Thursday, December 31, 2015

New Year’s Resolution: Making Ethical Choices

I’ve had the pleasure of spending a great deal of time reading really interesting stuff over the holiday break. My reading has inspired me to help the Mid-Michigan District Health Department make a New Year’s resolution to take additional steps to avoid ethical lapses in the future. Let me explain.

The Atlantic magazine has a great article by Jerry Useem on how ethical lapses happen in organizations called What was Volkswagen Thinking? (in reference to the automaker’s installing software in their vehicles to defeat emissions tests). Useem explores other well-known examples including the decision by Ford to keep making Pintos even after it was shown they were prone to exploding; Morton-Thiokol’s vote to launch the Challenger even after they knew the O rings were leaking in cold weather; and B. F. Goodrich’s sale of aircraft brakes to the Air Force that they knew would overheat and fail.

Useem shows that often ethical lapses happen even though otherwise good and intelligent people are involved. He says that one thing organizations can do to reduce the chances of ethical failures is to have an explicit code of conduct that empowers people to act to prevent abuses. He uses the example of Johnson & Johnson’s “Credo”—their code of conduct—which guided their decision to immediately recall every bottle of Tylenol capsules at a cost of $100 million when they learned that someone had contaminated a few with a deadly poison. In Useem’s telling, the CEO was on an airplane when the news broke, and by the time he landed the recalls were already in motion.

Of course these are all examples from business. But there are plenty of examples from public health and the CDC has even developed a course on ethics in public health which is here.

I am thinking about how organizations can fight ethical lapses because Michigan is wrestling with a big one of its own right now: The failure of the responsible State government agencies to alert the residents of Flint that it was likely their water was contaminated with lead over the past spring and summer. Unlike many of the cases explored by Useem in which it took years for the facts to come out, you can read in detail about what really happened right now, because has posted FOIAed documents on its website. I personally know many, perhaps most, of the people whose emails are there. I know them to be good and intelligent and consider many close friends. But in their emails you can see them struggling to understand what to do when data emerge that seem to show that lead levels are increasing. At the time, they believe there are contradictory sets of results. We now know with hindsight that wasn’t the case—all the data showed that lead levels were increasing. But at the time, they hadn’t figured that out yet. It took weeks, but you finally see more emails asking what it means if there is a chance the high lead results are correct? (It would mean we should sound the alarm.)

But none of this prompts me to throw rocks at the State, it makes me worry about where, in my own organization, we might be at risk of making similar mistakes.  And, it makes me wonder how we can strengthen our code of conduct (we call it our Guiding Principles—page four of this document) to make it clear employees are empowered to warn against ethical lapses.

There are some things happening that could turn into ethical lapses if we don’t watch it. For example, are we doing enough to raise the issue of ground water quality? After all, I am sitting on a mountain of data that says there is potentially disease causing human poop from failed or non-existent septic systems in our rivers and streams, where people canoe, fish and even swim. But there is only a little bit of activity going on to do anything about it. Of course our situation is different from Flint, because while we do have citizens on one side of the issue clamoring for a clean-up, we have just as many on the other side clamoring for nothing to be done because it could raise costs to real estate and agriculture. So we are on the horns of a political dilemma, and that means things will only change very slowly.

Another threat of a lapse could be coming from some of the innovative new clinical projects we have started that are costing us money, without as of yet having generated much new revenue. One example is the project in which we are supporting primary care services being offered to patients of Community Mental Health in one of the counties we serve. I love this project because really sick people are getting good physical health care for the first time. But I have had staff come to me and ask me to shut the project down because of its costs and the strain it places on our billing “department” (one person—go Bonnie!) while it hasn’t generated the expected income. I’ve asked them to keep going because I think we are learning things that will help us innovate in the future, and I think the money will come.  But maybe I’m just NASA not listening to Morton-Thiokol and there will be a financial explosion. Okay, it isn’t completely like that because our partner in this project is committed to it and is covering most of the cost overruns. Or am I just rationalizing a threat away?

And then there is another set of lapses that are created by omission rather than commission. For example, how can we do more to reach out to the growing migrant laborer population in our district? Why can’t the Collaboratives in our counties do more to address stagnating incomes and stubbornly high poverty rates? Why do I always seem to be too busy to spend more time just hanging out with staff and getting to know them better? (That’s the advice Coach Dantonio would give me I’m sure--see the 10th paragraph of this.)

Clearly I can’t foresee all the potential ethical lapses on my own.  Co-workers will know about others that I am unaware of. What I want to do is encourage everyone in the organization to take the threat of ethical lapses seriously.  When I wanted to get staff to stop collecting data on paper (which cost us a lot of staff time which means money) and always automate data collection projects I “branded” the concept with the phrase “Let the robots do the work” which seemed to create a helpful picture of where we wanted to go. I’d like to do something similar with the concept of avoiding ethical lapses.  I’m having trouble coming up with something. I don’t think any of these work:

If it could explode—that’s a bad thing.
It’s been _____ days since anyone was poisoned.
Not losing our jobs because of ethical lapses is job one!

