Change Master Projects Class of 2005

A Healthier Fayette County through Strategic Planning of the Public Health System: Insights and Recommendations

Prepared by: Jessica E. Cobb, B.S., R.S.; Wendy N. Compton, B.S., R.D., L.D.;
Sandra B. Conners, A.B., M.B.A., D.B.A.; Barbara J. Quam, B.S.N., R.N.
Mentors: Dr. George Graham, Dr. David D. Gale

Full Report (pdf format)

Lexington/Fayette County currently has no means for effectively coordinating the health improvement efforts among the various parties involved in public health. These parties include the Lexington-Fayette County Health Department, five acute care hospitals, four additional hospitals, numerous private practices, ambulance (EMS) services and nursing homes. Other parties that deliver health care include private and public institutions that provide education at all levels, veterinary clinics (because of the possibility of zoonotic diseases), and businesses in general (occupational health). Other concerned parties include health insurers, governmental entities, day care centers, not-for-profit organizations and so on. These parties are all part of the “local public health system,” defined by the Local Public Health System Performance Assessment Instrument, developed by the National Association of County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC), as “all public, private, and voluntary entities, as well as individuals and informal associations, that contribute to the delivery of public health services within a jurisdiction.”

The result of this fragmented approach to community health improvement initiatives is uncoordinated and duplicated services, possible inattention to important concerns and a consequent less than optimal health status improvement. Mobilizing community partnerships to identify and solve health problems and developing coordinated plans that support local health efforts in the context of state and national priorities has been increasingly emphasized in public health (Sirio, et al. 2004).

The number of parties in a county of a quarter million that serves as the health care hub for Central and Eastern Kentucky is considerable and the health needs are considerable. While NACCHO and the CDC maintain that “local public health agencies are the natural leaders in the development of a cohesive local public health system,” there is currently no central coordinating body that exists for county health efforts. The only exception is the Health Care Emergency Planning Committee (HCEPC) which includes representatives from many of the parties above; however, the scope of their effort is limited to emergency preparedness efforts in a twenty county region surrounding Fayette County.

Both NACCHO and the CDC maintain that local public health agencies have unique responsibilities to enable, assure, and enforce the provision of these essential services by entities within the local public health system. They can assure an adequate statutory base for local public health activities, advocate with system partners for local policy changes to improve health, and assure that funding for public services meet the critical health needs of their populations. In addition, local public health agencies can provide important leadership in maintaining and improving the performance and capacity of local public health systems to provide appropriate public health services.

Whether as leader, convener, partner, collaborator, enabler, or evaluator, local public health agencies play key roles in coordinating the performance of local public health systems. By developing public health performance standards to identify and benchmark superior performance, local public health systems and their local public health agencies will be better equipped to assess and improve the delivery of Essential Public Health Services and achieve improvements in community health.

In order to perform its central role in improving the health care system, the Lexington-Fayette County Health Department (LFCHD), under the direction of Dr. Melinda Rowe, appointed a cross-functional team of five LFCHD employees in April 2004 to explore whether a county-wide health care system strategic planning effort should be initiated. This report is an assessment of that team’s activities, outcomes and recommendations.

Can You Hear Me Now?

Prepared by: Renee Blair, BSN; Dennis Chaney, BS, MPA; Nancy Crewe, BA, MA; Mark Hensley, BS;
Marcia Hodge, BA; Paul Hopkins, BS, AS, RRT; Rosie Miklavcic, BSN, MPH; Rebecca Tandy, BS
Mentor: F. Douglas Scutchfield, M.D.

Full Report (pdf format)

Our Kentucky Public Health Leadership Institute Team sought to determine the perceptions of local health department directors and state public health staff regarding state-local communications in Kentucky’s public health system. A survey sent to directors and state staff showed a majority of the directors who responded to the survey rated communication between local health departments (LHDs) and Department for Public Health (DPH) as fair; no director rated communication as “excellent.” The majority of DPH staff who responded rated LHD-DPH communications as “good.” Both directors and state staff cited specific examples of excellent and poor communications and made recommendations for improvement.

