New Hampshire

1
New Hampshire Quality Improvement Learning
Teams Reducing Preventable Risk Factors that
Predispose to Chronic Disease Focus on
reducing childhood obesity
2
Existing NH Public Health Infrastructure

• 234 cities and towns
• Health Officer required by statute
• 5 communities with public health departments
• No county health departments
• State level
• DHHS (lead agency),
• Department of Environmental Services
• Department of Education
• Department of Safety
• Strong community-level informal public-private
  partnerships
• Currently engaged in a regionalization process

3
Selection processMini-Collaboratives (QuILTs)

• RFP
• Ranked target area
• Reducing Preventable Risk Factors that Predispose
  to Chronic Disease
• Focus on reducing childhood obesity
• Formal proposal review process
• Aligned with state health priorities and
  strategic plan

4
QuILTs

• Currently 1st of 2 cohorts, 3 each, 15 months
• Caring Community Network of the Twin Rivers
• Lakes Region Partnership for Public Health
• Mascoma Valley Health Initiative
• Content experts
• Regina Flynn, Health Promotion Advisor -
  KidPower! Program, NH DHHS - Nutrition Health
  Promotion
• Mindy Fitterman, M.Ed., R.D., Nutrition
  Consultant, NH Fruit and Vegetable Program DHHS,
  Division of Public Health Services
• Timeline
• Kickoff 9/08
• Monthly meetings conference call, LiveMeeting,
  in person
• Mid session 4/09
• Completion 11/09
• Mentors to Cohort 2 through 4/2011

5

• Lead Susan Laverack
• Identify an Opportunity Obesity
• Belknap County
• One of top 4 health issues
• Greatest overweight and obese WIC enrolled
  children
• 75 of residents consume lt 5 servings fruits
• Assemble a Team
• Lakes Region Physical Activity and Nutrition
  Committee (PAN)
• LRGHealthcare (Dieticians, Education and
  Outreach), Parks and Recreation Director, UNH
  Extension Specialist, Belknap-Merrimack CAP
  Laconia Child Care Director
• SAU Superintendent
• Pleasant Street School Staff
• Principal, nurse, teachers, SAU food director,
  guidance counselor

6
Examine Current Approach Identify Potential
Solutions

• Current approach
• School w/ high interest level, fragmented
  coordination
• Nurse and Guidance Counselor teach a 4-wk
  Wellness Curriculum for 5th grade
• Few healthy eating/active living activities
• Potential Solutions
• Interventions based on 5-2-1-0 w/ focus on the
  5 in one 2nd Grade classroom
• Consulted with DHHS and local nutritional experts
• Determined all possible ways food is consumed by
  students before, during and after school -
  greatest potential to impact improvement at snack
  time

7
Develop an Improvement Theory

• Through multi-component nutritional intervention
  the of 2nd grade students who bring a fruit or
  vegetable for snack will increase.
• AIM 2nd Grade Students will bring fruit and/or
  vegetable for snack at least 60 of the time by
  6/09
• Multi-component nutritional information and
  activities to 2nd grade students
• Taste Testing
• Visit to grocery store
• Design bulletin board
• Prepare serve healthy foods to 5th grade Book
  Buddies
• Integrate project into schools Wellness
  Committee

8
Check the Results

• ? Fruit/Vegetable ID and understanding of
  nutritional benefits (pre-post test)
• Cycles of Change
• Dec Taste Tests
• Feb Trip to Grocery Store
• April School-Wide Principals Tie Challenge
• May Prepare serve healthy snacks to 5th
  graders
• ? awareness and enthusiasm across the school

9
Establish Future Plans

• Improve processes for working with QuILT members
• Broaden successes to fifth grade
• Developmentally-appropriate activities (e.g.,
  student involvement in tracking tools and data
  collection)
• HEAL funding source to broaden initiatives to
  other schools within region
• Explore Snack Policy (informal)
• create school-wide practice this is how we do it

10
Improve Nutrition Literacy and Food Choices in
Elementary Students and their Families
Mascoma Valley Health Initiative in partnership
with Canaan Elementary School Lead Susan F.
Houghton, MA, PhDc., ED, MVHI
11
Improvement Theory/ Assemble Team

• Building the Team
• Elementary school Guidance Counselor
• Elementary Principal
• SAU Superintendent
• Pediatrician
• Pediatric NP
• Community Health Manager, Alice Peck Day Hospital
• MVHI Project Coordinator

• Improvement Theory
• Rates of overweight and obesity, and
  obesity-related chronic disease, can be
  positively impacted through nutrition education
  that
• Integrates hands on learning
• Involves the family
• Results in an increase in healthy food choices

12
Current Approach/Potential Solutions

• Snack packing literacy Whats in your snack?
• Calcium and bone density how do beverages
  matter?
• Find the Fiber in food labels how special
  is Special K?
• Healthy eating! Popcorn, salsa, vegetables.
• Posters based on new food pyramid
• Family night and poster show
• Family quiz game
• 4-Ingredient Trail Mix Cheerios, Dried
  Cranberries, Raisins, Chocolate Chips
• Group work benefits of nutrients

