Improving Monitoring and Evaluation of Environmental Public Health in Maryland 2009-2010 Environmental Public Health Leadership Institute Fellow(s): Rebecca Love; MPH, CHES Policy Analyst; Maryland Department of Health and Mental Hygiene (on leave) 498 La Mesa Ave., Encinitas, CA 92024 760-274-3871 rlove@ouhsc.edu Mentor(s): John McLeod; RS, MPH Director; Cuyahoga County Board of Health Environmental Health Services (Acknowledgements): Jeanette Jenkins; MHS Director; Office of Health Policy and Planning, Family Health Administration, Maryland Department of Health and Mental Hygiene
EXECUTIVE SUMMARY: Administrative data can be used for public health surveillance purposes and be applied to use in developing, monitoring, and evaluating environmental public health programs. This data, primarily collected for billing purposes from hospitals or insurance entities, also can contain demographic, disease diagnosis, comorbidity, and utilization and quality of care information. Administrative data, therefore, can be used for a variety of purposes to meet program and grant requirements regarding disease and program monitoring and evaluation, as well as improving a health department's ability to fulfill the essential services of environmental health and to achieve Healthy People goals. Specific examples of uses related to environmental public health are the identification of rates of ambulatory-care sensitive conditions, such as diabetes, which can reflect the built environment; monitoring rates of emergency department visits for diseases affected by environmental conditions, such as asthma; or monitoring utilization of care and compliance with filling prescriptions and other prescribed care. This project focuses on hospital data and its application in environmental public health programs in the Maryland Department of Health and Mental Hygiene's (DHMH) Family Health Administration (FHA). FHA works to protect, promote and improve the health and well-being of all Marylanders through community-based public health efforts. FHA is responsible for several of Maryland s environmental public health services, including Asthma Control, Children's Environmental Health and Protection Advisory Council, Childhood Lead Screening, Tobacco Use Prevention, Pregnancy Risk Assessment Monitoring System, Behavioral Risk Factor Surveillance System, built environmentrelated programs Nutrition and Physical Activity and Obesity Prevention, and health care workforce programs. Project goals are to improve completeness of administrative data in order to more accurately monitor health status and identify and solve community health problems; to develop data-driven policies and plans to support health efforts; and to evaluate the effectiveness, accessibility, and quality of population-based services. The project objectives are to create a complete data set of all Maryland-resident hospitalizations for and to develop and incorporate indicators into a proposed web-based data dissemination tool that can be used in developing, tracking, and evaluating public health status, programs, and policies. The project's activities include pursuing hospital data reciprocity and/or data use agreements with Maryland s neighboring states; identifying uses of hospital data for programs, analyzing the data, and publishing associated reports; and testing of a web-based data query tool. The project uses the shifting the burden archetype to discuss the challenges and benefits of changing the approach to developing and analyzing administrative data. Accomplishments of the project have included identification of uses of hospital data for FHA programs; a state-wide analysis of rates of ambulatory-care sensitive conditions and use of this data to support increased resources and prioritization of resources for primary care workforce and chronic disease; data agreements with two additional states
and reciprocity agreements pending with three additional states; and establishment of data agreements with Medicaid, as a result of increased collaborations on hospital data, for environmental public health purposes. INTRODUCTION/BACKGROUND: This project arose out of a number of influences that included increased demand for data and surveillance, establishment of an expanded public health assessment function in FHA, the desire to develop an on-line data query tool to facilitate public access to data, and a growing recognition of the value of administrative data in informing public health policy and programs. FHA has seen an increased demand for expanding data sources and uses by grantors and programs for use in prioritizing, developing, and evaluating programs. Organizationally, the Office of Health Policy and Planning (OHPP) increased their responsibility in 2008 for providing FHA and its partners with access to public health datasets, analytical tools, and technical assistance in designing and evaluating programs and policies. Beginning in 2007, FHA began exploring development of an on-line data query tool that would give users the ability to use and display Maryland public health data. The tool would make Vital Statistics population, birth and death data; Behavioral Risk Factor Surveillance System and Pregnancy Risk Assessment Monitoring System data; and hospitalization data available through a single portal. The availability of this type of information would assist public health professionals in designing and evaluating public health programs in Maryland. The public would also benefit by having increased access to public health data. In addition to the above events, FHA also piloted the use of the National Environmental Public Health Performance Standards in 2008 with selected programs. Findings from the analysis indicated performance gaps in monitoring environmental and health status to identify and solve community environmental health problems, and in evaluating the effectiveness, accessibility, and quality of personal and population based environmental health services. Administrative data was identified as one means to improve performance in monitoring and evaluation, as data on hospital inpatient discharges and ambulatory care visits can be a key component of monitoring certain health conditions affected by the environment. Compared to the on-going availability and analysis of data from other sources, hospital data has been under-utilized in assessment and monitoring. While other divisions of DHMH analyze hospital data to ensure health care system infrastructure, FHA has not fully utilized the data for public health uses. Therefore, this project aims, in part, to provide appropriate hospital data and analytical support to FHA s programs. Ambulatory-care sensitive conditions (ACSC) are those conditions for which good outpatient care can potentially prevent the need for hospitalization, e.g. complications from diabetes. Assessing the rate of ambulatory care sensitive conditions using hospital inpatient data is a method to assess quality of the health care system, including those elements reflective of environmental health. A private corporation has conducted studies
assessing parts of Maryland, but a state-wide assessment of ACSC had not been completed. Problem Statement: Why has the Family Health Administration, a division of public health services, not been able to consistently use the full range of administrative data for environmental public health surveillance and monitoring?