In order to research possible remedies and give definite guidance for improving state-local communications, we did case studies on the communication philosophies and mechanisms in four states. These states have public health systems that resemble Kentucky’s, and their communication models were recommended as exemplary by Kentucky Public Health Leadership Institute (KPHLI) faculty and mentors. These states included Washington, North Carolina, Wisconsin, and Iowa. Research for case studies was based on interviews with certain key staff from each of these states and analysis of documents from state public health websites. Local health department directors in these states were not consulted or interviewed.

While we acknowledge that efforts are currently underway at the local and state level to improve communications, we believe LHDs and DPH could adopt certain “best practices” from these four states to effectively correct the problems with communications identified in our survey. Recommended best practices include: (1) making effective, responsive and timely state-local communication a core value for Kentucky’s public health system, (2) establishing liaison positions at the local level on a regionalized basis or assigning these duties to a staff member in each division at DPH, and (3) improving electronic communications through better state website design and enhanced use of existing technology such as the Health Alert Network, TRAIN, and the Distance Learning Center.

Our proposal to the Department for Public Health is one we believe to be realistic in achieving our goals. Its adoption can signal a new beginning for effective and efficient communication between both organizations leading to a strong and equally supportive relationship.

Evidence-Based Strategies in Kentucky Health Department Community Plans

Prepared by: Jennifer Redmond, MPH; William Lloyd Jordison, RN; Lisetta Whitworth, MSM
Mentors: John Poundstone, MD, MPH; Shawn D. Crabtree, LCSW, MPH

Full Report (pdf format)

Project Deliverables (pdf format)

Evidence-based public health has received attention in the public health field, and is now part of most grant applications, expectations and goals set for public health agencies. Books have been written, courses created and web pages dedicated to promoting and facilitating evidence-based public health. Even the American Public Health Association conference theme for 2005 is “Evidence-based policy and practice.”

We decided to investigate evidence-based public health in Kentucky in order find out the strategies used for selecting evidence-based programs that are included in the Kentucky Community Plan and Budget, which is the basis for all community program interventions conducted in local, district and state health departments in Kentucky.

Based on the background information, we asked the following questions in order to move forward with the project:

  • How are evidence-based programs used in Public Health and how do we determine which evidence-based programs to implement within the counties of Kentucky?
  • How do the Kentucky Public Health Departments measure the success or failure of the programs they implement within their communities?

We surveyed all Kentucky local and district health department directors; state cost center directors and two other surrounding states electronically (West Virginia and Tennessee). We requested information regarding methodology and tools used for choosing evidenced-based community programs. Also asked what information was needed and desired but not provided to make decisions about community programs. (Appendices A, B and C)

Once compiling the information received, we created a template to be used by both the state cost centers and local and district health departments in order to make evidence-based decisions about community programs. We pilot tested this template with local and district health departments and requested feedback that included an evaluation. (Appendix D)

Based on feedback and evaluation, we created the final template draft (Appendix E) that can be used by both local and district health departments as well as state cost center directors at the Kentucky Department for Public Health.

Three of the 10 Essential Public Health Services were included in our project including:

  • Essential Service #4 – Mobilize community partnerships to identify and solve health problems.
  • Essential Service #9 - Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
  • Essential Service #10 – Research for new insights and innovative solutions to health problems.

Health Departments must choose Community Plans for implementation each year in their budgets. The process of choosing which Evidence-based Community Plan to include in their budget provides the opportunity to mobilize community partnerships and collaborate in solving health problems, evaluate effectiveness and conduct research for new insights and innovative solutions to their community’s health problems.

52% of the county local/district health departments, two cost center directors and one surrounding state responded to the survey. Results were used to develop a template of questions that would assist local/district health departments in their decision-making process for community based programs. 48% of local/district respondents did not have a tool used to determine what programs to implement. Common methods for decision-making included using “gut” feelings, assessing funding sources, likeability of program and training needs. Respondents requested more communication concerning successes and failures of programs in other local and regional areas, more information about individual programs and are receptive to coalitions and community partner suggestions.

Although there is attention and need for implementing evidence-based public health in Kentucky, we discovered the need for Kentucky to have a protocol/template for selecting evidence-based strategies very early in our project and realized as we continued to research the subject that this need exists not only for Kentucky, but also for other states. We realize that this is a need that extends to the national level and that this is really “cutting-edge” work in the creation of a template that is designed to assist both states and communities in making their selection of strategies and programs.

