No Arm Left Behind : A Hospital -LHD partnership to provide free school physicals and immunizations to the underserved

State: IL Type: Promising Practice Year: 2015

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The Champaign-Urbana Public Health District has been working with the Carle Family Medicine Residency Program to provide school physicals and immunization clinics since 2012. These special clinics provide free physical exams and dental exams to all children, and Tdap and other immunizations billed to Medicaid or available for the uninsured and underinsured for a small fee. The establishment of this clinic was to provide options for low-income children to get the back-to-school health examinations required by Illinois Law. The state of IL requires all school children to meet certain medical requirements before entering schools. Students who did not comply with these requirements by October 15th will have to leave school until they are compliant. Noncompliance with health requirements, particularly immunization, poses significant public health threats, especially given that the increase in pertussis cases among school-aged children in 2010 has continued. Noncompliance also results in missed school days and may impact on students' educational outcomes. School Absenteeism also has a negative impact on school funding. These clinics are offered on Saturday mornings at least five times during summer and fall.



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Champaign-Urbana Public Health District
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No Arm Left Behind : A Hospital -LHD partnership to provide free school physicals and immunizations to the underserved
The Champaign-Urbana Public Health District (CUPHD) is the local public health authority for the Cities of Champaign and Urbana and Champaign County, Illinois. Champaign County is located in east central Illinois and has 998.39 square miles with a population density of 201.8 people per square mile. In 2013 the US Census Bureau estimated the population to be 204,897 residents, a 1.9% increase since 2010. The current population of Champaign County is composed of 74.5% Caucasian, 12.8% African American and 9.6% Asian (2013 U.S. Census Bureau estimate). The percentage of Hispanic residents in Champaign County in 2013 was 5.1%. Foreign-born residents make up 11.5% of Champaign County's total population. CUPHD has a mission to improve the health, safety and wellbeing of the community through prevention, education, collaboration, and regulation. An indication of this commitment is demonstrated by us achieving accreditation by the Public Health Accreditation Board.  CUPHD offers an array of services and programs that reach people of all ages of the Champaign County. CUPHD devotes time and efforts to serve priority populations including the elderly, rural, impoverished, women, and childhood populations who are particularly vulnerable and lack adequate access to health services and resources.  Vaccine preventable diseases are significant public health threats. The state of IL requires all school children to meet certain medical requirements before entering schools. Students who did not comply with these requirements by October 15th will have to leave school until they are compliant. Noncompliance with health requirements particularly immunization poses significant public health threats, especially given that the increase in pertussis cases among school-aged children in 2010 has continued. Noncompliance also results in missed school days and may impact on students' educational outcomes.  The practice aims to prevent missed school days and decrease vaccine-preventable diseases by increasing compliance with school health requirements.  The clinics have a focus on medically underserved children. The objective is to decrease overall non-compliance with back-to-school health requirements. The clinic is collaboration between the CUPHD and the Carle Family Medicine Residency Program. It was our intention to keep the clinics at very low cost. Most of the essential personnel (e..g, MDs) are volunteers--they are participating to fulfill their program requirement. We utilized existing resources and equipment already in place at the CUPHD so there is no need to purchase additional software or hardware. There is minimum preparation needed to open the clinic. The primary tasks take place on the day the clinic opens. Since its opening in 2012, we have served over 1,200 clients from all over Champaign County. The non-compliance rate with back-to-school health requirements in Champaign County has decreased from 1.6% in 2011-2012 school year (the year before the practice started) to 1.4% in 2012-2013 school year (the year when the practice started). The non-compliance rate continued to decrease to 1.3% in 2013-2014 school year. Overall, the objective has been met.  Community partnership/collaboration and administrative support were keys to the success of the program.  The practice has the potential to prevent vaccine preventable diseases and related death. It specifically addresses the disparities in vaccine coverage and improves health of children in medically underserved communities.  CUPHD website is http://www.c-uphd.org. A flyer of the proposed practice can be found via: http://www.c-uphd.org/news-item.html?item=198  
Vaccine preventable diseases pose significant public health threats. US immunization programs have been very successful in eradicating smallpox, eliminating polio and reducing most other vaccine-preventable diseases by 98-99% (Salmon et al., 2005). The major contributor to this success is compulsory immunization. In recent years, public attention has shifted from the risks of disease to the risks of vaccination and the highly successful practice of mandatory school immunization is increasingly under attack. However, unvaccinated children are at greater risk of more than contracting vaccine-preventable diseases. They also increase the risk of disease transmission to others in the community. There are significant disparities in timely vaccination coverage, with low-income children at greater risks for untimely vaccination coverage (Smith et al., 2009). Therefore, ensuring compliance with vaccination especially targeting low-income children is important to reduce disparities in vaccination coverage and decrease vaccination-preventable diseases. The establishment of the clinic was a direct response to the rising pertussis epidemic in the US. During 2012, 48,277 cases of pertussis were reported to CDC, including 20 pertussis-related deaths. This was the most reported cases since 1955. Infants, children through 7-10 years old and adolescents aged 13-14 are the among the highest risks groups for contracting pertussis. We examined data on pertussis incidence and noncompliance numbers on the school health requirements at Champaign County, IL. The pertussis incidence in Champaign County has been on the rise since 2010. It rose to over 11 per 100,000 in 2012 from less than 2 per 100,000 in 2009. In addition, Champaign County has a considerable immigrant population. Champaign is home to the Central Illinois Refugee Center and the University Illinois at Urbana-Champaign. During the summer, Champaign County welcomes a large influx of international students and visiting scholars, some of whom bring school-age children with them. Most of the immigrant population come from countries where immunizations are not required or the requirements are poorly enforced. This poses a threat to the public health of the local community.  