MAINE PUBLIC HEALTH NURSING ANNUAL REPORT FY2010 July 1, 2009 – June 30, 2010 Ninety Years of Caring 1920-2010 State of Maine Department of Health and Human Services Maine Center for Disease Control and Prevention Message from the Director Dear Reader, Thank you for your interest in Maine Public Health Nursing (PHN). This Annual Report covers PHN operations July 1, 2009 to June 30, 2010 (Fiscal Year 2010). Fiscal year 2010 (FY2010) was a very important time for PHN. Three major events occurred illustrating the history, breadth of capacity, and excellence of PHN:  PHN celebrated our 90th year as a premier health resource for the residents of Maine.  PHN fully responded, as an entire Program, to the tasks required during the H1N1 influenza immunization campaign.  PHN was granted full accreditation by meeting national standards of excellence as put forth by the Community Health Accreditation Program (CHAP), a nationally recognized accrediting body. Through all of this effort PHN continued to serve the residents of Maine by providing quality public health nursing care, both population-based as well as care of the individual client. We look forward to continuing our efforts as we move into the second decade of this century. If there are any questions and/or concerns, please access our website at: www.mainepublichealth.gov or contact me at: janet.j.morrissette@maine.gov. Sincerely, Janet G. Morrissette, MSN, RN PHN Director Robert Wood Johnson Executive Nurse Fellow Maine Public Health Nursing Program 286 Water Street, 7th Floor 11 State House Station Augusta, Maine 04333 Tel: 207-287-4476 TTY: 1-800-606-0215 “I am sure we have no greater agents in the state, through whom we may extend the health program of the state, than the public health nurses” Edith L. Soule – 1922, First Director of Public Health Nursing 2 Table of Contents Cover Page Director’s Letter Table of Contents/Acknowledgements Maine Public Health Nursing Functions and Principles Serving Individual to Society PHN: A Short History Maine: a Unique Challenge Schematic of PHN Organization FY2010 Priorities & Key Initiatives/FY2010 in Review Demographics and Statistics How Are We Doing? Accreditation Response to H1N1: A Novel Virus Maternal and Child Health Services (MCH) Tuberculosis Control PHN’s Standing Committees Status Report: Additional Accomplishments Challenges and Inspirations/Issues and Special Concerns Resources 1 2 3 4 5 6 7 8 9 10-11 12 13 14 15-17 18 19 20 21 22 Acknowledgements Maine Center for Disease Control and Prevention Dora Anne Mills, MD, MPH – Director (During the time of this report) Division of Family Health Valerie J. Ricker, MSN, MS – Division Director Public Health Nursing Program Janet G. Morrissette, RN, MSN – PHN Director Prepared by: Pamela J. Correll, RN, MS – PHN Consultant, Informatics Dwight Littlefield, RN, MBA – PHN Consultant Coline Ludwig – Student Intern 3 Public Health Nursing Functions and Principles • The role of Public Health Nursing (PHN) serves to make a positive difference on environments and conditions enabling populations to achieve optimal health and quality of life. • PHN involves assessing health status, defining health options, developing policies, and assuring access to services for individuals, families, and communities. • PHN uses both science and skill to identify and address health related issues through prevention, screening and early detection, treatment, and ensuring continuity of care. • Public Health Nurses seek to reduce diseases, human hardship, and their economic cost. MISSION Public Health Nursing provides expertise and leadership to improve the health of populations VISION Healthy, productive, and safe Maine people and communities 4 Serving Individual to Society Public Health Nursing has defined its role as: “assessing health status, defining health options, developing policies, and assuring access to services for individuals, families, and communities” (Foundation Statement, PHN Policy and Procedure). Home Visit Services •Adult Health •Breast feeding Support •Children with Special Health Needs •Communicable Diseases •Growth and Development •Lead Poisoning Management •Newborn/Infant Assessment •Parenting •Pregnancy •Refugee/Migrant Health •SIDS/Childhood Deaths •Tuberculosis Population Services •Clinics •Communicable Disease prevention and control •Environmental health •School Health •Special Projects •Breastfeeding InServices •Health Resources •Smoking Cessation •TB-TST Trainers Community Services •Advisory Boards •Coalitions •Collaborations with Groups and Agencies •Health Forums •Needs Assessments 5 PHN: A Short History The Division of Public Health Nursing and Child Hygiene was created