Behavior Over Time Graph: Administrative Data use for Environmental Public Health Level of commitment to building data-based programs an Inability to respond effectively to health concerns Programs need for data Ad-hoc data agreements and analyses Variable Gap between resources and environmental public health safety Adequacy of data Program efficiency in monitoring environmental public health Time
Causal Loop Diagrams and applicable Archetypes:
10 Essential Environmental Health Services: Describe how your project seeks to enhance or fulfill one or more of the 10 Essential Environmental Health Services and/or the three (3) functions described in the IOM report: assessment, policy development and assurance. This project fulfills several of the Essential Environmental Health Services. Directly, it addresses monitoring and evaluation by providing data with which to monitor environmental and health status, and allows for improved evaluation of the effectiveness, accessibility, and quality of personal and population-based environmental health services. Indirectly, increased knowledge of health status, trends, and risks will impact the ability of the department to inform and educate people about environmental health issues, as well as guide policy-makers in developing appropriate policies and plans that support individual and community health efforts. National Goals Supported 1. Describe how your project seeks to support one or more of the CDC Health Protection Goals http://www.cdc.gov/about/goals/default.htm or meets one or more of the Healthy People 2010 Objectives http://www.cdc.gov/nchs/about/otheract/hpdata2010/abouthp.htm.
This project supports Healthy People (HP) 2010 goals addressing the improvement of data availability to measure achievement of other HP 2010 goals and to monitor diseases related to the environment. For example, HP 2010 goal 5-10: Reduce the rate of lower extremity amputations in persons with diabetes is measured by hospital discharge data and monitoring such rates provides information about the built environment. Additional goals supported include: 23-2. Increase the proportion of Federal, Tribal, State, and local health agencies that have made information available to the public in the past year on the leading health indicators, and priority needs. 23-12. Increase the proportion of Tribal, State, and local public health agencies that provide or assure comprehensive epidemiology services to support essential public health services. 8-27. Increase or maintain the number of Territories, Tribes, and States, and the District of Columbia that monitor diseases or conditions that can be caused by exposure to environmental hazards. 2. Describe how your project supports any or all of these national goals or initiatives. National Strategy to Revitalize Environmental Public Health Services http://www.cdc.gov/nceh/ehs/docs/nationalstrategy2003.pdf This project most directly supports Goal I and II: Build Capacity and Support Research. The project will assist in expanding the nation's capacity to anticipate, recognize, and respond to environmental public health threats and improve access to technology, as part of building capacity. Additionally, the project will help to identify environmental antecedents to disease outbreaks as part of supporting research. 3. Environmental Health Competency Project: Recommendation for Core Competencies for Local Environmental Health Practitioners http://www.apha.org/programs/standards/healthcompproject/corenontechnicalcompetencies.htm This project addresses the assessment elements of the recommended core competencies for local environmental health practitioners: research, data analysis and interpretation, and evaluation. Developing this data source, making the data available, and providing support in analyzing the data will increase the capacity of practitioners to analyze data, recognize meaningful test results, interpret results, and present the results in a meaningful way to different types of audiences.
