Capital contable

D

S

Visiting nurse programs offer a unique opportunity to efficiently reach pregnant women and new mothers in high-risk communities. Traditional home nursing visits can be enhanced to visually assess hazards, collect dust samples, inform occupants and rental property owners of hazards, demonstrate specialized cleaning methods for lead dust, and discuss lead poisoning risks. Further, and most critically, the nurses can provide referrals to available lead hazard control resources and other resources.

B

Immediate/Direct Results: Education and referrals provided during home nursing visits directly benefit the families served. The physical presence of nurses in the homes provides a mechanism for nurses to identify conditions that may warrant emergency interventions, even outside the context of formal policies for such action.

Public Health Benefits: Lead safety improvements triggered by nurse visits benefit siblings and future occupants. In addition, home nurse visits provide a mechanism for targeting available lead hazard assessment and/or control services to high-risk families who can benefit immediately. Over time, cumulative efforts will help improve the lead safety of the housing stock.

Other Indirect/Collateral Benefits: Word-of-mouth among new mothers may reinforce efforts to raise awareness among families in the community. Nurse referrals may help generate referrals to other community programs, such as weatherization or lead hazard control, thereby reducing marketing efforts for such programs.

S

P

I

City- or County-Wide

P

A

K

P

Health Department

C

E

Staff requirements: Staffing needs depend upon whether the lead activities are provided as an adjunct to home nurse visits that are already being made, or whether they are an entirely new service, and by the scope of services provided.

Other resource requirements: If nurses will be collecting dust samples or demonstrating lead-safe cleaning techniques, they will need the appropriate tools (such as wipes for dust sampling, HEPA vacuum, etc.) and protocols, along with any necessary training.

Institutional capacity required: Management support is the most likely element required for continued support of a staff-intensive effort.

Cost considerations: To maintain the visiting nurse program’s existing coverage of its target population caseload, the incremental cost of adding lead safety to the visiting nurse protocol will need to be reimbursed so that the staff can be expanded accordingly.

Timing issues: Can be implemented at any time.

Feasibility of Implementation: High. As demonstrated by the adoption of this strategy in multiple jurisdictions, the strategy is feasible in multiple variations.

Targeting High-Risk Housing

CAPITALIZE ON HOME NURSING VISITS TO TARGET PREVENTION SERVICES

P

O

/B

Use of this strategy requires ongoing commitment of nursing staff time and training.

If programs seek to add lead hazard education to previously planned nursing visits, they may run the risk of overwhelming both parents and the nurses by providing too much information at one time, ultimately making the sessions less effective.

Nurses and families may be frustrated by the lack of meaningful lead hazard control resources available in the community. Pregnant women may resist interventions that could lead to uncomfortable relationships with landlords or even evictions; the program should develop a contingency strategy for landlord retaliation (with assistance from a legal aid agency and/or the code enforcement agency) and explain it to their patients.

A

R

N/A

I

#1

S

P

With the support of a CDC $100,000 primary prevention grant, WI CLPPP developed and pilot-tested a nursing home visitation program in two high-risk Wisconsin communities (Racine and Sheboygan). Although the one­

time CDC grant has ended, the program since has evolved into a different but sustainable format, with 34 programs run by local health departments throughout the state.

The initial pilot program, which targeted low-income, primarily Medicaid-eligible, pregnant women through the Prenatal Care Coordination Program (PNCC), provided prenatal lead education and referrals, environmental assessments, and feedback to property owners. Fourteen PNCC nurses were trained as Lead Sampling Technicians and equipped with HEPA Vacuums. During initial prenatal home visits, a nurse provided information about childhood lead poisoning and potential lead hazards in the home environment. The nurse also conducted a visual assessment of the home, collected pre- and post-cleaning lead dust samples from floors and windows, demonstrated lead dust reduction measures, and provided cleaning supplies to the parent. During a second visit four-six weeks later, nurses reinforced messages and collected lead dust samples from the same locations to assess the effectiveness of measures that were taken to reduce lead dust. Pre- and post-cleaning results were provided to clients. Finally, property owners were informed in writing of the results of the dust sampling, given a copy of the HUD Lead-Paint Safety Field Guide, and encouraged to repair deteriorated painted surfaces. Families and property owners were also encouraged to enroll their properties in the HUD Lead Hazard Reduction Program if appropriate.

After CDC funding ended, Wisconsin revised the program to reach a broader target audience by adding an additional lead-specific home visit to existing prenatal and newborn visitation programs. Local health departments (LHD) now choose the level of intensity of services provided during their lead visits, selecting various combinations of three options: lead education, environmental assessments, and feedback to property owners. Due to capacity and resource constraints, not all LHDs are doing dust sampling; some are using LeadCheck swabs. The state is continuing to support local efforts, currently devoting about 15 percent of two FTEs to support the program and budgeting about $35,000 per year. Local LHDs estimate their costs at about

$3,000 per year. To help build capacity and support dust sampling, Wisconsin is training an additional 23 nurses as lead sampling technicians and plans to offer free dust sample analysis through the state lab.

Jurisdiction or Target Area: Wisconsin

Targeting High-Risk Housing

CAPITALIZE ON HOME NURSING VISITS TO TARGET PREVENTION SERVICES

Primary Actor: WI Department of Health and Family Services, Childhood Lead Poisoning Prevention Program Secondary Actor(s): Local health departments throughout the state

Staffing utilized: At the state level, the project required 0.2 FTE for the first year.

