1. Providing services for EBL children in underserved areas through local partnerships Jennifer Lowry, MD Amy Roberts, RN, BSN Ryan Allenbrand, MS, CIEC Children’s Mercy Hospital and Clinics and Healthy Homes and Childhood Lead Poisoning Prevention Health Department City of Kansas City, MO.

2. Lead Back Story CDC’s Healthy Homes and Lead Poisoning Prevention Program for FY12 provides for only $2 million - down from $29 million in FY11. Impact –HH/CLPP funds 35 state health departments (and local partners) to monitor blood lead screening and respond to every child who has EBL with home inspection and referrals for medical intervention and lead remediation –Without the program, health departments will be unable to help lead-poisoned children obtain medical care and housing repairs –HUD’s lead hazard control grantees depend on CDC surveillance to identify those children at highest risk.

3. CDC’s Healthy Homes/Lead Poisoning Prevention Program Budget National Center for Healthy Housing. July 2013

4. Positions Eliminated or Shifted National Center for Healthy Housing. July 2013

5. Kansas Kansas eliminated program –Lead results reported to Epidemiology as Lead Poisoning Prevention Program no longer exists –No home investigations performed –Local health departments “accept” lead patients and provide “education” In past year, over 40 referrals to Center for Environmental Health (CEH) for elevated blood leads and need for home assessments Limited resources at CEH resulting in tiered approach for response using PEHSU lead document as a guide

6. Case: What a mess!!! PEHSU is called by PCPs office regarding 2 year old child with an EBL of 21.2 mcg/L. Three months prior it was 14.6 mcg/L. PCP had called state health department and was told that they couldn’t do anything due to funding. Referral made to PEHSU.

7. REGION 7 Mid-America Pediatric Environmental Health Specialty Unit Children’s Mercy Hospital Kansas City, MO

8. Jennifer Lowry, MD Director of MAPEHSU Clinical Pharmacology and Medical Toxicology Pediatrician Department of Pediatrics Children’s Mercy Hospital Kevin Kennedy, MPH, CIEC Managing Director, CEH Erica Forrest, MS, RRT Environmental Health Coordinator (Training, Community Outreach and Education) Ryan Allenbrand, MS, CIEC Healthy Homes Program Manager Environmental Hygienist D. Adam Algren, MD Michael Christian, MD Toxicologist for MAPEHSU Clinical Assistant Professor Department of Pediatrics, CMH Department of Emergency Medicine, Truman Medical Center Stephen Thornton, MD Medical Director, University of Kansas Hospital Poison Control Center Lisa Oller, RPh, CSPI Project Coordinator and Manager for MAPEHSU University of Kansas Hospital Poison Control Center

9. KCMO Health Dept. How did we get involved in this?

10. KCMO CLPPP/HH Program 20 yrs investigative experience Comprehensive case management Federal, local, regional and state funding Established relationship with CMH/CEH

11. What do LPHAs have to offer? Resources Mandate Enforcement Experience Field Staff

12. Regional Partnerships Benefits Increased capacity Increased training and competency Opportunity to review and quality control current processes and procedures Test replicability of processes Risks Financial Legal OOJ Lack of enforcement No mandate

13. KCMO CLPPP/HH received referral from PEHSU Reviewed with Admin. Researched the feasibility Established a team Consulted with CMH/CEH Conference call with other agencies

14. Center for Environmental Health Operates out of a non-profit children’s hospital (Kansas City, MO) 15 years of performing residential and commercial environmental assessments Residential, hospital, and school environmental assessment program Lead investigation and education (EBLs) Primary Care Physician (PCP) office training on Environmental Health Training Center for National Center for Healthy Housing

15. Case continues….. Case reviewed with Dr. Lowry, KCMO HD, and CEH staff. Based on environmental risk factors, information learned during initial contact with family, and EBL level, decision was made to provide courtesy visit.

16. To get everyone on the same page, we had a multiagency conference call CMH-CEH KCMO Health Dept. EPA DHSS (both KS and MO) OSHA Local Health Dept.

17. Investigation Health Educator – Health Department Nurse Education and triage Health & Environmental History EBL Investigator(s) Environmental Sampling and visual assessment Health Educator & EBL Investigator Hypothesis Generation Visual Assessment & In-home Education Assessment Reporting with Issues & Actions Follow-up & Case Management

18. Home visit revealed: Lead paint hazards Product hazards Ongoing renovation

19. CEH Initial Contact with families –Risk Stratification (L1, L2, or L3) –Education and Triage –Review Health & Environmental Home History –Determining need of home investigation

20. Initial Phone Triage Background, behavior, and household risks Occupation or Hobbies Dietary Risk Factors Water Risks Soil Risk Factors Paint and Remodeling Risk Factors

21. Case Management System

22. Report Delivery & Resources -Provide healthy home cleaning supplies to family - Referrals to local community and public health agencies -Loaner HEPA vacuum when possible - Feedback to Landlord and enforcement when needed

23. Applying resources in regional partnerships (what to consider) Jurisdictional guidelines Funding streams (local vs state vs fed.) Grant restrictions Legal restrictions License restrictions (esp. nurses and risk assessors) Restrictions on equipment (esp. XRF, vehicles and sampling)

24. Case continues…. Exterior concerns: –Suspect lead paint in bare soil near foundation –Qualitative test showed presence of lead on front porch columns –Living room window sill tested positive for lead –Sidewalk chalk tested positive for lead Interior of home: –Home built between 1905 &1915 –Chipping paint on interior of windows & kitchen door –Possible remodeling dust lingering on floors –Living room window sill tested positive for lead

25. Case continues…. Occupational concerns: –Dad working at manufacturing plant –Clothes not washed separately –Dad walks into home and plays with children prior to bathing Involve OSHA? –Agency to Agency referral challenges –Extraordinarily sensitive situation –Pros and cons

26. Case continues…. Provided family with cleaning supplies, walk-off mat, vacuum equipped with HEPA filter, and touch-up paint Education provided on control and potential removal of lead hazards CEH reached out to weatherization agency for assistance

27. How is the family doing? Family cleaned contaminated areas Stopped renovation Painted hazards Removed product hazards Dust wipe follow-up Child’s lead level improved

28. Continued Challenges Who pays? Lack of resources Who’s responsible? Determining who’s involved Equipment access Consistent educational message

29. Goals and Success Reduction in EBL levels Provided comprehensive education Established local public health relationships Filled in gaps in state EBL coverage Opening eyes of continued need of EBL’s

30. So how does the partnership work now? PEHSU accepts referrals. Consults with the Center for Env. Health who provides follow up. Local Health Dept. is consulted. KCMO Health Dept. is consulted as needed for referrals or other resources. Referral to Kansas DHSS for enforcement.

31. Moving Forward Continued collaboration with local health departments Empowering families Reaching out for grants Reimbursement possibilities

32. Thank You! Any Questions?

33. Jennifer Lowry, jlowry@cmh.edujlowry@cmh.edu Amy Roberts, amy.roberts@kcmo.orgamy.roberts@kcmo.org Ryan Allenbrand, rnallenbrand@cmh.edurnallenbrand@cmh.edu