identified in the Colorado Revised Statutes, including duties and responsibilities.
• Colorado Health Departments: High level review of health departments in Colorado, with more detailed information regarding the structure and services of the Tri-County Health Department.
• Budget Impact: Financial considerations of a municipal health department prepared by utilizing the City and County of Broomfield as a comparative entity. Staff estimates that annual operating costs of a municipal health department would be $3-4 million plus additional one-time costs for a facility and equipment. In order to avoid a reduction in levels of service, an additional revenue source, such as an additional mill levy on Castle Rock residents, would be required.
Discussion
Formation of public health agencies, including structure and required duties/functions are provided in Title 25 of the Colorado Revised Statutes (CRS). The following discussion is intended to provide a summary of the statutory basis for public health agencies, an overview of health departments in Colorado and information on the Tri-County Health Department (TCHD), which serves Douglas County and the Town of Castle Rock.
Statutory Overview
Formation and Modification of Public Health Agencies
CRS Title 25 establishes the State Department of Public Health and Environment (CRS §25-1-102) and requires formation of County or district public health agencies (CRS §25-1-506). Contiguous counties are able to merge into a public health district that serves all unincorporated and municipal corporations within the boundaries of the district. Formation of municipal public health agencies is included in CRS §25-1-507, which states:
Except as otherwise provided by law, the mayor and council of each incorporated town or city, whether incorporated under general statutes or special charter in this state, may establish a municipal public health agency and appoint a municipal board of health. If appointed, the municipal board of health shall have all the powers and responsibilities and perform all the duties of a county or district board of health as provided in this part 5 within the limits of the respective city or town of which they are the officers.
Note that references to “part 5” in this discussion refer to the section of CRS Title 25 entitled “Public Health” in its entirety.
Joining or Withdrawal from a Public Health Agency
Counties that border an existing district may join an existing health agency by agreement of the county commissioners (CRS §25-1-513). Counties may also join with other counties to create a public health district as established in (CRS §25-1-506).
Per State statute, Counties can withdraw from a district by a resolution of the board of county commissions and after providing one-year’s written notice to the public health agency (CRS §25-1-513 (2)). Municipalities may withdraw from a county or district public health agency by resolution of the city council (CRS §25-1-513 (3)). It is not clear in statute how to form a municipal health agency or the required notification period. Upon withdrawal from a district, the county or municipality creates its own public health agency or joins another contiguous county to form a new district. With the formation of a municipal health department, CRS §25-1-507 notes that the Mayor and Town Council would appoint a municipal board of health that would have all of the powers and responsibilities provided in the statute. Not only would the formation of a new health department include the complexities of forming an entirely new operation, but also of disconnecting/transitioning finances and programs from TCHD. While statute is unclear regarding the required notice for a municipality to withdraw, one to two-year transition period seems reasonable given the numerous legal and operational needs that would be required.
