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Integrating Chronic Disease and Environmental Health Education into Home Visiting Programs
Summary
Impact Statement:
Home visiting programs are an important intervention to improve the health of women and children, but they are generally done in programmatic silos. A state health department used QI to improve the process and systematically address both chronic disease and environmental health risk factors during a home visit, standardize the assessment and referral process and enhance education. As a result, an increased percent of families received referral interventions and education related to both chronic disease and environmental health during home visits.
Summary:
Several home visiting programs are funded through the state of Arizona, and multiple assessment and referral protocols that address environmental health have been used. In addition, there has been missed opportunity in home visiting programs to provide chronic disease referral and education for adults in the home. These two issues can be better addressed by integrating the environmental health and chronic disease expertise that the Arizona Department of Health Services (ADHS) has available at the state level into two state-funded home visiting programs: Health Start and the High Risk Perinatal Program (HRPP). The resulting standardized assessment process maximizes the time and effort of home visitors while they are in the home by providing them with environmental health and chronic disease resources and referral protocols. These actions will ensure positive outcomes for the clients and families enrolled in the home visiting programs.
Organization that conducted the QI initiative:
ADHS
Citation:
Sjolander, S. Public Health Quality Improvement Exchange. Integrating Chronic Disease and Environmental Health Education into Home Visiting Programs . Wed, 05/28/2014 - 21:49. Available at https://www.phqix.org/content/integrating-chronic-disease-and-environmental-health-education-home-visiting-programs. Accessed September 14, 2024.
Background and Aim
Aim statement:
By October 31, 2013, ADHS will increase home visitors' knowledge and provision of educational materials on environmental health and chronic disease by 70% and will increase referrals by 30% when the assessment indicates. This project will be completed by standardizing environmental health and chronic disease assessment and referral components into two state-funded home visiting programs that serve families with young children: Health Start and the HRPP.
Need For The QI Initiative:
The ADHS Bureau of Women’s and Children’s Health convened an internal Zero to Five workgroup in 2008, which identified the need for a standard home safety assessment tool. However, a mechanism was not then in place to move the recommendation forward. In 2011, ADHS initiated a number of quality improvement (QI) activities including the formation of a QI council that advises the Managing for Excellence Program (MEP). Concurrent with the strategic planning and QI activities occurring as part of the accreditation process, federal funding for lead poisoning and other environmental issues was coming to an end. Key stakeholders from the offices of the director, maternal and child health, chronic disease, and environmental health came together to discuss how the expertise within the chronic disease and environmental health areas could be integrated into an assessment and referral process within ADHS-funded home visiting programs.
The members of this initial workgroup who chose the final QI project included the following:
• Diane Eckles, environmental health;
• Tifney Tihey, workforce development;
• Toni Means, maternal and child health;
• Tim Vaske, chronic disease;
• Sara Rumann, Health Start;
• Jessie Toporek, Healthy Homes;
• Mary Ellen Cunningham, maternal and child health/HRPP;
• Sheila Sjolander, assistant director of public health prevention services; and
• Janet Mullen, deputy director of the division of planning and operations.
A grant opportunity through the Association of State and Territorial Health Officials (ASTHO) and the Robert Wood Johnson Foundation (RWJF) provided the funding from the National Demonstration Initiative on QI Practices in State Public Health Programs. The National Demonstration Initiative provided the impetus to commence work on the QI project.
Area for Improvement:
ADHS funds several home visiting programs; however, the home visiting programs use different formats to capture information regarding eligibility criteria, demographic data, services provided during the visits, and safe home assessment tools. In addition to this disparity in data collection, it was determined that two resources provided by ADHS, the Bureau of Tobacco and Chronic Disease and the Office of Environmental Health, were being underused by community health workers and community health nurses. Referral rates by home visitors to chronic disease resources were limited to the Arizona Smokers' Helpline (ASHLine) when it was determined that a baby was exposed to smoking. Baseline data collected from a sample of home visitors indicated that the referral rate for chronic disease resources was only 27%. The referral rate for environmental health resources was even lower (17%).