The clinic specifically addressed problems with traditional medicine, including unequal access, fee-for-services, tight and inconvenient schedules, and fragmentation. It is specifically tailored to the needs of the local community, where there is a large immigrant population and a high percentage of low-income children--populations at high risk for being uninsured or underinsured. The clinic provides free physical exams and dental exams to all children, and Tdap and other immunizations billed to Medicaid or available for the uninsured and underinsured for a small fee. By providing free exams and low-fee immunizations, we are addressing the unequal access problem of traditional medicine. The clinic is conveniently located at the CUPHD main site and open on Saturdays. We intentionally schedule the clinic on Saturdays in consideration of the needs of pediatric clients--they need the presence of parents or guardians to receive services. Many low-income parents work during the week or at inconvenient times that are often in conflict with regular office hours of a medical practice. We also addressed the fragmentation of services problem by proving a one-stop shop where clients can get physicals, dental, and immunizations at the same location on the same day. To ensure that resources and personnel time are maximized, we open the clinic one Saturday in July, August, and September and twice in October. These times are selected because it coordinates well with school-start dates, when the demand for the services will be the highest. In order to reach to all the targeted clients, we utilized multiple channels to advertise the clinic. We posted updated information on the CUPHD website, Facebook and Twitter accounts and with fliers posted at CUPHD and with community partners. We also partner with local newspaper and other organizations to advertise the clinic in their publications. In addition, we partner with local schools and send the posters advertising the clinics to selected schools in the district. Before the practice was in place, there was no program in the county that provided similar services. A search in the NACCHO model practice database did not reveal similar practices. The practice is innovative is several ways. It is an excellent example of public-private agency collaboration that serves mutual interests and multiple purposes while keeping costs very low. It is a model that is replicable to other communities.    
Global Immunization|Nutrition, Physical Activity, and Obesity
Goal: to prevent missed school days and decrease vaccine-preventable diseases by increasing compliance with school health requirements with a focus on medically underserved children. The objective is to decrease overall non-compliance with back-to-school health requirements. The clinic is collaboration between the CUPHD and the Carle Family Medicine Residency Program. It was our intention to keep the clinic keeps at very low cost. Most of the essential personnel (e..g, MDs) are volunteers--they are participating to fulfill their program requirement. We utilized existing resources and equipment already in place at the CUPHD so there is no need to purchase additional software or hardware. To ensure the practice reaches its intended population--low-income children who are medically underserved, we took the following steps and designed the clinic to meet their unique needs. First, the school physicals and dental services are free of charge. The immunizations are available with no out-of-pocket cost for children on Medicaid, and are charged with a small fee for other children. Second, the clinic is conveniently located at the main site of CUPHD where a direct mass transit bus serves on the day it opens. Third, the clinic is opened on Saturdays, which is much more convenient for working parents. Fourth, the clinic opens before school begins in the Fall, giving parents enough time to take their children in and get required exams. In other words, it's proactive. Fifth, fliers and information about the clinic are widely distributed throughout the community through multiple channels. There is minimum preparation needed to open the clinic. The primary tasks take place on the day the clinic opens.  There is minimum preparation needed to open the clinic. The primary tasks take place on the day the clinic opens.  The clinic opens on one selected Saturday in July, August, and September; and two selected Saturdays in October.  CUPHD is the lead in implementation of the practice. In collaboration with the Carle Family Medicine Residency Program, CUPHD leads the charge in providing space, equipment, advertisement, and personnel, except physicians, for the practice. In addition CUPHD provides the administrative support for all practice related activities. The staff at CUPHD also collected data for the evaluation of the practice.  The main partner Carle Family Medicine Residency Program provides medical residents to conduct the school physicals. The schools and the community support this practice by facilitating the distribution of flyers and information about the practice. The collaboration is an excellent example of a replicatable, public-private agency collaboration that serves mutual interests and multiple purposes while keeping costs low. The Residency Program requires residents to conduct a community-oriented primary care senior project. The clinic was established to as means for the residents to fulfill that requirement and practice their skills. CUPHD leads the effort to respond to public health and health equity issues including lack of vaccination coverage and shortage of school health requirement services that are convenient and affordable to low-income clients. The clinic utilizes the skills and resources from both agencies, the MDs from the Residency program to conduct exams, and the staff, equipment, space, high concentration of low-income clients, and media resources of the CUPHD.  The practice does not require start-up cost. In-kind costs include personnel time at the clinic and facilities and administrative support.
