Providing services for EBL children in underserved areas through local

partnershipsJennifer 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 7Mid-America Pediatric Environmental Health Specialty UnitChildren’s Mercy HospitalKansas City, MO

Jennifer Lowry, MDDirector of MAPEHSU

Clinical Pharmacology and Medical ToxicologyPediatricianDepartment of PediatricsChildren’s Mercy Hospital

Kevin Kennedy, MPH, CIECManaging Director, CEH

Erica Forrest, MS, RRTEnvironmental Health Coordinator

(Training, Community Outreach and Education)

Ryan Allenbrand, MS, CIECHealthy Homes Program ManagerEnvironmental Hygienist

D. Adam Algren, MDMichael Christian, MDToxicologist for MAPEHSU

Clinical Assistant ProfessorDepartment of Pediatrics, CMH Department of Emergency Medicine,Truman Medical Center

Stephen Thornton, MDMedical Director, University of Kansas

Hospital Poison Control Center

Lisa Oller, RPh, CSPIProject Coordinator and Manager for

MAPEHSUUniversity 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)

• 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

• 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.eduAmy Roberts, amy.roberts@kcmo.org

Ryan Allenbrand, rnallenbrand@cmh.edu