Public Health Board Oversight/Appointment
County or district public health agencies are under the oversight of a public health board (CRS §25-1-108). The public health board is comprised of at least five members serving five-year terms. County health board members are appointed by county commissioners, and district health boards are required to have at least one representative from each county in the district. District members are selected by an “appointments committee” that consists of one county commissioner from each county within the public health district. Appointees must reside in the county in which they represent, and there are requirements in place to ensure that “no business or professional group or governmental entity shall constitute a majority of the district board” (CRS §25-1-108(3)(b)). Officers, such as the president of the board, are elected to the position by the members of the board. In addition to required duties of the health department, which are discussed later, public health boards also have the following powers and duties as stipulated in CRS §25-1-108(5):
• (a) To develop and promote the public policies needed to secure the conditions necessary for a healthy community;
• (b) To approve the local public health plan completed by the county or district agency, and to submit the local plan to the state board for review;
• (c) To select a public health director and (d) to fill a vacancy in the public health director position;
• (e) To provide, equip, and maintain suitable offices and all necessary facilities for the proper administration and provision of core public health services, as defined by the state board;
• (f) To determine general policies to be followed by the public health director in administering and enforcing public health laws, orders, and rules of the county or district board, and orders, rules, and standards of the state board;
• (g) To issue orders and to adopt rules not inconsistent with the public health laws of this state nor with the orders or rules of the state board as the county or district board may deem necessary for the proper exercise of the powers and duties vested in or imposed upon an agency or county or district board by this part 5;
• (h) To act in an advisory capacity to the public health director on all matters pertaining to public health;
• (i) To hold hearings, administer oaths, subpoena witnesses, and take testimony in all matters relating to the exercise and performance of the powers and duties vested in or imposed upon a county or district board;
• (j) To provide environmental health services and to assess fees to offset the actual, direct cost of such services;
• (k) To accept and, through the public health director, to use, disburse, and administer all federal aid, state aid, or other property, services, or moneys allotted to an agency for county or district public health functions or allotted without designation of a specific agency for purposes that are within the functions of an agency, and to prescribe, by rule consistent with the laws of this state, the conditions under which the property, services, or moneys shall be accepted and administered. The county or district board is empowered to make agreements that may be required to receive such moneys or other assistance.
• (l) To approve, as provided for in section 25-1-520, a clean syringe exchange program proposed by an agency. A county board of health or district board of health shall not be required to approve a proposed program.
Public Health Agency Duties and Responsibilities
In addition to the duties of the health board shown previously, public health agencies have numerous statutorily required duties and responsibilities. While subject to available appropriations, public health agencies “shall provide or arrange for the provisions of services necessary to carry out the public health laws and rules of the state board, the water quality control commission, the air quality control commission, and the solid and hazardous waste commission according to the specific needs and resources available within the community.” (CRS §25-1-506(3)(a)). These needs are determined by the board, statewide public health improvement plan and a county/district/municipal public health plan. Additional duties and responsibilities are outlined in CRS §25-1-506(3) and include:
• Preparation and completion of a community health assessment at least every five years (this collaborative process includes community engagement in plan development and implementation/evaluation over the course of several years)
• Advise the health board on public policy issues necessary to protect public health and environment
• Provide quality core health services that are deemed essential by the state board and within the statewide public health improvement plan
• Administer and enforce laws related to:
o Public health, air pollution, solid and hazardous waste and water quality
o Vital statistics
o Orders, rules and standards of the state board
• Investigate and control the causes of epidemic or communicable diseases
• Establish, maintain and enforce isolation and quarantine for the purpose of protecting the public health
• Close schools and public places to prohibit gatherings of people when necessary to protect public health
• Investigate and abate nuisances when necessary in order to eliminate sources of epidemic or communicable diseases and conditions affecting public health
• Establish, maintain or make available chemical, bacteriological and biological laboratories, and to conduct such laboratory investigations and examinations as it may deem necessary or proper for the protection of the public health
• Purchase and distribute to licensed physicians and veterinarians, with or without charge, as the county or district board may determine upon considerations of emergency or need, approved biological or therapeutic products necessary for the protection of public health
• Initiate and carry out health programs consistent with state law that are necessary or desirable to protect public health and the environment
• Collect, compile and tabulate reports of marriages, dissolutions of marriage, and declarations of invalidity of marriage, births, deaths and morbidity, and to require any person having information with regard to the same to make such reports and submit such information as is required by law or the rules of the state board
• Make necessary sanitation and health investigations and inspections, on its own initiative or in cooperation with the state department, for matters affecting public health that are within the jurisdiction and control of the agency
• Collaborate with the state department and the state board in all matters pertaining to public health; the water quality control commission in all matters pertaining to water quality; the air quality control commission and the division of administration of the state department in all matters pertaining to air pollution; and the solid and hazardous waste commission in all matters pertaining to solid and hazardous waste
• Establish, subject to available appropriations, a child fatality prevention review team
If the board of health does not have sufficient appropriations to fulfill all of the duties stated above, the board is required to set priorities for fulfilling the duties and include the priority list in its public health plan.
