Not working from scratch: evidenced based public health and qi

1. Mary Kushion, Central Michigan District Health Department Robert Harmon, Duval County Health Department Not working from scratch: evidenced based public health and qi

2. QUALITY PLANNINGTogether We Can! Mary L. Kushion, MSA Health Officer Central Michigan District Health Department June 20, 2012

3. 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

4. “Do we have a grant for that?” • Limited resources • Willing community • Pro-active • Great opportunities

5. Opportunities • National Health Policy Forum presentation • Interns in need of projects • National Association of Local Boards of Health support

7. CMDHD’s Website

10. Infant Nutrition 2

11. 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

12. 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

14. 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

15. Maternal and Infant Health

16. Nutrition, Weight Status and Physical Activity

17. 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

18. 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

19. 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)

21. Public Health Technology

24. 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

25. 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!

26. 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 Forum June 20, 2012 Portland, OR

27. Duval CHD Facts • Population ~915,000 • Consolidated city-county government • 19 clinic sites (6 mobile) • ~700 staff • Budget of ~$48 million/yr • Full service, metro, academic local health • Part of Florida Dept. of Health

28. Duval CHD Senior Mgmt Team Org Chart – 2012

29. DCHD Revenue for FY 2011-12 by Source (Total = $48.5 M) 29

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

31. DCHD Priorities (cont) • Focus on quality improvement, accreditation and Sterling journey • Upgrade technology and implement EHR • Improve facilities • Enhance 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 projects • Oversees FL PH Practice-based Research Network • Involved in several QI projects • Visit 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

36. 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 Immunization Service Line

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 to • Provide services which are more integrated and seamless • Improve quality of care • Reinforce DCHD’s mission and strategic plan • Have a patient-focused approach to care • Improve patient satisfaction • Take excess cost out of clinical processes • Define responsibility and accountability for programmatic, clinical and financial performance

38. 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.

39. Evidence-Based Immunization Practices • Interventions • 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. • 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. • 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.

40. More Evidence-Based Immunization Practices • Resulting Changes • Patient reminders and recalls • Health Technicians and Licensed Practical Nurses are authorized to administer vaccines • Immunization policies are based on ACIP recommendations • Combination vaccines are readily available • Educational posters for parents now reflect immunization best practices

41. 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)

42. Other Accomplishments • Implementation 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.

43. 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)

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)

45. Outreach Initiatives UpdatesEvidence 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.

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)

50. My contact info • DCHD Web site: www.dchd.net • E-mail: robert_harmon@doh.state.fl.us • Phone: 904-253-1010