Procedural description and limitations of collaborating with health care providers in lead poisoning screening in Miami

1. Procedural description and limitations of collaborating with health care providers in lead poisoning screening in Miami-Dade County, Florida Janvier Gasana, MD, MPH, PhD, Kristy A. Siegel, MPH, CHES, Janisse Rosario, MPH, and Emily A. Owens, MPH Florida Children’s Environmental Health Alliance, Stempel School of Public Health, Florida International University, Miami, Florida • From 1997 to 2001, only 23.2% of 54,342 Medicaid-eligible children were being screened for lead poisoning in the county. • In the most at-risk communities of Liberty City, Little Haiti, Little Havana, and Overtown, screening rates ranged from 15.7% to 38.7%. • Clarify reimbursement. • Necessary procedures to follow and who to contact if appropriate payment is not received are key elements. The local public health officer should offer to personally intervene with insurance carriers if physicians feel they have been denied appropriate reimbursement. Such an offer eases physicians’ minds, creates substantial goodwill, and results in surprisingly few requests to the health officer. • Make known available support. • Local public health should continue to provide private sector patients services that their physicians do not provide and should take special care to ensure that physicians are aware of the support that is available. • Build demand. • Parents of children at risk for lead poisoning can be educated and motivated to seek blood lead screening from their physicians if local public health is diligent and skillful in marketing meaningful messages to them. • Demonstrate leadership. • Meaningful public / private collaboration in childhood lead poisoning prevention does require that local public health institutions have the competence, credibility, and audacity to assume leadership positions. It can be expected that some members of the private medical community will be skeptical, even hostile, to public health leadership. Thus, the final step requires that local public health officials have the courage to lead. RESULTS / DISCUSSION • Of the thirteen physicians initially contacted, less than half agreed to sign the Memorandum of Understanding. The reasons given for not collaborating with the PAL Project included: • Reimbursement issues • Lack of desire to participate and/or Belief that CLP is not an issue for their patients • Confidentiality concerns raised by Heath Insurance Portability and Accountability Act (HIPAA) standards To combat these collaboration issues, we have revised our partner-seeking process. It now includes: • Clear delineation of the role FCEHA plays in the reimbursement to physicians for screening uninsured children within the target area. We also provide to the physicians the proper Medicaid reimbursement code to help ensure that documentation is filed correctly for Medicaid-eligible patients. • In our presentations to physicians, we use GIS images of our target area, clearly illustrating the disproportionately high prevalence of CLP, while at the same time showing the latest findings on health effects of lead exposure. In addition, we show the screening rates for lead poisoning for the state of Florida, Miami-Dade County, and finally, the rates for our targeted communities. This highlights the sequential decrease in rates as we go from state to local, which indicates more needs to be done in the local sector. Also illustrating the pertinent role physicians who serve this community can play in decreasing the rates of CLP by increasing the rates of screening. • With the new HIPAA rules and standards, it is important for us to demonstrate to the physicians the steps taken to respect and ensure confidentiality of their patients. Protected health information (PHI) is only recorded for blood lead screenings, to facilitate in the identification, notice, and treatment of a child with an elevated blood level. The community risk assessment surveys do not request PHI and are not matched to blood results, thereby increasing the security of the data gathered. Following the revised and improved partner-seeking process, we have now been able to increase our partnership to ten physicians, as well as eight clinics that serve the target communities and residents. ABSTRACT Many health care providers are unaware of the lead burden affecting children in Miami-Dade County, Florida. Data provided by the Agency for Health Care Administration shows that in 2001, the screening rates for blood lead levels of children in the zip codes comprising Little Haiti, Liberty City, Little River, Little Havana, and Overtown ranged from 15.6% to 38.7%. Based on these findings, the Florida Children’s Environmental Health Alliance initiated the Partnership Against Lead (PAL) Project. Among the goals of the PAL Project is to motivate health care providers to routinely screen children six