Creating and Utilizing a Public / Private

Partnership For Health Education in Maine

By MaryAnn Amrich, RN; Victoria Rogers, MD; Lisa Belanger, MSN, FNP; Teresa Hubley, MPA, PhD, Christopher Stenberg, MBChB, Jennifer Childs-Roshack, MD

Introduction

The Partnership

This paper describes the formation and maintenance of a partnership, called Maine Kids Run Better Unleaded (MKRBU), between Maine's Bureau of Health (BOH), the City of Portland and Barbara Bush Children's Hospital (BBCH). This partnership was formed in order to promote appropriate blood lead testing practices among Maine physicians.

Blood lead testing is especially recommended at ages 1 and 2 for any child shown to be at particular risk and for any child under 6 not previously tested (CDC 1997). Studies of lead poisoning in Maine had shown blood lead levels to be relatively high and especially so among Medicaid-covered children (Maine Medical Assessment Foundation 2000). However, in 1998 when this partnership was formed, blood lead testing rates for the state of Maine were low and dropping.

As Maine continues to monitor lead testing rates, the partners have noticed the screening rates have begun to improve. This improvement results, in part, from the flexible and creative solutions the MKRBU developed in response to the problems with, and barriers to, lead testing in the state of Maine. This information concerning the problems and barriers to screening had been gathered from a statewide survey. This survey asked all primary care providers their attitudes, beliefs and practices in relation to lead screening and testing in the state of Maine. A major project formed in response to the results of the survey was a one-on-one physician education project, currently in progress throughout the state.

Reasons for Formation

Dr. Victoria Rogers, M.D., one of the principle founders of MKRBU, refers to her work at the Barbara Bush Children's Hospital in 1998:

In 1998, when the new AAP (American Academy of Pediatrics) lead screening guidelines were published, I started thinking about our practices at the BBCH. I knew we weren't routinely screening our high-risk children. I then started wondering what everybody else was doing. When I asked a few people in our community, it appeared nobody knew about the new CDC (Centers for Disease Control and Prevention) and AAP guidelines (which mirror CDC's guidelines). Most people said they DID NOT routinely screen Medicaid kids or even ask whether kids were at risk for lead poisoning. I thought I should do some "leg work" working with the state program. I had heard that MaryAnn (Amrich, the state program director) had done a survey back in the early 1990's when she was in Portland (while working for the Childhood Lead Poisoning Prevention Program within the City of Portland’s Health & Human Services Department). I thought it would be a good idea to survey the practitioners who care for Maine children to find out what their knowledge, attitudes, beliefs and practices were in relation to lead screening. MaryAnn and I got talking and it was clear there were a number of people involved with lead screening on a state and local level including, the Portland Health & Human Services Department (PHHSD).

Dr. Rogers and her colleagues, Dr. Christopher Stenberg, director of the Ambulatory Care Center at the BBCH and Dr. Jennifer Jewell, then a Pediatric Resident at BBCH, developed a 10 question survey. In 1999, they mailed the survey out to all physicians who provided well child care, including Pediatricians, Family Physicians and General Practitioners. The surveys elicited 334 responses, a nearly 80 percent return rate. Most physicians responding to this survey claimed to test all patients appropriately, although state data on testing rates (which averaged around 11% of the under age 6 population for the entire state) did not reflect such widespread practice. Most physicians also claimed familiarity with CDC's testing recommendations, though only close to half considered lead a "problem" in Maine.

Through the surveys, physicians reported a variety of barriers to greater testing. These included lack of staff knowledge and lack of time for testing. Another barrier to successful testing was found in the physician practice of handing patients lab slips and asking them to go off site to obtain the sample. Physicians often assumed, but did not ensure, that patients followed through with testing. Physicians also expressed frustration that if testing were conducted, they could not be assured the patient would receive appropriate services as a result. This last situation had the effect of discouraging physicians from screening, as they were not sure if positive screens generated services elsewhere or if they themselves were required to follow up on all the patients' needs.

When Dr. Rogers and her colleagues shared this information with the BOH and PHHSD staff, the implications were clear to all. Physicians in the state of Maine were unaware of services available to them in support of treatment and testing for lead hazard exposure. They were also unaware of the potential risk of poisoning among their patients and they clearly did not ensure testing of their patients as recommended. The group realized that there was a need for an education campaign, directed to Maine physicians, to address all of these gaps between knowledge and practice. As physicians themselves, the BBCH staff further realized that the message would best come from within the physician community. However, the need for support from the state, which was generating the practice guidelines for physicians and providing case management services, and the PHHSD, which had experience screening, case managing and educating the at-risk population, was also evident.

