Monday, October 6, 2014

Are We Ready? No!

I am talking about Ebola of course. And yes I am exaggerating, because Ebola cannot break out and ravage communities in the US the way it can in Africa. But in a larger sense it is true we are not prepared. Many people would be shocked to learn how weak and fragmented our public health system has become (expect to see more of the kind of Ebola-bungles that have recently occurred in Texas). Even fewer people realize this is the result of policy choices we have made that have turned out badly.

First some basic facts. The CDC’s budget was $6.5 billion in 2010. It is $5.9 billion now. I am happy to say that some of these cuts are likely to be restored next year, but we are still expecting a $54 million cut from emergency preparedness. State and local public health depend on the CDC for much of their budgets, so cuts at the federal level trickle down and affect the ability of public health to respond to local problems. The chart on the right shows the budget trends for the Mid-Michigan District Health Department for the past five years.  According to the National Association of County and City Health Officials, local health departments have laid off 48,300 people since 2008. That’s a huge reduction in our ability to respond. Cuts at the CDC affect hospitals, too, which have taken a 33% whack to funding for hospital emergency preparedness activities.

Another fact that would surprise many people is that we do not have a strong, vertically integrated public health system. The CDC is a federal agency accountable to Congress. State public health is accountable to governors, and local public health in most places is a local agency, like a sheriff’s department. Each level of the system is accountable to a different authority and it is difficult to coordinate their work or get them to communicate effectively and efficiently.

This state of affairs isn't an accident. It is the result of policy choices made in the past. Obviously we could have a more unified system if we wanted it and worked together to make it happen, but in many places in America we do not want that. Some states reject or refuse to participate in some public health activities proposed by the federal government—think of the states that refused to expand Medicaid. And in some state’s public health codes local units of government may be able to refuse to participate in many statewide activities.

It is interesting to compare public health in Michigan with public health in Texas. In Michigan, local public health is part of county government. But instead of letting things go flying off in all directions, Michigan’s public health code mandates that local government provide a basic set of standard public health services, directs the State to fund those services (sort of), and evaluates their effectiveness through Michigan’s Local Public Health Accreditation Program. Compare this with the situation in Texas as reported by Kaiser Health News:

Public health experts argue that the state’s response system is “fragmented” and vulnerable to local budget cuts, which they say could hamper crisis-response efforts in the case of diseases that are more easily transmitted…  “In the event of a public health emergency ... the resources necessary to adequately respond to that are not all in the control of the health department,” Sanchez [Dr. Eduardo, the former commissioner of the Texas Department of State Health Services] said. “You have to have the money and the authority — whether it’s informal or formal — to actually lead a response and take care of business.”

Even in Michigan with it's integrated system, the effects of budget cuts show themselves all the time. Recently we got a call from a school about a mercury spill but we could not respond because our employee who was trained on mercury had moved on to another job. We lack the resources to have redundancy in that position. On another occasion we called the State after hours for assistance with a meningitis case, but the person staffing the 24/7 hotline didn't know how to direct our call.  The State is short-staffed, too. Both of these issues were ultimately resolved, but when you work inside the system you see the potential for serious breakdown.

Both Texas Governor Rick Perry and CDC Director Tom Frieden are telling us that we are prepared for Ebola and everything is going to be OK. But Tom Frieden also warns about the consequences of further budget cuts and reductions in capabilities, and Dr. Frieden understands the importance of global public health. We have underfunded public health locally and feel the consequences of that, but we have also allowed many other counties in our world to languish with almost no public health infrastructure at all, and this is a huge threat to all of us.

The biggest threat to this country from Ebola is not it spreading here. It is an Ebola outbreak spreading in Pakistan or Indonesia or other south Asian counties that do not have the public health capacity to stop it. If Ebola gets into south Asia and starts to spread, be prepared for serious consequences for the global economy.

Tuesday, September 23, 2014

Getting Performance Management Right--Let the robots do the work!

