Download 2015 LHD of the Year Award

2015 LHD of the Year Award
LHD NAME: Sevier County Health Department (Sevierville, TN)
LHD SIZE (population served): Medium (50,000–499,999)
LHD Overview
The Sevier County Health Department is a local health department (LHD) in the East Tennessee Region
of the Tennessee Department of Health. It provides services in a rural county with a total population of
93,570, of which 13.4% live in poverty. Tourism provides the largest portion of employment. During
FY2013–2014, the health department provided services to 10.4% of the population. Of the population
receiving services in 2014, 17.3% were Hispanic with limited English proficiency. A variety of services
(WIC, Family Planning, Primary Care, Dental, Immunizations, Well Child Checks, Communicable Disease
Testing/Treatment, Pregnancy Testing/Presumptive Eligibility, Home Visiting Programs, Vital Records)
are provided by 39 staff (16 clerical, 2 nutrition, 8 nurses, 4 nurse assistants, 2 nurse practitioners, 1
physician, 1 dentist, 1 dental assistant, 1 disease intervention specialist, 2 social counselors, and 1
custodian). The LHD also has one health educator doing health promotion activities in the community. In
addition, all LHD staff members are required to identify barriers and behaviors that adversely affect the
health of the community and to be involved in primary prevention initiatives focused on improving
community health. Projects this year have addressed breastfeeding, tobacco use, immunizations, dental
health, nutrition, exercise, and neonatal abstinence syndrome reduction.
Statement for LHD of the Year Award
Issue
Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn exposed to
addictive illegal or prescription drugs in the womb. Nearly all drugs, whether illegal or prescription, cross
the placenta from the mother's blood stream to the developing baby. This means that whenever an
expectant mother is addicted to drugs, her unborn baby becomes drug dependent. Once a baby is born,
he/she no longer receives that drug from the mother and begins to experience the painful symptoms of
withdrawal.
NAS is associated with an increased risk of complications in the neonatal period and higher costs to the
healthcare system, particularly Medicaid. NAS increases the risk of respiratory complications at birth,
low birth weight, prematurity, feeding difficulties, and seizures.1 TennCare, Tennessee’s Medicaid
program, covered 75–87% of infants diagnosed with NAS from 2008 to 2011. TennCare estimates
suggest that care of NAS infants exceeds $40,000 in the first year of life—nine times the cost of care for
otherwise healthy infants.1 In addition, 22.7% of the TennCare infants born drug dependent were placed
in the custody of the Department of Children’s Services (DCS) within the first year of life, compared to
1.4% of all other TennCare infants during 2011.2
Over the last decade, the incidence of NAS in Tennessee has increased by 15-fold, far exceeding the
national three-fold increase over the same time period.3 The Tennessee Department of Health made
NAS a reportable condition on Jan. 1, 2013. At the close of that first reporting year, 921 NAS births (at a
rate of 11.6 per 1,000 live births) had been reported across the state.1 The greatest number of NAS
births (268) was observed in the 15-county East Tennessee Rural Region (ETR), at a rate of 34.4 per
1,000 live births.3 Approximately 29% of the reported NAS births in Tennessee were to ETR residents.
Sevier County residents were responsible for 4.1% of the NAS births reported across the state and 14.6%
of those reported in the ETR. The inpatient hospitalization rate for any diagnosis of NAS in Sevier County
for the period 2009–2011 was 2.5 times greater than the rate for Tennessee (16.6 per 1,000 live births
for Sevier County compared to 6.7 per 1,000 for Tennessee).4 The inpatient hospitalization rate for
deliveries with any maternal substance abuse for the period 2009–2011 in Sevier County was two times
greater than the rate for Tennessee (40.5 per 1,000 live births for Sevier County compared to 20.6 per
1,000 for Tennessee).4 While the use of “prescription drugs only” was the most common exposure
source reported in most Tennessee regions, that was not the case in the ETR, where 49.3% reported the
exposure source to be “illicit/diverted drugs only.”3 In Sevier County, the use of “illicit/diverted drugs
only” as the exposure source accounted for 80% of the reported cases in Sevier County.5 In light of the
large number of “illicit/diverted drugs only” exposure sources, it seemed prudent to develop strategies
to intervene during the preconception period and prevent drug-exposed pregnancies in a population at
risk to use illicit/diverted drugs.
Goals/Objectives
Sevier County Health Department’s goals were twofold:
1. To reduce the number of babies born with NAS in Sevier County within 10 months of developing
and implementing a primary prevention initiative (PPI) focused on (1) educating female inmates
in the Sevier County Jail about NAS, the risks associated with use of addictive illicit, diverted, or
prescription drugs during pregnancy, and the availability of long-acting, reversible
contraceptives (LARCs) from the health department; and (2) making LARCs available on a strictly
voluntary basis to women while they are incarcerated.
2. To develop a PPI that can be successfully replicated in other counties in the ETR by November
2014.
Implementation
Sevier County Health Department engaged in the following activities in pursuit of the above goals and
objectives:

Participated in and collaborated with the Sevier County NAS reduction task force, known as
MOMs (Moms on Meds), to educate community members about the increasing incidence and
consequences of NAS.



















Assembled a regional NAS sub-committee at the request of the ETR Director and under the
leadership of the ETR Community Services Director to strategize and plan program details.
Developed an algorithm to guide planning and implementation of an initiative to provide LARCs
to jail inmates.
Developed PowerPoint presentation with an embedded video clip of a NAS baby in withdrawal
to educate LHD staff about NAS and the importance of the PPI.
Developed outreach plan with two educational pamphlets, one on NAS and one on LARCs, to
use in securing the cooperation of jail officials in providing a time and place to do an educational
presentation and transport for inmates who wanted to receive a LARC.
Developed referral and tracking forms.
Developed educational presentation and pamphlet to inform inmates about the risk of NAS
associated with the use of illicit, diverted, or prescription drugs during pregnancy and how to
minimize the risk of pregnancy through the use of LARCs.
Developed standardized clinic documentation tools.
Selected pilot sites: Sevier County (population 93,570) and Cocke County (population 35,479).
Met with the local sheriff, jail administrator, and jail nurse to educate them about NAS (cause,
local incidence, and associated costs), explain the proposed PPI, and secure their cooperation in
implementing the initiative.
Met with LHD staff to educate them about NAS and the importance of the PPI.
Identified LHD staff best suited to implement the program.
Implemented initiative in January 2014.
Collaborated with the jail administrator to schedule and conduct the educational presentation
with the female inmates.
Used LHD staff (both clinical and clerical) to conduct an educational presentation in the jail.
Collaborated with the jail administrator to arrange for guards and transportation to the LHD for
inmates interested in a LARC.
Conducted VRLAC clinics using resources already existing in the LHD to provide services while
participants were still incarcerated. Note: The methods, initiative, and clinics are referred to as
VRLAC (Voluntary, Reversible, Long-Acting Contraceptives) to emphasize to those outside the
medical community that the program is 100% voluntary and the method 100% reversible.
Collaborated with UT Family Physicians to provide experience for residents to place LARCs at no
cost to the local health department.
Developed an access database (ETR Epidemiologist) for reporting and tracking data.
Followed the PDCA (PLAN-DO-CHECK-ACT) continuous improvement cycle after each phase of
the implementation, from securing the “buy-in” from local staff to data collection and
reporting—to evaluate the processes and revise it to ensure success as other counties begin to
replicate and implement the program.
Outcomes
The Sevier County MOMs group has educated 13 community groups and held two community forums to
educate residents in Sevier County about NAS and its increasing incidence locally.
As of Dec. 31, 2014, the Sevier County Health Department gave six presentations and placed 38 LARCs
through its initiative. Nine months following the implementation of the program, the number of NAS
babies born began to level off. During the first four months of 2014, there were 20 NAS babies born to
Sevier County residents; 22 in the second four months; and only three in the last four months. As of
March 20, 2015, 50 LARCs have been placed through the Sevier County VRLAC clinics. Only one NAS
birth was reported in January/February 2015, compared to 11 in January/February 2014, a 90.9%
reduction.
By the end of November 2014, two other counties had joined the pilot sites in implementing the PPI. As
of March 20, 2015, there are nine counties in the ETR that have done presentations to local jail inmates
and seven that have conducted VRLAC clinics. A total of 20 presentations have been completed, with
396 participants, 155 referrals, and 115 LARCs placed.
Information from the patient histories of those referred in the ETR revealed the following:







89.0% reported a history of drug use;
63.8% of those reporting a history of drug use reported their specific use to be illicit drugs;
27.1% reported having used drugs during a previous pregnancy;
41.3% reported having had a previous unplanned pregnancy;
20.6% reported having already had a least one child born drug dependent;
21.9% reported having had a child taken into state custody; and
80.6% reported no method of contraception being used.
Based on the 2011 average TennCare health costs in the first year of life for an infant born drug
dependent ($62,973),2 providing LARCs to 115 at-risk females and preventing only one pregnancy for
each participant would represent a potential savings of $7,241,895, not to mention the costs associated
with 22.7% of NAS infants being taken into DCS custody within their first year of life.2 The savings could
be greater if more than on pregnancy was prevented. Depending on the method chosen, the length of
contraceptive protection ranges from three to 10 years.
The PPI has also been replicated in two sites in the Northeast Tennessee Rural Region; expanding to two
additional sites in that region in the near future are being planned.
The Sevier County Health Department Director, ETR Medical Officer, and a 4th Judicial District Judge (a
member of the Sevier MOMs group) have spoken at two statewide group meetings (The Tennessee
Association of Drug Court Professionals and The Tennessee Association of Alcohol, Drug and Other
Addiction Services) about this initiative. Both associations deal specifically with individuals in addiction.
As a result of the partnerships established through the MOMs group, the Sevier County Health
Department Director and ETR Medical Officer also met with judges and parole officers in Sevier County
to educate them on NAS and the initiative implemented in the jails. They agreed to make NAS and
contraceptive education through the health department a mandatory part of sentencing for anyone
convicted of drug or drug-related charges. Participants in these educational sessions will also receive
instruction on the contraceptive methods available in the health department and how to access these
services.
Recommendations
Sevier County Health Department recommends the following activities to LHDs that are interested in
implementing similar programs:










Take the time to educate community leaders and stakeholders.
Establish strong community partnerships, emphasizing what each partner will need to invest and
the benefit to each partner and the community.
Keep in mind the jail’s commitment in terms of time and staff; make it as convenient as possible.
Identify staff with a “heart” for the program; staff must treat the inmates with compassion and
respect for the program to work.
Employ both the clinical and clerical staff when doing the educational presentation to introduce
inmates to the staff with whom they will work.
Work with the jail to ensure the educational setting is as conducive to learning as possible.
Identify a separate entrance and waiting area for inmates so that they are not “paraded” in
front of other clients in the health department.
Meet individually with the jail nurse to explain the specific clinic processes, possible medical
complaints that those receiving the LARCs may have, how to best address those complaints, and
make arrangements for the nurse to observe at least one VRLAC clinic.
Take the time to listen and educate the inmates about what to expect following insertion to
reduce the risk of them wanting to have it removed prematurely.
Follow the PDCA continuous improvement cycle to make the initiative work in each individual
clinic setting.
References
1. Ramakrishnan, M. (2014). Neonatal Abstinence Syndrome: How States Can Help Advance the
Knowledge Base for Primary Prevention and Best Practices of Care. Arlington, VA: Association of
State and Territorial Health Officials.
2. Data source: Division of Health Care Finance and Administration, Bureau of TennCare.
3. Miller, A. M. & Warren, M. D. (2013). Neonatal Abstinence Syndrome Surveillance Annual
Report 2013. Nashville, TN: Tennessee Department of Health.
4. Bauer, A. & Li, Y. (2013). Neonatal Abstinence Syndrome and Maternal Substance Abuse in
Tennessee: 1999–2011. Nashville, TN: Tennessee Department of Health.
5. Data source: Division of Policy, Planning and Assessment – Surveillance, Epidemiology and
Evaluation, Tennessee Department of Health.