in 1920 as a collaborative effort among the State Department of Health, the American Red Cross, and the Maine Public Health Association. Edith L. Soule was appointed the first Director of the Division of Public Health Nursing and Child Hygiene. As director, her responsibilities included assisting in creating educational and organizational work as well as preparing monthly reports on services rendered by nurses. In 1920, Edith Soule was the only staff member of the Division of Public Health. Starting in 1922, Ms. Soule corresponded with Governor Baxter to obtain funding so that more nurses would be available to travel to different counties of Maine. The goal was to improve prenatal health and reduce rates of infant mortality. In 1923, the first public health nurse was hired and over the years, the staff grew. Public health nursing played a significant role in advancing public health. With an increasing need for Public Health Nurses in remote parts of Maine, Edith Soule was able to get two Ford automobiles for the department. From 1937-1941 the responsibilities of Public Health Nurses included home visits to expectant mothers, infants, preschool children, school children, crippled children, and morbidity cases. In addition, they were responsible for providing immunizations and tests of smallpox, diphtheria, typhoid, and tuberculosis. Over a particular 5-year period, the Public Health Nurses conducted 135,831 home visits. Although the number of Public Health Nurses per county has fluctuated over the years, Public Health Nurses have continually played an important role in perpetuating healthy individuals and healthy communities in Maine. For 90 years, Public Health Nursing (PHN) has worked to make a positive difference on environments and conditions enabling populations to achieve optimal health and quality of life. Public health nursing involves assessing health status, defining health options, developing policies, and assuring access to services for individuals, families, and communities. 6 Maine: A Unique Challenge PHN uses both science and skill to identify and address health related issues through prevention, screening and early detection, treatment, and ensuring continuity of care. Public Health Nursing faces unique challenges in providing equitable healthcare services throughout the State of Maine. Demographic and Geographic Factors in Maine Uneven population distribution and density One third of Maine’s population lives in the 2 southernmost counties, or 7% of the state’s land area Regions of large refugee populations Concentrated in the Portland and Lewiston/ Auburn areas Most of Maine is rural Race of PHN Clients A barrier to accessing health care The diversity of the population we serve Racial and ethnic minorities experience serious health disparities Childhood poverty Maine 23.6% vs. National 20.7% (2008 Maine Development Foundation) 7 Maine Department of Health and Human Services Schematic of PHN Organization FY2010 Maine Center for Disease Control and Prevention Division of Family Health Public Health Nursing Janet G. Morrissette, RN, MSN Director, Public Health Nursing Ellen Bridge, RN, BCHE Public Health Nursing Consultant Dwight Littlefield, RN, MBA Public Health Nursing Consultant Theodore Hensley, RN, MSN Public Health Nursing Consultant Jackie Roberson, RN, BSN Public Health Nursing and Office of Public Health Emergency Preparedness Pamela Correll, RN, MS Public Health Nursing Consultant Luanne Crinion, RN, MS Supervisor ~ Southern Unit Steve Garascia, RN, MSN Supervisor ~ Central Unit Jane McQuarrie, RN, BSN Supervisor ~ Costal Unit Lewiston Office PHN II – 4 PHN I – 5 Augusta Office PHN II – 3 PHN I – 3 Bangor Office PHN II – 3 PHN I – 4.8 Houlton Office PHN II – 3 PHN I – 2 Sanford Office PHN II – 1 PHN I – 0.8 Skowhegan Office PHN II – 1 PHN I – 1 Ellsworth Office PHN II – 1 Caribou Office PHN II – 3 Portland Office PHN II – 5 PHN I – 2 Rockland Office PHN II – 1 PHN I – 2 Machias Office PHN II – 1 Vacant Supervisor ~ Northern Unit Fort Kent Office PHN I – 1 Calais Office PHN II – 1 PHN I – 1 Not all staff positions were continuously filled during this time period. 