The amount of public health a taxpayer dollar can buy ultimately depends on how efficiently and effectively services are delivered at the local level. But it is really hard to get 3,000 local health departments to behave themselves. For this reason, public health is engaged in a major effort to improve its ability to manage it own performance. The Public Health Foundation, the Public Health Accreditation Board and the CDC--among many other public health partners--have performance management initiatives. A common goal of all these initiatives is to encourage local health departments to engage in performance management.

I worry that if this effort isn't done right, it could be counterproductive. What if a national performance management effort makes 3,000 local health departments waste their time on busy-work projects dreamed up at the federal level? Because becoming more effective is so important, performance management is part of the strategic plan of the Mid-Michigan District Health Department. But in order to make sure we are not wasting our time, and are really becoming more efficient, we take what is, perhaps, a unique approach.

First, let me say that we have already made a lot of progress building our performance management system and I am very proud of the high level of staff engagement in the process. One reason for our success is that we have a firm foundation. Many of the programs we operate already contain elements of performance management. The MiWIC and MCIR databases, for example, enable WIC and immunization program managers to easily run revealing reports. Michigan's minimum program requirements for Family Planning, Children's Special Healthcare Services, and Hearing and Vision Screening, among others, all contain elements of performance management. Many Environmental Health programs are moving in this direction. Another reason we are having success is that we have a dedicated a full time position (Ross Pope) to performance management.

But, as we work to extend and deepen performance management, we have to make many difficult choices that will have long-term consequences. The two most important choices are "What to measure?" and "How to measure?" MMDHD's work is guided by a clear theory of how performance management works that tells us what and how to measure. Its two principles are:
  1. Only measure something if the information will change your behavior. Another way of saying this is "Measure just enough to get what you need and then stop".
  2. Automate everything. If it takes a lot of staff time to collect information it probably isn't worth it. Our motto is "Let the robots do the work."
What you really want to measure are key indicators of the efficiency of your own workflows. How quickly are clients being served? What proportion of clients are getting services that meet your gold standard? What proportion of billable services are actually being collected? The answers to such questions have immediate relevance to what your staff are doing now.

A performance management system delivers information to people. You want the acquisition of the information to be effortless. And the information should be so relevant to what they are doing that it changes their behavior almost instantly. Consider two really basic and funny examples:

When you are driving in your car, you have on the dashboard in front of you information about the performance of your vehicle--the speedometer and fuel gauge, for example. You glance at the dashboard frequently and change what you are doing in response to the information. If the speed limit is 65 and your speedometer says 75, you take your foot off the gas just a little (why some people don't is a topic for another day). What if, instead of displaying your speed or the amount of gas in your tank, the dashboard displayed the national traffic fatality rate for the current year compared to previous years, or information about automobile manufacturers' recalls of defective vehicles? The fatality rate and recalls are very important information. But they change so slowly you would soon stop looking at the dashboard. Information on fatalities and recalls wouldn't tell you anything about the performance of your own vehicle. That information is irrelevant.

What if you didn't have a speedometer in your car but you wanted to know your speed? One thing you could do is use a stopwatch to get the time between mile markers and calculate your speed that way. If the stopwatch told you it took you a minute to go from one mile marker to the next, you would probably realize you were going 60 miles per hour. What if the stop watch said 55 seconds? You would probably realize you were going faster than 60 miles an hour. But are you going faster than the speed limit of 65? Could you do the math in your head? Now you are flying down the road a mile a minute, fiddling with devices and not concentrating on what you are doing. The effort of calculating your speed has made you guilty of distracted driving. The attempt to measure your performance has actually degraded your performance.

I have seen plenty of examples of public health agencies pushing in the wrong direction on performance management. The National Association of County and City Health Officials (NACCHO) recently gave a webinar on performance management that featured a prominent local health department that explained that it took 7 FTEs for them to maintain their performance management system. Many of the things they measured were nothing other than things they should have been measuring as part of routine surveillance anyway, like mortality and morbidity data. They had not identified things that would change the way they did their day-to-day operations. In my mind, this system seemed to have huge costs and questionable benefits.