Did you laugh?  I hope so. I think one thing that is wrong with these is that they are negatively phrased; they talk about what is to be avoided rather than what to do.  How ethical lapses happen is an important question, but the solution ought to be phrased positively as making ethical choices.

So help us out here. If you can think of some way to brand the concept of making ethical choices that works in a public health setting please send it along.

Saturday, December 12, 2015

Gripped by Fear

This post was inspired by a question my mother, Barbara Cheatham, of Issaquah, Washington asked me. 

According to the media we are all gripped by fear. The media is focusing on terrorism in particular right now, but we also have guns, mass shootings, police violence against minorities, violence against people thought to be Muslim, and lots of other things to be fearful of, apparently. I am not going to pick apart all the trends in this short article. I just want to quickly make the point that violence overall, including gun violence, is not increasing.

When Barack Obama was elected president gun sales shot up, apparently because people thought gun laws were about to be tightened up.  I thought it would be enlightening (in a dark kind of way) to see if gun violence increased as  a result. More guns = more shootings, right? I waited for a few years to pass and then made the following chart for my state of Michigan.

Gun violence had not increased even though there were more guns out there!  Many years each of the three counties I work in have no homicides at all, even though the air is filled with the sound of gunshots throughout the fall (Thank a hunter for saving you from a car-deer crash).

Curious about what this meant I then graphed the number of assaults. The chart below is for Montcalm County, one of the counties I work in, although you'll get similar results for most, if not all, communities in the country.

Assaults are actually going down! This is a nationwide trend. We just don't beat on each other like we used to.

Remember when looking at these data on homicide and assaults that people mostly shoot or otherwise kill or maim their own family members, friends and acquaintances. Of 532 homicides in Michigan last year, 52 victims were strangers to their killer (in 204 cases the relationship could not be discerned from the report). The rest of the victims were family members, friends or acquaintances. Strangers are not attacking us at an increasing rate in public places. This is not happening. The chart below is the overall homicide rate for Michigan going back to 1980. The homicide rate has been cut in half.  But not our fear.

I've done a little bit of reading on this, and I do not think there is a good explanation for this decline. Obvious candidates like the aging of society don't survive statistical tests. For whatever reason, overall, we are a more peaceful people than we have ever been. This is a wonderful thing and we need to avoid messing it up by over-reacting to the bad things that are happening.

It is true that the United States has a higher homicide rate, especially for gun homicides, than many other places. And it is true that while gun homicides are declining, gun suicides are increasing. And, yes, terrorism is real.  So there are many serious problems related to violence with which we must wrestle. But lets do so while understanding that overall we are safer than ever before.

Friday, November 20, 2015

Assessing the Health of Our Community

A Community Health Assessment and Improvement Plan (CHA/CHIP) is a community-based assessment of health status and the factors affecting health, accompanied by a specific plan created by the community to improve health.

The Mid-Michigan District Health Department serves Clinton, Gratiot and Montcalm counties. The first CHA/CHIPs were created in these counties in 2012. Now, all three counties have teams working to assess these CHA/CHIPs and revise them based on the past three years of experience. The process in Gratiot County is called Live Well Gratiot. In Montcalm it is Healthy Montcalm. Clinton County is collaborating with Eaton and Ingham counties on a tri-county plan called Healthy! Capital Counties. Colorful logos developed to brand these projects are at the top of this post.

It is challenging working on three plans at once. Why not just do one plan for the entire district? The reason is that the three counties are distinctive, with strong community identities, different service providers to collaborate with, and even different health problems to a surprising extent. Another reason is related to our unique take on what a CHA/CHIP should be. Let’s face it, we live in a time of data overload and to some extent, planning overload. For example, many of the organizations we partner with are required by their funders to pull together collaborations to write community assessments and strategic plans. So, we don’t want to try to substitute our plan for theirs, nor do we want to appear to be trying to get them to do our work. Instead, we want the CHA/CHIPs to call out those most important activities that our partners are already doing to promote health, and describe how we can support them. Our plan should braid together all the good work that is being done and show how together we can have maximum impact on health.

The data we have been looking at for the three counties tell some compelling stories.  The first is that chronic disease remains by far the most important health challenge including heart disease, stroke, diabetes and related problems. In Gratiot and Montcalm, especially, we have not improved lifestyles much if at all. We are still eating poor diets, not getting much exercise and continuing to have high rates of smoking. This is clearly evident in high chronic disease mortality rates. (Clinton County, parts of which include affluent suburbs of Lansing, is somewhat better off and is one of the healthiest counties in Michigan, if not actually very healthy.)

You may be aware that the national media have recently been reporting that among low income Americans mortality rates have started to rise again after years of steady decline. This is a striking trend and is unknown in the rest of the world. Chronic disease contributes to this, but also driving this trend are mental health problems including substance abuse and suicide.  In our data we saw how poverty drives poor mental health which in turn leads to myriad health problems.