Project Logic Model: Goal 1. To create a complete data set of all Maryland-resident hospitalizations for analysis of environmental public health-related disease hospitalizations. Resources/Inputs Activities Outputs TIER I Short & Long Term Outcomes, Impacts. Funding Partners Federal State Private/Found ations Human Resources Staff Time Federal (CDC, HRSA, NIH) Health Departments Public Health Programs Academic partners Medicaid and commissions Program Design and Development Engage stakeholders Conduct gap analysis Develop draft indicators Develop objectives and plan for comprehensive hospital data set 1. # of meetings 2. # of partners 3. # of programs invested in serving on committee to develop indicators 4. # of identified indicators 5. # of states interested in establishing reciprocity agreements 6. # of programs interested in using data 7. # of website hits 8. # of programs incorporating data into program planning 9. # of website trainings 10. # of data use trainings 11. # of reciprocity agreements Learning 1.Increased capacity of programs to use hospital data 2.Implemented delivery of trainings 3.Increased number of programs and LHDs trained 4.Increased collaboration between partners Programs gain knowledge and skills in monitoring and evaluation Results 1. Improved monitoring and evaluation of environmental public health 2. Improved health of populations Behavior Increased application of data to program and policy development Increased intradepartment al-level collaboration on data projects Increase in projects addressing needs of underserved
PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES: Program Goal 1. To create a complete data set of all Maryland-resident hospitalizations for analysis of environmental public health-related disease hospitalizations 2. To develop and incorporate environmental health information into a web-based data dissemination tool for community health that can be used by program staff, policy makers, and health care providers in developing, tracking, and evaluating health status, programs, and policies. Health Problem Incomplete data hinders the ability to fully monitor environmental and health status to identify and solve community health problems; to develop data-driven policies and plans to support health efforts; and to evaluate the effectiveness, accessibility, and quality of population-based health services. Outcome Objective Maryland will have environmental health data publicly available that reflects a full Marylandresident hospital data set, and will have arranged with adjacent states to acquire data on Maryland-resident hospitalizations and have a process in place to assure on-going, sustainable access to the data for future years. Determinant The Maryland-resident hospital data set and public access to data. Impact Objective The number of programs at the local and state level using the data for program and policy planning and evaluation will have increased significantly from baseline. Contributing Factors 1. Lack of clarity on which division should take leadership in developing a complete hospital data set. 2. Resources available to develop and maintain a web-based community health data portal and populate with appropriate environmental public health information. 3. Program and policy maker commitment to using data for monitoring, prioritizing, developing and evaluating program resources and decisions. Process Objectives 1. Stakeholders (public health and others within the Department) will recognize the benefits of a complete hospital data set and agree on the roles of the stakeholders in acquiring and applying the data. 2. Conduct a gap analysis of the data needed compared to those routinely analyzed and published. 3. Number of programs and local health departments aware of hospital data for planning and policy.
METHODOLOGY: Event: Meeting of stakeholders Activities: Understand the need for and application of the data for various stakeholders, e.g. public health as well as health financing programs. Agree on the point person or entity to pursue reciprocity agreements with other states. Establish an on-going committee of interested stakeholders to address the issue and that serves as a basis for additional data issues in the future. Event: Meet to draft list of needed data using results of gap analysis. Activities: Meet with program directors and other stakeholders to elicit data needs and application of hospital data. Develop document with current data relative to ideal data sources and information. Identify gaps in data and use as basis for list of new data sources to develop. With stakeholders, review and finalize list of needed data. Implement analysis of data and produce and publish draft data reports. Train programs and local health department staff on new resource. Event: Cooperative plan implemented. Activities: Present data and interactive web site to programs and local health departments (LHDs). Determine data use baseline. Develop internal plan to integrate and monitor use of data by programs and LHDs. RESULTS and NEXT STEPS: FHA participated in federal training on how to use administrative data to address state policy questions and received technical assistance in applying tools for hospital data. FHA conducted a state-wide analysis of ambulatory-care sensitive conditions, which includes conditions related to environmental public health, such as asthma and diabetes. FHA entered into data agreements with four adjacent states, however not all of these datasets contain all elements needed and therefore continuing efforts are being undertaken to expand access to data. FHA began discussions with the entity with authority to enter into data-reciprocity agreements, and provided information on why FHA needs access to complete hospital datasets. FHA piloted analysis of hospital data using Maryland and District of Columbia hospital data for Maryland residents.
