'In Closing'

Lindsay Menard, MPH

La Crosse, Wisconsin

As my final weeks of being a Wisconsin Population Health Service Fellow draw near, I have had the opportunity to reflect upon the past 22 months and recognize how much I have grown and how fortunate I am to have been part of such compassionate, innovative, and inclusive communities.  I want to use this blog post to focus on one of those communities, the La Crosse County Health Department, by highlighting one particular project I helped advance, the accreditation process.The accreditation journey has fostered my professional and personal development during my time as a Wisconsin Population Health Service Fellow.

Getting Started

Almost two years ago, the only thing I knew about national voluntary public health accreditation was that the Public Health Accreditation Board (PHAB) had released a set of standards and measures in 2011 to help state, local, and tribal health departments ensure the three core functions of public health and the ten essential health services were being met.   I had to quickly get myself up to speed on the purpose of accreditation (with the use of resources such as: the PHAB Online Orientation, Embracing Quality in Public Health: A Practitioner’s Performance Management Primer, and Developing a Local Health Department Strategic Plan: A How-To Guide), the reasons the La Crosse County Health Department was pursuing it, and how I could add value to the process. 

Lessons Learned

The first lesson I learned is that people and organizations always have room for improvement, and that it is important to introduce quality improvement efforts in a way that does not threaten staff or the good work they were already doing.  I framed this concept in many different ways.  For example, when discussing performance management and quality improvement ideas (Domain 9 in the standards and measures established by PHAB) with public health nursing staff I highlighted the fact that we are already reaching a large proportion of the community with seasonal influenza vaccinations, and then asked them to think about how we could reach even more people and improve upon the structure of community influenza clinics.

I have also learned to be open to change, to document change, and to encourage change (even if I am hesitant about it myself).  Change does not come easily to most people, including me.  Learning how to maneuver change, address change resistors, and embrace change has been important throughout the accreditation process.  We, the La Crosse County Health Department, had to overhaul and develop new systems.  Changing the infrastructure of an organization is no easy task.  It took time, patience, and various forms of training to get new or changed systems to “stick.”  And as a new employee and  Wisconsin Population Health Service Fellow, I was essentially charged with testing the status quo.  I had to learn to build rapport and earn the trust of staff.  There was a period during the transition when everyone (including me) had to adjust to the shift in the organizational structure. 

The third lesson I learned was how important communication is at all levels of an organization, not just at a local health department.  It is important for leaders to communicate on a regular basis with all staff members and it is equally important for leadership to explicitly reach out to staff for feedback.  Communicating thoughts, ideas, improvements, and questions can be extremely difficult.  Encouraging a safe environment for all to communicate is essential.  Otherwise, trust and morale break down. To communicate with staff about the new systems, plans, and policies and procedures (P&Ps) that were created, adopted, and implemented a department newsletter was created (Figures 1 and 2).  The newsletter highlights the accreditation process, discusses the twelve domains developed by PHAB, states new changes, and captures health department news.   Through the accreditation process, I have learned to develop newsletters and frame messages for staff and the media in a meaningful and concrete way. 

Figure 1:                                                  Figure 2: 

     

Final Thoughts

In closing, the accreditation process has increased the capacity of the La Crosse County Health Department to deliver the ten essential services AND it has made me a better public health professional.  I have increased my knowledge of public health, fostered many professional skills, learned to manage change, and recognized the value of communication throughout an organization.   I will carry the many lessons and skills I have learned throughout the Fellowship program with me for the rest of my career.  Fellowship faculty and staff explain it best, “Through this intensive process, academic health departments and their UW School of Medicine and Public Health—based partners have developed a way to take talented and highly motivated early-career professionals and transform them into confident, emerging leaders, with cutting-edge skills, competencies, and connections to improve population health outcomes and advance health equity in Wisconsin and beyond.”[i] I am proof.  I have been transformed.

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[i] Ceraso, M., Swain, G.R., Vergeront, J.M., Oliver, T.O., & Remington, P.L. (2014). Academic Health Departments as Training Sites for Future Public Health Leaders: A Partnership Model in Wisconsin.  Journal of Public Health Management and Practice, 20 (3), 324-329.