Consider this: the Public Health Accreditation Board requires local health departments to engage in performance management. But it doesn't define what that means! If a health department has a highly distracting and uninformative operation it calls performance management, would they be accreditable?  Shouldn't we insist that a performance management system actually improve performance?

Let me end by bragging about the MMDHD team's recent achievement. This is the report you can see in the graphic above. The report consists of a variety of productivity data on a couple of dozen different programs, which is available for any period of time at the push of a button. You can see caseloads blooming or tanking, failures to bill, etc. instantly. No one creates these reports. The work of setting up the programming has been done, and now the report generates itself from the data on our server on demand. Clinic staff regularly consult this report to plan their work. Next we need to extend this level of automation to our environmental health and administrative functions. Let the robots do the work!

Sunday, August 17, 2014

Local Public Health and Ebola? Really?

The outbreak of Ebola Virus Disease in West Africa, which has killed over 1,000 people, is undeniably a terrible tragedy. Yet it can seem remote at the present time, with few lessons for us. In fact, there are at least two things we can glean from thinking about Ebola: 1) If things go badly Ebola could threaten us, and steps are already being taken to make sure we are prepared.  2) Ebola is spreading because of the weakness of the public health system in West Africa. North America has its own crop of deadly contagious diseases like diphtheria, polio, etc. but we do not have many outbreaks of these today because of our public health system, especially vaccinations.

The spread of Ebola is alarming and is causing public health officials to worry it will rage out of control.  On the ground reports indicate that quarantines are not working. People are able to move away from infected areas, bringing the disease with them. One of the possible scenarios with this disease is that it could spread throughout much of Africa. If that happens, then, there is even the chance the disease could leap out of Africa and cause sporadic outbreaks in other places in the world that lack effective public health services. Then it would only be a matter of time until cases appear here. In fact, a virus with some similarities to Ebola, MERS-CoV, has caused many infections in the Arabian Peninsula, but also numerous cases in places like Europe, the US and elsewhere.

No, I don't think a large-scale Ebola outbreak is possible in Michigan.  We have good public health services that would race ahead of the infection and put it out.  And local public health is very much a part of the team that would quash an outbreak if an Ebola case appeared. But complacency isn't an adequate response. In fact, we just completed training for a similar situation.

Here's the scoop:  MMDHD's Medical Director, Bob Graham, actually serves three local health departments.  In addition to us he is also Medical Director of the Central Michigan District Health Department (CMDHD) and District Health Department #10 (DHD#10). Doc, as everyone calls him, worked with the Communicable Disease and Emergency Preparedness staffs in the three departments to organize a training on responding to MERS-CoV that was held on July 30th in Mt. Pleasant. MERS-CoV is the nasty coronavirus that has killed nearly 300 people in the Arabian Peninsula. Like Ebola, it has a high mortality rate and poses a significant risk to health care workers. So training and preparation are critical to being able to respond appropriately.

The training focused on awareness of the travel history of people with symptoms, proper infection control in the event you could have a case and the initiation of surveillance and contact tracing to find any other cases immediately.  In addition to local public health, attendees represented laboratories, hospitals, emergency departments and transport, and the State. This is the team that will stop MERS-CoV, or Ebola, if we get it.

Why did we do training on MERS-CoV in Mid-Michigan? Because we live in a global village. It will always be that way from now on. We have students and their families from the Middle East studying in places like Central Michigan University, Ferris State and elsewhere, not to mention people from that part of the world who just love Pure Michigan and have settled among us, bringing us their skills and knowledge. In Mid-Michigan the West African diaspora is smaller, but it is there.

Before I leave this topic I have to make a couple of more observations.  We have tolerated an inadequate, underfunded public health system in West Africa, and now the worst is happening.  When this outbreak is over, we will need to fix this problem, as big as it is, or things like this will just keep happening.