CONCLUSIONS and EXPECTED OUTCOMES: With a focus on expanding access to and analysis of data sources in FHA, efforts are being undertaken to address hospital data issues from a broader perspective. Rather than individual programs requesting and receiving custom reports, FHA is changing its approach to pursue omnibus data agreements that both provide additional resources to programs, as well as establishes public health s role in using administrative data. As new tools have been developed for use with this data, it can be used to meet funding requirements as well as more precisely show areas of highest need and the impact of interventions in those areas. This project and data efforts will continue to develop and aim to integrally involve all data users in developing data agreements that provide added value to the data that programs already have, and make the case for a shift to long-term planning of data management by demonstrating potential efficiencies. This will involve identification of uses of hospital data for additional programs, completed analyses of data for the identified uses, and publication of associated reports. These continuing and new objectives will be pursued by raising awareness among stakeholders about how current approaches may inhibit achieving an appropriate, long-term solution and may result in program inefficiencies and fragmentation, and how different approaches may enhance program effectiveness and build the case for public health more generally by showing program efficiency, innovation, and evidence-based efforts. The project will also aim to demonstrate how increasing access to and analysis of data will improve the capacity of each program to deliver their core functions because data is integral to each phase of program development and evaluation, e.g. planning, implementation, monitoring, and evaluation of outcomes. Complete data sets and readily available access would provide data on a reliable, year-to-year basis which could potentially allow for more in-depth research on environmental health issues. In addition, bringing public health programs together to collaborate with the state s health data organization to establish data agreements may potentially build and mobilize new partnerships to work together on addressing environmental public health and on pursuing similar agreements for other needed data. Successfully establishing a long-term data agreement for public health may be used as a precedent for establishing other agreements within the department, such as with Medicaid, and can serve as a model for other states. LEADERSHIP DEVELOPMENT OPPORTUNITIES: Rebecca Love Participation in EPHLI has been immensely beneficial in my leadership development, in meeting and developing relationships with leaders in the field of environmental health, and in learning about my strengths and developing a program to address areas in which I would like to improve. The Institute curriculum has been helpful in my professional development by affording me leadership opportunities and the ability to apply leadership skills in a variety of settings. The activities, individual and group mentoring, and in-person workshops provided opportunities for insight into my own development, as well as equipped me with tools and leadership concepts
which I have been able to apply in the professional setting. The strategies for identifying priorities and the information imparted on essential environmental public health services have been useful in identifying areas of potential improvement for programs. I am grateful to CDC and my leadership coach, mentor, and teammates in providing invaluable resources, feedback, and guidance in approaching organizational and health systems thinking from a different perspective. I have already observed how this training has positively impacted my approach to change and to continuous assessment, policy development, and assurance in environmental public health.
ABOUT THE EPHLI FELLOW(s) Rebecca Love most recently served as Senior Policy Analyst for the Family Health Administration in the Maryland Department of Health and Mental Hygiene, where she was responsible for policy and data development, analysis, and decision-making. Her areas of focus included access to care for underserved populations, rural health, public health assessment, and public health policy. Prior to joining FHA in 2006, she worked at the National Environmental Education Foundation as program manager of the Health & Environment programs, which focused on environmental education for health professionals. She has an MPH from George Washington University and a BA from Haverford College, and is presently on leave from FHA to complete a full-time, yearlong accelerated BSN program.
REFERENCES 1. Osaki, C. 2004. Essential Services of Environmental Health. Northwest Center for Public Health Practice, University of Washington School of Public Health and Community Medicine, Seattle, WA. 2. Centers for Disease Control and Prevention. 2006. Health Protection Goals. Atlanta, GA: Department of Health and Human Services. 3. U.S. Department of Health and Social Services, Office of Disease Prevention and Human Services. Healthy People 2010. Available at: http://www.healthypeople.gov. Atlanta, GA: Department of Health and Human Services. 4. Centers for Disease Control and Prevention. 2003. A National Strategy to Revitalize Environmental Public Health Services. Atlanta, GA: Department of Health and Human Services. 5. American Public Health Association. Environmental Health Competency Project: Recommendation for Core Competencies for Local Environmental Health Practitioners. Available at http://www.apha.org/ppp/env_comp_booklet.pdf.