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NOT WORKING FROM SCRATCH: EVIDENCED BASED PUBLIC HEALTH AND QIMary Kushion, Central Michigan District Health Department
Robert Harmon, Duval County Health Department
QUALITY PLANNINGTogether We Can!
Mary L. Kushion, MSAHealth Officer
Central Michigan District Health DepartmentJune 20, 2012
Quick Overview
• Together We Can – 6 county health improvement planning process.
• Started in 2010 as result of:– Health department’s strategic plan– Preparation for PHAB– Poor showing in County Health Rankings
“Do we have a grant for that?”
• Limited resources• Willing community• Pro-active• Great opportunities
Opportunities
• National Health Policy Forum presentation• Interns in need of projects• National Association of Local Boards of Health
support
CMDHD’s Website
Using The Guide to Community Preventive
Services In Our Community
Including a Cross Reference Guide to the
Areas of Focus of the Central Michigan Health Improvement Planning Working Groups
Cross Reference Guide – Areas of Focus of the Central Michigan Health Improvement Planning Working Groups Referenced to the Sections of The Guide to Community Preventive Services
Health Improvement Areas of Focus
Guide to Community Preventive Services Section H
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Adolescent Health
Alcohol – Preventing Excessive Alcohol Consumption
Asthma Control
Birth Defects
Cancer Prevention and Control
Cancer Prevention & Control: Client–Oriented Screening Interventions
Cancer Prevention & Control: Provider–Oriented Screening Interventions
Cancer Prevention & Control: Education and Policy
Preventing Skin Cancer: Parents & Caregivers
Preventing Skin Cancer: Community–Wide
Cancer Prevention & Control: Promoting Informed Decision Making for Cancer Screening
Diabetes Prevention and Control
Date April 14, 2011
Time 9AM – 3PM
Location Doherty Hotel & Conference Center, Clare, MI
Sponsor Together! We Can Health Improvement Council
Join Us!
Mary Kushion, Health [email protected]
(989) 773-5921 ext. 8421www.CMDHD.org
We will be sharing 2011 County Health Rankings and providing updates on the achievements made in the past 12 months! We will also discuss the plans created to improve the health status in central Michigan. Continental breakfast and lunch provided! Free parking!
Infant Nutrition
How to avoid starting from scratch to invent the wheel
Gave Summit participants “Samples and Examples”:•CDC Community Guide•NACO’s “Healthy Counties Database•“What Works?” Policies and Programs to Improve Wisconsin’s Health•County Health Rankings website
Example from the packet• MATERNAL AND INFANT HEALTH • Expand Teen Parent Program/Support groups which emphasize the importance of
completing high school and continuing education to be in the best position to get a job to afford to raise a family.
• Offer smoking cessation interventions to pregnant women to quit smoking and prevent relapse.
• Promote benefits of breastfeeding (bonding with baby, health benefits of breast milk, cost savings)
• Nurse Home Visiting Programs (Nurse-Family Partnership)• Support/training groups for new parents• Community-wide campaigns to promote the use of folic acid supplements• Recruitment and retention of obstetricians
Eight Priority Areas
• Access to Health Services• Nutrition, Weight Status, and Physical Activity• Reproductive and Sexual Health• Maternal and Infant Health• Substance Abuse• Abusive, Violent and Controlling Behavior• Environmental Health• Transportation
Maternal and Infant Health
Nutrition, Weight Status and Physical Activity
Current Situation Strategy OutcomeThe Michigan rate for children ages 10-17 that exceed a BMI of 30 or more is 30.6%.2
Institute a community campaign to encourage fruit, vegetable and water consumption.
Reduce the percentage of children (ages 10-17) who report a BMI of 30 or more by at least 2% per year for 9 years to reach or exceed the Healthy People 2020 goal of 14.6%.
Promote the “healthy plate” approach to diet/nutrition.
Develop and implement a community campaign to promote recreational facilities and activities by December 2012.
Institute school policies such as expanding school-based physical education classes, active recess and walking/biking to school.
Create better access for Project Fresh participants.
Other evidence-based strategies..