Even though terrible diseases like diphtheria or polio are present in the US, we don't have outbreaks, because most people are vaccinated against these diseases. People in West Africa really wish there was a vaccine against Ebola.Learn from them. Let's appreciate our public health system and take care of it.  For it to work we all need to do our part. Get your vaccinations, people!

Sunday, July 13, 2014

Public Health and the Health Endowment Fund

I want to muse publicly about the Michigan Health Endowment Fund (MHEF). This is the fund created by the Michigan Legislature which will spend 1.5 billion dollars of Blue Cross Blue Shield of Michigan’s money to improve health over the next decade and a half.  The fund endeavors to serve children and seniors in areas such as infant mortality reduction, wellness, access to healthy food, health technology, health-related transportation and food borne illness reduction. How much will the fund give away in this fiscal year? Several tens of millions of dollars, probably.

The creation of the fund is not occurring in a vacuum.  Michigan’s leadership is also driving the creation of the State Innovation Model (SIM) with funding from CMS.  The SIM aims to control healthcare costs and drive improvements in health outcomes through payment reform, and by strengthening connections between providers and the prevention community in sustainable Community Health Improvement Regions (CHIRs). MHEF is explicitly seen as supporting the SIM.  The selection of Rob Fowler as Chair of MHEF signals this, since Fowler was deeply involved in the development of the SIM and also championed Healthy Michigan.

Let me ask and tentatively answer two questions:  1. What should MHEF pay for with its money? 2. Can local public health play a role in MHEF-funded projects, and if so how?

It is good that MHEF has a broad mandate because there are lots of things that need attention across the State.  However, if there is one thing MHEF should focus on it is childhood obesity; and it almost certainly will address childhood obesity. To make a substantial, long term difference in the cost of health care we must prevent the current young generation from being sicker than their parents. And if we don’t do that, obviously, we will continue to get worsening health outcomes.  The MHEF Board knows this. Reducing childhood obesity will be a holy grail of their efforts. (By the way: I don’t think the much ballyhooed leveling off in childhood obesity rates is a sign of impending victory.  I think it is just really hard to make kids any heavier than they are.)

A great deal is known about how to reduce childhood obesity. There are best practices related to physical activity, the consumption of healthy food, breast feeding and non-motorized transportation, etc. But to really move the dial, experts agree, the one best practice is to create and implement a comprehensive state plan that integrates work in all of these sectors and more. Fortunately, Michigan has a state plan called the Michigan Healthy Eating and Physical Activity Strategic Plan: 2010-2020. To learn more about it click here  and here. In short, the Michigan Department of Community Health with support from the CDC established the Michigan Nutrition, Physical Activity and Obesity Program (MNPAO) to write the state plan.  MNPAO, in turn, reached out to others and convened the Healthy Weight Partnership to implement the state plan with funding through Building Healthy Communities grants.  Of course when the State’s economic fortunes went south, so did support for Building Healthy Communities.  But the plan is still a good one.

So there it sits, a plan rife with best practices, championed by a who’s who of prevention experts in all sectors of health and health care.  We don’t need to scratch our heads wondering what to do, we just need to pick up the plan and run with it.

Can local public health play a role in MHEF-funded efforts to fight childhood obesity? First, let’s give credit to local public health for what it is already doing by providing WIC services, including nutrition education and breast feeding promotion, to half the young families in this state.  In recent years, WIC has focused on integrating comprehensive health education aimed at obesity reduction into its program, and the USDA says this seems to have had a positive effect on childhood obesity levels.

But as I just mentioned, really making progress against childhood obesity over the long term must involve implementation of a comprehensive plan involving the entire community of prevention providers. And this is where local public health can really shine.  Local public health helped to create Michigan’s state plan and implemented important pieces of it while Building Healthy Communities was funded. But more importantly, local public health has a special relationship with the rest of the prevention community that gives it a unique role.

