1 WELCOME Ellen Bloom, MPH Health Educator Indiana State Department of Health Indiana Lead and...
-
Upload
richard-rose -
Category
Documents
-
view
215 -
download
0
Transcript of 1 WELCOME Ellen Bloom, MPH Health Educator Indiana State Department of Health Indiana Lead and...
1
WELCOME
Ellen Bloom, MPHHealth EducatorIndiana State Department of HealthIndiana Lead and Healthy Homes Program
2
LEAD RULE410 IAC 29
REPORTING, MONITORING, AND PREVENTIVE PROCEDURES FOR LEAD POISONING
Indiana State Dept of Health
Indiana Lead and Healthy Homes Program (ILHHP)
http://www.in.gov/isdh/19124.htm
4
From a Statute . . .
Statutes aka Public Laws, Codes, Acts● Come from Indiana Legislature and start as Bills
● Statutes may grant a State Agency the power to adopt rules
● Senate Bill 538 (passed by the General Assembly) Public Law 135-2005 (signed by the Governor) IC 16-41-39.4
Indiana Code 16-41-39.4● Granted ISDH statutory authority to adopt rules for case
management of a child with lead poisoning – Title 410
● http://www.in.gov/legislative/ic/code/
● Health – Title 16
5
To a Rule
Rules aka Administrative Codes, Regulations
● Promulgated by State Agencies based on authority granted by the Legislature in a statute
● Have the force and effect of law
Indiana Administrative Code (Rule by ISDH) Rule 410 IAC 29-2-1:“Local health officers shall ensure the provision of case management to all children under seven (7) years of age in their jurisdiction.”
● http://www.in.gov/legislative/iac/
6
LHD Authority and Responsibility
Rule 410 IAC 29-4-1Simply restates this already existent power to inspect:
● Local health officers may enter upon and inspect private property, at proper times (think “reasonable”) after due notice (owner and residents), in regard to the possible presence, source, and cause of lead poisoning and lead hazards.
● Local health officers may order what is reasonable and necessary to prevent lead poisoning or remediate lead hazards.
● Remediation shall be followed by a clearance examination.
7
LHD Enforcement Powers
Issue an Order to Abate* (IC 16-20-1-25)● Specify conditions in writing● Name shortest reasonable time for abatement● Enforceable by injunction in local court by county attorney
Eliminating an unlawful condition – not necessarily abatement as defined in lead hazard control laws
Dwelling Unfit for Human Habitation (IC 16-41-20-1)
(1) – Want of repair and/or(4) – Unsanitary conditions
● Order to Vacate in 5-15 days (IC 16-41-20-4)● Declare a Public Nuisance (IC 16-41-20-6)● Order repair (IC 16-41-20-7)● Serve on tenant and owner
8
LHD Enforcement Powers
Nuisance Law (IC 32-30-6) (6-6) Whatever is injurious to health (6-7) County OR City attorney may bring a civil
action to abate or enjoin a nuisance
Other tools: Municipal Laws, County Ordinances, Local Building Codes, IKE Model Code
Build relationships with County/City Attorneys and Local Judges
9
Alternate Option
Local Health Departments may submit cases to Attorney General by providing the following documentation:
● Risk assessment;
● Statement about children living in home OR lead poisoned children
who used to live in the home;
● Copy of notice provided to property owner requesting lead hazard
remediation within reasonable time period;
● Referral letter stating that a property owner has failed to take steps
to remediate;
And
● Authorization for the AG to take action on behalf of the LHD.
11
Who is our target population?
At-risk Child (410 IAC 29-1-2) is one who:• lives in or regularly visits a house or other structure
built before 1978• has a sibling or playmate who has been lead poisoned• has frequent contact with an adult who works in an
industry or has a hobby that uses lead• is an immigrant, refugee, or has recently lived abroad• is a member of a minority group• is a Medicaid recipient• uses medicines or cosmetics containing lead• lives in a geographic area that increases the child’s
probability of exposure to lead
12
The Team Approach
The case management team (in ideal cases) includes:
Case managerChild’s caregiverHealth educatorNutritionistEnvironmentalistChild’s primary care provider
13
Definitions
Case management - the process of providing, overseeing, and coordinating lead poisoning services (410 IAC 29-1-4).
Case manager - a person authorized by a health department and trained by the ISDH to perform case management protocols (410 IAC 29-1-5).
Case managers must be trained within 6 months of hire
14
Case Management (410 IAC 29-2-1)
Child case management includes:
Outreach and identification of EBLL children• Service planning and resource identification• Service implementation and coordination• Retesting• Monitoring of child case management service
delivery, program advocacy, and program evaluation
15
One step further
Effective case management includes:
Ongoing communication with the caregivers and other providers.
