Providing services for EBL children in
underserved areas through local
partnerships
Jennifer Lowry, MD
Amy Roberts, RN, BSN
Ryan Allenbrand, MS, CIEC
Children’s Mercy Hospital and Clinics and Healthy Homes and Childhood Lead Poisoning
Prevention Health Department City of Kansas City, MO.
Lead Back Story
• CDC’s Healthy Homes and Lead Poisoning
Prevention Program for FY12 provides for only $2
million - down from $29 million in FY11.
• Impact
– HH/CLPP funds 35 state health departments (and local
partners) to monitor blood lead screening and respond to
every child who has EBL with home inspection and referrals
for medical intervention and lead remediation
– Without the program, health departments will be unable to
help lead-poisoned children obtain medical care and housing
repairs
– HUD’s lead hazard control grantees depend on CDC
surveillance to identify those children at highest risk.
CDC’s Healthy Homes/Lead Poisoning
Prevention Program Budget
National Center for Healthy Housing. July 2013
Positions Eliminated or Shifted
National Center for Healthy Housing. July 2013
Kansas
• Kansas eliminated program
– Lead results reported to Epidemiology as Lead
Poisoning Prevention Program no longer exists
– No home investigations performed
– Local health departments “accept” lead patients
and provide “education”
• In past year, over 40 referrals to Center for
Environmental Health (CEH) for elevated
blood leads and need for home assessments
• Limited resources at CEH resulting in tiered
approach for response using PEHSU lead
document as a guide
Case: What a mess!!!
• PEHSU is called by PCPs office
regarding 2 year old child with an EBL
of 21.2 mcg/L. Three months prior it
was 14.6 mcg/L.
• PCP had called state health department
and was told that they couldn’t do
anything due to funding. Referral made
to PEHSU.
REGION 7
Mid-America Pediatric Environmental
Health Specialty Unit
Children’s Mercy Hospital
Kansas City, MO
Jennifer Lowry, MD
Director of MAPEHSU
Clinical Pharmacology and Medical
Toxicology
Pediatrician
Department of Pediatrics
Children’s Mercy Hospital
Kevin Kennedy, MPH, CIEC
Managing Director, CEH
Erica Forrest, MS, RRT
Environmental Health Coordinator
(Training, Community Outreach and
Education)
Ryan Allenbrand, MS, CIEC
Healthy Homes Program Manager
Environmental Hygienist
D. Adam Algren, MD
Michael Christian, MD
Toxicologist for MAPEHSU
Clinical Assistant Professor
Department of Pediatrics, CMH
Department of Emergency
Medicine,
Truman Medical Center
Stephen Thornton, MD
Medical Director, University of Kansas
Hospital Poison Control Center
Lisa Oller, RPh, CSPI
Project Coordinator and Manager for
MAPEHSU
University of Kansas Hospital
Poison Control Center
KCMO Health Dept.
How did we get involved in this?
KCMO CLPPP/HH Program
• 20 yrs investigative
experience
• Comprehensive case
management
• Federal, local, regional
and state funding
• Established relationship
with CMH/CEH
What do LPHAs have to offer?
•
•
•
•
•
Resources
Mandate
Enforcement
Experience
Field Staff
Regional Partnerships
Benefits
• Increased capacity
• Increased training and
competency
• Opportunity to review and
quality control current
processes and
procedures
• Test replicability of
processes
Risks
• Financial
• Legal
• OOJ
• Lack of enforcement
• No mandate
KCMO CLPPP/HH received
referral from PEHSU
• Reviewed with
Admin.
• Researched the
feasibility
• Established a team
• Consulted with
CMH/CEH
• Conference call with
other agencies
Center for Environmental Health
• Operates out of a non-profit children’s
hospital (Kansas City, MO)
• 15 years of performing residential and
commercial environmental assessments
• Residential, hospital, and school
environmental assessment program
• Lead investigation and education (EBLs)
• Primary Care Physician (PCP) office
training on Environmental Health
• Training Center for National Center for
Healthy Housing
Case continues…..