FEATS : Family Education Access To Services

Prepared by: Carolyn Richey, RN; Lisa J. Houchin, MS; Don Crask, BS, MS; Micheal Kathman, RN, BA;
Yvonne T. Pfanenstiel, BS, BSN
Mentor: Darlene Walls, BA, MA

Full Report (pdf format)

Public Health is static, an ever changing kaleidoscope of concerns. Public Health departments are at the center of this storm. We strive every day to “connect the dots” of what’s affecting our communities and what we can do to lessen the effect. Our public health workforce is diverse in their disciplines, from environmentalists to social workers to health educators to RN’s and to support staff we often are so engrossed in our own endeavors that we fail to notice what the other hand is doing. We often lack the time and foresight to think outside the box and find out what each of us is doing and work to enhance each others field of expertise.

Our change master project is a tool that can be used by health departments to educate their employees and make the community aware of services the health departments can offer. Our idea is to have a CD with a master template of all services offered throughout the state of Kentucky. The individual health departments can modify the master template to the services offered. Individual health departments can also modify to reflect what services are offered in the community as referrals.

Implementing the MAPP Process in Louisville Metro
2005 Balderson Leadership Project Award Runner-Up

Prepared by: Janita Perry, R.N., B.S.N.; James McCammon, Ph.D.; Dave Langdon, B.S.;
Janice Cunningham, M.A., C.A.D.C.; Sheila Andersen, J.D., M.A., B.S.N.
Mentor: Genie E. Prewitt, M.S.N.

In Louisville Metro there exists a lack of awareness of health status and health disparities and a lack of collaboration for improving the health of Louisville Metro residents. For many indicators, Louisville Metro rates are poorer than national rates.

Full Report (pdf format)

The project team examined the possibility of initiating Mobilizing for Action through Planning and Partnerships (MAPP) in response to this lack of awareness and coordination. MAPP is a process developed by the National Association of County and City Health Officials and the Centers for Disease Control and Prevention to assist communities in improving the health and quality of life for residents through community-driven strategic planning. The process includes six phases: Organize for Success; Visioning; Four MAPP Assessments; Identify Strategic Issues; Formulate Goals and Strategies; and the Action Cycle.1, 2

The project team consulted with officials from the Northern Kentucky, Nashville, and San Antonio Health Departments to determine the feasibility of initiating MAPP in Louisville. As a result of these consultations, the project team decided to first begin a media campaign to raise awareness of the health issues in Louisville and then to complete phases one and two of the MAPP process during the 2005 term of the Kentucky Public Health Leadership Institute. The project team also created a budget and identified agency funds to complete the other four phases of the MAPP process in the months following the 2005 KPHLI term.

The media campaign consisted of:

  • A regular Health Department spot on the WHAS-TV News at 11:00 PM.
  • The publication of the Health Department newsletter Health Matters.
  • The creation of a Health Department television show, also called Health Matters.
  • To further raise awareness of health issues in Louisville, the project team released the Health Status

Assessment Report, 2004 and secured front-page newspaper coverage for the report as well as coverage on three television stations.

To implement the Organize for Success phase of MAPP, the project team worked with the Louisville Coalition of Neighborhoods and the Louisville Department of Neighborhoods. The team compiled an extensive list of all agencies and groups partnering with the Louisville Metro Health Department. The project team sought and gathered applications from community leaders wishing to serve on the Community Health Council to oversee MAPP. The project team also sent out letters to leaders from the health, education, business, and law enforcement communities inviting them to serve on the Council.

To implement the Visioning phase of MAPP, the project team held a meeting on February 28, 2005 at the University of Louisville with the Community Health Council. The meeting formulated a vision statement of what a healthy Louisville might look like as well as a list of values to be considered in implementing that vision. On March 29, 2005 the project team held a follow-up meeting with the Council to finalize the vision statement and values and to seek volunteers for the Four MAPP Assessments.