Do Our Built Environment Redesigns Consider Health AND Equity?

Carly Hood, MPA, MPH

Population Health Service Fellow

Wisconsin Center for Health Equity

Health First Wisconsin

Wisconsin Division of Public Health

Madison, Wisconsin

Monday I attended the Population Health Sciences seminar “Retrofitting Suburbia: Urban Design for Public Health” given by Ellen Dunham-Jones who is a Professor of Architecture and Urban Design at the Georgia Tech School of Architecture. It was a great lecture with a wealth of insights on areas around the country that have undergone various methods of design to recover and invigorate the empty lots and strip malls blighting our nation. Such methods include everything from reinhabitation (repurposing of old buildings) and redevelopment (building new structures on old properties), to “regreening “or simply tearing things down to put in more space for trees, gardens and space to be active. (Archive coming soon!)

Somewhat counterintuitive and disturbing, I was surprised to learn that we have seen a dynamic shift in where poverty in our country exists, and today there are more poor people living in the suburbs than the cities (reinforced by this infographic).

This is in part the result of what’s known as the “drive til you qualify” phenomenon whereby if you want a shorter and cheaper commute, you have to be able to pay for it in home price (and vice versa). This lack of regulation on housing prices and affordability, as Professor Dunham-Jones pointed out, has led to uneven and unsustainable patterns in development as we see them today.

But it was as she shared pictures of a case study (one from her incredible database of 800 locales!) from my home state of Oregon that I got to thinking…not all suburbs are created equal. She was sharing changes made to a structure in a suburb of Portland called Lake Oswego which happens to have the greatest concentration of Portland-area homes worth more than $1 million. And so it struck me: Are the people in Lake Oswego the people most in need of retrofitting for the “public’s health?” Now I recognize that this is just one of many examples of a suburb that is reusing space for new purposes; some examples are found in impoverished communities, others in more well off areas. And Professor Dunham-Jones did share stories from both ends of the spectrum. But given that lower socioeconomic status has consistently been associated with poorer health outcomes (which holds across the income gradient), if one of the goals of “retrofitting suburbia” is to improve population health, wouldn’t we be more successful at achieving this goal if our efforts were more often targeted in areas with poor health, less community cohesion, and fewer options for safe shared space?  

There’s no doubt empty strip malls, large parking lots, and poorly designed suburban neighborhoods are not only eye-sores, but are contributing to our car-dependent and chronic-disease ridden country.

But should we be looking towards those with longest commutes, fewest parks, and/or highest rates of morbidity to consider such beneficial transformations? And even before we ask those questions, I’d explore just what may be occurring inside those communities that we can’t see from the outside…Kaid Benfield, Special Counsel for Urban Solutions at Natural Resources Defense Council, highlights, “As [suburban] properties have declined, so have their rents, making them affordable to small, often entrepreneurial businesses,” businesses often owned and frequented by inner-suburb immigrant populations. Says Benfield, “The risk is that, as we reshape these old properties with new buildings and concepts, the replacement properties will be much more valuable than their predecessors; indeed, that’s why new development is appealing to investors and how it is made possible.  Overall, that’s a good thing.  But small businesses either go under, unable to afford new rents, or relocate as a result. “ In housing policy, when an area is rezoned many cities now have inclusionary zoning policies e.g: “a percentage of units in a new development or a substantial rehabilitation that expands an existing building set aside affordable units in exchange for a bonus density. The goals of the program are to create mixed income neighborhoods; produce affordable housing for a diverse labor force; seek equitable growth of new residents; and increase homeownership opportunities for low and moderate income levels.” But that policy doesn’t necessarily translate to the rezoning of small, local businesses run by lower and middle class populations.

Furthermore, the potential negative implications of redesigning run-down suburbs don’t just apply to small business owners; development and the resulting risk of gentrification can hurt the workforce and overall economy of an entire region as is the case in DC where the free market is picking winners and losers by pricing much of DC’s workforce out of the area.

This can happen in cities and in suburbs. And—as my economics side must loudly add—that’s just capitalism functioning as it’s supposed to! Without a “check and balance” of some sort, that’s the way our system is meant to function.