• School-based programs to reduce violence• Increasing alcohol taxes and limiting hours of
sale• Promote the use of folic acid supplements to
pregnant women• Comprehensive risk reduction interventions
for adolescents
And more..
• Worksite wellness programs• Enhanced school-based physical education• Following CDC recommendation for routine
HIV testing for persons aged 13-64• Providing smoking cessation classes• Smoking bans and restrictions
The link to QI and Accreditation
• Just because it is “evidence-based” doesn’t make it a QI project
• Need to do the PLANNING and DOING and CHECKING and ACTING (meetings, spreadsheets, charts, graphs, surveys, and more meetings)
Public Health Technology
Future Plans
• Upload community health assessments and health improvements plans on Dashboard to monitor and evaluate and revise as necessary
• Store and share evidence-based practices, policies and interventions
• Submit the evidence we collect to the CDC task force for review
Closing Thoughts
• Look to see what is already being done in communities similar in size that seems to be working
• Document the actions taken – reserve time to evaluate and revise –it is a great QI effort!
• Remember – all evidence-based interventions started out as an innovative idea! Foster those too!
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Evidence-Based Public Health Practice
and Quality Improvement
Robert G. Harmon, MD, MPHDirector, Duval County Health
DepartmentJacksonville, FL
Presented to Community of Practice for Public Health Improvement: 2012
Open ForumJune 20, 2012Portland, OR
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Population ~915,000Consolidated city-county
government19 clinic sites (6 mobile)~700 staffBudget of ~$48 million/yrFull service, metro, academic
local health Part of Florida Dept. of Health
Duval CHD Facts
28
Duval CHD Senior Mgmt Team Org Chart – 2012
2929
DCHD Revenue for FY 2011-12
by Source (Total = $48.5 M)DCHD Revenue for FY 2011-12 by Source
(Total - $48.5 M)
State GR23%
Medicaid37%
Federal Grants24%
Other Fees4%
Contracts12%
30
DCHD Priorities
Reduce health disparities, especially infant mortality, HIV/AIDS/STDs, cancer, heart disease & stroke
Control epidemic of obesity, inactivity and diabetes
Expand immunization, reproductive health, and TB services
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DCHD Priorities (cont)
Focus on quality improvement, accreditation and Sterling journey
Upgrade technology and implement EHR
Improve facilitiesEnhance community, government
and media relations
32
Quality Improvement Program
Linked to statewide Quality/Performance Improvement Program
Led by Executive Quality Council (quarterly meetings) and departmental policy
Operated by Quality Coordinators Committee (monthly meetings) and Quality Councils in each division
Tracks more than 100 measures via “Top Ten Scorecards”
Linked to strategic plan and annual budget
33
Institute for PH Informatics and Research
Includes nine staff and annual budget of ~$473 K
Produces bimonthly statistical reports, including data for 6 sub-county health zones
Has >25 research, demo and evaluation projectsOversees FL PH Practice-based Research
NetworkInvolved in several QI projectsVisit on www.dchd.net
34
General Uses of Community Guide
All senior managers are asked to use it in planning, budgeting, operating and evaluating their programs
Community partners are included in the process, especially via the Healthy Jacksonville coalitions
No formal training or evaluation of CG to date Strong endorsement from leadership, including
new service line (product development) teams for reproductive health, immunization and TB
Presence of research institute helps to promote evidence-based focus
35
More General Uses of Community Guide
Reference in annual strategic and budget planning retreats
Reference at weekly executive budget review committee meetings, where requests for filling vacant positions and seeking outside grants are reviewed
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Immunization Service Line
•The goal of the service line is to prevent the occurrence of vaccine-preventable diseases in Duval County through increasing childhood, adolescent, and adult immunizations rates
•The current health indicators that are priorities for the service line are
•Percent of two year olds fully immunized•Adults 65 and older who have a flu shot in the last year•Kindergarten students fully certified•7th grade students fully certified
37
Service Line Management (SLM)
DCHD adopted the SLM model in 2009, based on corporate product development and management practices. Leadership identified immunizations, sexually transmitted infections, and family planning as priority areas of concern. In 2010 the Immunization and Reproductive Health Service Lines were created.