Local public health doesn't need to provide the lion’s share of preventive services in the communities it serves.  Indeed, its proper role is to understand and support the entire fabric of preventive services, to make sure gaps in services are identified and assure the gaps are filled.  This concept is elaborated in the model called the Ten Essential Public Health Services.  There is a name for this process of convening the community to enhance preventive services and that is Community Health Assessment and Improvement (CHAI). The State of Michigan has engaged in this process and so have many, although not all, local health departments. Here is an example of a local CHAI from the Capitol Area.  And by the way, this is exactly the kind of work the SIM imagines will be done in the Community Health Improvement Regions.

Bringing all this together, then, local public health ought to advocate to MHEF that the best way to address childhood obesity in Michigan is to implement the state plan in conjunction with the SIM.  We ought to advocate that all the members of the Healthy Weight Partnership should be supported to play their part in the plan, while putting ourselves forward as the natural conveners and evaluators of local efforts.  To get ready for a conversation with MHEF, we need to identify what it will take to do a good job of convening and evaluation and that is what we should ask for.

We also need to talk frankly with MHEF about two threats to the success of this effort. One threat is the concept of innovation embedded in MHEF’s definition of what it wants to fund.  The CDC does not say we need a new round of innovation.  Millions have already been spent to identify best practices that can be shown to be effective.  The CDC says that what we need to do is comprehensively implement these best practices via state plans.  The worst thing we could do is to turn our attention away from what we know works and start over again in the dark.

The second threat is episodic funding.  MHEF grants are anticipated to sunset after three years.  But we already tried tackling childhood obesity through a series of short term innovation grants under Building Healthy Communities! We know this won’t create long term change.

Here I am not arguing that we should turn MHEF into a permanent funder of public health prevention—that is the role of the State, and the State’s plan for long term funding of prevention is the SIM.  But this thinking does help to clarify where MHEF funding should be targeted, and that is on answering the question “How can local communities leverage the State Innovation Model to develop more sustainable funding for local prevention efforts?”

MHEF grants for reducing childhood obesity—which must be short term and aimed at innovation—should focus on identifying how the work of local teams of Healthy Weight Partnership members can be integrated into the Community Health Improvement Regions (CHIRs) envisioned in the SIM. The SIM explicitly says that, in the future, these CHIRs should be the locus of sustainable preventive services in Michigan communities.  They will be sustainable because state and other funds will flow to them, but also because payment reform will mean payors will reimburse prevention providers for activities with a proven return on investment. This last piece is critical. To make long term change we must not waste time implementing one-off projects.  MHEF and local public health ought to work together to ensure that CHIRs focus on nurturing sustainable childhood obesity reduction efforts, and to accomplish this, these efforts must generate real, measurable ROI that is visible to providers and payors. The state plan tells us who and what will accomplish this. Local public health should be spreading the word.

Sunday, May 4, 2014

The Revised Total Coliform Rule

Are we looking at more work for local public health without funding to do it? Consider the revised total coliform rule (rTCR): whenever this happens it is bad for the health of the public.

When you find coliform bacteria in a water sample it is an indication that the water could be contaminated. These bugs themselves do not cause illness, but they are universally present in our bowels, so where they go bad guys like E. coli or salmonella may not be far behind. Last year the Environmental Protection Agency (EPA) published a new rule which tightens up the kind and number of inspections that health departments have to do when they discover coliforms. The details are complicated, and if you want to read about them, they are here.   And here is the beautiful detail of the rule from the Federal Register, including projected health benefits and costs.

The new rule is based on good science, so if it is implemented it is likely to reduce illness and even save lives.  But as EPA noted when it published the rule, the increased inspections are going to be costly.  According to EPA’s calculations, the savings from reduced illness and death will outweigh the increased cost, so that seems like a good deal for the country.

The problem is that there is no way for EPA to capture that savings and send it to States who can send it to local health departments (LHDs) to pay for the increased inspections. If somebody does not die of a gastro-intestinal illness, lots of people save money (although they don’t know it)—the insurance company, the family, the employer—but they are not passing that savings on to the health department who employs the sanitarian who finds the contaminated well and gets it cleaned up. They don’t know something bad didn’t happen.