A cooperative approach to solving any problems that may arise.
Eliminate lead hazards in the child’s environment.
Efforts to decrease the child’s BLL.
16
Where Do We Begin?
• Timeframe for action varies according to the child’s blood lead levelA case manager should schedule an appointment with the child’s caregiver as soon as possible after being assigned the case.
• Higher levels require a quicker responseWhere feasible, priority should be given to children with the highest BLLs and those less than two (2) years of age.
• Highest levels treated as medical emergenciesSee case management chart (rainbow chart)
17
What is a Confirmed EBLL?
An elevated blood lead level is confirmed in the following situations:The initial test was a venous testThe initial test was a capillary test, and was
followed by a venous (preferred) or a capillary test within the recommended time frames (see rainbow chart)
18
Action levels defined
….for confirmed blood lead levels between zero (0) and nine and nine-tenths (9.9) g/dL….
● Notify primary medical provider within 10 working days of receipt of test results by the local health officer.
● Provide educational materials to the parents or family of the child regarding prevention of lead poisoning.
● Any additional actions the local health officer believes will assist the family in preventing the child’s blood lead level from increasing.
19
10-14.9 µg/dL…
● Begin case management services within 10 working daysBegin case management services within 10 working days
● Notify the primary medical provider within Notify the primary medical provider within 5 working days5 working days
● Arrange testing of children under 7 years old in the home Arrange testing of children under 7 years old in the home
● Conduct an initial home visit Conduct an initial home visit
● Initiate an environmental inspectionInitiate an environmental inspection
● Provide written notice to property ownerProvide written notice to property owner
● Ensure coordination of long-term services and retestingEnsure coordination of long-term services and retesting
20
15-19.9 µg/dL…
● Begin case management services within Begin case management services within 5 working days5 working days
● Notify the primary medical provider within 5 working days Notify the primary medical provider within 5 working days
● Arrange testing of children under 7 years old in the home Arrange testing of children under 7 years old in the home
● Conduct an initial home visit Conduct an initial home visit
● Initiate an environmental inspectionInitiate an environmental inspection
● Provide written notice to property ownerProvide written notice to property owner
● Ensure coordination of long-term services and retestingEnsure coordination of long-term services and retesting
21
20- 44.9 µg/dL…
● Begin case management services within 5 working daysBegin case management services within 5 working days
● Notify the primary medical provider Notify the primary medical provider immediatelyimmediately
● Arrange testing of children under 7 years old in the home Arrange testing of children under 7 years old in the home
● Conduct an initial home visit Conduct an initial home visit
● Initiate an environmental inspectionInitiate an environmental inspection
● Provide written notice to property ownerProvide written notice to property owner
● Ensure coordination of long-term services and retestingEnsure coordination of long-term services and retesting
22
45 – 69.9 µg/dL…
● Begin case management services within Begin case management services within 24 hours24 hours
● Notify the primary medical provider immediatelyNotify the primary medical provider immediately
● Arrange testing of children under 7 years old in the home Arrange testing of children under 7 years old in the home
● Conduct an initial home visit Conduct an initial home visit
● Initiate an environmental inspection within Initiate an environmental inspection within 2 working days2 working days if the if the structure was built before 1978structure was built before 1978
● Provide written notice to property ownerProvide written notice to property owner
● Ensure Ensure coordination of chelation therapycoordination of chelation therapy, long-term services and , long-term services and retestingretesting
23
70 µg/dL or greater…
● Begin case management services within Begin case management services within 24 hours24 hours
● Notify the primary medical provider immediatelyNotify the primary medical provider immediately
● Initiate a home visit and environmental inspection within Initiate a home visit and environmental inspection within 24 24 hourshours for pre-1978 dwellings for pre-1978 dwellings
● Treat child’s condition as a Treat child’s condition as a medical emergencymedical emergency● Admit child to hospital for chelation therapyAdmit child to hospital for chelation therapy● Obtain venous blood test 1 month after completion of therapyObtain venous blood test 1 month after completion of therapy
● Arrange testing of children under 7 years old in the home Arrange testing of children under 7 years old in the home
● Provide written notice to property ownerProvide written notice to property owner
● Ensure coordination of long-term services and retestingEnsure coordination of long-term services and retesting
24
Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6)
1. Notify child’s primary medical provider Assist in setting appointment, if necessary
2. Visit child’s residence (and other sites where the child spends significant amounts of time)
Provide educational materials to parents and caregivers
Assess factors that may impact the child’s BLL (including sources of lead, nutrition, access to services, family interaction and caregiver understanding)
25
Remember. . .