There were many bright spots in the data. For one thing, youth substance abuse including tobacco and alcohol continues to go down and marijuana has not started increasing as many had feared with the change in attitudes toward marijuana. Connecting Point has been highlighting the downward trend in teen pregnancy rates for some time, and that continues. Our three counties have very low homicide and assault rates as well. Finally, the three counties have very low infant mortality rates. This is a precious asset which we must nurture and try to understand better. We have high rates of family poverty, as mentioned, and many of the problems that come along with that. But our children are nonetheless getting a surprisingly healthy start in life.

It seems the work before us is to build on the healthy start our youth are getting and turn that into a healthy adulthood. To do this we need to do much more than simply hector people to eat less and move more. We need to attack the rural poverty that leaves so many without the means to live healthier.

Saturday, August 15, 2015

Don't Touch That Water

When I first interviewed Bob Gouin, our Director of Environmental Health, after I become Health Officer, I asked him about the strengths and weaknesses of the Department. He mentioned one weakness which seemed particularly serious to him. He said we were not doing surface water testing. Therefore, he could not tell the public whether the rivers and lakes in Mid-Michigan are healthy or unhealthy. We did not have a budget for testing, which is expensive, and his efforts to get grants had failed.

Because of the work of a number of community partners we are starting to get access to data on water quality from all three of our counties: Clinton, Gratiot and Montcalm. This is enabling us to create a portrait of the health of our watersheds, and the findings are troubling.

First I want to thank those who are doing the testing for sharing their results with the Health Department. Having access to these data is enabling us to act as if we have a funded water quality monitoring program and to do the things a local health department should do, such as assess possible threats and issue advisories to the public if warranted.

Currently testing is being done by the Clinton Conservation District (thanks John Switzer) on the Upper Maple and Looking Glass; the Kent Conservation District (thanks Connie Redding) on the Flat River; and by Alma College (thanks Tim Keeton) which is working with the City of Alma (thanks Phil Moore) on the Pine River. The work of the Clinton and Kent Conservation Districts is being paid for by federal Clean Water Act grants in support of comprehensive watershed management, and Alma College is testing because that's the sort of thing those Scots do.

I also want to thank Megan McMahon and several others at the Michigan Department of Environmental Quality (DEQ) for helping to ensure that the testing being done follows approved protocols and can be used to draw valid conclusions.

We are testing for E. coli, an indicator species of gut bacteria that is both a health threat itself and, if found, alerts you to the likelihood that other bad bugs may be present. Testing is a little bit complicated. You have to draw the samples in a way that ensures they aren't contaminated and that gives a fair assessment of the entire water body. You have to get the samples to an approved lab within time limits. You have grow bacteria colonies in a standardized way and count them correctly. Finally, after counting, you compute the geometric mean of the samples. The geometric mean is a kind of average that discounts outlying values. The rules for all this are well documented by DEQ and our testers know what they are doing.

One of the things the Clinton Conservation District is doing is getting DNA profiles of their E. coli. That way you can tell if it came from cows, pigs, geese, deer, etc., and we do see all of those, although cow is the most common. There is a less expensive way to test for human E. coli--poop sniffing dogs. Next week a dog will be in Mid-Michigan testing samples from the Upper Maple and Looking Glass. The picture below shows a dog checking samples. If she gets a hit she sits down. The dogs are 99% accurate.

Love those dogs!
Health Departments use a two-part protocol developed by EPA and adopted by DEQ to determine if E. coli is within safe limits. The first part applies to swimming. If you are swimming your head is probably going under the water and E. coli is touching your lips, so the standard is strict. There should be no more than 130 E. coli colonies per 100 milliliters averaged over a 30 day period, or 300 from a one day sample. The second part applies to boating and fishing (getting your arms or feet wet) and the limit is 1,000 E. coli from a one day sample.

What's so bad about E. coli? An infection is sometimes mild, but it can cause serious gastrointestinal illness and rarely death, and it can also cause nasty skin infections. If human E. coli is in the water bad pathogens like Giardia and Cryptosporidium are probably in there, too. E. coli from agricultural runoff can be antibiotic resistant, so an infection could be difficult to treat.

But I checked local hospital reports and I know that our emergency rooms are not being mobbed by people with E. coli related illness. It is always present in the environment in low levels, so should we really be freaking out? The real concern with high levels of E. coli is that it is yet another indicator of our rivers being saturated with nutrients generated by our modern agro-industrial way of life. These nutrients cause the toxic algae blooms that threaten the drinking water of Great Lakes cities, and they are causing our river fronts to be choked with plants and algae, sabotaging economic development plans and property values. So, yes, you should worry about the river water making you sick (don't get it in your mouth), but even if you never go near a river you should be concerned about the long term impact on drinking water and the economy.

So what are are results? Alma college has sampled at five locations on the Pine upstream from Alma and has found that a good chunk of the time the river is not safe for swimming. The worst days are right after a rainstorm. Furthermore on six different occasions the river was not even safe for boating or fishing. On Monday I am going to meet with folks from the Kent Conservation District to see their data, but they have already told me that the Flat River has tested positive for human E. coli. We should have the results from the Upper Maple in a few days, but we already know DEQ tested that river a couple of years ago and it had elevated E. coli levels then, and since then the animal and human pressure on that river has only increased, so we expect bad news.