The goals of the service lines were too Provide services which are more integrated and seamlesso Improve quality of careo Reinforce DCHD’s mission and strategic plano Have a patient-focused approach to careo Improve patient satisfactiono Take excess cost out of clinical processeso Define responsibility and accountability for
programmatic, clinical and financial performance
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Results The DCHD used vaccination findings and
recommendations from the Guide to Community Preventive Services (Community Guide) to increase 4:3:1:3:3:1 series immunization rates among the our own clinics’ two-year-old population by 20% in two years. Immunization levels increased from 75% in Feb 2009 to 90% in Feb 2011.
The DCHD’s Immunization Service Line won the 2nd place award of the Public Health Foundation’s national “I’m Your Community Guide!” contest.
DCHD’s success story will be included in the inaugural webcast of Public Health Works, a collaboration between the Public Health Foundation and the Centers for Disease Control and Prevention. The program is titled “Immunization Strategies: Using the Evidence and What Works to Improve Practice.” Broadcast is scheduled for late July or early August 2012.
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Evidence-Based Immunization Practices
Interventionso Patient reminders and recalls: Incorporated the use of the Florida
Shots registry to extract data indicating which children needed reminders and recalls on a monthly basis. Many errors in data were discovered through this process, such as children that were no longer in the area or who were no longer clients.
o Health care system-based interventions (education and policy): The health department had staff to administer vaccines, but they were not trained or authorized to do so. Also, physicians were accessible but decided not to give the necessary immunizations, creating missed opportunities. The health department implemented a large-scale training for all clinics, which trained Health Technicians and Licensed Practical Nurses to administer the vaccines, which were formerly only administered by Registered Nurses. In addition, policies that clearly reference ACIP recommendations for vaccination were communicated to providers and combination vaccines were made readily available.
o Community-based interventions (educational media for parents and caregivers): Originally, printed educational materials on immunization showed the range of time a child could receive vaccines and still be considered up-to-date, instead of including a timeline indicating when a child should receive shots. Following clarification of policy for children to obtain immunizations at the earliest eligible opportunities, educational posters were revised and distributed to reflect recommendations that would maximize immunization rates.
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More Evidence-Based Immunization
Practices Resulting Changes
o Patient reminders and recalls o Health Technicians and Licensed
Practical Nurses are authorized to administer vaccines
o Immunization policies are based on ACIP recommendations
o Combination vaccines are readily available
o Educational posters for parents now reflect immunization best practices
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December 2011. This data includes immunization coverage level for 4 DTP/DTaP, 3 OPV/IPV, 1 MMR, 3 Hib, 3 Hep B, and 1 VZV (4/3/1/3/3/1). Immunization rates are critical to prevent the incidence and spread of serious communicable diseases. Immunizations are among the Department of Health’s most cost-beneficial services. (DOH County Snapshot)
0102030405060708090
100
2007 2008 2009 2010 2011Duval 72 83 79 88 92
Palm Beach 62 58 65 90 90
State 82 86 86 94 98
Perc
enta
ge2 year old CHD clients fully immunized >90%
Duval
Palm Beach
State
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Other AccomplishmentsImplementation of the Healthy School
Immunization Award helped to improve the Immunization levels for Kindergarten and 7th graders.
Private and public schools exceeded the target levels of 95% for the first time in 2010/2011 and continue to rank above the state average for 2011/2012.