8 Priorities & Key Initiatives Following are highlights of FY2010 public health priorities and key initiatives: •Accreditation through CHAP •Pandemic Health Emergency (H1N1) •Complete revision of PHN Policy Manual Fiscal Year 2010 in Review July 2009 August 2009 H1N1 Vaccine Summit August, 2009 Maternal & Child Health Services Title V Block Grant Program Application And Annual Report July, 2009 September 2009 October 2009 Accredited by CHAP September, 2009 Invoked COOP Plan to deal with H1N1 October, 2009 November 2009 December 2009 1st H1N1 Community Clinic December, 2009 January 2010 February 2010 March 2010 April 2010 Started Planning Organizational Response to Neonatal Abstinence Syndrome March, 2010 Electronic Policy & Procedure System went Live April, 2010 Publication of Program Utilization of Omaha System to Promote Public Health November, 2009 International Symposium for Medication Safety Presentation January, 2010 Poster Presentation for Cold Chain at Maine Nursing Summit April, 2010 May 2010 June 2010 Poster Presentation for ASTDN for CHAP Accreditation May, 2010 Hospital Liaison work to Promote Continuity of Care June, 2010 9 Demographics and Statistics Public Health Nurses serve clients in multiple ways. Clients can be visited individually, as population-based services, or by non-visit case management. During FY2010, PHN admitted 4,133 unduplicated clients, providing a total of 21,581hours of service. This included 10,382 hours for individuals; 4,503 in population based services; and 6,696 in non visit case management. Ages of PHN Individual Clients 81 to 99 Years 65 to 80 Years 51 to 64 Years 31 to 50 Years 20 to 30 Years 13 to 19 Years 7 to 12 Years 3 to 6 Years 6 Months - 2 Years 0 - 6 Months 0 200 400 600 800 1000 1200 1400 1600 PHN Client Referral Sources Physician, 3.69% Other DHHS Program, 2.22% Population, 0.06% Home Health Agency, 0.06% Clinic, 0.02% Primary HCP, 0.33% Other Community Org., 15.35% Hospitals, 74.84% Child & Family Services, 3.42% 10 Demographics and Statistics Percentage of Individual Client Visits Per Program Adult/Geriatric Health 2.21% Community/ Environment 0.11% TB 19.59% Child (0-17) 29.83% Refugee 13.55% Other Disease Control 0.01% Parenting 14.24% Prenatal 3.32% Postpartum 17.14% Percentage of Population-Based Client Visits Per Program Migrant Health 0.37% Disaster Health 1.65% Child (0-17) 24.63% Parenting 1.17% Postpartum 0.8% Prenatal 0.32% Community/ Environment 54.42% TB 8.48% Adult/Geriatric Health 4.53% Other Disease Control 0.16% Refugee 3.47% 11 How Are We Doing? KBS Improvement Measures The Omaha System enables PHNs to assess and address the complex needs of its diverse client populations with the aid of standardized Problems, an Intervention Scheme to address those Problems, and the Problem Rating Scale for Outcomes in terms of Knowledge (K), Behavior (B), and Status (S). Because nursing documentation of PHN services is automated, the program can report client service outcomes. At 2010 discharge, clients showed an increase in measurement of their knowledge, behavior, and status compared to admission values. The following table demonstrates the 15 most frequently assessed problems for clients discharged in FY2010: 12 Accreditation The Community Health Accreditation Program, Inc. (CHAP) is an independent not-forprofit accrediting program created in 1965 as a joint initiative between the American Public Health Association (APHA) and the National League for Nursing (NLN). In 2001 CHAP became an independent non-profit corporation and is the premier accreditation program for community health organizations. CHAP has regulatory authorization to assess home health agencies. Over the past three years, Public Health Nursing has completed a five-step process to gain accreditation from CHAP. In order to gain accreditation from CHAP, a particular program must adopt particular standards of excellence that emphasize how an organization is run. The Accreditation Process: Step 1. Application Step 2. Submit Self Study Step 3. The Site Visit Step 4. Board of Review Step 5. Accreditation On September 14, 2009, Public Health Nursing gained accreditation from CHAP. This means that the Maine Public Health Nursing Program “has voluntarily met the highest standards of excellence for home and/or community health” (CHAP iii). In addition, PHN received a commendation, a statement that indicates an organization EXCEEDED the requirements of a specific standard. “Administrative and management personnel promote techniques and team building options that provide for an informed Public Health workforce.” (PHIV.3b) Core: community-based health care in today’s health care arena Public Health: public health services at the local municipal, regional, state, and tribal level & leadership during a public health emergency “To define and advance the highest standards of community based health care” CHAP Mission 13 Response to H1N1: A Novel Virus In late April 2009, a novel strain of Influenza A (H1N1), also known as 2009 H1N1 Influenza, emerged and was detected in the southern United States (US) and Mexico. Between April 2009 and February 2010, there were an estimated 59 million cases of H1N1 flu in the US. These cases