At a meeting in Alma last Thursday organized by Gary Rayburn, Tim Keeton presented the Alma College data, and after hearing the results, community members asked the Health Department to issue an advisory for the Pine River. One person even said we should put a sign at the boat landing on the Mill Pond saying the river is CLOSED. We will take action after talking to Alma officials.

The fact is we see the same picture everywhere we look.  DEQ tests Michigan rivers on a five year rolling schedule and regularly finds excessive E. coli.  The Saginaw Chippewa Tribe Utility Services Department tests the Chippewa River just to our north, which is a major regional canoeing and swimming destination and publishes its results here. They find the same thing we have: you shouldn't swim except in a few locations, and sometimes you shouldn't boat or fish.

I realize these results can be confusing.  How do I know if the river is safe today? "Our family has been canoeing for years--should we stop?" There is no way to know if the river is safe today. It takes time to process and analyze test results. By the time you get the results the water you tested is 100 miles down stream. The best advice is to stay out of the river after a rainstorm and never get the water in your mouth.

But E. coli points to other issues that everyone should care about: the water in the Great Lakes is getting dirty again--this time its not toxic chemicals but nutrients like fertilizer and manure from agriculture and also human poop that are causing toxic algae blooms and imperiling economic development. We need to clean things up again!

There are plenty of things we can do to clean up the water. We can require farms to process their manure to reduce the amount that needs to be spread on the land.  We can restore buffer strips and wetlands near water bodies to capture runoff. We can get homes that have no septic tanks, or broken ones, to get working ones. Simple steps like these will work if they are actually put in place.

Governor Snyder has just released a comprehensive plan for managing Michigan's water and fulfilling our responsibilities to the other Great Lakes states and provinces: Sustaining Michigan's Water Heritage. The plan promises assistance to communities like us in Mid-Michigan. And, while I am increasingly cynical about such promises in this era of cutbacks and mandates, there is one reason to think something will happen. Michigan's elites value our billion dollar "Pure Michigan" tourism industry. But if tourists arrive at our rivers, lakes and beaches and there is a big "CLOSED" sign there, they will be very disappointed, and may not come back.

Sunday, July 5, 2015

Why Aren't I Excited Yet?

When I first started working at the Mid-Michigan District Health Department I was alarmed to see that it had experienced five years of steadily decreasing budgets. This meant decreasing staffing levels, too, since our only large expenditure category is for personnel. As I visited the branch offices and spoke with staff I made a point of showing them a chart of the budget (like the first five bars of the chart below) and explained to them that this trend was a threat to their jobs. I said that we needed to work together to reverse this by expanding our programming and increasing our efficiency. My wife called it my “straight talk” tour. In fairness, staff knew this already and were already working hard on quality improvement projects and expanding billing, so the foundation for a turnaround was well laid.

I am happy to say that the trend has been reversed. During the 2012-13 fiscal year, we bottomed out with 68 FTEs. This year we have 72 FTEs. This year for the first time in several years we are giving staff raises, which are long overdue. And we are proposing to the Board of Health a budget over 6 million dollars for the first time in five years.

MMDHD Revenue and Expenditures FY 2008-15. Up at last! 

So why aren’t I excited yet?

The reason is that our traditional environmental and personal health programs are still underfunded and understaffed. Funding from the Michigan Department of Health and Human Services will be flat again this year and we expect the same from County appropriations. This means that with every year that passes, inflation eats into our ability to run these programs. Meanwhile, the workload continues to increase. We have new minimum program requirements in environmental health and Children’s Special Healthcare Services, for example. We have been hit with major new requirements in Emergency Preparedness.

Look at the chart, above. In 2013-14 and 2014-15 Revenues and Expenditures were right around 5.8 million dollars. In 2015-16 we expect to spend and earn 6.1 million. All of the increase is due to new programming including Community Health Workers, Drug Free Communities and other activities that have their own funding streams. The dollars they bring in cannot be directed to support other underfunded activities. This is really a double whammy, because as we add programs we increase the pressure on the administration and supervisors. We need to add at least two supervisors to cope with the workload, but our overhead budget has not increased at all.

Imagine how this looks to the average Michigander: Your budget is going up but I still can't get a well permit on time? The reason is the new money we have brought in is not for the well program.

We don’t have many friends out there. For example, the Michigan Restaurant Association is on a tear to get the legislature to cut the fees we charge for restaurant inspections. This move would effectively bring restaurant inspections in Michigan to a halt. The result, predictably, would be an increase in communicable disease outbreak investigations, which is also flat funded.

One friend is the Ingham Health Plan Corporation. In January the work of our Community Health Workers will become billable to Medicaid Health Plans. The Corporation is trying to help us figure out how to price the services of the Health Workers so that the overhead costs of supervision and technology are fully covered. We need a lot more of this business-like thinking.

