480 likes | 623 Views
Toolbox for Improving Program Processes and Health and Housing Outcomes: Experiences of the NYSDOH Lead Primary Prevention Program. Panelists. Moderator: Amy Murphy, MPH, Consultant & TA Provider to the NCHH & NYSDOH Panelists: Cathe Bullwinkle, Oneida County Health Department
E N D
Toolbox for Improving Program Processes and Health and Housing Outcomes: Experiences of the NYSDOH Lead Primary Prevention Program
Panelists Moderator: Amy Murphy, MPH, Consultant & TA Provider to the NCHH & NYSDOH Panelists: • Cathe Bullwinkle,Oneida County Health Department • Debra Lewis, Onondaga County Health Department
NY State CLPPP 8 original pilot locations funded in 2007 15 grantees operating through 2013
NCHH • Provides technical & evaluation assistance • Grantees required to conduct cost analysis and/or outcomes evaluation
Technical Assistance Briefs • Cost Analysis Templates & Guidelines • Effectiveness of targeting high risk blocks • Post-remediation follow-up • Projecting the burden of exposure in areas with low screening rates
Approaches to Cost Analysis • Cost of Illness: Economic burden of a disease • Cost Analysis: Value of the resources required to implement an intervention • Cost-Effectiveness Analysis: Costs saved because an adverse health condition was prevented • Cost-Benefit Analysis: Net benefit determined by subtracting the monetary benefit (averted adverse health or environmental outcomes) from the cost of the intervention
Cost Analysis • Health Care Expenditures • Special Education • Juvenile Delinquency • Early Intervention Program • Cost of Program Services • Benefit of Window Replacement • IQ & Lifetime Earnings Loss • Return on investment
Cost of Illness • Magnitude of a public health problem in monetary terms • Medical, nonmedical, social and educational costs • Potential savings associated with an implementing an intervention
Health Care & Public Costs • Direct health care costs of lead poisoning: • Screening • Medical Management • Nursing Case Management • Environmental Services • 2006 Consumer Price Index • Conservative estimates • Includes only direct medical costs for children
Special Education Expenditures • Impaired neurobehavioral function • 20% of children with blood lead levels >25 µg/dL will need special education. • School districts have average annual cost of special education • Standard Education: $8,322 Special Education: $14,317 • Differential: $5,995 • Three years of special education needed on average
Juvenile Delinquency • Estimated that 10% of juvenile delinquency may be attributed to lead poisoning. • $34,000 per year to incarcerating youth.
IQ & Lifetime Earnings Loss Basic Formula IQ loss within BLL group X Earnings loss per IQ point X Number of children/ category = Net lifetime earnings loss
Mathematical formula for the 2-10 µg/dL group 1. Average Rate of IQ Loss per µg/dL within BLL Group X Total IQ Points Lost within BLL Group 5 x .513 = 2.565 2. Lifetime Earning Loss X Total IQ Points Lost = Loss per child $18,948 X 2.565 = $48,627 3. Applied to the number of children within BLL Group (60) Lifetime earning loss x Number of children 60 X $48,627 $2,917,636
Costs of Lead Exposure in NYS • Cost of illness estimates 2010 • Impact of lead exposure on health care expenditures, special education, and lifetime earnings loss • NYC: $1,555,637,637 (62%)
Early Intervention • Identify children served by EIP • Eliminate those served due to other issues • De-identify eligible children • Extract & organize EIP service data • Link EIP services to costs
Oneida County Costs of Child Find & Early Intervention Newly Diagnosed Children with EBL > 15 ug/dL • Refer all children < 3 at risk for developmental disabilities • Screening - Ages & Stages Questionnaire • 186 children 2009-2010 • 5.3% of all new admissions to CF & EIP
Calculating EIP Costs • Identify children with lead exposure being served by EIP. • Determine if children are being served by EIP because of lead exposure • De-identify the children by assigning a unique child ID. • Extract and obtain information on EIP services received and enter into an Excel spreadsheet. • Date of enrollment • Length of enrollment • Service type: Speech Language Pathology (SLP), Occupational Therapy (OT), Physical Therapy (PT), Special Instruction Teacher/Special Education services, Other Services • Determine costs for EIP Services (In Oneida County, the cost per unit is the same for all services) • Calculate the value of third party reimbursement for services (if available) • Calculate the cost of EIP services per year and per child.
Early Intervention Program • Evaluation to assess & monitor needs • $59.43 per child • Costs of Services: $134,414 (2009-10) • $4,596 Average Total Cost of EIP/Child • $2,143 Average Net Costs after Reimbursement/Child
Additional Efforts • Cost of Illness Estimates 2009-11 • Prevalence Decreases in Target Areas • Quantify the impact of program efforts over time
Onondaga Compare EIP Costs: • Children identified with EBL > 5 ug/dL before EIP enrollment • Children identified with EBL > 5 ug/dL after EIP enrollment • Children receiving EIP services who did not have an EBL
Methodology • Obtain EIP intake logs for 2009 < 36 months of age • Match with LeadWeb Surveillance Data for children • Extra EIP Child Service Reports of eligible children • Calculate Costs of EIP services for each category
Discussion of Findings • Children without an EBL referred at an earlier age due to more severe delays and greater need for services? • Would the findings have been different if used a threshold of 15 ug/dL? • Need to control for age? Referral source? • Look at multi-year service data?
