Developing Regional Collaboration for Underserved Populations

State: MO Type: Model Practice Year: 2015

The Kansas City, Missouri Health Department (KCHD,) is an urban, local health department which is designed to serve the population of just over 500,000 people who reside within the three hundred and eighteen (318) square mile City limits. In addition, KCHD serves the daily population of approximately 1 million which includes residents as well as people who work within the City. KCHD also serves, provides resources for and collaborates with, the residents and agencies in the fourteen county, Greater Kansas City Metropolitan Area. The demographics of Kansas City, proper are sixty percent (60%) white, thirty percent (30%) black or African American, and ten percent Latino (though parts of the Kansas City Metropolitan Area approach thirty percent (30%) Latino. Public Health Issue: Two years ago, when the US Center’s for Disease Control (CDC) funding for Childhood Lead Poisoning Prevention was cut, many state and local lead poisoning prevention programs and services were eliminated. Such was the case in the State of Kansas. The state lead poisoning prevention program was eliminated and the local public health departments (LPHAs) and health care providers were left with few resources to care for their lead poisoned children. Frustrated staff from LPHAs and local healthcare providers in Kansas began calling the Poison Control Center at the University of Kansas Medical Center for direction and resources. The Director of the Poison Control Center was familiar with the Childhood Lead Poisoning Prevention Program at the Kansas City, Missouri Health Department and requested a consult for a seriously lead poisoned child. A consult team was established and that team collaborated with the Poison Control Center and the local children’s hospital, The Children’s Mercy Hospital(CMH). The success of the collaboration resulted in the development of a regional collaborative to help provide resources for Kansas’s lead poisoned children. Lead poisoning is an environmental disease. Treatment requires identification and elimination of the source of exposure. It requires experienced risk assessors to determine hazards in the home and in-home nurses to provide education, assessment and referrals to help minimize the damage that lead can cause. Testing needs to be done on the home, the soil, toys and food. Testing must also regularly be done on the children to diagnose and follow the illness and evaluate the success of treatment. Once, Kansas had all those resources but not any more. Children were ill, parents were begging for help, healthcare providers were frustrated. There was no one agency who could step in with all of the needed resources. The Director of the Poison Control Center, CMH staff and KCHD staff developed collaborative agreements and practice guidelines to provide at least some resources for lead poisoned children in Kansas. The goal of the collaborative was to cobble together resources for this underserved population.  These resources included: consultation and education to LPHAs and healthcare providers and provide inspections and home visit to the most seriously ill children. Lead poisoned families would also receive receive cleaning supplies, HEPA vacuums and home lead test kids to evaluate their ability to reduce hazards in the home. Staff from the agencies in the collaborative would provide telephone support and on site training and education on request. Once the idea had been hatched, the collaborative brought in the Kansas Department of Health and Environment, and the Region 7 Environmental Protection Agency. It has been a little over a year since the project was developed and it is progressing slowly but steadily.  The initial objective to provide home visits to all seriously lead poisoned children was adjusted to provide visits to those with the most persistent poisoning due to the sheer number of patients and the lack of financial support. The success of the practice can be attributed to the sheer persistence of the Director or Poison Control and staff from CMH and KCHD and the close partnership they shared before the collaborative was developed. The milestones of the project are measured in processes such as the development of MOUs and Scope of Work Agreements between partners and the development of a ‘triage’ system to provide resources to the most seriously lead poisoned children. The public health impact of the practice is huge, that despite a lack of resources, agencies can take a stone and by adding bits of resources they can each spare, make a soup that can feed the hungry.    
The public health issue is the lack of resources for lead poisoned children. The target population is primarily children six years of age or under who reside in under served areas of the state of Kansas and the Kansas side of the Kansas City, Missouri Greater Metropolitan Area. While there are over 1500 affected children in the Greater Kansas City, Missouri area, the number is greatly increased when the children from Kansas are included in this figure. Currently, decreased testing across the state and a lack of surveillance (recently corrected) leaves exact numbers unclear. While the percentage of children reached directly is approximately 50 children in the past year. The training and support of partner LPHA staff extends the reach of the project considerably. In the past, lead poisoned children in Kansas received investigation from the state including case management, inspection with environmental sampling, follow up and enforcement. LPHAs had strong support and resources from the state lead poisoning prevention program. These resources are no longer available. This collaborative is not better than a fully equipped state program but it is better than nothing. This practice is innovative in that it is tough to develop a close, functional, long term working relationship with other agencies. Often agencies are only out to get what they can get out of a collaborative or they are there in name only and cannot provide resources. This is a true collaborative for the good of a group of children and all of the partners give a lot and none of them really get anything in return.  
The goals of the practice are to provide services to lead poisoned children in Kansas. To reach this goal, KCHD staff reached back to our referring partner, the University of Kansas Poison Control Center and also partnered with The Children's Mercy Hospital Pediatric Environmental Health Center to put together resources and a plan to help Kansas children. First, we put together a team from KCHD to visit the initial lead poisoned child, then we helped provide training and experience to CMH staff to increase their capacity. They worked with Poison Control staff to develop a triage system and began seeing more patients. We began to put together MOUs and collaborating agreements and providing phone consults with LPHAs in Kansas. The KCHD and CMH teams combined and helped increase the capacity of the LPHAs where we were seeing the most lead poisoned children. KCHD made agency to agency referrals to OSHA on a number of cases and worked with the LPHAs in the workplace investigations. The criteria for who was to receive the practice is any child who is lead poisoned. The timeframe for the practice is ongoing. As the practice evolves, more stakeholders are joining including ATSDR, additional LPHAs, local healthcare providers and social work staff at CMH. Frequent communication and collaboration on other projects helps foster collaboration on this practice. This group started the practice with no funding and still has none, though the team has submitted grant applications for some funding. Securing funding will allow the practice to reach more patients.
The main objective of the practice is to provide resources for lead poisoned children and the providers who treat them. The collaborative group has provided resources to over 50 children thus far. The most compelling evidence for the practice is the improvement in blood lead level in most of these children. In addition, the collaboration resulted in the identification of two companies whose safety practices were insufficient and whose employees were being exposed and bringing toxic lead home, contaminating their houses and poisoning their children. Both of the companies have improved their practices and their employees (over 80) have been made aware of the dangers of lead. Many of the homes of children whose exposure was identified as lead paint hazards in their home have repaired those hazards. Data collection for this practice is ongoing and analysis is still in the early stages. Performance measures including number of children seen, number of homes inspected, dust wipe results and full analysis of blood lead test results are in process at the time of this writing. The biggest modification to practice so far is the addition of plans to provide education to large numbers of workers in companies whose practices are resulting in take home exposure for themselves and their children.Most children are poisoned by deteriorating lead paint and it was a surprise to see how many children in Kansas are exposed by take home lead from manufacturing.
Since this practice was established with very minimal resources, it is very sustainable in it's current form. The type of resources provided to families (test kits, home visits, inspections, home repair etc.) can expand and contract based on what is available. The biggest resource is the commitment and expertise of the partners and one of the best ways to sustain that is to continue to work closely on multiple projects. This makes sure the agencies have reasons to stay in collaboration and keeps communication pathways open. Diversifying projects and funding (within the environmental/healthy housing realm) also allows for sustainability.  
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