Monday, June 29, 2015

Working More Earning Less

Health Departments and their employees are responsible for displaying cultural competency: that is, we need to have knowledge about the lives of the people we serve and have command of resources that are appropriate to their needs. We need to understand that health inequities exist--that access to the resources to promote health is unequally distributed; and that in order to combat this we need to work to modify the root causes of health inequity.

I often struggle to articulate these concepts both with my coworkers and to community members. The Mid-Michigan District Health Department (MMDHD) is in the process of renewing the community health assessment and improvement plans (I will just call them Assessments) our communities have created in all three of the counties we serve. In updating the Assessments, I happened upon a new (to me) way of understanding what is happening economically to our communities. It gave me a new way to try to show community members something about inequality and how it is connected to root causes.

Some quick background on our Assessments: The three counties we serve--Clinton, Gratiot and Montcalm--are so different from each other that it does not make sense to do a single Assessment for the entire district. It would be easier, but the results would not really reflect the characters of the counties. The project in Montcalm is called Healthy Montcalm; in Gratiot it is Live Well Gratiot; and the Assessment for Clinton County is a regional project involving Ingham and Eaton counties which do think of themselves as being part of a unified region. It is called Healthy! Capital Counties.

Here are three charts that I have been sharing with residents during our discussion of the root causes of health problems, especially health inequity. These slides happen to be for Gratiot County but the picture is the same in all three.

The first chart, above, is unemployment. Unemployment was so high a few years ago it was difficult to fathom how we would ever get out of it. Happily, unemployment is returning to more normal levels and our counties are catching up with the State as a whole, which is catching up with the nation. Now for the bad news…

This chart, above, is average household income. The chart shows that while we are working, we are not earning more money. You would think if there are more wage-earners in households, because employment is up, that household incomes would be rising, but they are not. Now for worse news…

This chart is of the poverty rate, which continues to increase in spite of increased employment. As we just saw, average household incomes are not changing, but inflation is chugging along at its expected 1-2 percent per year. So slowly more and more households are sinking below the poverty line. One term that people use to describe such households is Asset Limited Income Constrained (ALICE). People are working, but their incomes don’t cover even the basics.

The story this tells is very important in explaining people's behavior--they are working but they are less and less able to access basic care for themselves and their families over time. This is why the expansion of Medicaid is so important. As Michiganders lose ground, Medicaid provides a way for them to access preventive and health services.

Finally, Michigan's legislature, believing that suffering may cause low income Michiganders to work harder and earn more, wants to mandate that after two years on Medicaid, they must go into the health insurance marketplace with its huge deductibles and co-pays. Michiganders just can't afford it. They are working, but their incomes are not going up.

The final thing about all this that bothers me is that these charts also describe MMDHD's workforce. My team worked without any pay raise for a number of years, and the increases they are getting now just keep pace with inflation. Part of what is so crazy about this is that their skill levels keep increasing as they learn new technologies and apply concepts, like quality improvement, to making their work more and more efficient. But their pay does not change to reflect this. In this way they are exactly like the people they serve. Maybe understanding this will help to see--it's not an us/them thing, it's just us.

Sunday, April 12, 2015

More Community Health Workers

Imagine that a public health worker goes into the home of a diabetic patient to explain the importance of eating a healthier diet.  While in the home he notices ashtrays overflowing with cigarette butts, empty liquor bottles strewn about, no food in the cupboards, the water has been shut off and the patient complains of anxiety and depression. If the worker just delivers their healthy eating message and leaves, the patient obviously will never be able to control their diabetes and will wind up in the emergency room. Medical care has a limited impact on a person’s health, while economic, social, educational, and environmental factors are much more influential.  About half of all health care expenditures go to treat the sickest five percent of the population.

In 2012 the Mid-Michigan District Health Department recognized that we needed to change the way we do business. We knew that the Mid-Michigan Health Plan, which we used to pay for care for people in our District, was going to go away.  The federal government was going to stop funding county health plans. At the same time, we were interested in starting to work with the sickest and most expensive people in the community. We thought that if we could reduce the cost of these patients we might be able to persuade other health plans to fund the work.

Thinking along the same lines, the State of Michigan began encouraging health departments to consider the Pathways Community HUB Model. Pathways was originated by Drs. Sarah and Mark Redding in 2004. The Reddings began by working with native Alaskans who had tuberculosis. When medical treatment failed to make a lasting improvement in their patient’s health, the Reddings recruited community members to help make changes in their living conditions such as adequate heat during the winter, a consistent food supply, and safe transportation to the health clinic. When the patients’ health finally improved, the Reddings adapted this model to their current medical practice in Mansfield, Ohio, where they applied it to low-income pregnant women.

Pathways uses lay Community Health Workers (CHWs) to address the social conditions that affect health.  Importantly, CHWs are not nurses or social workers, they are individuals from the community who share the life experiences of their clients, which means they often have more credibility. The CHWs find individuals at greatest risk, refer them to health and social services, make sure they actually get served, and document the results.  By carefully documenting their work CHWs make it possible to demonstrate the value of what they do in dollars and cents.

Another important part of the Pathways model is the Community HUB. It is where the database the CHWs use is housed and managed. It takes referrals, distributes them to the CHWs, creates reports on their work, and handles contracts and payments. The HUB holds the network of CHWs together.