Improving Childhood Wellness in an Innovative Way

Prepared by: Tracy Aaron, CHES, Gina M. Baldwin, RN, BSN, RaeAnne E. Davis, MSPH, Peggy Tiller, RN, BSN,
Jaime R. Wilson, BS
Mentor: Janet Tietyen, PhD, RD, LD

Full Report (pdf format)

In recent years there has been mounting concern among those in the medical, educational, and physical fitness arenas regarding the increased prevalence of childhood obesity in the school age population. The physical, psychological, and social ramifications of such a disease in a child are taxing. Overall, our society is moving toward healthier lifestyle choices. Fast food restaurants are offering healthier menu selections. Communities are providing incentives for increased physical activity. But what positive interventions are being made on behalf of children and their caregivers?

In June 2004 our group was compelled to make a difference when it came to the problem of obesity in elementary school children. Specifically, we were interested in parent’s or caregiver’s perceptions and concerns regarding their children and healthy weight. Additionally, we wanted to work with parents and caregivers to make the message of healthy weight in elementary school children a positive one. Equally, we were concerned with helping those directly involved with parents or caregivers of elementary age children and equipping them with information and tools to promote healthy weight and reduce the problem of childhood overweight.

To assess the perceptions and needs of caregivers with elementary age children who were obese or at risk for overweight, we conducted focus groups in select elementary schools in south central Kentucky. Based on the focus group findings, we were able to develop a survey distributed to parents/caregivers of elementary school age children in three school districts in south central Kentucky, assessing parents’ perceptions of healthy weight in elementary school age children. The surveys also assessed parents’ specific needs to aid them in making healthy dietary and physical activity choices for their children.

Upon tabulating the focus group and survey results, we developed positive messages regarding healthy weight in elementary school age children. We compiled a summary report of our focus group and survey findings and distributed it to key stakeholders in the three south central Kentucky elementary school districts involved. The information from our focus groups and surveys in the elementary schools and the findings from an informal survey conducted at the Growing Healthy Kids Conference 2004 aided our group in planning and making preparations for the Growing Healthy Kids and Parenting Conference 2005. In 2005, the Growing Healthy Kids Conference will focus on educating those involved with children, and will also target workers directly involved with parents in different arenas. Our group’s findings helped shape the agenda, identify areas of interest and speakers for the conference.

Our group’s work, findings, and related materials were presented to our fellow scholars and guests at the 2005 KPHLI graduation summit and we anticipate sharing our findings at the Growing Healthy Kids Conference 2005.

Supporting Practice Through Quality Nursing Documentation
2005 Balderson Leadership Project Award Runner-Up

Prepared by: Kathy Fields, MPA, RN, CS, Karen King, RN, Marla Jean Powell, RN, Beverly Aldridge, RN,
Rinda Vanderhoof, RN, Sarah J. Wilding, RN, MPA, BSN
Mentors: Beverly Siegrist, EdD, MS, RN, Margaret Stevens, RN

Full Report (pdf format)

Special thanks to Libby Sammons, Supervisor of the Local Health Administration Systems Section, Division of Administration and Financial Management, Department for Public Health.

Nursing documentation provides the basis for accountability and funding for public health nursing services. Appropriate documentation includes a complete and accurate nursing note, assignment of the appropriate level of visit and identification of the appropriate primary and secondary diagnostic codes.

Observational site visits and interviews support that local health department nurses generally provide quality services. However, nursing documentation is not always consistent with care provided or the level of visit that could be coded. Caution to avoid fraudulent billing and failure to recognize the required components for appropriate documentation may lead to under-coding. This may result in decreased revenue for local health departments, underreporting of services provided, and poor results from audits.

This Change Master Project goal is to increase operational competency of local health departments by: 1) assessing knowledge of current coding, 2) clarifying appropriate documentation and coding to support nursing practice, 3) developing and recommending tools to assist with training of local health department nurses, and 4) promoting the availability of ongoing training.

The methodology includes surveying local health department nurses regarding their comfort level with coding and documentation and perceived barriers. Fifty one counties responded: over 35% reported never receiving training on coding and documentation and over 75% reported not having training within the year. Over 80% of respondents felt annual training and tools to assist with coding levels and diagnostic codes would be helpful. Interviews were conducted with state DPH staff to clarify requirements, identify barriers from a state and program perspective and explore strategies and resources. Group members met to develop a format for tools, explore resources, assign tasks, and develop a timetable.