• Case reviewed with Dr. Lowry, KCMO
HD, and CEH staff.
• Based on environmental risk factors,
information learned during initial contact
with family, and EBL level, decision was
made to provide courtesy visit.
To get everyone on the same
page, we had a multiagency
conference call
•
•
•
•
CMH-CEH
KCMO Health Dept.
EPA
DHSS (both KS and
MO)
• OSHA
• Local Health Dept.
Investigation
Health Educator – Health
Department Nurse
• Education and triage
• Health & Environmental History
EBL Investigator(s)
• Environmental Sampling and visual
assessment
Health Educator & EBL Investigator
• Hypothesis Generation
• Visual Assessment & In-home Education
• Assessment Reporting with Issues &
Actions
• Follow-up & Case Management
Home visit revealed:
• Lead paint hazards
• Product hazards
• Ongoing renovation
CEH Initial Contact with families
–Risk Stratification (L1, L2, or L3)
–Education and Triage
–Review Health & Environmental Home
History
–Determining need of home investigation
Initial Phone Triage
• Background, behavior,
and household risks
• Occupation or Hobbies
• Dietary Risk Factors
• Water Risks
• Soil Risk Factors
• Paint and Remodeling
Risk Factors
Case Management System
Report Delivery & Resources
-Provide healthy home
cleaning supplies to family
- Referrals to local
community and public
health agencies
-Loaner HEPA vacuum
when possible
- Feedback to Landlord
and enforcement when
needed
Applying resources in regional
partnerships (what to consider)
•
•
•
•
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Jurisdictional guidelines
Funding streams (local vs state vs fed.)
Grant restrictions
Legal restrictions
License restrictions (esp. nurses and
risk assessors)
• Restrictions on equipment (esp. XRF,
vehicles and sampling)
Case continues….
• Exterior concerns:
– Suspect lead paint in bare soil near foundation
– Qualitative test showed presence of lead on front
porch columns
– Living room window sill tested positive for lead
– Sidewalk chalk tested positive for lead
• Interior of home:
– Home built between 1905 &1915
– Chipping paint on interior of windows & kitchen
door
– Possible remodeling dust lingering on floors
– Living room window sill tested positive for lead
Case continues….
• Occupational concerns:
– Dad working at manufacturing
plant
– Clothes not washed separately
– Dad walks into home and plays
with children prior to bathing
• Involve OSHA?
– Agency to Agency referral
challenges
– Extraordinarily sensitive
situation
– Pros and cons
Case continues….
• Provided family with cleaning supplies,
walk-off mat, vacuum equipped with
HEPA filter, and touch-up paint
• Education provided on control and
potential removal of lead hazards
• CEH reached out to weatherization
agency for assistance
How is the family doing?
• Family cleaned
contaminated areas
• Stopped renovation
• Painted hazards
• Removed product
hazards
• Dust wipe follow-up
• Child’s lead level
improved
Continued Challenges
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Who pays?
Lack of resources
Who’s responsible?
Determining who’s
involved
• Equipment access
• Consistent educational
message
Goals and Success
• Reduction in EBL levels
• Provided comprehensive
education
• Established local public health
relationships
• Filled in gaps in state EBL
coverage
• Opening eyes of continued need
of EBL’s
So how does the partnership
work now?
• PEHSU accepts referrals.
• Consults with the Center for Env. Health
who provides follow up.
• Local Health Dept. is consulted.
• KCMO Health Dept. is consulted as
needed for referrals or other resources.
• Referral to Kansas DHSS for
enforcement.
Moving Forward
• Continued
collaboration with
local health
departments
• Empowering
families
• Reaching out for
grants
• Reimbursement
possibilities
Thank You!
Any Questions?
Jennifer Lowry, jlowry@cmh.edu
Amy Roberts, amy.roberts@kcmo.org
Ryan Allenbrand, rnallenbrand@cmh.edu