Colorado Health Departments
Attachment A includes a listing of all health departments in Colorado. As seen in the listing, there are no public health departments operated solely by municipalities in Colorado at this time. Certain municipalities such as Denver and Broomfield, which are also counties, operate health departments. Public health matters for the Town of Castle Rock, as part of Douglas County, are under the oversight of the Tri-County Health Department (TCHD), which also serves Adams and Arapahoe counties. Following is more information about the history, structure and services provided by TCHD.
History of Public Health in Colorado
The Colorado Association of Local Public Health Officials (CALPHO) provides a number of resources pertaining to public health in Colorado. The following historical information has been summarized from resources available on their website (www.calpho.org <http://www.calpho.org>).
Colorado’s State Board of Health was first established in 1877 with many of the same responsibilities of today’s health agencies. Dr. Florence Sabin was instrumental in improving the healthcare system across Colorado. Dr. Sabin was appointed by Governor Charles Vivian to a new health subcommittee. Dr. Sabin’s biography (found at <https://coloradoencyclopedia.org/article/dr-florence-rena-sabin>) notes that the state exceeded the national average in 13 of the 20 major causes of death at that time. The “Sabin Bills” were passed in 1947 resulting in the organization of the State Health Department, a fair appointment process for the advisory board and securing funding to assist with health facilities and services.
The State Health Department was subsequently renamed to the Colorado Department of Public Health and Environment (CDPHE) in 1994. The role and makeup of public health agencies was formalized in the 2008 Public Health Act.
Tri-County Health Department
TCHD was formed by Adams, Arapahoe and Jefferson Counties on January 1, 1948. Jefferson County separated from the district health department in 1958 to create its own county health department, and Douglas County joined TCHD in 1966. Douglas County in 2009 reestablished TCHD as the public health agency of Douglas County. This was required by the Colorado Public Health Reauthorization Act of 2008. The purpose of this act was to ensure that public health services were available to everyone in Colorado.
TCHD’s Board of Health is comprised of nine members, three from each county within the district. As provided by statute, board members serve five-year terms with staggered end dates. Board members are appointed by their respective County Commissioners. Douglas County residents interested in serving on this board can apply on the Douglas County website (<https://www.douglas.co.us/government/commissioners/citizen-advisory-boards-committees-and-commissions/>). Each of the current board members representing Douglas County have medical accreditations including Master of Public Health (MPH), Nurse Practitioner (NP) and Registered Nurse (RN). Current board members representing Douglas County are as follows:
• Zachary Nannestad, MPH (Term expires January 2024) - Board Vice President
• Marsha Jaroch, NP (Term expires January 2025)
• Paulette Joswick, RN (Term expires January 2023)
TCHD serves more than 1.5 million people in the three-county area and operates out of 11 offices across the district, including one in Castle Rock. Note that formation of a municipal health department may be complicated by the unincorporated enclaves located throughout Castle Rock. Town law enforcement has successfully divided responsibilities in these enclaves, but it is important to understand nuances associated with forming a municipal health department. For example, Castle View High School would be under a Town municipal health department while Douglas County High School would remain with TCHD since it is located in unincorporated Douglas County. Similarly, restaurants/businesses in the Castleton Court area would be under the jurisdiction of different health agencies depending on which side of the street they are located.
In addition to the Statewide public health improvement plan, each health agency is required to prepare a health plan for its specific area. The 2019 - 2024 Public Health Improvement Plan for TCHD includes four priorities, which are listed with vision statements below:
• Access to Mental and Physical Health Care Services
o Vision: In a healthy community, all people across the life course, regardless of their income or other circumstances, can access high-quality physical health, mental health, and substance use services.
• Mental Health
o Vision: In a healthy community, positive mental health and social connections allow people to have the mental and physical energy, vitality, and resilience to live joyfully and cope with the stresses of life, work productively, and make meaningful contributions to their communities.
• Health and Food
o Vision: In a healthy community, all residents can access safe, nutritious, affordable, and culturally relevant food and are able to practice healthy eating habits.