resulted in approximately 265,000 hospitalizations and 12,000 deaths nationwide. About one-third of cases, one-third of hospitalizations, and about 10% of deaths nationwide occurred in children younger than 18 (compared with less than 1% of deaths during an average seasonal influenza year). About 90% of the deaths due to H1N1 were among those younger than 65, while about 90% of the deaths due to seasonal flu are among those 65 and older. Wash Your Hands! Cover Your Cough! Stay Home If You Feel Sick! The disease surge in Maine started in late October and lasted about 10 weeks to the end of December, with a peak during the days around Thanksgiving. Maine Public Health Nursing collaborated with the Maine Immunization Program, other State and Federal Programs, Schools, and Communities to effectively respond to and implement prevention measures during the 20092010 flu season. Department of Health and Human Services Maine Center for Disease Control and Prevention www.mainepublichealth.gov PHN resources were implemented to:  Provide recommendations, education, and resources to schools and the public;  Organize and participate in immunization clinics; 114 State Employee clinics – 124 School and Community Clinics  Promote vaccine education by providing information to the on-line Toolkit;  Participate in the August 20, 2009 Vaccine Summit in Augusta;  Assist in H1N1 vaccine distribution and storage throughout the state of Maine H1N1 vaccine distribution issues helped create new alliances and bridges with health care providers, schools, and residents. Maine has been recognized on the national level as an example of how to best handle the declared emergency, specifically regarding vaccine distribution within schools. 14 Maternal and Child Health Services (MCH) Public Health Nursing serves the MCH needs of Maine residents by providing a seamless, consistent approach to the needs of women, infants, and children with identified health needs and children with special health needs. Performance Goal for Maternal and Child Health efforts: Families in Maine with pregnant and postpartum women, infants, and children will have improved health, well-being, growth and development in a safe supportive environment. Priorities Serve the health and special health needs of women, infants, and children Positively impact: risk of child maltreatment infant mortality low birth weight and health status of children Specific Efforts Educational resources such as: Breastfeeding advocacy Educate parents to reduce the incidence of Shaken Baby Syndrome: The Period of Purple Crying Assessments: Prenatal/Postpartum Well-Child Immunization Lead Screening EPSDT (Early Periodic Screening, Diagnosis, and Treatment) Outreach and Triage: Assist MaineCare children through age 21 Address referrals, appointments, and developmental needs 15 Maternal and Child Health Services The following graphs show the components of PHN Maternal and Child Health Services during FY2010. PHN staff made a total of 10,385 MCH Service visits, spending a total of 12,887 hours providing MCH Services.* 8000 # PHN: Number of Hours Providing Maternal and Child Health Visits in FY2010 6000 H o 4000 u 2000 r s 0 Child Parenting Postpartum Prenatal Visit Type # 6000 5000 V 4000 i 3000 s 2000 i 1000 t 0 s PHN: MCH Visit types By number of visits in FY2010 Child Parenting Postpartum Prenatal Visit Type MCH services are evidence based and generated the following outcomes: Program Child (0-17) Parenting Postpartum Prenatal # Clients K% Improved B% Improved S% Improved 914 79.8% 69.4% 71.6% 347 77.2% 67.2% 71.9% 740 71.6% 66.9% 69.9% 124 76.5% 58.3% 64.6% # Clients with Actual / Potential Problems Discharged *<1% missing assignments of Program to visit data 16 In addition to the efforts of PHN staff, some MCH services are contracted in certain areas of Maine through the Maternal and Child Health Services Title V Block Grant Program. Contracted Agencies (Grantees) are: • Home Health Visiting Nurses of Southern Maine Cumberland Division York Division Portland Public Health Division Androscoggin Home Care and Hospice Bangor Public Health Nursing, a Division of Bangor Health & Community Services Downeast Health Services, Inc. • • • • During FY2010, the Maternal and Child Health Grantees made a total of 11,195 Maternal and Child Health visits. 7000 # 6000 V i s i t s 5000 MCH Grantees: Visit types By number of visits 4000 3000 2000 1000 0 Child Parenting Postpartum Prenatal Visit Type Ethnicity of Grantee Clients 0.89% Gender of Grantee Clients 2.54% FrancoAmerican 27.26% Hispanic NonHispanic Female Male 72.74% 96.57% 17 Tuberculosis Control PHNs serve as case managers and work closely with the Maine TB Control Program to identify, control, and prevent TB disease.  