Alas, the challenges remain—and professor Dunham-Jones spoke eloquently to these: How do we ensure beautifying old structures isn’t pushing out the very people who are making the only use of them? How do we even determine if in fact retrofitting efforts ARE having an impact on health? And finally, I’d push us to ask: are we getting at the roots of the problem? Increasingly more and more people across the country are spending less time using services, purchasing goods and/or enjoying public space.  America’s poor paying jobs that demand long hours, multiple shifts, and/or too much time in transit are squeezing our middle class. An extreme example, but one we could do well to learn a lesson from before it’s too late, is that of China’s ghost cities, captured here on CNN.

I see the benefits of retrofitting our suburban landscape, and through Professor Dunham-Jones’ lecture, have learned of the amazing structures and spaces erected, community built, economies revitalized and local business improved through such efforts. I recognize health is not the only goal in redeveloping our suburban landscape, and equity can’t be the sole factor in determining repurposing projects. But that’s the lens I wear. And for those most sick and in most in need of a louder voice, I can’t help but ask, “How do we decide fairly which space to retrofit?”

A Local Health Department’s Journey in Pursuing National Voluntary Accreditation by the Public Health Accreditation Board

Lindsay Menard, MPH

La Crosse, WI

I started the fellowship program a little over a year and a half ago at the La Crosse County Health Department (LCHD).  As a student of health policy and administration in graduate school I was eager to learn the inner-workings of a local health department as I hope to be a Health Officer/Director one day.  Before I started work at my placement site, I knew much of my work would be dedicated towards helping the LCHD become a national (voluntary) Public Health Accreditation Board (PHAB) accredited health department.  This knowledge was exciting as I knew the accreditation process would allow me to see the daily operations of a health department.  Before I became immersed in the journey I thought I knew the complexity of this task, but I had dramatically underestimated the effort and resources needed to become an accredited health department.  With that, I do believe all of the work, effort, planning, and collaboration was and continues to be worth it. 

What is the purpose of PHAB accreditation you may ask? The purpose is to, “advance quality and performance within public health departments.  Accreditation standards define the expectations for all public health departments that seek to become accredited.  National public health department accreditation has been developed because of the desire to improve service, value, and accountability to stakeholders”.[i]

We, the LCHD, have met all of our established deadlines up to this point.  After submitting the accreditation application in March 2013, the accreditation coordinator and I traveled to PHAB headquarters in Virginia to attend accreditation coordinator training.  Upon our return to the LCHD we established domain teams and a system for uploading documentation.  Currently we are finalizing documentation collection and uploading documents into e-PHAB (the electronic database used by health departments, PHAB staff, and site visitors throughout the final stages of the process).   We hope to have all documentation uploaded into e-PHAB by March 2014 and a site visit during the summer of 2014.

The process of becoming accredited is often described as an enormous quality improvement project.  The process initiates with a self-assessment to determine the accreditation readiness of a given health department.  In 2010, the LCHD completed their self-assessment and determined the gaps in their accreditation readiness to be Domain 7:  promote strategies to improve access to healthcare services; Domain 8: maintain a competent public health workforce; Domain 9: evaluate and continuously improve processes, programs, and interventions; and Domain 10: contribute to and apply the evidence-base of public health.  The past three and a half years have been dedicated to addressing these gaps, building capacity on existing strengths, and developing sustainable systems to ensure mechanisms are in place to continuously meet standards and measures established by PHAB for years to come.  

The majority of my time at the LCHD has been spent addressing the gaps identified in the accreditation readiness self-assessment.  I have helped the LCHD develop and implement a performance management system.  We are embarking on our second year of implementing this system and are continually striving to improve the method in place for selecting standards, establishing measures, and reporting on the progress of the standards.  We have established a quality improvement (QI) committee charged with facilitating and implementing the quality improvement plan and P & P (policy & procedure).  The QI process has resulted in over eight QI project proposals being submitted to the QI Committee  and  three of those have been initiated throughout the department.  We revised and updated the department’s strategic plan to ensure we are compliant with PHAB’s standards and measures (The NationalAssociation of County and City Health Officials (NACCHO) developed an invaluable guide  to help us maneuver this process).  We also created a workforce development team consisting of division managers to create, implement, and revise a new department-wide workforce development plan.