It is VERY important that EBLL history be included as part of the permanent medical problem list on a child’s medical chart!
Why?Family may change providersAlerts schools of the need to provide more
intensive monitoring of the child
26
Conduct home visit to include:
Medical, developmental, behavioral history Lead education, including medical effects and
environmental sources A determination of potential household exposures Evaluated risk for other family members, including
pregnant women Nutrition assessment or referral Developmental assessment or referral Referral to other social services as appropriate
27
Referral Examples
First StepsWICEarly Head Start/Head StartParents as TeachersYMCA programsFSSA (Medicaid, Food Stamps, TANF)Other local agencies
28
Initial Home Visit From Receipt Of BLL Test Result
BLL (µg/dL) Time frame for home visit
10 – 14.9 Within 10 working days
15 – 19.9 Within 5 working days20 – 44.9 Within 5 working days45 – 69.9 Within 24 hours>70 Immediately
29
How Do I Notify Child’s Guardian?
● Attempt to visit child’s primary residence ● Telephone call to child’s parent/guardian
What if the caregiver does not have a telephone, nor are they at home to receive initial notification and education?
● Leave information at door● Mail (certified) letter to parent or guardian
30
Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6)
3. Implement child case management services
● Develop a written plan for intervention
The plan is based on the needs assessment determined through communication with primary healthcare provider, environmental investigation, home visits (including developmental and social evaluations), and parental involvement.
31
How to Create a Written Plan
Work with the caregiver Identify priorities Short-term goals
Exposure reductionCaregiver educationReferralsFollowup for siblings or pregnant women in the
home
32
How to Create a Written Plan
Work with the caregiverLong-term goals
Housing remediationEnforcement actionsDevelopmental and early intervention followup
Ensure the plan is relevant to the family’s needs and contains realistic goals
33
How Long is a Child in Case Management?
Baseline Lead Time for 50% to reach <10 µg/dL
10-14 µg/dL 9 months
15-19 µg/dL 14 months
20-24 µg/dL 21 months
25-29 µg/dL 24 months
Roberts, J. R., Reigart, J. R., Ebeling, M., Hulsey, T. C. (2001) Time required for blood lead levels to decline in nonchelated children. Journal of Toxicology, Clinical Toxicology, 39, 153-160.
34
Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6)
● Provide an environmental inspection* to include (410 IAC 29-1-14):
Risk assessment of child’s primary and secondary addresses
Environmental investigation
*Although environmental services may be provided by the case manager, environmental inspector, or other program staff;
the case manager is responsible for ensuring that
a child receives services in a timely fashion!
35
Environmental Inspection from Receipt of BLL Test Result
CEBLL (µg/dL) Time frame for environmental
inspection:*10 – 14.9 Within 10 working days15 – 19.9 Within 5 working days20 – 44.9 Within 5 working days45 – 69.9 Within 2 working days>70 Within 24 hours
* For CEBLL child at or above ten, with a pre-1978 primary or secondary residence, case management must include an Environmental Inspection.
36
Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6)
4. Provide written notice, including risk assessment, to property owner of lead hazards present and required remediation options (per 410 IAC 29-1-22).
5. Ensure retesting (per 410 IAC 29-1-21).● Arrange testing for other children under age
seven at same residence.
37
Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6)
6. Provide continuing child case management services until case closure
Coordinate the activities of the case management team
Evaluate compliance and success of the plan Ensure that needed care is provided Follow up on referrals or other problems identified
during the child’s care
38
Case Closure (410 IAC 29-2-2)
1. “Case complete”
● The child has at least 2 consecutive confirmed tests less than 10 μg/dL in a six (6) month period, AND
● environmental lead hazards have been remediated and passed a dust clearance test, …AND…
● Referrals have been made for long term medical, developmental, environmental and follow-up.