Foundations

First Steps

Maine is a relatively rural state in which each professional field is small enough for personal contact. The very first step in forming what was to become MKRBU was indeed the act of following up on personal information, as described above. Staff at BBCH made contact with the state level Childhood Lead Poisoning Prevention Program (CLPPP). Staff at CLPPP then suggested personal contacts on the local level.

A second step was for the group to secure funding. The BBCH applied for and received funds from the Mattina R. Proctor Foundation. The grant totaled $150,000 for a 2-year period. The goal of the grant-funded project was to follow up on the surveys by creating an intervention for physicians focused on issues raised by the surveys.

Goals

The initial goals of MKRBU were set through a steering committee composed of representatives from each of the original three partners: the hospital, the state and a local public health department with extensive experience in testing for and responding to lead poisoning. The steering committee was responding to the discrepancies that were found between the survey results and the state lead screening rates. The mission of the group was to increase the screening rate in Maine by addressing the needs of the physician community around support and education.

The group knew that they must have input from many of those affected by and influencing the interaction between physicians and their patients. Therefore, the first goal set towards realizing this mission was coalition building.

Other goals came out of a series of meeting over a six-month period. These goals are:

  • Develop a collaborative initiative, inclusive of state and local groups, to address the issue of lead poisoning
  • Increase awareness of lead poisoning throughout the state
  • Closing the loops--so we are all aware of each others efforts
  • Standardization of materials
  • Double the screening rate for Medicaid children--from 12% to 24% (This is the major measure of program effectiveness)

Procedures

In order to sustain momentum for the partnership, MKRBU needed to establish a method of fostering communication and mutual identification with the group. The group needed leaders, an established membership and regular meetings.

The leadership of the MKRBU reflected the ideal of drawing strength from partnership while keeping responsibilities clear. Dr. Rogers assumed the day-to-day leadership of the project. MaryAnn Amrich, the director of the BOH program, and Dr. Christopher Stenberg of BBCH were co-facilitators and co-directors of the project. Dr.Jennifer Childs-Roshack, a family practitioner, also represented the Maine Medical Center. Lisa Belanger, Ronda Jones and Andrea Thompson represented the PHHSD Healthy Homes Program.

The MKRBU wanted also to create linkages with other agencies in the state that may serve children at risk for lead poisoning. Early attempts to directly include other agencies and organizations (such as the American Academy of Pediatrics) were not successful. However, MKRBU personnel overlap with many groups serving the target population, including the Lead Advisory Council, which assists the state in crafting policy aimed at lowering the incidence of lead poisoning in the state of Maine. These memberships allowed MKRBU representatives to bring the concerns of their partnership into many different forums. Though still a small group, MKRBU began to multiply its influence through cross-organizational connections. MaryAnn Amrich comments, "It's okay to start with a small group of committed people".

The MKRBU met once a month for the first 2 years and then moved to a schedule of every other month. The group currently meets on an "as needed" basis. For example, Dr. Rogers plans to call the group together in the fall of 2002 for a meeting to give them an update on activities pursued over the summer. Dr. Rogers comments that members of the group have been focused lately on "other meetings and more specific goals, such as the physician lead screening task force". The latter group was created by a new state law, which went into effect in the spring of 2002. The law mandated that a physician task force draft the new lead screening guidelines for the state. Again, the energies of MKRBU members may be channeled into other projects at times but the group meetings bring them back to focus on their core goals.

As the monthly meetings first got under way, the MKRBU found that little facilitation was needed. The group members tended to automatically take responsibility for each supporting function. Little controversy arose in the context of the meetings. Fostering a group vision helped members to stay focused and reduced the tendency to push individual agendas.

Structures

Activities

  1. Identity Matters

One of the most important activities a group undertakes is creating its essential identity. In order to do this, a group needs a name. Another way of reinforcing the group identity is to create a graphic representation, or logo. The group borrowed its name from an EPA education poster that shows several little children and the legend "Runs Better Unleaded". After EPA personnel confirmed this name could be used, the group modified the name by adding the state name and the word "Kids". The group then created a logo consisting of children running and playing.