Realizing the impact home visitors could have on health burden and resulting economic costs if they could identify and provide education and referrals for environmental health resources and/or chronic disease resources, ADHS examined the home safety assessment instruments being used by the state-funded home visiting programs. This examination revealed that environmental safety information specific to the kitchen, bathroom, children’s area, and general safety were being collected. However, specific data regarding the presence of environmental health hazards such as flaking paint, use of ceramic pottery for cooking (triggers for lead poisoning screening), and evidence of pests in the house (asthma triggers) were not included. In addition, no information was being collected on the presence of chronic disease in any family members in the household. Given the ongoing relationship between the home visitor and the client, staff thought that there were additional opportunities for the home visitors to be more efficient and holistic in their approach to a family’s health and, when appropriate, to effectively make referrals to ADHS resources. The goal was to maximize the time spent with families with young children by doing a better job of comprehensively addressing multiple health issues. By also quickly assessing whether the adults in the family could benefit from support for chronic disease, ADHS can save health care dollars in the long term.
The QI project that ADHS undertook initiated a systems management approach to two ADHS home visiting programs. The desired outcome was a model system of coordination across maternal and child health, chronic disease, and environmental health to improve training, assessments, and data collection for home visiting programs serving prenatal and postpartum women with children ages 0–2 in Arizona.
Root Cause:
Using a tree diagram, a cause-and-effect analysis tool, staff highlighted a chain of causes and ultimately found the root cause of the problem. The effect is identified first, along with major groups of causes. The diagram then asks "why" for each branch. One issue that staff identified was "multiple home safety assessments being used by home visiting programs." They determined the root cause to be that assessment tools were developed by home visiting programs in silos because they were being funded by different sources and created years apart. Each program was responding to the program requirements at the time. The age of the programs was also a factor; the HRPP is more than 30 years old, and Health Start is nearly 20 years old. Although Health Start requires a home safety assessment, and all contractors use the same assessment tool, for other home visiting programs like the HRPP, there is no standardized tool used among contractors. Other causes identified were "scope of training for environmental health and chronic disease was limited for home visitors and program staff" and "limited data collected from assessments."
Planning and Execution Details
QI Implementation:
Two state-funded home visiting programs were selected for the pilot project: Health Start and the HRPP/Newborn Intensive Care Program (NICP). A 10-member QI team was assembled and met bi-weekly for at least 2 hours for the past year. The team selected Comprehensive Health Assessment Team (CHAT) as its brand name. CHAT was led by an external facilitator and staffed by a public health fellow from the University of Arizona. The team followed the Plan, Do, Study, Act (PDSA) model. A team charter was developed and refined throughout the QI process as the project evolved.
The intent was to integrate environmental health and chronic disease components into two existing home visiting programs. The process-mapping exercise was conducted over three meetings, and each time the mapping was completed, staff had a better understanding of each others’ programs and processes, which was critical to what the team was trying to achieve. A tree diagram for the cause-and-effect analysis highlighted a chain of causes. The root cause was determined to be that assessment tools were developed by home visiting programs in silos because they were funded by different sources and created years apart. Each program was responding to the program requirements at the time. Five major effects were identified from the tree diagram and were used in developing a theory of improvement.
The theory of improvement tool assisted the team in identifying short- and long-term outcomes. The tree diagram was examined to help identify key strategies. Five individual action groups were created to complete specific tasks identified for the QI pilot project. Each group created an action plan using a template, and a master timeline/Gantt chart was developed for the work of the action groups. One of the main objectives in the QI project was to develop a standardized home safety assessment with environmental health and chronic disease components. Data collection methods and performance measures were identified to determine the impact of the proposed improvement. The Healthy @ Home assessment tool was piloted by 30 home visitors/nurses in both urban and rural settings. A training module was developed for the home visitors participating in the pilot. The pilot was conducted from February to May 2013; June and July were follow-up months. The trained home visitors were provided with the Healthy @ Home assessment tool and a complete packet of Arizona Home Safety and Family Wellness Assessment educational materials and referral sources.
Follow-up with pilot participants indicated that home visitors increased their scope of knowledge to include environmental health and chronic disease issues. Approximately 233 families were surveyed at the home visiting pilot program sites and were pregnant or postpartum women with children ages 0–2. These families are at high risk for or currently have health problems. Pilot sites were located in the following counties: Apache, Coconino, Maricopa, Mohave, Pima, Santa Cruz, and Yavapai.
The QI project process and results have been presented to ASTHO, the American Public Health Association, ADHS leadership, the National QI forum, the Arizona Local Health Officers Association, the State Environmental Health Directors’ meeting, the Injury Prevention Advisory Council, and the ADHS Bureau of Women’s and Children’s Health epidemiologists and data managers.