• Health and Housing
o Vision: In a healthy community, quality, attainable housing is available, and people have the tools and resources to stay in their communities and feel connected to their neighborhood.
In addition to required core services, these four priorities help guide the programs offered by TCHD. The department is divided into eight functions as demonstrated on its organizational chart in Attachment B. In addition to the necessary administrative functions (finance, budget, facilities, etc.) and human resources functions, there are six programmatic divisions that are responsible for delivering services to the 1.5 million people in the district. According to TCHD’s website (<https://www.tchd.org/572/Division-Descriptions>), descriptions of these six programmatic divisions are shown below:
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Nutrition Division Promotes wellness across the lifespan through nutrition policy and programs to improve the nutritional health status of clients and the community. |
Nursing Division Focuses on promoting good health for children and adults through linkages to health insurance and health care services, nurse case management, disease prevention and clinical, preventive and health education programs. |
Environmental Health Division Focuses on preventing communicable disease and environmental conditions that could be harmful to health through education/consultation, response and investigation and enforcement of regulations. |
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Emergency Preparedness, Response, and Communicable Disease Surveillance Division Leads agency efforts to promote coordination, collaboration and communication among all divisions in TCHD to ensure that public health is an effective partner in preparedness, response and recovery efforts. Additionally, the division conducts surveillance, investigation, and mitigation efforts in response to incidents of communicable disease. |
Planning and Information Management Division Helps programs to achieve maximum efficiency and effectiveness through data collection, analysis and mapping services, informatics, information technology, performance management and quality improvement, program planning and accreditation. |
Community Health Promotion Division Works directly with community members and leaders to promote health and wellness across all ages through programs including aging initiatives and injury prevention, community nutrition, diabetes education, healthy beverage partnership, mental and behavioral health promotion, tobacco and substance abuse prevention and worksite wellness and breastfeeding policy work. |
There are numerous programs offered through TCHD related to public and environmental health. Some of the specific services provided are listed below with more information included in the brochure in Attachment C.
• • Provision of vital records including issuance of birth and death certificates
• Health inspection services for restaurants, mobile food (food trucks/push carts), temporary food events (festivals, etc.), swimming pools, childcare centers and body art/tattoo facilities
• On-site wastewater treatment (septic) system approvals and permitting for installation, repair and use
• Consultations on environmental exposures
• Land use consultation
• Methamphetamine laboratory clean-up consultation
• Syringe disposal services, overdose prevention, wound care education and kits, referrals to mental health and addiction services
• Emergency preparedness and response
• Disease outbreak identification and management
• Analysis of community health data
• Tobacco prevention, youth vaping prevention, marijuana resources and opioid abuse resources
• Injury prevention
• Sexual health including birth control services, emergency contraception, pregnancy testing, testing/treatment for sexually transmitted infections (STIs) and health exams
• Immunizations including flu shots, routine and travel vaccinations
• Maternal and Child Health (MCH) services including breastfeeding support, healthcare programs for children with special healthcare needs, pregnancy related depression support and nursing support
• Women, Infants and Children (WIC) program that provides free nutritious food and nutrition education to participating families plus breastfeeding support and referrals to other programs as needed (such as dental care or SNAP)
• Household chemical roundup events
• Nutrition education
• Public communication
• Providing numerous resources to the public on a variety of other topics including mental health, worksite health and wellbeing, chronic disease prevention, sun safety and more
The 2021 adopted budget for TCHD is approximately $55.5 million. There are numerous funding sources that support this budget including county appropriations, county program-specific funds, grants/contracts, fees/donations, State funds, Federal pass-through funds, Medicaid funds, use of fund balance and in-kind revenue. The chart below, from TCHD’s adopted budget, represents the proportion of revenue received from these sources.