The accreditation process allowed the LCHD to identify areas of improvement from an established and vetted set of standards and measures.  Without these universal principles established by PHAB we would not know what systems, operations, or processes need improving or what goal(s) we should be working towards. Throughout the entire journey many lessons were learned by the health department and me.   Not only has the La Crosse County Health Department grown in its capacity to provide effective, efficient, culturally competent, and equitable services but the professional journey and skills I have developed and fostered along the way are invaluable and will guide me throughout my career. 

Lessons learned by the La Crosse County Health Department in their accreditation journey:

· It is necessary to engage staff at all levels whether it be by developing documentation, creating new systems, collecting documents, or ensuring they know their role in implementing the various department-wide plans.

· Following a work-plan/timeline for key milestones throughout the process is helpful; allowing for flexibility with deadlines is also important.

· Engage stakeholders, partners, and board members at the onset of the process as it is critical in obtaining the necessary resources (staff, fees, etc.).

Lessons learned by me in the accreditation journey:

· The process of becoming accredited ensures health departments are delivering public health services that meet the needs of community members, targeting the use of limited resources, and are accountable to the residents served.

·The work involved in operating, directing, and overseeing a health department is vast and intricate.

·Developing systems from scratch is complicated, always evolving, and fun.

· Facilitating the creation of a strategic plan is the easy part; implementing and evaluating it is more difficult.

In my final months at the La Crosse County Health Department I am excited to complete the accreditation journey and hopefully participate in a site-visit by PHAB site visitors.  I hope I can update you with the great news that the La Crosse County Health Department earned accreditation by the end of 2014. 

P.S.  As of this poisting, 22 health departments have been accredited nation-wide with 4 of them being from Wisconsin.  GO WISCONSIN!!!!

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[i] Public Health Accreditation Board. (2013). What is Accreditation? Retrieved from

http://www.phaboard.org/accreditation-overview/what-is-accreditation/

Reflections on Native American Heritage Month from the Menominee Reservation

Lauren Lamers, MPH

Population Health Service Fellow

Menominee Tribal Clinic

Keshena, Wisconsin

Shawano-Menominee Counties Health Department

Shawano, Wisconsin

 

 

On October 31, President Obama declared November 2013 to be National Native American Heritage Month - a time to celebrate Native American culture and recognize the rich contributions Native Americans have made to the United States.  Prior to beginning the fellowship, I would likely have given this month little more than cursory notice. Since beginning my placement with the Menominee Indian Tribe of Wisconsin, however, Native American heritage has taken on a whole new meaning for me. 

As the president acknowledged, along with celebrating the culture and traditions we might typically associate with Native American heritage, “we must not ignore the painful history Native Americans have endured - a history of violence, marginalization, broken promises, and upended justice.”[1]  Unquestionably, coming to understand some of the more painful events in the history of the Menominee Tribe has been one of the most personally challenging learning experiences of my fellowship so far.

In the early 1800s, the Menominee Tribe resided on a land base of approximately 10 million acres in what is now Wisconsin, Michigan, and Illinois.  Through a series of treaties in the nineteenth century, the tribe’s lands were reduced to the 235,000 acres of its present-day reservation.  Menominee children were separated from their parents and sent to boarding schools where they were forbidden to speak their language or practice traditional elements of their culture.  In the 1950s the Menominee Termination Act removed federal recognition of the Menominee as a sovereign American Indian tribe.  In addition to losing their tribal status, the Menominee suffered severe economic hardships and lost portions of their land and many of the healthcare and educational services the government provides to federally recognized tribes.  Although the Menominee fought for and eventually won back federal recognition in 1973, the effects of termination were devastating.

Perhaps the most disconcerting part about this history, however, is that the Menominee, like American Indian and other historically marginalized communities around the country, are still struggling with the impact of the injustices they experienced.  This phenomenon is known as historical trauma, which has been defined as the “cumulative emotional and psychological wounding across generations, including the lifespan, which emanates from massive group trauma.”[2]  In other words, experiences like forced relocation, assimilation, and termination so profoundly disrupted the lives of American Indian people and caused such emotional and psychological damage that their effects still plague American Indian communities. 