QI Methods:
QI Tools:
Other QI tools:
Gantt chart
Theory of improvement
Outcome matrix
QI Tool Documentation:
Initiative Dates:
4/1/12 to 10/1/13
Initiative Duration:
Between 18-24 months
Methods of evaluation:
A mixed methods evaluation approach was used for the QI initiative and included both quantitative and qualitative methods. Evaluation methods and specific performance measures were identified during the planning process, before implementation of the pilot. The training of home visitors was evaluated using a pre-/post-test and a follow-up application survey. Participants in the pilot completed the online pre-test before completing the Web-based training module. Included in the pre-test were items on knowledge of home safety and family wellness, knowledge of resources, and provision of referrals in which the home visitors were asked to think about the last few home safety assessments they have conducted. They indicated how often (using a Likert-type scale) they discussed the results with the client and provided a referral to environmental health, chronic disease, and/or health safety resources when needed. The post-test was administered at the end of the pilot phase, and the same questions were asked.
The percent change between pre- and post-tests was calculated for individual items and overall for each of the major areas. The criterion for success is a 70% increase. A series of satisfaction items was asked regarding the training and the materials received. A follow-up application survey was also administered to measure the extent to which participants were using the information gained in the training during their home visits. Throughout the pilot project, feedback was solicited through open-ended questions posted online for the home visitors participating in the pilot. After the pilot, feedback was solicited to obtain input on changes to the instrument or any recommendations regarding the materials provided.
The Healthy @ Home assessment tool was used to collect quantitative data at baseline, at the completion of the pilot, and at follow-up. The tool was used to calculate a composite score that was based on whether each element of the Healthy @ Home assessment was received by a family. If a family was not eligible for a specific element, the item was not included in the calculation. The criterion for success was at least a 70% composite score.
Frequency counts of families that received referrals from the home visitor were collected. The data source was the Healthy @ Home checklist for referrals. Data were collected at baseline, after the pilot, and at follow-up. The percent change between the pre- and post-tests was calculated. The criterion for success was a 30% increase.
In addition to the Healthy @ Home data collection, the number of chronic disease self-management referrals made to the Arizona Living Well Institute (AZLWI) was tracked.
Other Information:
Other information can be found on the Healthy@Home ADHS website (http://www.azdhs.gov/phs/owch/healthy-at-home/index.htm).
Supplemental Materials:
Testimonials
Sample of materials produced
Initiative photo(s)
Website URL
Supplemental Files:
| Attachment | Size |
|---|---|
 testimonials.docx | 13.3 KB |
 Healthy_@_Home_Assessment-9-2013.pdf | 768.52 KB |
| Healthy_@_Home_Assessment-9-2013_Spanish.pdf | 759.58 KB |
 Picture1.jpg | 45.59 KB |
| Picture2.jpg | 41.2 KB |
| Picture3.jpg | 33.06 KB |
Results
Measurable QI Outcomes:
Success measure 1:
A composite score was calculated for home safety and family wellness.
The criterion for success is 80% of families will receive at least a 70% composite score for receiving the information and referrals indicated by the assessment.
Results:
• Out of 208, 154 (74%) had at least a 70% composite score.
• Came close to meeting the target.
Success measure 2:
Increased knowledge and practice of providing education when indicated to environmental health or chronic disease resources.
The criterion for success is a 70% increase in home visitor knowledge of environmental health and chronic disease resources.
Knowledge:
• Pre-test: 71.25%
• Post-test: 89.75%
• Percent increase: 25.9%
Results:
• Did not meet target, but pre-test knowledge was higher than expected.
• Pre-knowledge of home visitors in the pilot was underestimated.
The criterion for success is a 70% increase in provision of educational materials by a home visitor to a family when indicated by scores on the Healthy @ Home assessment.
Provision of chronic disease educational materials:
• 202.8% increase
Provision of environmental health educational materials:
• 100.0% increase
• Aggregate: 151.4% increase
The target was exceeded.
Success measure 3:
Increased number of referrals provided by home visitors when need is indicated by the score on the Healthy @ Home assessment.
The criterion for success is a 30% increase in referrals by home visitor when indicated by family answers on the Healthy @ Home assessment. The percent change between the pre- and post-tests is calculated.
Results:
• Aggregate referral pre-test: 21.4%
• Aggregate referral post-test: 31.1%
• Percent increase: 45.3%
The target was exceeded.
Other QI Outcomes:
Of home visitors, 95% recommended adopting the assessment tool, and the tool and referral process were formally adopted state-wide in the Health Start program.