  1. Physician Education

The group's core challenge was to create activities designed to address the findings of the survey conducted by Barbara Bush Children's Hospital. Since several physicians were involved with the group, they served as key informants around the question of how physicians get information and how they change their practices. All the physicians shared the opinion that physicians must be directly consulted in order to ascertain the problems and challenges they face in complying with recommended procedures for lead screening. Furthermore, they agreed that physicians are most likely to listen to members of their own community, who would be most likely to understand the difficulties involved in changing the workflow of a busy practice.

As a result of this consensus, MKRBU decided to support a model whereby a physician would visit all offices wishing to receive guidance. The members of the group identified "drug reps" or pharmaceutical detailers as the most relevant model. Detailers bring samples and free presents in person to every physician's office in order to create interest in the company products. It was decided the physician consultant would not only visit the physicians but also bring along a packet of helpful educational materials.

The physician consultant’s materials included any available statistics about lead screening and poisoning in the area to be visited. At first, MKRBU members proposed using the statistics for each individual practice available from Medicaid. After some discussion, however, they came to support the idea of looking at wider areas, such as counties. The physicians would not then be singled out but would bear the responsibility of the rates for an entire area. The Bureau of Health provided the data for this presentation.

In preparation for the physician outreach campaign, every practice that provides well child care in Maine was initially contacted by mail. These first mailings informed the physicians about the lack of lead screening among Maine's high-risk children. Physicians were then offered the opportunity to learn more about lead screening issues through either a site visit from Dr. Rogers or an informational packet that could be delivered to their offices via email or the U.S. Postal Service. Dr. Rogers was the first physician consultant, with future consultants to be recruited on a local basis. Dr. Rogers started her visits with the county that had the lowest screening rate in tandem with a relatively high poisoning rate. To date, 252 physicians have been contacted through 48 site visits.

3. Supporting Materials and Presentations

While the staff of the Barbara Bush Children's Hospital provided the labor for office visits, other members of the MKRBU provided support in the form of educational materials. The Bureau of Health in particular had many brochures and other items to contribute to the effort.

The group also assisted in the creation of materials geared to the office visit project. These included:

  • A summary sheet of the actions and interventions needed for each level of lead poisoning.
  • A Physician Resource Sheet listing local and state phone numbers and contacts for issues relating to lead poisoning prevention and treatment.
  • A one-page reference card on the basics of screening and education points to be covered with parents of lead poisoned children.
  • A one-page fact sheet about lead poisoning in Maine; the who, when, what, where, why and how of lead poisoning.
  • A process flow chart of what happens after the child’s blood is drawn; where it goes and what happens with the results.
  • A one-page procedure guide on how to obtain a capillary lead screen.
  • A short list of references on lead poisoning, lead screening and treatment options for lead poisoned children.

The members of MKRBU presented to several forums involving medical personnel including:

  • The Maine chapter of the American Academy of Pediatrics (AAP) annual meeting.
  • The National Association of Children’s Hospitals and Related Institutions (NACHRI) annual meeting (poster presentation)
  • The CDC regional Lead Grantee conference for the Northeast
  • The CDC national Lead Health Education conference (both poster and oral presentations)

The group also generated publicity through related program newsletters covering such events as the beginning of the office visits. One widely reported event was Dr. Jennifer Jewell's receipt of the national AAP Injury and Poison Prevention Award for her outstanding work with the MKRBU Program. Dr. Jewell was one of the lead investigators involved in the lead screening survey.

Changes

The physician office visits and surveys have provided a steady stream of feedback to the MKRBU. This information has in turn influenced the activities of group members. For example, physicians have indicated that they do not get a report on case management activities that are coordinated by the BOH and executed by local agencies, such as the PHHSD Healthy Homes Program. The response to this finding was to establish a reporting mechanism that ensures physicians are kept up to date on the progress of case management.

Another important finding from physician contact is that physicians would like to be reminded of the appropriate intervals for re-testing. This information was incorporated in the state laboratory form that is sent back to the providers along with the patient lead level. State law in Maine requires that all blood lead testing be executed through the Health and Environmental Testing Lab (HETL) run by the state of Maine.

As physician office visits progressed, it was frequently found that office practices perceived a shortage of time and expertise among their staff for conducting the necessary capillary blood draws on site. Physicians had been sending patients to outside labs but the patients often did not follow through for a variety of logistical reasons. Many indicated they would perform the capillary blood draws if they could be assured they had the time and expertise. As a result, Jodi Widor, RN, one of the BBCH outreach nurses, and staff from the BOH began sponsoring capillary draw trainings for office-based staff.