This historical trauma manifests itself in clear and tangible ways among the Menominee Tribe today.  Menominee County is the poorest county in Wisconsin and one of the poorest in the United States.  Rates of obesity, diabetes, teen pregnancy, and substance abuse are high, and according to the County Health Rankings, the county ranks last for health outcomes in Wisconsin.

Yet when I think about American Indian heritage and my experiences on the Menominee Reservation so far, one theme resonates more powerfully for me than past injustices or historical trauma:  resilience.  The Menominee Nation has shown incredible determination, innovation, and passion for improving lives in their community.  They have fought to preserve their language and culture, and several programs currently work to pass traditional teachings and practices to Menominee youth.  They have carefully protected their natural resources and have been nationally recognized for their sustainable forestry management.  They have also made great strides toward improving the health of their community.  Just a few of their recent efforts to improve community health include:

·         Convening a community engagement workgroup that brings stakeholders together from numerous sectors of the Tribe and county to address youth obesity, teen pregnancy, and school readiness

·         Providing school-based preventive dental services to Head Start, elementary, and middle school children

·         Planting a community orchard

·         Expanding opportunities for physical activity in the community and implementing healthier nutrition guidelines in schools

·         Holding Bridges out of Poverty trainings to help health and social service professionals better understand how to work with clients struggling with intergenerational poverty

·         Identifying innovative ways to address adverse childhood experiences and implement trauma-informed care in local health, education, and social service agencies

 

While the social, economic, and health challenges in Menominee are great, the dedication and passion of local leaders and community members to address these challenges is truly awe-inspiring. I am humbled and privileged to have the opportunity to work in this community. 

So this November as the nation recognizes Native American heritage, I would challenge us all not only to learn more about traditional American Indian culture or the historical injustices American Indians have faced, but to truly celebrate the legacy of strength and resilience that enables tribes like the Menominee to continue striving to improve lives in their communities.    

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[1] The White House. Office of the Press Secretary.  Presidential Proclamation – National Native American Heritage Month, 2013.  Available online at http://www.whitehouse.gov/the-press-office/2013/10/31/presidential-proclamation-national-native-american-heritage-month-2013

 

[2] Brave Heart, M.Y.H., Chase, J., Elkins, J., Altschul, D.B.  2011.  Historical trauma among indigenous peoples of the Americas:  Concepts, research, and clinical considerations.  Journal of Psychoactive Drugs 43 (4): 282-90.

Second year fellow gives an update of her summer activities at the Great Lakes Inter-Tribal Epidemiology Center

Bemidji Area Tribal Environmental Health Assessment

Over the summer I spent most of my time at Great Lakes Inter-Tribal Epidemiology Center (GLITEC) working on an assessment of environmental health priorities and resources among the 34 Tribes in the Bemidji area, an Indian Health Service area that covers Minnesota, Wisconsin, and Michigan.  This is part of a larger effort by GLITEC to start addressing environmental health in addition to the established focus areas of behavioral health, maternal and child health, and chronic disease. 

The assessment had three parts: a review of Tribal websites to see if there were any environmental services or resources identified, a survey completed by Tribal health directors and environmental staff, and key informant interviews.  Raymond Allen, a NARCH intern and student at Ripon College, and Alex Cirillo, an MPH student at the University of Michigan, were both extremely helpful in conducting the assessment.  We received 28 surveys from health directors and environmental staff and conducted 17 key informant interviews with staff from the Environmental Protection Agency (EPA), Great Lakes Indian Fish and Wildlife Commission (GLIFWC), and staff from the Department of Natural Resources and Department of Health in Minnesota, Wisconsin, and Michigan.

  

I shared the assessment results with staff at the IHS Bemidji office in September and am wrapping up the final report, which will be reviewed by a sample of health directors and Tribal environmental staff, then shared at Tribal health director meetings and posted on the GLITEC website.