• Current Approach
• A faculty-developed nutrition curriculum
• Big 3 macro-nutrients
• Environmental Challenges
• Food Desert
• Socieconomics
• Intervention
• Target 4th grade students (n50)
• Teach new food pyramid, macro- and
  micro-nutrients, focus on Calcium
• Nutrition literacy reading food labels

13
Check the Results

• Measurements Food Knowledge and Family
  Participation
• Family night drew more than 75 people
• 40 copies of 4-Ingredient Trail Mix recipe
  distributed
• New School-wide Wellness Policy developed,
  Approved by School Board and Implemented Fall 09
• QuILT leader member of Wellness Committee

14
Next Cycles of Improvement

• Increase focus on food choices
• Measuring snacks brought from home
• Increase in-school and take-home messaging about
  snacks
• Follow current 4th graders to Middle School next
  year
• Incorporate food preparation (classroom kitchen)
• Integrate other activities to teach a healthy
  food environment curriculum
• Physical activity energy balance

15
C
CNTR
Caring Community Network of the
Twin Rivers Working Together for
Healthier Communities
841 Central Street, Franklin, NH 03235
Telephone [phone] Fax [phone]
website www.ccntr.org
Childhood Weight Management and Obesity
Prevention Quality Improvement Serving a
Population of over 34,000 Michael Loomis,
MPH Community Program Specialist
16
Team Members

• Rick Silverberg, LICSW (CCNTR)
• Michael Loomis, MPH (CCNTR)
• Sally Minkow, BSN, CHES (LRGH)
• Rick Wilson, MD (LRGH)
• Melissa Rizzo, M.Ed (LRGH)
• Wendy Pavnick, PA-C (Health First Family Care
  Center, FQHC)

17
Assessment of Need
18

• Upon notice to parent from school nurse of
  overweight or obese status and health risks
  related, parents respond with negative feedback
  with noted reflection to absence of discussion
  during primary care visit
• Run report at 3 local primary care practices of
  children ages 2-19 with a well-child visit in
  2007 fiscal year with a documented BMI or BMI
  percentile
• Focus on Primary Care Setting and how weight
  related risk and behavioral assessment is being
  delivered to youth

19
PLAN

• Documentation Rates Baseline
• BMI documentation rates in 2-19 year olds with a
  well-child visit between 7/1/07-6/30/08 among 3
  local primary care practices vary (12.6-90)
• EMR well-child vital sign template with BMI risk
  rating calculator identified and uploaded
• PCP Wellness Champion to test QI in clinic

20

• CHRONIC CARE MODEL!

21
PLAN

• To begin process, educate providers on BMI
  measures, community profile, available referral
  resources
• Update Medical staff on research identifying
  weight-related health as an indicator for chronic
  disease risk
• Motivational Interview training
• BMI behavioral risk screening tool
• EMR technology that auto-calculates BMI risk
  rating at well-child office visit

22
Improvement Theory

• The team will improve health care provider access
  to timely BMI risk rating analysis through
  redesign of clinical flow to assess behavior,
  provide effective communication strategies and
  referrals, and interpret weight related health
  into diagnosis and treatment
• Goal of all 3 Primary Care Practices documenting
  at least 65 of childrens BMI seen in the
  following year

23
DO

• Review evidence and recommendations for
  increasing assessment, prevention, treatment and
  clinical guidelines
• Identify EMR BMI risk rating tool and upload for
  prompt evaluation at time of visit
• Designate a Wellness Champion in clinic
• Create and educate medical staff on clinical
  office flow for weight-related health risk factor
  assessment

24

• Document SM goal in pts chart as a measurable
  health indicator
• Educate providers on referral resources to
  community HEAL interventions
• Identify locations suitable for outreach
  activities to distribute printed materials to
  community members

25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
STUDY

• GOAL REACHED!
• After 1 year of new EMR applications and provider
  education, all three Primary Care Clinics were
  documenting at least 65 of childrens BMI and
  using EMR 5210 tab to discuss weight related
  health by focusing on preventing the risk factors
  (72, 89, 92)
• Promote routine calculation of BMI risk rating at
  each clinical encounter as a VITAL SIGN to
  encourage weight-related health and its impact on
  the patients overall health and well being as
  well as its impact on public health

32

• ACT
• Continue to educate and promote the importance of
  daily behaviors related to 5210 Healthy NH
• Continue to foster collaboration between CCNTR
  and local PCP about referral for local
  nutritional and physical activity resources
• Continue to utilize QI tools in day-to-day
  activities
• Continue broad community outreach to target
  population

33

• Establish Future Plans
• Continue familiarizing CCNTR staff with QI
  concepts, tools and methods with particular
  evidence on evidence-based interventions
• Relay obesity statistics, trends and health
  indicators to health care partners to further
  develop QI echoing community efforts
• QI will be expanded to other Healthy Eating
  Active Living (HEAL) sectors in the region
  (worksites workplaces, schools, food
  recreation industries, communities
  municipalities

34
Each partner brings their own influence on the
community to the table. When we put them together
it creates a Quilt covering our community with
a universally delivered message