Michigan convened a Revised Total Coliform Workgroup to discuss how to implement the new rule. We know that EPA is going to twist our arms until we do so, so we need to start planning for it. The workgroup’s Final Report (I can't find it on-line) says “All Workgroup members agreed that the rTCR will require more time and resources to administer than the current Total Coliform Rule (TCR) does, especially at noncommunity water supplies (NCWS). The need for additional resources could be a critical issue for many of Michigan’s LHDs.”  (Noncommunity water supplies are places with wells that serve water to the public like a rural school or church.)

Indeed resources will be an issue. The Final Report estimates that there will be over 3 hours of additional work per noncommunity water supply. Considering all the rural facilities that serve water to the public, a health department like MMDHD might need a whole FTE to complete this work. But the State of Michigan has not been given additional dollars to add to our contract.

There are two main ways LHDs supplement State dollars going into their water programs.  One is general fund dollars from county governments.  But in most places in Michigan those dollars are frozen or declining.  Another is fees.  In most of the State county boards of commissioners will not support a jump in the fees charged to places like schools and churches for their well permits.  As far as they are concerned these wells are safe now and they don't want to charge more for what looks to them like the same result.

Fearing the worst, a few LHDs in Michigan have asked if they can drop their noncommunity watersupply programs without losing their accreditation.  I suspect the answer is "No". On top of that, there are good reasons the public should insist on monitoring.  A lot of these systems are aging. They are developing cracks and filling up with gunk where the bugs can grow once they get in.  To leave the public without protection would be nuts. But for all levels of government to simultaneously fail to address the question of how to pay for that protection is nuts, too.

Monday, April 28, 2014

Health Disparities

I am going to write about an event that occurred recently in Alma in Gratiot County, Michigan.  As part of that, I am going to mention some of the sobering facts of life about that part of the state. So before I get into that, I want to say how beautiful Gratiot County is.  Visit the Parks and Recreation website for some Gratiot eye candy. And has a great photo essay on the Gratiot County wind farms which, in addition to being beautiful, are helping to propel economic recovery.  Beauty is also in people’s hearts.  Whether you are talking about the folks who volunteered to develop the Great Plan, or the ones who turn out every week to volunteer at the Gratiot County Free Clinic, it seems like there is no limit to their giving.

The last week of March I attended Michael Vickery’s Health Communication class at Alma College with Dr. Rakesh Saxena from MidMichigan Medical Center – Gratiot, to talk about community health. The discussion turned to the Gratiot County Free Clinic—which had been a focal point of their studies that semester—and students began to challenge us.  The Free Clinic’s target population is uninsured people with chronic health conditions.  It aims to help its patients manage their chronic conditions by connecting primary care with services like counseling, nutrition education and incentives for lifestyle changes, so they can recover their health.  But some of the students were suggesting the Clinic wasn’t doing all it could to accomplish that goal. For example, the Clinic had not yet secured a volunteer dietician to do the nutrition education. The push from the students was welcome.  After the class, Dr. Saxena approached me to ask if the Health Department could help him secure a dietitian ASAP.

But I thought there was another issue that some of the students—like many of us—found difficult to integrate with their thinking about preventive health care services, and that is the fact that differences in health—health disparities—are caused by more than differences in access to care.  People who come to the Free Clinic tend to be much sicker to begin with, and for reasons I will explore below, are less likely to benefit from care than others. Providing care by itself cannot eliminate these disparities.

And Mid-Michigan does have health disparities. A significant proportion of the population of Gratiot County is low income. Eighteen percent live below the poverty line, 18% were uninsured before the role out of the Affordable Care Act, and only 13% have a college degree.  The health outcomes of the low income folks are worse than those with higher incomes. Half of those with incomes below $15,000 have high blood pressure, while only 16% of those with incomes above $75,000 do. The breakdown is the same for obesity. Thirty-two percent of those with incomes below $15,000 have high cholesterol while only 19% of those with incomes above $75,000 do so. It’s like this for every important measure of health status.