In 2013, MMDHD convened a Tiger Team of health care and human services partners to consider launching a Pathways project. Looking at data from hospital partners, the Tiger Team was convinced we could reduce the cost of care significantly if we addressed the mental health issues of the most expensive patients. At the same time, health department staff (the Quality Vision Action Team) working on our strategic plan decided the concept was so important that they made it the center piece of the plan.  In March 2014, while we were working on the business plan, the Ingham County Health Department offered us a grant to hire a CHW. Ingham County was one of three sites in Michigan to receive large grants from CMS to launch Pathways projects and they decided to fund CHWs in neighboring Clinton (which we serve) and Eaton counties. Muskegon and Saginaw were the other Pathways sites. Along with a grant to cover the CHW’s salary, we would also get HUB services provided by the Ingham Health Plan Corporation and training provided by the Michigan Public Health Institute.

We hired our first CHW, Shelley McPherson, and her work had an immediate impact in Clinton County. Before long people from other agencies in the community were telling me hiring Shelley was one of the best things we ever did. And the stories of her work were very moving: saving a Veteran from losing his home, getting mental health services for someone who had never had them before, helping people get heat, food, medications, quit smoking, and the list goes on.

It was clear we needed to expand the program into Gratiot and Montcalm Counties. So we approached the Mid-Michigan Health Plan Board with a request for funding. The Plan had a fund balance, and they agreed to fund two positions which were filled by Molly Smith and Samantha Tran. Before long Shelley was so busy she had a waiting list, and the Health Plan agreed to hire another CHW for Clinton County and that position was filled by Angie Felton. All three of these CHWs were MMDHD employees who were looking for a way increase their involvement in the community.

Today our CHWs are working with over 100 people per month (Angie is just ready to be trained), and there are Pathways projects in 18 counties in Michigan. We got a peek at some embargoed data that CMS has on the performance of the CHWs. It shows that the cost and utilization of care definitely goes down when expensive patients work with CHWs. There is still one piece of the puzzle missing, however. Our CHWs are not yet able to bill health plans for their services. This will require policy changes by the State of Michigan. It is very important that the State make these changes before the Mid-Michigan Health Plan runs out of money. You can bet we are spending a lot of time in Lansing trying to make sure this happens as soon as possible.

Saturday, April 4, 2015

Cross-Jurisdictional Sharing

The State Innovation Model
Banner of State Innovation Model Report

I want to return to an important topic: the fact that the way in which preventive services are delivered is undergoing a profound change in Michigan, as it is in most states. In particular, I want to focus on one way in which local health departments can get ready for these changes called Cross Jurisdictional Sharing. The Cross Jurisdictional Sharing (CJS) model helps health departments find ways to maintain or expand services by sharing them (I'll define "sharing" below).  It was developed by the Center for Sharing Public Health Services with funding from the Robert Wood Johnson Foundation and has been championed by our professional association, the National Association of County and City Health Officials (NACCHO). But I further want to argue that we often misunderstand the sharing of services as simply being a way to make due with less, when in fact, sharing can be one way to truly realize healthier communities by meaningfully expanding the services we offer. Health departments that want to grow their capabilities need to be thinking about sharing.

Many changes in health and health care are being driven by the Affordable Care Act, which aims to improve health while reducing the cost of health care. In Michigan one of the most important manifestations of the Affordable Care Act (the Act or Obamacare) is the State Innovation Model, The State Innovation Model (Innovation Model) is a detailed blueprint for how public health and health care will work together in the future to truly achieve a healthier population. Other examples of the Act at work in Michigan include Pathways to Better Health projects, increasing reliance by local health departments on billing for services, changes in the way programs are funded, partnerships between health departments and hospitals in community health assessment and improvement, and more. These changes are compelling health departments to rethink how they are organized. The CJS model says health departments need to share, that is, to adopt more programmatic and administrative innovations that extend beyond their local jurisdictions and more often include partners outside public health. Cross jurisdictional innovations may allow public health to fully play its designated role in assuring that robust population health services endure and opportunities for preventing disease and injury increase, so that the goals of the Affordable Care Act are realized.

CJS is often promoted by State or local governments primarily as a search for increased efficiencies due to decreasing budgets. The goal is to maintain a basic set of traditional preventive services like food and water programs, communicable disease, immunizations, and a few others by delivering the same amount of services at lower cost per unit. These are the traditional public health services developed in the 19th and 20th centuries which led to steep declines in mortality. In Michigan the delivery of these services was generally governed locally by cities and counties and that is more or less the basis of local public health today. Let’s call this the scarcity model of CJS. Honestly, the scarcity approach has accomplished some great things.  It has led to some of the most important innovations in public health in Michigan, including the formation of district health departments (like the Mid-Michigan District Health Department, where I work) involving multiple counties, and some health departments have reworked and automated business processes to gain efficiencies. Indeed, at least in the data we have looked at, health departments are maintaining service levels at a reduced cost.