The data collected from the Healthy @ Home assessment tool provided information to ADHS related to public health initiatives that have been implemented for families, such as how well families understand infant safe sleep practices or dangers of secondhand smoke. This will help the home visiting programs and other public health programs target education efforts where understanding appears to be the weakest. The QI project also resulted in developing valuable resources for home visitors, including a new website and a new toolkit with information for families.
The QI project legitimized a home visitor's concern about the adults in the home. Although home visitors may have wanted to discuss the health of the adults, the focus of the programs has almost exclusively been on the infants or children in the home. By adding the chronic disease questions to the assessment, home visitors had a state-endorsed mechanism to discuss the health of the adults for the first time.
From the environmental health perspective, as federal funds for lead poisoning screening ended, the QI project had an important outcome of providing a mechanism to help ensure that children were screened for lead poisoning and families received education on sources of lead poisoning and other environmental hazards.
Lessons Learned, Observations and Insights:
The findings reflect the success of implementation in Health Start. Although two HRPP sites were expected to participate in the pilot, only one participated and submitted data. One lesson learned is that the team should have included additional HRPP sites in the pilot. The HRPP is different from Health Start in that it serves medically fragile babies who have been in the neonatal intensive care unit, and it uses nurses rather than community health workers. The HRPP may visit a family only once or twice, whereas the Health Start home visitors are typically able to have an ongoing relationship with families. The differences in the program make it unreasonable to assume that the Healthy @ Home assessment will work as well as or in the same manner that it does in Health Start.
Members of the QI team learned additional valuable lessons throughout the project. Insights from CHAT members provide the following information on what worked for the QI process:
• Working for an extended period as a team with a high level of organizational and staff commitment. The team had regular bi-weekly meetings with an agenda and minutes. Team members were dedicated, and the project had a high level of leadership support. The assistant director for public health prevention services was the team leader, and the deputy director of ADHS was the team sponsor.
• Engaging a facilitator to take the team through the QI process and assist with document development and data analysis. Team members were fairly new to QI, so a skilled and experienced consultant was critical to success.
• Engaging a student intern to provide critical support to the project and facilitate workgroups. The intern helped keep work moving between meetings and enjoyed a great learning experience in the process. She graduated and has since become an ADHS employee working in maternal and child health.
• Having a process in place for feedback from the home visitors in the pilot and responding in an appropriate and timely manner. Involving the home visitors throughout the entire project was important because they are the ultimate users of the standardized assessment. Their feedback was vital to the success of the home assessment.
• The interdisciplinary nature of the project was beneficial beyond project activities. Maternal and child health staff, environmental health staff, and chronic disease staff learned a great deal about each other's subject matter, enabling enhanced collaboration on other projects.
Lesson learned included the following:
• Communication and follow-up were not being conducted as assumed with the pilot site that ended up not participating. Implementing a method for early communication, face-to-face meetings, and follow-up to ensure that the process was understood was a lesson learned.
• Be flexible; there is a need to identify options for administering the Healthy @ Home assessment tool when the resistance is to the length of time to administer.
• Identifying resources for chronic disease self-management and environmental health takes time and work and will mean ongoing effort to ensure families have access to resources.
• Be realistic in defining the measures for success.
• Anticipate that the planning stage will take longer than expected. ADHS's planning stage lasted about 9 months.
• Training is important; ensure that training can be provided before implementation of the pilot and that just-in-time training can be provided if warranted.
Future Plans:
After the pilot, minor changes were made to the Healthy @ Home assessment tool based on feedback from home visitors involved in the pilot and the results of the data. The training module for home visitors was also revised based on the results of the pre-/post-test and the data collected from the Healthy @ Home assessment tool.
The Healthy @ Home assessment and referral process was adopted state-wide and implemented in all Health Start sites in January 2014. The Health Start policy and procedure manual was updated to incorporate the Healthy @ Home assessment. Continual assessment of the tool will be accomplished through pre-/post-tests for the training component and tracking the number of referrals.
The Healthy @ Home assessment has not been adopted yet in the HRPP. With only one HRPP site participating in the pilot, CHAT determined there were no adequate data on that program to make recommendations. The HRPP staff will conduct a separate process to determine whether the assessment tool will work in this program.
Training and Preparation
QI Related Training Received:
Team members participated in monthly QI webinars and conference calls held by ASTHO through the National QI Demonstration Initiative. ASTHO provided QI technical assistance, and Jane Dowling, PhD, of Wellington Consulting Group, served as QI facilitator and consultant.