Expedited Partner Therapy toolkit

Fellow Katarina Grande helped develop a toolkit for sites implementing expedited partner therapy (EPT), the practice of prescribing medication to partners of individuals with sexually transmitted infections. The project builds off work by Fellow alum  Marisa Stanley, who helped pass EPT legislation in Wisconsin.

Link to toolkit: http://naccho.org/topics/HPDP/hivsti/news/std/p2.cfm

Fellows make waves at WI Public Health Association Conference

Fellows and Fellow alums attended, presented, and led the 2012 Wisconsin Public Health Association Conference. The event, held at the Kalahari Resort in the Wisconsin Dells, gave us a chance to share our research and initiatives, hold trainings, and learn about public health across the state. Here's an overview of our involvement:

2012 State of the Tribes

Leaders of the Wisconsin Indian Tribes. From Left: Stewart Bearhart, (St. Croix) Bob Chicks, (Stockbridge-Munsee) Ed Delgago, (Oneida) Craig Corn, (Menominee) Mike Wiggins, (Bad River Ojibwe) Mic Isham, (Great Lake Indian Fish and Wildlife Commission) Front: Tom Maulson (Lac du Flambeau) and Harold "Gus" Frank, (Forest County Potawatomi)

photo source:

http://wcmcoop.com/members/corporate-press-misrepresents-state-of-the-tribes-address-as-pro-mining/

Although I grew up in Wisconsin, I knew very little about the American Indian population here until I started the fellowship and was placed part time with the Great Lakes Inter-Tribal Epidemiology Center (GLITEC), based in Lac du Flambeau. GLITEC is an Indian Health Service-funded data center serving the 34 federally recognized tribes in Minnesota, Wisconsin, and Michigan. Eleven of those tribes are in Wisconsin – Oneida, Forest County Potawatomi, Stockbridge Munsee, Menominee, Ho-Chunk, and six bands of Ojibwe, including St Croix, Red Cliff, Lac Courte Oreilles, Bad River, Lac du Flambeau, and Mole Lake Sokaogon. The population of each tribe ranges from roughly 1,000 to 20,000 members. Each tribe is a sovereign nation and has a government-to-government relationship with the State.  Each tribe has a legislature and a chair or president elected every 1-4 years.

Fellow represents WI at Inaugural National Health Impact Assessment Meeting

Marjory Givens (former Fellow) and Paula Tran Inzeo representing Wisconsin at the Inaugural Health Impact Assessment meeting in Washington, DC

Fellow Paula Tran Inzeo and Marjory Givens (former fellow) represented Wisconsin at the Inaugural National Health Impact Assessment Meeting in Washington, DC the first week of April. The meeting, hosted by the Health Impact Project (a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts, capitalized on the burgeoning national interest in Health Impact Assessment (HIA) and convened policy makers, public health professionals, HIA practitioners and anyone with an interest in learning more about HIA. Paula and Marjory have been actively working on building capacity of practitioners in Wisconsin to conduct HIAs and played a large role in a recent demonstration grant awarded to the UW Population Health Institute to conduct an HIA on Transitional Jobs Programs. The grant, awarded by the National Network of Public Health Institutes and the Health Impact Project, is one of two that is a part of a broad initiative,  Increasing the National Capacity for HIAs: Utilizing the Nation's Public Health Institutes, which is intended to promote and support the growth of the HIA field.

Fellow works on Communities Putting Prevention to Work initiative

source: http://www.hhs.gov/recovery/programs/cppw/factsheet.html

Fellow Kelli Stader is transitioning into a new role for the remainder of her fellowship. She will be serving as the Nutrition Coordinator for the Communities Putting Prevention to Work (CPPW) initiative. CPPW supports 50 communities around the country tackling obesity and tobacco use at the local level. The grant focuses on environmental and system changes that can make healthy living easier. La Crosse County and Wood County received funding through this initiative and have both made significant progress in improving their community environments to support health. They have developed Farm to School programs, improved vending choices at worksites, created Safe Routes to Schools, and developed after-school physical activity programs for students. Check out their stories: http://www.preventionspeaks.org/stories/tag/La%20Crosse%20Co%20WI and http://www.preventionspeaks.org/stories/tag/Wood%20Co%20WI!