However, CJS may also be looked upon as creating opportunities for public health to expand into new areas of work to meet modern public health challenges, and we can call this the expansive model of CJS. Expansive CJS may include alternative governance models such as intergovernmental agreements, the creation of new not-for-profit organizations and public-private partnerships. Examples of the expansive view of CJS in Michigan include the development of a network of public dental clinics associated with health departments, local health led federally qualified health centers and school-based clinics, the cooperative establishment of funds for the private financing of health department construction, the establishment of county health plans to provide a health benefit for uninsured people, hospital partnerships for health assessments and the sharing of personnel, and participation in the Pathways projects. Obviously there isn’t a simple distinction between the two visions of CJS—efficient health departments are probably more able to innovate—the point is the expansive form of CJS already has deep roots in Michigan.

Now public health is being challenged to respond to new demands for leadership and innovation. The Innovation Model envisions a network of Community Health Innovation Regions that both complement and support clinical medicine. Community Health Innovation Regions (Innovation Regions) will complement traditional health care by providing community-based population health services, and Innovation Regions will support traditional medicine by participating in care-coordination activities, particularly those that provide community-based supports for basic needs and lifestyle changes that are required meet the goals of primary prevention. It is clear in the Innovation Model that health departments will not be the Innovation Regions. Rather the Regions will be broad-based, inclusive collaboratives. Health departments will perform the fundamental public health function of assurance—assuring that Innovation Regions exist, and providing leadership where required.

What local health departments will have to do in the Innovation Regions will be completely different from what they did in the past. In the 19th and 20th centuries the role of health departments was based their statutory authority to compel people to stop doing things that made other people sick. For example they could quarantine a person with a communicable illness, or stop someone from serving contaminated food. These functions are still important, but the future will demand much more.  In an Innovation Region, a health department will need to be able to act as the public health component of an integrated system of preventive care that sprawls across political jurisdictions following medical trading areas. For example, in an Innovation Region, health departments will need to work on developing an enhanced capability to manage population health data; electronically exchange data on shared clients with health care systems; demonstrate the return on investment of community-based prevention to Region investors; or bill for services to sustain care coordination activities. In most health departments these capabilities are just beginning to be developed, and the capability to do it regionally has only been experimental.

I want to close by pointing out that it is not a simple thing to move from the jurisdictions of the 20th century to some new, future configurations.  For example, at Mid-Michigan, we just examined the financial benefit to our counties of being part of our district health department. We discovered that each county is probably saving half a million dollars by being part of the district health department versus going it alone. You can look at this in two ways: one is that with that kind of benefit at stake, counties will be reluctant to experiment with CJS. But the other way to look at it is that it is proof of the value of sharing, and that even more benefits are possible if we search for them.

Monday, February 2, 2015

On January 9th snow squalls unleashed a huge, 187vehicle pile-up on I-94 in Michigan near Kalamazoo. Twenty three people were hospitalized and one died as a result. The crash involved both sides of the freeway, sparked a fire and explosions (a truck full of fireworks burned!) and closed the freeway for two days. There were two other chain collisions in Michigan the same day.

There have been several other such crashes across the country recently. Two people were killed on January 8th in a chain collision on I-80 in Pennsylvania; on January 18th, 26 vehicles piled up on I-84 in Oregon; and on January 14th nine vehicles crashed in a pileup on I-90 in Washington. Crashes like this occur all over the world. The main cause is reduced visibility due to fog, dust, smoke or snow. Snow (and ice) is the worst because it makes roads slippery, too.

The thing about it is, these crashes can be prevented. I don’t think they can be eliminated, but the frequency, size and cost of these events can be reduced. We know why these collisions occur. The National Weather Service successfully predicts the conditions that reduce driver’s ability to see or cause roads to ice day-in and day-out, year after year; and they make their predictions available for free in just about every medium known to humanity. I am not simply talking about weather forecasts, but specific warnings that include estimated timing and locations of hazards.

Here is an example of some pretty sophisticated technology being used in Georgia to slow traffic when it is foggy. California has similar technology in some places. But preventing these collisions doesn’t depend on technology. When the National Weather Service says fog or snow or whatever is likely in a specific location, we just need to send a few troopers or deputies to the freeways with their flashers going and the kind of flashing signs we already use to post temporarily lower speed limits.  Just slow ‘em down. 

I have talked to local law enforcement people about this in the past. The main barrier to implementing something like this seems to be leadership. It isn’t easy for law enforcement to introduce new practices without clear authority to do so. Who decides? Who has jurisdiction? And they worry about taking on additional work without a way to pay for it. This would be a great opportunity for some simple legislation sorting these issues out. 

Thursday, January 1, 2015

Doubting a Big Doubt

In Larry Gonick’s Cartoon History of the Universe, Gonick puts words in Socrates' mouth: “I doubt the really big doubts,” he has the sage saying. Let’s begin the New Year by doubting a really big public health doubt about e-cigarettes. Public health is sounding an alarm over e-cigarettes, but I doubt that is the correct response. What I am going to argue is that we are in the midst of a significant, permanent transition in our national nicotine regime from one based on tobacco to one based on pharmaceutical nicotine. When this transition is completed in a generation, mortality rates from lung cancer and heart disease will be much lower. Public health needs to understand this transition and proactively help the public manage it, so we get the greatest benefit possible.