Information about the Community
Population Size:
Population Characteristics:
Arizona is the sixth largest state in the nation, with a total area of 114,000 square miles. In 2011, the estimated population of Arizona was 6,438,178. Of the population, 75% live in urban areas, where the population density is 673 people per square mile. Of Arizona residents, 23% live in rural areas, where the density is 44 people per square mile. The proportion of the Hispanic population in Arizona is twice that of the nation (30% compared with 15% nationally). In addition, the proportion of African Americans in Arizona is 5%, and there is a higher proportion of Native Americans (6% compared with 2% in the nation). According to the 2010 Census, approximately 30% of Arizona's population is Hispanic or Latino of any race, and whites make up the largest single race group at 73%. In Arizona are 21 federally recognized American Indian tribes, each representing a sovereign nation with its own language and culture.
Information about the Health Department
Local/State Relationship:
Decentralized
PHAB Accreditation Status:
Planning to submit application for accreditation in the next year
Annual QI Initiative Frequency:
QI activity level:
Organization Type:
QI Staff Information
Total number of Staff on QI Team:
11
Total number of FTEs on QI Team:
1.00
QI team members:
Role in the Initiative:
Team sponsor
Role in Organization:
Deputy Director, ADHS
FTE:
0.05
Name (Optional):
Janet Mullen
Role in the Initiative:
Team leader
Role in Organization:
Assistant Director, Public Health Prevention Services
FTE:
0.10
Name (Optional):
Sheila Sjolander
Role in the Initiative:
Subject matter expert and team member
Role in Organization:
Office Chief, Office of Environmental Health
FTE:
0.10
Name (Optional):
Diane Eckles
Role in the Initiative:
Subject matter expert and team member
Role in Organization:
Office Chief, Workforce Development
FTE:
0.10
Name (Optional):
Tifney Tihey
Role in the Initiative:
Subject matter expert and team member
Role in Organization:
Office Chief, Office of Women’s Health
FTE:
0.10
Name (Optional):
Toni Means
Role in the Initiative:
Subject matter expert and team member
Role in Organization:
Office Chief, Bureau of Tobacco and Chronic Disease
FTE:
0.10
Name (Optional):
Anna Alonzo
Role in the Initiative:
Subject matter expert and team member
Role in Organization:
Manager, Health Start Program
FTE:
0.10
Name (Optional):
Sara Rumann
Role in the Initiative:
Subject matter expert and team member
Role in Organization:
Bureau Chief, Bureau of Women’s and Children’s Health and HRPP
FTE:
0.10
Name (Optional):
Mary Ellen Cunningham
Role in the Initiative:
Intern
Role in Organization:
MPH Intern, University of Arizona
FTE:
0.10
Name (Optional):
Cristina Ochoa
Role in the Initiative:
Subject matter expert and team member
Role in Organization:
Manager, HRPP/NICP
FTE:
0.10
Name (Optional):
Valerie Odeh
Role in the Initiative:
Performance improvement manager (PIM) and accreditation coordinator
Role in Organization:
PIM, Team Member
FTE:
0.05
Name (Optional):
Pragathi Tummala
Collaborations
Partner Organization Types:
Contact Information of the Submitter
First Name:
Sheila
Last Name:
Sjolander
Organization:
ADHS
Submission Status:
Completed
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Comments
This effort is an excellent
This effort is an excellent example of how to get a tremendous "bang for the buck" when conducting home visitations. Kudos on the many improvements achieved as a result of this initiative!
As funding decreases, this is
As funding decreases, this is a good example of how we can streamline our public health work, work across grant funding silos and still serve our communities.
Margy Robinson MPH
HIV Care Services Mgr.
Multnomah County Health Dept.
Portland, OR
Thanks for sharing your
Thanks for sharing your initiative! We are looking at how to integrate home visiting and case management between maternal health, environmental health and population health for things like lead poisoning prevention. This was a great example!
Hannah Silveus, Prevention Health Specialist
CDC Public Health Associate
RiverStone Health
123 South 27th St. | Billings, MT 59101
People suffering from chronic
People suffering from chronic diseases such as heart disease, stroke, diabetes, cancer, obesity etc. has bring great limitations in daily activities which affect their life quality completely. Home care programs for such patients are highly useful that can make their life comfortable. Adaptation and the use of home care tools available at ilexmedical.com and many other sites, enable the person to do right thing at the right time in the right place. Many home care organizations provide such facilities which not only help in surviving, but help in giving some positive hopes to live long life as well.