County appropriations are direct amounts assessed to the three counties within TCHD and make up 20% of total revenue. These appropriations are determined by County populations and a per-capita rate for services. For 2021, this per-capita rate is $7.10 - no change from 2020. Due to the population increase, Douglas County experienced a 2.6% increase for 2021, resulting in a contribution of $2,550,521 to Tri-County Health Department. There is no specific mill levy within Douglas County that is assessed for the purpose of funding this contribution to TCHD, meaning that Castle Rock residents do not pay additional taxes specifically for health services.
Weld County Health Department
Weld County is a home-rule county currently operating its own health department. The board of health is appointed by the County Commissioners and consists of nine members. Six members are appointed from six different geographic areas and three members are appointed at-large. Throughout the COVID-19 pandemic, the Weld County Commissioners stated that they would not enforce the State Public Health Orders. The County believes that the Governor’s executive orders should have been issued following a thorough rulemaking processing under the Administrative Procedures Act rather than being formed independently. The legal determination of Weld County actions is unclear at this time, however, it does not appear that there is any State law that allows a county, regional or municipal health agency - even within a home-rule area - to be separate from the State health department.
Status of Douglas County Health Department
Town Council considered establishment of a Castle Rock municipal health department in July 2020. At that time, Douglas County also indicated its plan to withdraw from TCHD in order to form a County health agency. Town Council decided at that time to cease looking into a municipal health department and, rather, work with Douglas County in their efforts. Currently, Douglas County is still considering withdrawal from TCHD.
Recent discussions with Douglas County officials indicate that the withdrawal from TCHD and formation of a Douglas County Health Department will be a priority moving forward. As the Douglas County Commission reviews the issue of a Douglas County Health Department in the coming weeks, County staff informs Town staff that the current direction to establish a separate Douglas County health department will proceed, with likely full implementation targeted for January 1, 2023. Existing agreements for funding in 2021 and 2022 cannot be removed, there are significant transitions for State and Federal funding for health departments that must occur and it is functionally and statutorily necessary to have this transition for establishing a new Board of Health, staffing, facilities and related items. Castle Rock Town Council may, if it desires, adopt a resolution to request the County be as expeditious as possible in the formation of the County Health Department; and, to respectfully request a role in governance of the health board.
Local Health Agency Authority
Local health agencies have rights and responsibilities as set out in Title 25 of the Colorado Revised Statutes. Each agency is responsible for oversight of health services and programs that align with State priorities. Local health agencies are generally able to provide stricter regulations/orders than the State but are not able to have less restrictive measures in place.
It will be important for Council to bear in mind that the property tax cost of establishing a local health department cannot guarantee that such department’s local public health orders would not be superseded by CDPHE orders. If a Town health department public health order was contrary to the views of CDPHE regarding public health, it is likely that such Town order would be overruled and superseded.
Budget Impact
If Town Council wishes to pursue the creation and development of a municipal public health department, additional planning related to one-time capital costs (office building, land, equipment, etc.) and ongoing operational funding will be required. Town staff has performed a high-level analysis of the City and County of Broomfield budget in order to better understand the financial support required to operate a public health department. Broomfield estimates its population to be 73,761 as of November 30, 2020, making it a reasonable comparison with the Town of Castle Rock.
The City and County of Broomfield offers both public health and human services to its residents. Broomfield’s public health department offers numerous services consistent with TCHD including, but not limited to, reproductive health, immunization, substance abuse programs, tobacco education and vital statistics.
Broomfield’s public health division is budgeted within the county’s general fund. According to the proposed budget for 2021, budgeted expenditures total $3,727,924. This budget information equates to per-capita costs of $50.54 for Broomfield, compared to the current Douglas County contribution of $7.10 to TCHD for each County resident. This is an increase of 11% from Broomfield’s 2020 revised budget with increases related to temporary needs associated with COVID. This budget provides funding 25.82 full-time and 4.5 part-time personnel including a director, assistant director, administrative staff, nurses, reproductive health administrator, nutritionist, public health educator, environmental health specialists, emergency preparedness coordinator and more.