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Chapter 1003.22, Florida Statutes provides for the requirement of proper documentation prior to school entry and attendance. ** Certificate of immunization (HRS 680-A) is issued when 5+ doses of DTaP, 4+ doses of polio, and 2 doses of measles, 1 mumps, 1 rubella [preferably 2 MMR], 3 hepatitis B and 1 varicella (or 4 DTaP, 3 polio, 2 measles, 1 mumps, and 1 rubella, 3 hepatitis B and 1 varicella if the last dose of DTaP and polio were given on or after child's fourth birthday) are administered. National target is 95%. (DOH)
2007 2008 2009 2010 2011
Duval 93.4 93.8 91.4 95.8 93.9
Miami-Dade 90.8 81.8 82.4 78.9 88.9
State 93.6 89.8 91.3 91.3 92.6
020406080
100
Pe
rce
nta
ge
Kindergarten Students w/Certificate of Immunization
44
Chapter 1003.22, Florida Statutes provides for the requirement of proper documentation prior to school entry into seventh grade. **Florida Certification of Immunization (DH 680-Part A) is issued when (valid) 3 or more doses of any diphtheria and tetanus toxoids and pertussis vaccines including diphtheria and tetanus toxoids, and any acellular pertussis vaccine (DTaP/DTP/DT), 4 or more doses of any poliovirus vaccine, 2 doses of measles, mumps, and rubella(preferably as MMR), 3 or more doses of hepatitis B vaccine, 1 dose of varicella vaccine (or proof of serological evidence of immunity or disease history), and 1 dose of Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) vaccine are administered. National target is 95%. (DOH)
2007 2008 2009 2010 2011
Duval 89.2 89.7 81.7 95.8 98.2
Miami-Dade 83.5 85.1 86.2 85.2 89.5
State 94.4 93.7 93.4 94.7 95.4
020406080
100
Pe
rce
nta
ge
Seventh Grade Students w/Certificate of Immunization
45
Outreach Initiatives Updates
Evidence Based Practice: Community – Based Interventions GABI (“Get a Baby Immunized”) – provide birthing hospitals
(Shands and Memorial) with an immunization package for new mothers and fathers to educate about recommended vaccinations and to tell new parents where shots can be accessed. As of this date 1014 packets have been distributed to Memorial and Shands. (Initiated Sept 2011)
MIO (“Mobilized Immunization Outreach”) – taking information, education, and vaccinations out into the community. As of 09/12/2011 – 05/31/2012) over 4500 encounters via health fairs, community shot clinics, and workshops.
Project Healthy School Immunization Report – monitoring middle schools to assure they are achieving 95% or better immunization rates as required by Florida Law. Rewarding schools who achieve the 95% and identifying and assisting schools that do not achieve the outline goal.
46
Social Media
The team continues to pursue the use of social media Currently we are introducing the HHS Text4baby and
the Vaxtext tools to new parents. Both services are free and voluntary. The services
provide reminder messages concerning immunizations and other relevant preventive care messages directly to the parent’s mobile phone.
The messages coincide with the age of the child. Currently this information is included in all GABI packages delivered to Shands and Memorial birthing centers and at health fairs.
47
Action Plan Items Under Discussion
1) Physician led quality improvement initiative – goal is to close the gap in immunization levels of 2 year olds in Duval County. The model was successfully used in Virginia to improve 2 year old immunization levels over an 18 month period from 50.9% to 69.7%.
2) Immunization Workshop 2012: Host a One-Day Immunization conference in order to provide education on Immunization Policy and Practices.
3) Partner with Pharmaceutical Reps in hosting “Dinner Talks” with Private Providers in the community to encourage their participation in efforts to increase immunization levels in Duval County.
DCHD 2009 DUVAL 2009 DCHD2010 DUVAL 2010 DCHD 2011 DUVAL 2011
Series1 83.0% 77.6% 88% 75.24% 92% 78.70%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Rat
es
A Comparison of Health Department and Overall Community Immunization Levels for 2
year olds in Duval County
48
DCHD Immunization Clients, Visits and Services by Fiscal
YearFiscal Year
Clients Visits Services
2010/2011
16,378 22,026 99,510
2009/2010
15,745 22,242 103,299
2008/2009
16,809 23,186 103,565
49
Increasing the influenza vaccine coverage rate among adults aged 65 and older will decrease disease, decrease hospital length-of-stay, decrease medical costs, and increase quality of life. The national target is 75%. (Behavioral Risk Factor Surveillance System, DOH County Snapshot)
010203040506070
2007 2008 2009 2010 2011Duval 66.2 60.1 68.1 63.9 60.9
Miami-Fort Lauderdale-Miami Beach 48.3 52.1 59.8 44.8 50.8
State 64.7 63.5 64.8 64.6 65.3
Perc
enta
geAdults aged 65 and older that have had a flu shot in
the last year