Research identified the Evaluation and Management Level 8b Tool as an effective computerized aid to nursing documentation and coding. SOAP note format includes subjective, objective, assessment and plan information and provides documentation of the history, exam and decision-making that determine the appropriate service code. The CPT coding system assigns a service code that denotes the complexity of the service and the reimbursement level. The ICD-9 Code system is used to identify primary and secondary diagnoses. T.R.A.I.N. is a web-based learning management system for public health that can be accessed in the worksite and other sites with Internet connection.

Results/Products to be available for Local Health Departments include:

  • CD ROM - Evaluation and Management Level 8b
  • SOAP Note Guidelines to meet CPT Code Requirements
  • List of Most Commonly Used ICD-9 Diagnostic Codes
  • T.R.A.I.N. Module for Nursing Documentation and Coding
Wellness Riders : Health Promotion Resource Tool Kit

Prepared by: Katharine Lay, BS., SW, PH, Judy Solomon, B.S , Tammie Muse R.N., BSN
Mentors: J. David Dunn, Dr. Sc. in Hyg., M.P.H., Suzie Hamm

Full Report (pdf format)

Project Deliverables (pdf format)

When Thomas Edison invented the light bulb, he tried over 2000 experiments before he got it to work. A young reporter asked him how it felt to fail so many times. He replied, “I never failed once. I invented the light bulb. It just happened to be a 2,000-step process.” (Jack Canfield, CSSII)

"As a society, we can no longer afford to make poor health choices such as being physically inactive and eating an unhealthy diet; these choices have led a tremendous obesity epidemic. As policy makers and health professionals, we must embrace small steps toward coordinated policy and environment changes that will help Americans live longer, better, healthier lives." (U.S. Surgeon General).

The importance of physical activity and good nutrition are crucial to preventing chronic diseases that account for 7 of every 10 U.S. deaths and for more than 75% of medical care expenditures. Physical inactivity and unhealthy eating contribute to obesity, cancer, cardiovascular disease, and diabetes. Along with tobacco usage these two behaviors are responsible for over 400,000 deaths each year.

According to the Centers for Disease Control Behavioral Risk Factor Surveillance System (BRFSS), obesity has reached epidemic proportions and nearly 59 million adults are obese. This epidemic not only reaches adults but also affects the percentage of young people who are overweight. The percentage of young people that are obese has doubled in the last 20 years. Promoting healthy eating and physical activity in worksites can create an environment that supports healthy behaviors, which is essential to reducing the epidemic of obesity.

Worksites can play an important role by influencing lifestyle behaviors of employees that in turn can affect change in the home with their children. Eighty-two percent of the U.S. population is linked to the worksite in one-way or another. Worksites can be environments that create change, especially when employees and employers work together to initiate efforts that result in lifestyle changes. The high demands of work, which induces fast-paced lifestyles, unhealthy eating habits, and lack of physical activity, contributes to the problem of poor health and negative lifestyle behaviors. These unhealthy lifestyle behaviors of employees influence job performance, which leads to decreased productivity, increased absenteeism, lower moral, and high health insurance claims. These fast-paced lifestyles, along with the typical workweek that consist of 47 hours, family commitments and obligations influence Americans to eat “on the run” contribute even more to the problem along with the lack of physical activity.

Americans spend on the average $17 billion each year on fast food, an average of 17 hours sitting in front of the television and 50.6 hours sleeping, this leads to 114 hours per week of sedentary behavior, which equates to nearly five full days of no physical activity. Preventable illness makes up approximately 70% of the burden of illness and the associated expenses of rising insurance costs. Every year U.S. businesses spend billions of dollars addressing the epidemic of obesity. According to a 1999 National Worksite Health Promotion Survey, 90 percent of U.S. companies sponsor at least one health-promotion activity, but only half of these organizations regard health as a core business value, essential to business objectives.

Our project sees first hand the crucial need for health and wellness education that can be utilized by human resource mangers and by health educators in the worksites. Our tool kit will provide materials and onsite health education that can enable human resource managers to implement wellness activities that will promote positive lifestyle behaviors and empower employees to take a more active approach toward improving their health.