All confirmed or suspect TB cases are reported to the Maine TB Control Program.  Daily visits are made to clients with a diagnosis of TB to monitor taking prescribed medications. Most clients with active TB disease are on medication for 6 months  In addition to seeing clients with active TB disease, PHN monitors clients being treated for Latent TB infection (LTBI). These clients are infected with TB but do not have active TB disease. Treatment recommendations for these clients typically include antibiotic therapy for 9 months to prevent the development of active disease. PHN provides monthly visits to assess the client’s response to treatment, provide education and increase compliance with the treatment regimen.  Clients who are either contacts of TB cases or refugees (as part of their arrival process in the United States) are skin tested for TB infection and referred for further medical evaluation as indicated by the test results.  Healthcare workers at risk for exposure to TB must be tested for TB infection and PHN provides skin test training to a variety of community healthcare providers. During FY2010, PHNs devoted a total of 4,919 hours to TB control services. LTBI 32% Contact Investigation Case/Suspect PHN TB Control Services by Client Type 56% 12% Specific Efforts: • Tuberculin Skin Test (TST) Provider Training • TST administration • Ensure that TB patients take prescribed medications TB Control services are evidence-based and generated the following averaged outcomes: TB Control Summary Program LTBI TB Case/Suspect TB Contact Refugee # Clients* K% Improved 252 32 28 234 #Clients with Actual/Potential Problems Discharged 89.1% 83.30% 82.30% 89.70% B% Improved 59.7% 67.80% 59.60% 66.80% S% Improved 75.8% 70.90% 83.30% 86.80% 18 PHN has Standing Committees - made up of Members from Staff and Management Documentation Committee In 2002, the Documentation Committee was initiated to support the organization’s implementation of an electronic health record. PHN utilizes CareFacts™, a documentation software application, and The Omaha System, an ANA-recognized terminology, to document nursing care. Continuing its mission to support nursing practice with documentation excellence, while maintaining national accreditation standards, the Documentation Committee focused on: Advancement of user perspectives on Electronic Health Record (EHR) challenges, including • balancing streamlined documentation effort with comprehensive, high quality client health information • documentation of care for family/household member care who have inter-related health issues and individual EHRs • electronic signature • improved capture of the unique case management services that PHNs provide Safety & Risk Management Committee The Safety & Risk Management Committee works closely with Public Health Nursing staff to continually strengthen a safe and healthy work environment for PHN employees. The Committee promotes best practice standards, safety education and resources, and risk reduction plans. The Committee reviews reported incidents and injuries and recommends policies and procedures to the management team and the Quality Improvement (QI) Committee. Quality Improvement Committee The PHN Quality Improvement (QI) Committee provides oversight, support, and leadership for quality improvement activities. The QI committee monitors ongoing quality assurance (QA) activities for both the overall PHN Program level and PHN unit level. All PHN staff participate in indicator selection as well as project charter design and implementation. Standard methods are used, including the Plan-Do-Check-Act cycle. Focused quality improvement attention was paid to referral response effectiveness and client satisfaction at discharge and early admission. Clients offered the following survey responses about their satisfaction with PHN services: ACT PLAN CHECK DO “It was the best service. It helped me understand a lot of things I did not know. It was really helpful and appreciated.” “The nurse was amazing during the two home visits we had after the birth of our son. She made me feel more confidence in myself and my baby’s growth.” 