A portion of the funding for Broomfield’s health department comes from a Public Health mill levy of 1.230, estimated to result in $1,869,777 in 2021. While not explicitly detailed within the budget, it is reasonable to assume that other sources of funds used to support public health include charges for service, licenses/permitting and intergovernmental revenue such as grants.
Assuming comparable financial needs for a municipal health department in Castle Rock, current revenues would not be able to sustain operational costs. A new revenue source, such as a property tax assessment, would need to be identified and approved for this purpose. Based on the Town’s 2021 valuation, staff estimates that over three mills would need to be assessed on Castle Rock residents to support municipal health department operations. Given TABOR requirements, Castle Rock voters would be required to approve a new tax needed to operate a municipal health department. If Town Council would like to include a proposed municipal health mill levy to Castle Rock voters as part of the November election, Town Council would need to prepare and approve the first reading of the ballot question no later than August 17, 2021.
Any mill levy - likely to be four to five mills including capital costs - approved by voters should be exempt from TABOR revenue growth limitations, so that the addition of this revenue does not harm our ability to adequately fund core Town services such as police, fire and road maintenance. This “De-brucing” should occur concurrent with voter approval of any mill levy. Additionally, a new property tax mill levy for a local health department competes with future revenue needs for core services. This decade is likely to see the need to ask voters for a property tax mill levy to supplement existing revenue streams to support the Town’s public safety - police and fire - departments going forward. Four or five mills of property taxes for a health department may make it unlikely that voters will support a new and additional mill levy for police and fire that will likely be needed in the future for Castle Rock to maintain our levels of service in this area.
The Town does not currently have available facility space to house a municipal health department. A municipal health department would require construction or acquisition of space. TCHD’s Castle Rock office is located at 410 S. Wilcox St. and is approximately 12,000 square feet. TCHD acquired this site in 2019 for a cost of $4.3 million. Castle Rock Water prepared a contract for construction of a new administration building to be located on existing Town property. This facility was estimated to be roughly 13,000 square feet and Town Council approved a construction contract for $3.94 million for the project. Note that this is building construction only, with no land acquisition costs. Based on this information, it is reasonable to assume that construction or acquisition of a health department facility for Castle Rock would cost between $4 - $5 million depending on specific needs including locations, land/facility availability and site specifications. In addition to physical space, the facility would need to be equipped appropriately. Staff has not researched the investment required and does not have an estimate for these one-time costs. Similar to operating costs, a funding source would need to be identified for these one-time costs as well.
The Town does not have the authority to collect impact fees for a public health purpose, so debt issuance would likely be required to accommodate facility space and equipment costs. In addition to an operating mill levy, the Town could ask voters to approve an additional debt service mill levy to repay debt over time. The combined mill levy to Castle Rock residents to fund public health operations and debt service for one-time costs could be up to five mills depending on actual costs.
Next Steps/Considerations
Town Council has numerous options for future action related to health department services for Castle Rock residents. Among the options include:
• Consider a resolution encouraging Douglas County to expedite their withdrawal from TCHD and seek a role in County health department formation and governance.
• Remain within Tri-County Health Department jurisdiction.
• Seek legal requirements that any public health order impacting the Town of Castle Rock only occur with the majority concurrence of Castle Rock Town Council. This would allow for Town elected officials to determine the appropriateness of any public health order (PHO) impacting Castle Rock residents and businesses. This would likely require either statutory changes and/or changes with intergovernmental agreements (IGAs) between the County and TCHD. This does have the advantage of getting at the issue concerning the lack of local control of PHOs from TCHD, but it would not change the authority of the State acting through CDPHE that would require State statutory changes.
• Pursue formation of a municipal health agency. This approach requires addressing the numerous legal and operational needs discussed previously, including identification funding sources. Noting the deadline for Council consideration for first reading on an ordinance for a mill levy is the only Council meeting in August - August 17.
Attachments
Attachment A: Colorado Health Department Listing
Attachment B: Tri-County Health Department Organizational Chart
Attachment C: Tri-County Health Department Brochure