years of age and under for lead poisoning, following the recommendations established by the Centers for Disease Control and Prevention. One strategy for increasing screening in the high-risk communities is to contact providers and establish a partnership. Using the seven action steps outlined by Dr. Thomas L. Schlenker to effectively collaborate with providers in lead poisoning, we have identified and contacted 13 physicians in the communities. Less than half of the contacted physicians signed a Memorandum of Understanding. The reasons given for not signing included reimbursement issues, lack of desire to participate, and confidentiality concerns raised by the new HIPAA standards. Confidentiality concerns are a newly raised issue in this field. As such, we are working diligently to combat this issue, along with the others, to continue our objective to help eliminate childhood lead poisoning in our high-risk communities. GOALS OF PAL PROJECT • To motivate health care providers to routinely screen children through engagement of providers in the community. • To establish a partnership among local government agencies, community-based organizations, private organizations, educational institutions, health care professionals, parents, and other interested professionals. • To educate parents and children to decrease exposure in the home due to unawareness of sources and hand-to-mouth behaviors. SEVEN ACTION STEPS • Dr. Thomas L. Schlenke’s Seven Action Steps toward Effective Collaboration: • Establish a rationale. • Address the seriousness of the disease, its prevalence, the adequacy of screening methods, and the benefits and costs of treatment adjusted for the unique circumstances of the community. • Document the problem. • Current blood lead levels from an appropriately selected sample of children in the community are best. Should be presented to the physicians in brief, graphic, and easy-to-read written materials, discussed at grand rounds and other medical meetings, published in appropriate professional journals, actively marketed to the local media, and distributed as directly as possible to the families most at risk. • Attend to logistics. • Local public health officials should visit physicians’ offices and invest the necessary time to train their staffs in phlebotomy techniques, interacting with laboratories, and reporting results. Although initially labor intensive, such professional outreach creates productive and long-lasting collaborative relationships. METHODS BACKGROUND • Based on the goals of the PAL Project: • Motivation of health care providers through: • Signing of Memorandum of Understanding • Using a risk assessment questionnaire • Providing educational materials (to patient and provider) • Reimbursing screenings of non-insured • Establishment of partnership through: • Serving position on board; active in decision-making process • Collaborating on grant-writing and education and promotion of screening • Education of parents and children through: • Conducting presentations at pre-schools and daycare centers • Screening the children after the presentations • Organizing health fairs for the community • Disseminating information in a culturally-competent manner • Miami-Dade County is one of the poorest counties in the nation. • Unique in that it serves as a major port of entry to many immigrants and refugees from predominately Cuba and Haiti. • Miami-Dade County Health Department has received about 400 reports of elevated blood lead levels annually since 1999. • The inner-city areas of Liberty City, North Miami, Little Havana, Little Haiti, Overtown, and Downtown Miami represent a disproportionate share of the percentage of lead poisoned children less than 72 months of age when compared to the distribution of the children of the same age in the population. • Over 60% of all childhood lead poisoning (CLP) cases reported are residents of the Liberty City, North Miami, Hialeah/Miami Lakes, Little Havana, and Little Haiti areas. REFERENCES ACKNOWLEDGEMENTS • Centers for Disease Control and Prevention. (1997). Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials. Atlanta • Gasana, J. & Chamorro, A. (2002). Environmental lead contamination in Miami inner-city area. Journal of Exposure Analysis of Environmental Epidemiology, 12, 265-272. • Miami-Dade County Health Department. (2004). Lead Poisoning in Miami-Dade County: The Last Five Years 1999-2003. Epi Monthly Report, 5, 5, 1-4. • Needleman, H. (2004). Lead Poisoning. Annual Review of Medicine, 55, 209-222. • Schlenker, T.L. (1999). Collaborating with Private Sector Physicians: The Example of Childhood Lead Poisoning. Journal of Public Health Management and Practice, 5, 6, 35-40. • Silbergeld, E.K. (1997). Preventing Lead Poisoning in Children. Annual Review of Public Health, 18, 187-210. Florida International University Dev Pathak, MS, MBA, DBA Veronica Bedford Barry University Jeremy Montague, Ph.D.