LEAN QI Process Goal: To study the enforcement process Process Elements: • Process mapping • Visioning • Time studies • Policy review • Inclusion of staff at all levels
Issues of Concern • Gaining access/contacting tenants • Multiple field visits • Clerical task duplication • Inefficient management of electronic documents • Long compliance time frames • Hearing schedule backlog
Policy & Procedure Changes • Updated tenant screening form • Integration of enforcement efforts – • Combine hearing notice, order posting, reinspections • Notice & Information eliminated • Policy on vacant properties • Electronic case files and folders
Additional Efforts • IQ & Lifetime Earnings Loss
Costs of Program Services 1. Document protocols or procedures 2. Specify staff roles 3. Develop time estimating worksheets 4. Document time for each step over a period of time 5. Average time across staff 6. Identify hourly rates 7. Calculate intervention costs 8. Determine indirect costs 9. Link to program outputs/activities
Risk Assessment Costs by Type • Includes program activities from the time a housing unit is referred into the program thru dust wipe clearance. • Risk Assessment - No hazards identified: $235.17 • Risk Assessment - Hazards identified: $1,088.70 • Risk Assessment – Enforcement: $1,366.22.* • Analysis: • When enforcement is needed the costs to the program increases, at a minimum, by $277.52. • This cost is incurred per hearing date. • Some cases have multiple hearing dates due to chronic non-compliance.
Monetary Benefit of Window Replacement • Energy Star Window Savings: • 15-24% reduction in energy bills • $20 for every dollar per year in energy savings • Increase in Property Values: • $100 per window • 95% costs of paint stabilization • Health benefits: • $6,847 Pre-1940 Housing • $2,847 1940-1959 Housing • $632 1960-1977 Housing • Formula: Market Value Benefit + Health Benefit – Lead Hazard Control Costs = Net Benefits (CBA) Varies by housing size, # of windows replaced and age of housing.
Data Required • Risk assessment costs • Window replacement costs • Paint stabilization costs • Cleanup and lead dust clearance costs • Number of windows replaced • Annual energy bill pre-lead hazard control
Projecting Prevalence Step 1. Are the demographics of children screened the same as the general population of children? Prevalence rate X Number of children < 6 Step 2. If not representative…. Determine prevalence rates by race Multiply by the number of children of that racial/ethnic origin Add the projections to determine the burden of lead exposure
Effectiveness of Targeting High Risk Blocks Questions: Is there a neighborhood effect? Efficacy of canvassing and focusing on exterior lead hazard control. • Identify comparable geographic areas • Document baseline prevalence • Determine post-intervention burden of lead exposure
Post-remediation Follow-up • How long to housing units remain lead safe? • What is the level of maintenance after LHC and how important is it? • What is the contribution of dust lead tracked in from outside sources? • What is the value of a lead safe housing registry? • How realistic are community-wide remediation targets?
Post-remediation Follow-up Analysis • Number & extent of LBP hazards at each interval. • What rooms or components have a higher likelihood of reoccurring hazards? • How long do housing units remain lead-safe? • Where are dust lead levels the highest post remediation? • Variance based on who conducted the work?
Considerations • Change in inspectional/risk assessment protocols? • Change in interventions standards? • Change in who can conduct work? • Systems requiring maintenance? • Communicate results to owners.
Post-remediation Follow-up Options • Comparison of baseline & post-remediation paint condition. • Examination of post-remediation paint condition & dust levels. • Comparison of baseline & post-remediation paint condition & dust levels.
Return on Investment • Controlling lead hazards • For every dollar spent on LHC, $17-$221 returned in health benefits, increased IQ, higher lifetime earnings, tax revenue, reduced spending on special education and reduced criminal activity • Vaccination • Returns $5.30 - $16.50 for every dollar invested in immunizations
References • Gould E. 2009. Childhood Lead Poisoning: Conservative Estimates of the Social and Economic Benefits of Lead Hazard Control. Environmental Health Perspectives. 117(7): 1162-1167. Uses IQ point loss value of $17,815 from Schwartz, et al (1994) based on 2006 USD. • Korfmacher KS. 2003. Long-Term Costs of Lead Poisoning: How Much Can New York Save by Stopping Lead? Working Paper: Environmental Health Sciences Center, University of Rochester, 9 July 2003. Available: http://www.sehn.org/tccpdf/lead%20costs%20NY.pdf [accessed 10 October 2008]. • Lanphear BP, Hornung R, Khoury J, Yolton K, Baghurst P, Bellinger DC, et al. 2005. Low-Level Environmental Lead Exposure and Children’s Intellectual Function: An International Pooled Analysis. Environmental Health Perspectives. 113:894-899. • Nevin R, Jacobs D, Berg M, Cohen J. 2008. Monetary Benefits of Preventing Childhood Lead Poisoning with Lead-Safe Window Replacement. Environmental Research. 106: 410-419. • Oklahoma Department of Health. September 2010. Economic Impact of Childhood Lead Poisoning. The Bulletin. pp 40-43. Uses IQ point loss value of $18,958 based on 2009 USD (adjusted for inflation). • Zhou F, Santoli J, Messonnier ML, Yusuf HR, Shefer A, Chu SY. 2005. Economic Evaluation of the 7-Vaccine Routine Childhood Immunization Schedule in the United States, 2001. Archives of Pediatrics & Adolescent Medicine 159:1136–1144.