We conducted outcome evaluation to assess the impacts of the practice. The objective is to increase compliance with back-to-school health requirements. We used multiple sources of data to evaluate the impacts of the practice including data from client surveys (primary dat,a), administrative data from the practice, and data from the Illinois State Board of Education (secondary-data). Staff from the CUPHD conducted the client surveys (anonymous, voluntary, pencil-and-paper self-administered one-time surveys) to assess 1) whether we have reached intended target population--low-income, medically underserved children; 2) to explore unmet needs of clients, and 3) to evaluate the significance of the practice from clients' perspectives. We surveyed 40 households. Descriptive statistics were performed on the data.  According to our administrative data from the practice, we serve about 100 clients every time the clinic opens (the clinic opens 5 times per year, so the annual clients served were around 500). According to compliance data from the Illinois Board of Education (http://www.isbe.state.il.us/research/htmls/immunization.htm), the non-compliance rate with back-to-school health requirements in Champaign County has decreased from 1.6% in 2011-2012 school year (the year before the practice started) to 1.4% in 2012-2013 school year (the year when the practice started). The non-compliance rate continued to decrease to 1.3% in 2013-2014 school year. Overall, the objective has been met.   Data from the client survey further proved the success of the practice and showed that we have reached the target client population--medically underserved populations who are disproportionately uninsured and/or underinsured. We collected responses from 40 households. 17 responses were collected on September 20th, 10 collected on October 4th, and 13 on October 18th. About half of the respondents reported English as the only language spoken at home, followed by Spanish, Chinese, French, and Korean. The respondents were primarily non-Hispanic black (41%), followed by non-Hispanic white (23%), Asian (21%), and Hispanic (15%). More than half of the respondents reported combined annual family income of less than $20,000. Nearly half of the respondents had recently moved to Illinois in the past 6 months. About one-third of the children were new to Illinois schools. Half of the children did not currently have health insurance. Among those with insurance coverage, about one-third was covered by Medicaid and another one-third was covered by All Kids (CHIP). The socio-demographic profile of respondents suggested that the clinic successfully served targeted clients--medically underserved children, including racial/ethnic minorities, uninsured or underinsured, children in low-income households and, newly immigrants. These disadvantaged populations have limited options and resources for health care. The establishment of the current practice directly addresses the problems associated with traditional medicine to best meet the needs of medically underserved clients. When asked where they would have gone for back-to-school health examination if the clinic were not available, about half responded that they didn't know and 13% said they would have nowhere to go. 36% responded that they would be "extremely likely" or "very likely" to have missed schools because of non-compliance. These results are proofs of the impact of the current practice from the clients' perspective.
The main partner, the Carle Family Medicine Residency Program, is an ongoing program at the Carle Hospital in Champaign. As mentioned earlier, the practice serves the mutual interests of the residents and the interests of CUPHD. The Family Medicine Residents are required to take on one community project during their three years of residency training. The practice is an excellent opportunity for the residents to practice their skills and meet their program requirement. The interests from the residents in participating in the practice have been high from the start. In fact, the residents who initially participated and co-designed the clinic are leaving the residency program, and several new residents have already taken on this initiative and started working at the clinic. There is a nice continuity that ensures the practice will continue without interruption. 
I am a previous Model Practices applicant|NACCHO website
 
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