First, a quick primer on how people in public health view the world. We use a common lens: the leading causes of morbidity and mortality. That is, things that kill people are bad (even if you like them) and things that kill more people are worse. The same goes for things that make lots of people sick. Things that don’t kill people or don't make them sick are not the business of public health (even if you don’t like them for some other reason). So if mortality due to nicotine consumption is about to start to fall, public health must take notice.

There is strong evidence this “nicotine transition” is occurring. A survey by the National Institute on Drug Abuse has found that e-cigarette use has surpassed tobacco smoking among teenagers in the US. NIDA reports that 17 percent of 12th graders reported smoking an e-cigarette in the last month, compared with 13.6 percent who reported having a traditional cigarette. The difference is bigger among younger teens. Among eighth graders, reported e-cigarette use was 8.7 percent, compared with just 4 percent who said they had smoked tobacco in the last month.  What is going on? Maybe teenagers believe tobacco is harmful, so why would they smoke it when there is an alternative? I am not saying they are being consistent (Hookahs, for example). And there are plenty of good reasons to want to keep e-cigarette use low. The nicotine capsules are toxic. As the CDC warns, nicotine by itself can affect brain development and raise blood pressure. And since e-cigarettes are not regulated, the contents can be contaminated with harmful substances or other drugs. What I am saying is that the transition is occurring.

Let’s start by assuming that current smoking rates (both e and tobacco) level off at 25 percent and stay there for the next generation. However, let’s also assume e-cigarettes as a percentage of all nicotine products continues to rise until it is near 100%. That is, very few people are being exposed to the carcinogens and other harmful substances in tobacco smoke that are what kill you. The relationship between e-cigarette use and nicotine-related mortality would look like this:

If the relationship between e-cigarette use and nicotine-related mortality is as it is depicted in the graphic above, then we can evaluate possible future states of the world of nicotine using the leading causes of death as our lens. If tobacco use increases in the future the results are bad, no matter what e-cigarettes do, because mortality would increase due to the toxicity of the ingredients in tobacco smoke. However, tobacco use is at historic lows and people understand how harmful it is, so this is not likely to happen. If both tobacco and e-cigarettes decrease that would be really good since both are harmful. But if tobacco use decreases while e-cigarettes increase it would still be good, in the sense of “better than the current state,” because while e-cigarettes are harmful, the mortality associated with their use will be much lower than the mortality associated with the tobacco they would replace. Between these two scenarios, I think the latter is more likely than the former. E-cigarette use is just beginning to grow and is likely to increase before it levels off.

Possible Nicotine Futures
e-Cigarettes Decrease
e-Cigarettes Increase
Tobacco Increases
Really Bad
Tobacco Decreases
Really Good

Public health doesn’t like to think about this because it means accepting a less harmful—but not harmless—alternative to tobacco. But we must think about it. In order to get this good or at least “better” state of the world to happen we will need to accomplish two things: 1) We will need to nearly eliminate tobacco smoking, and 2) We will have to tightly regulate e-cigarettes to ensure they are as safe and as rarely used as they can be.

We call this kind of strategy harm reduction. In other areas public health has been a champion of harm reduction. Methadone, needle exchanges, nicotine patches, condoms, safety belts and air bags all make something that is potentially very harmful less so. Not harmless, just less harmful. And they save lives. In fact, harm reduction is the approach taken with tobacco, too. It is not illegal to smoke, but it is expensive, there are lots of restrictions on where you can smoke, and advertising is restricted. Because of this strategy we have gotten tobacco use to historic lows.

Sometimes being a purist leads to a future state of the world that is worse than what you started out with. Alcohol prohibition, which was achieved because it promised lower alcohol-related mortality, actually led to soaring alcohol mortality rates, because of the black markets it created and because people turned to toxic methyl alcohol.  Alcohol mortality fell again when prohibition was repealed, however, we missed an opportunity to reduce the harm from alcohol even further.

States adopted varying policies toward alcohol. Some restricted access to alcohol through blue laws, state sales, etc. But as time passed, alcohol became an ubiquitous, mass-marketed commodity almost everywhere, with the main social message being that alcohol consumption is acceptable, even desirable. Now we are dealing with binge drinking and the fiction that red wine is "good for you" (Medical marijuana anyone?). Social acceptability is what marijuana sellers are trying to achieve in Colorado and Washington now. I am all for decriminalizing marijuana because of the horrible, violent black market its ban created. But the alternative should not be the mass-marketing of marijuana. It should be a harm reduction approach.

Being purists about e-cigarettes could result in people continuing to smoke tobacco which will kill them. I believe we should consider trying to shift people from tobacco to other forms of nicotine by reducing access to tobacco even more, without banning e-cigarettes. But we also need to intensively regulate e-cigarettes and curtail their mass-marketing so the contents are safer and so the smallest number of people possible wants to use them.