It is tempting to believe that the best way to address health disparities is to focus on providing the same kind of health care to lower income people as is provided to folks with higher incomes. Indeed it is difficult not to think that way and we should provide equal care.  The provision of care is part of a heroic narrative that includes Albert Schweitzer’s missions, the establishment of Federally Qualified Health Centers and the Affordable Care Act itself. But while the provision of equal care may improve the health of low income people somewhat, it will not eliminate health disparities.

Our health is influenced by many factors of which care is only one. Here are some examples of other things that affect health which are related to income:

Social support—people in lower income households are more likely to have endured breakups or abuse. Family problems inhibit people from taking care of their own health.
Housing—lower cost housing stock is more likely to be unhealthy, for example having lead contamination, black mold, asthma-causing insects, etc.
Transportation—lower income people are less likely to have their own vehicles, may have poor access to public transportation (especially in rural areas) and have less ability to control their use of time because of the kind of work they do.
Emotional well-being—stress and worry inhibit people from taking care of themselves and economic insecurity is a source of great stress and worry.  A new study from the Michigan Department of Community Health illustrates this nicely.
Health behaviors—lower income people are more likely to do things that harm health like smoking. These behaviors go by many names from dysfunctional coping to self-medication, and while there may be good explanations for why people act this way, the explanations do not remove the harms.

One thing that makes us think about providing more care, rather than dealing with the other things that are the main causes of health disparities, is that it is hard to think about changing social conditions—reducing poverty, increasing community, establishing justice.  But practical examples of ways to make positive impacts are all around us.  Toward the end of the class I told the students my candidate for health hero in Gratiot County would be Don Schurr of Greater Gratiot Development, Inc.  By leading the charge to establish the wind farms, Don has helped to clean up the environment, create jobs, raise the incomes of local families, increase the budgets of the community’s human service agencies and one could go on and on. There are many people in Gratiot County who won’t need health care quite so soon because of Don’s work to improve the fundamental conditions in the community.

Friday, April 25, 2014

Hiring a Community Health Worker

I have written before about the shrinking staffs and budgets of local health departments.  The National Association of City and County Health Officials (NACHO) has published a sobering assessment of the state of the nation’s local public health system which documents layoffs, cutbacks and reductions in programming across the country.    Some local health departments have decided that the verdict from voters and legislators is clear: they do not value public health services.  These departments have reduced their programming to no more the minimum required by law. Other health departments are trying to find new ways to support preventive services in their communities.  Recognizing that funding from local, state and federal taxes will continue to decline, they are becoming social entrepreneurs, trying to identify who benefits financially from preventive services and entering into business agreements with them to sustain these services.

In Michigan, these ideas are part of the State’s plan for improving community health called the State Innovation Model (SIM). The SIM is comprehensive and contains many moving parts, but one piece of it focuses on what are called Community HUBs.  These HUBs may or may not be connected to local health departments, but they share one feature in that they deploy Community Health Workers (CHWs) who work with health care providers to ensure that the sickest and most vulnerable among us get access to preventive care.  CHWs do this by de-duplicating care plans and services and ensuring that clients get all the services to which they are referred, and they follow up to ensure compliance.

HUBs are not supposed to duplicate the care coordination efforts many health care providers are undertaking now.  They are supposed to step in where those efforts fail, with people who fall between the cracks in the health care system—people who frequently and inappropriately use emergency rooms, people with chronic mental health problems that are not under control, etc.

Obviously, there are groups who could benefit from the work of CHWs.  If CHWs are successful in getting people to use emergency rooms more appropriately, health plans would have to pay less for those patients.  And if those people become healthier, physicians and health care systems trying to achieve pay-for-performance goals stand to make more money.