Other resources utilized: N/A

Factors essential to implementation: The willingness of visiting nurse program to train nurses as LSTs, and lab resources for dust wipe analysis, were essential to implementing this strategy.

Limitations/challenges/problems encountered: Initial concerns about creating conflict by contacting property owners proved to be mostly unfounded. In fact, the program has been so popular that nurses in one locality fought successfully to protect it from threatened budget cuts.

Magnitude of Impact/Potential Impact: During the nine-month pilot, approximately 100 families received services. WI CLPPP estimates that some level of service has been provided to about 500 families statewide this year, and expects the number to reach 1,200 by the end of year. The program has been well received statewide by nurses and families.

Potential for replication: High. Widely replicable in jurisdictions with visiting nurse programs.

Contacts for Specific Information

Sue LaFlash Reghan Walsh

Public Health Nurse Health Education Specialist

WI Childhood Lead Poisoning Prevention Program WI Childhood Lead Poisoning Prevention Program

608-266-8176 608-261- 9432

[email protected] [email protected]

References for additional information

WI CLPPP has various program documents available in either hard copy or electronic form upon request. The core resource is the Prenatal and Newborn Home Visitation Resource Pack, which was designed specifically for local health departments to customize as needed. Also available is a Prenatal Education/Assessment Protocol.

I

#2

S

P

“Keep Your Baby Lead-Safe” (“KYBLS”) is an innovative home visiting program developed by the RI CLPPP to educate pregnant women about lead hazards and connect them with resources to control lead hazards in their homes. Originally piloted in Providence, KYBLS is now a collaboration of the CLPPP, the Family Outreach Program (FOP), the Department of Administration’s Energy Office, Blackstone Valley Community Action Project, and the Lead Hazard Reduction programs in the cities of Woonsocket and Pawtucket. Women eligible for KYBLS must both be pregnant and residing in either Woonsocket or Pawtucket; they may be either tenants or homeowners. Once enrolled, women receive an initial home visit from an FOP nurse (home visiting agency) who explains the project, administers an educational questionnaire on childhood lead poisoning, and answers any questions or concerns. With the family’s authorization, the FOP nurse arranges a joint second visit with the Energy Office Weatherization Program to conduct a visual assessment of the property. Depending on the visual assessment and other conditions of the home and type of occupancy, the Weatherization Program may provide educational materials; refer to community resources; provide cleaning supplies and demonstrate cleaning techniques that help maintain a lead-safe home; collect lead dust wipe samples at both initial and final stages of the project (which are analyzed by the state laboratory); and, upon eligibility, help secure weatherization services and/or reduced-cost lead hazard reduction work.

Targeting High-Risk Housing

CAPITALIZE ON HOME NURSING VISITS TO TARGET PREVENTION SERVICES

Through partnership with the Weatherization program, the KYBLS project aims to literally get a “foot in the door” by delivering an energy-efficient, lead-safe environment at no cost and with minimal involvement of the property owner. Weatherization program policies do not require the permission of the property owner to perform an initial energy assessment. The property owner’s signature is only needed in order to perform energy conservation treatments (which involve no cost to the property owner and no threat of legal penalty). CLPPP sought to utilize these facets of the Weatherization Program to initiate contact with property owners offering an opportunity to improve their properties for free, easing the concerns of women who feared conflict with or eviction by their landlord, and following up with contact regarding the need to repair lead hazards.

Following the birth of each participant’s child, the program uses RI health department (KIDSNET) and CLPPP databases to identify and track the child up to the first blood lead level screen, to serve as another method of evaluation method for the project. The educational impacts of the KYBLS project continue to be assessed through an analysis of both the pre- and post- educational surveys administered to participants at the initial and final stages of their enrollment, as well as the pre- and post- dust wipe samples taken by the FOP workers at the homes of KYBLS enrollees. RI CLPPP has budgeted $100,000 per year for KYBLS.

Jurisdiction or Target Area: Rhode Island

Primary Actor: RI Department of Health Childhood Lead Poisoning Prevention Program Secondary Actor(s): N/A

Staffing utilized: 0.75-1.0 FTE is supporting the project.

Other resources utilized: N/A

Factors essential to implementation: The essential factor is the cooperation between the health department and the weatherization agency.

Limitations/challenges/problems encountered: Unfortunately, implementation has proven to be very challenging, since a waiting list for weatherization services delays access to the property improvements to be provided at no cost, and property owners are not very enthusiastic about financing lead hazard controls via the loans that are offered. Many of the referred women refused services, could not be located, or did not meet eligibility requirements. Because the program began as a small pilot program, to date only a handful of properties have been successfully enrolled into lead hazard control or weatherization programs.

Magnitude of Impact/Potential Impact: From Nov. 2002 – Dec. 2003, 437 referrals were received, 135 women have been enrolled and received services, and another 52 women are being contacted to offer services.

Potential for Replication: Moderate if experience shows ways to overcome challenges encountered to date.

Contacts for Specific Information Magaly Angeloni

Program Coordinator

Childhood Lead Poisoning Prevention Program Rhode Island Department of Health

401-222-4602

Jill Barber

“KYBLS” Coordinator

Childhood Lead Poisoning Prevention Program Rhode Island Department of Health

401-222-5932

[email protected] [email protected]

References for additional information

RI CLPPP is willing to share its educational brochures, protocols, and database design for KYBLS.

Targeting High-Risk Housing