…OR…
39
Case Closure continued
2. “Administratively closed”
• the child moves to another state (referral)• the child moves to another county in Indiana (referral)• child reaches his or her seventh birthday (referral)• case management is blocked for religious or legal
reasons• death of the child • the child can no longer be located (5 attempts – next slide)
40
“Administratively Closed”
Five attempts to locate the child:At least one telephone call to parent or
guardianAt least one letter to parent or guardian Certified letter to parent or guardian Home visit attempt to last known residence
…AND…Any repeat (2nd attempt) of the above
- shows due diligence
41
State Responsibilities
● Oversight for county case management activities
● Notify counties via EBLL Manifest
● Provide guidance, support, and resources to local health departments, parents of lead poisoned children, physicians, health clinics and general public
42
Environmental Inspection(410 IAC 29-1-14)
The local health officer shall enter upon and inspectprivate property of the primary and secondary addressesoccupied by all lead poisoned children (CEBLL), if thestructure was built before 1978, to include:
● Risk Assessment (410 IAC 29-1-22)● Identifies specific lead hazards from structural sources of
exposure● Includes more information such as and history of dwelling,
occupancy by children under age 6, visual inspection, limited environmental sampling
● Environmental Investigation (410 IAC 29-1-15)● Presentation of results of the nonstructural sources of lead
hazards identified, including recommendations for reducing or eliminating exposure
43
Risk Assessment(410 IAC 29-1-22)
● Conducted by a trained, licensed risk assessor, according to “documented methodologies” established by law (326 IAC 23-4-2).
● Report given to the family and the owner (if the family does not own the home) including range of recommendations to mitigate identified lead hazards within 5 business days.
● Written notice of the required remediation options to be completed within 180 days. A clearance examination is conducted to establish the efficacy of remediation.
● Education of the family and owner on lead hazards in the home and temporary and permanent measures to protect children from further poisoning.
44
• Visual examination, underlying causes
• Exterior testing of deteriorated paint
• Soil testing of bare soil • Interior testing of deteriorated
paint• Water samples when called for• Dust samples and testing
“Documented Methodologies”
45
Local Health Officer may…order what is reasonable and necessary (410 IAC 29-4-1)
Risk Assessment Report
Remediation = actions that constitute either:
1. Abatement“Lead-free home”
2. Interim control of a lead hazard (326 IAC 23)
“Lead-safe home”
46
Lead Hazard Example
Remediation Options*:1. Remove and replace entire window with aluminum,
vinyl, or wood painted with lead free paint.2. Wet sand sill to bare wood, repaint with non-lead
based paint.3. Remove loose paint and repaint.
* All of these must be done using lead safe work practices.* All of these must be done using lead safe work practices.
Lead based paint deteriorated on a window sill
47
Lead Safe Work Practices(IC 13-17-14-12)
• Find the causes of the problem• Prioritize work • Separate work and occupied spaces• Isolate high dust areas• Wet dust/sand, low temp heat guns• Correct causes of the problem (friction, impact, or substrate
deterioration)• Dispose of waste safely• Educate occupants about risks
from lead based paint
48
Remediation shall be followed by dust clearance examination (410 IAC 29-4-1)
• Licensed clearance examiner or risk assessor
• Required for all remediation• Visual examination of the
area• Dust sample testing for lead
49
Risk Assessor Training
• Environmental Management Institute (EMI) in Indianapolis
• ILHHP maintains waiting list for the training
• Scholarships available for LHD staff
• Within the limits of the ILHHP budget, ISDH will cover the cost of the training classes. LHDs will have to pay for the travel expenses.
50
Resources
• 247 licensed risk assessors in Indiana. • About half of them are private environmental.• Price generally between $400 and $700. • 31 LHDs have licensed risk assessors on staff*,
many have more than one.
*LHD counties with licensed risk assessors: Allen, Bartholomew, Boone, Dearborn, Decatur, Delaware, Elkhart, Fayette, Floyd, Grant, Hamilton, Hancock, Hendricks, Howard, Jackson, La Porte, Lake, Lawrence, Madison, Marion, Marshall, Miami, Monroe, Morgan, St Joseph, Tippecanoe, Vanderburgh, Vigo, Wayne, Wells, Whitley
51
Resources
• Indiana Community Action Agency (CAA) network has 37 licensed risk assessors in their service areas around the state
• Other service entities (cities, non-profits, housing authorities, state agencies) have risk assessors
• Indiana Public Licensing Agency (IPLA) maintains the current list of licensed Risk Assessors, Lead Inspectors and Lead Contractors at:
Website:
http://www.in.gov/pla/
52
Indiana Lead and Healthy Homes Program
State Responsibilities include:
● Oversight for county case management activities
● Notify counties via EBLL Manifest
● Provide guidance, support, and resources to local health departments, parents of lead poisoned children, physicians, health clinics and general public
Child case management includes:
Outreach and identificationof EBLL children
• Service planning and resource identification
• Service implementationand coordination
• Retesting• Monitoring of child case
management service delivery, program advocacy, and program evaluation
53
Contact Information
Ellen Bloom, MPHHealth EducatorIndiana Lead and Healthy Homes ProgramIndiana State Department of Health2 N. Meridian Street, 5th floorIndianapolis, IN 46204317.233.1290317.233.1630 [email protected]