The Mid-Michigan District Health Department has taken one tiny step in this direction.  We have hired our first Community Health Worker!  This person will be working with residents of Clinton County through a HUB located in Lansing.  We are nervous about it, because the HUB doesn’t have any contracts with health plans or hospitals yet.  It is still coasting on grant dollars.  However, we have spoken to some of the plans to find out what their attitude is.  They tell us they love what the Ingham HUB does for their patients and are anxious to see evidence that money has been saved so they can justify signing contracts.

In my opinion, CHWs should not primarily be based in health departments, but should be located in any provider of preventive health services who needs to increase their capacity.  CHWs could help all kinds of community-based organizations improve outcomes for their clients, whether they be substance abuse prevention coalitions, United Ways, mental health providers, etc.

This is an exciting and important experiment.  CHWs could potentially open up a new model for sustaining preventive services and reverse the fraying of the safety net. In five years will human service agencies in Mid-Michigan have a complement of CHWs out in the community?  I hope so.

Thursday, January 2, 2014

Did You Call?

Did you try to call or visit the Mid-Michigan District Health Department during the Holidays only to find out that we were closed?  Yes, we were closed the entire week between Christmas Eve and New Year’s Day—primarily to save money. But we were also very busy.  Protecting the health of the public health is a 24/7 operation.  

No sooner had staff gone home for the weekend before Christmas Eve when ice storm warnings were posted for much of Michigan. During the evening of Saturday, December 21st, freezing rain began falling in a swath that cut through Mid-Michigan, including Clinton County.  Many trees (some of them beloved, like the huge Locust in my back yard) collapsed or disintegrated under the weight of the ice, shredding power lines.  The area affected was so large that it would take a week to restore power for many people-- a week during which the temperature dropped into the teens many nights. Ultimately, over half a million homes and businesses would lose power (14,000 in Clinton County) and at least seven deaths would result.  Instead of having a long vacation, staff would be working long hours dealing with the public health consequences of this event. 
Public health has three main roles in an ice storm that includes power outages:

1.      Ensure that restaurants understand how to handle frozen and refrigerated food when the power goes off, and make sure unsafe food is not sold or fed to the public.

2.      Provide the public with information about the health risks of prolonged power outages.  These include food issues, but also the cold itself, and the risk of carbon monoxide poisoning that occurs when people affected by the storm use generators, wood stoves and other open-flame heaters incorrectly.

3.      Consult with emergency managers and first responders if shelters are being established to ensure that the food and water supply is safe.  
On the morning of the 22nd as the scope of the damage became clear, Larry St. George, the Emergency Management Coordinator at Clinton County, asked first responders to be prepared for activation of the Emergency Operations Center (EOC).  He activated it the next morning and staff reported promptly.  Because the power was out at the EOC’s primary location, we had to use the backup at the Sherriff’s office.  Our main goals were to get shelters established and also provide some support for power crews working in the frigid conditions.  Shelters were established in Bath, DeWitt, Maple Rapids and Ovid. Health Department staff who responded to this event included our Medical Director, Public Information Officer, the Director of Environmental Health and Sanitarians.

In spite of our efforts, one person did die in Clinton County. The death was due to carbon monoxide poisoning resulting from the unsafe use of a generator.  It wasn’t a merry Christmas in Clinton County. Only half the affected homes had power by the 26th.
Disease did not take a vacation during that week either, meaning our nurses also kept busy.  On the 31st we got a call from a regional hospital about a patient seen at an emergency room with symptoms and test results compatible with bacterial meningitis. The challenge for us was to determine if we were dealing with an infectious case and if so how to respond.  Our Medical Director, Dr. Graham, ultimately determined the symptoms were the result of an infection from a surgical procedure and that we did not need to prophylax people exposed to the patient. We also had other more routine public health events that kept our team hopping:  dog bites, influenza and gastrointestinal outbreaks in nursing homes, etc.

So if you tried to call or visit us, I’m sorry we missed you. But please remember, we were working hard every day of the break to make sure you and the ones you love are healthy!