19 Status Report: Additional Accomplishments Data/Informatics:  Contributed PHN service data to community stakeholder review of public health issues, including maternal/infant exposure to cannabis, opiates, and opioid agonists and antagonists  Completed prototype development and implementation of a new, electronic Policy and Procedure (P&P) System that uses computer and information science to support a PHN’s ability to locate P&P guidance to support practice decision making  Added new PHN Standard Operating Procedures (SOP) and incorporated them within the digital intranet policy and procedure manual  Collaborated with ME CDC Environmental Toxicology Program partners to develop electronic health record tools that support PHN assessment/documentation of families with known/suspected environmental safety risks  Expanded staff access to electronic meeting tools to advance committee work and other organizational initiatives Emergency Preparedness:  Completed Maine Public Health Nursing Emergency Response Plan and circulated to all Public Health Nursing offices  Developed protocol for emergency preparedness handouts for all Public Health Nursing clients, standardized for all units  Developed standard for annual Emergency Preparedness update and review to provide ongoing opportunity for education and training that defines roles and responsibilities for Public Health Nurse during a declared Public Health Emergency  Initiated standard “Call Down” exercises for availability to respond to an emergency or to work off hours Other:      Provided Sexual Abuse/Assault trainings for all PHN staff Revised Zero-Based Budget to more accurately reflect PHN functions Hired a new PHN Consultant to fill a vacancy due to retirement Conducted and/or participated in 257 influenza clinics, immunizing over 9353 people Conducted 17 TB Skin Test training classes with 138 participants - learning to administer and read TB skin tests  Developed a standardized procedure for disposal of used PAPR filters  Established a procedure defining the activity for PHN School Vaccine Clinic Resource Nurses  Established a procedure defining the activity for PHN Hospital Liaison Resource Nurses 20 Looking Ahead: Challenges and Inspirations  Provide new PHN Consultant with training on Strategic National Stockpile (SNS) deployment  Prepare to engage in the Home Visitation Grant Program resulting from Health Care Reform (ACA) Legislation  Prepare for transition to paperless review of Bright Future Assessment forms and follow-up contacts for children insured through MaineCare in Maine  Participate in training and drilling for Emergency Preparedness & Response by PHN Staff and Management  Recruit and hire personnel as vacancies occur  Maintain a well educated staff and provide educational opportunities. Issues & Special Concerns for Public Health Nursing:  Financial sustainability  Remaining competitive in attracting qualified staff  Providing and expanding population based services while having the capacity to fill needed gaps in individual services  Providing services in expanding population areas of the state while maintaining the level of service in rural areas with zero growth of PHN staff  Maintaining continuity of operations with an increase in retiring workforce 21 Resources For more information on Maine Public Health Nursing, visit: http://www.maine.gov/dhhs/mecdc/local-public-health/phn/ Maine Center for Disease Control and Prevention http://www.maine.gov/dhhs/mecdc/ Flu Resources http://www.flu.gov www.maineflu.gov American Public Health Association http://www.apha.org Maternal and Child Health Bureau http://www.mchb.hrsa.gov Maine Center for Disease Control and Prevention Public Health Nursing Key Bank Plaza/7th Floor/Water Street State House Station #11 Augusta, Maine 04333-0011 Images: Page 19, Permission granted for The Omaha System by Karen S. Martin, RN, MSN, FAAN FY2010 - A Year of Transition 22 DHHS Non-Discrimination Notice The Department of Health and Human Services (DHHS) does not discriminate on the basis of disability, race, color, creed, gender, sexual orientation, age, or national origin, in admission to, access to, or operations of its programs, services, or activities, or its hiring or employment practices. This notice is provided as required by Title II of the Americans with Disabilities Act of 1990 and in accordance with the Civil Rights Act of 1964 as amended, Section 504 of the Rehabilitation Act of 1973, as amended, the Age Discrimination Act of 1975, Title IX of the Education Amendments of 1972 and the Maine Human Rights Act and Executive Order Regarding State of Maine Contracts for Services. Questions, concerns, complaints or requests for additional information regarding the ADA may be forwarded to DHHS’ ADA Compliance/EEO Coordinators, 11 State House Station – 221 State Street, Augusta, Maine 04333, 207-2874289 (V), 207-287-3488 (V), 1-800-606-0215 (TTY). Individuals who need auxiliary aids for effective communication in program and services of DHHS are invited to make their needs and preferences known to the ADA Compliance/EEO Coordinators. This notice is available in alternate formats, upon request.