Louisville’s Syringe Exchange – Preventing HIV Transmission while Pointing to Recovery

(Note: This guest piece was written by Dr. Sarah Moyer, Louisville’s Chief Health Strategist and director of the Louisville Metro Department of Public Health and Wellness)

December 1 was World AIDS Day.

Louisville, like the rest of our region and most of our country, has been facing tremendous challenges brought on by the worst opioid epidemic in American history. One of those challenges has been protecting the community from HIV which can be spread when people who inject drugs share needles. When this happens, not only are drug users at risk, but so is the community.

Many people who do not use drugs are at risk for HIV because they are sexual partners of injection drug users. Pregnant women who inject drugs or who are partners of injection drug users run the risk of transmitting HIV to their children in utero.  HIV transmission can easily spread from those injecting drugs to the overall community.

Protecting the community from HIV was a primary consideration when Louisville created Kentucky’s first syringe exchange program in June 2015.  The small city of Austin, Indiana, just 35 miles north of Louisville on I-65, had an unprecedented new 235 HIV cases that year as a result of needle sharing among those injecting drugs. Given the relative populations of the two cities, Austin’s 235 cases would have translated to more than 36,000 new HIV cases in Louisville.

Numerous studies have found that syringe exchanges are successful in preventing the spread of HIV and other viruses such as hepatitis C. A series of three-year longitudinal studies investigating the effect of New York’s legalization of syringe exchange programs found that HIV prevalence fell from 50 percent to 17 percent.  The number of HIV cases linked to injection drug use in Washington D.C. dropped by 95 percent from 2001, prior to DC’s syringe exchange program, to 8 cases in 2015.

The CDC has released a study of 220 counties across the United States that are most vulnerable to outbreaks of HIV and hepatitis C based on factors such as overdose deaths, per capita income, unemployment and sales of painkillers. Fifty-four of those vulnerable counties are in Kentucky, mostly in the southern and eastern parts of the state.  The study said that there were 18 Kentucky counties that were even more vulnerable to spikes in HIV and hepatitis C than was Austin, Indiana.

The primary goal of Louisville’s Syringe Exchange program is to prevent the transmission of HIV, hepatitis C and other blood-borne diseases. The program brings people with opioid use disorder in contact with the healthcare system where they can be tested and treated for HIV and hepatitis C.  It provides free sterile syringes, HIV and hepatitis C testing, disease prevention supplies and education on wound care and proper syringe disposal.  It also provides life-saving fentanyl test strips and the overdose reversal drug naloxone.

The Louisville Metro Syringe Exchange Program also makes referrals to drug treatment. Our Syringe Exchange staff members have developed a bond of trust with the people they serve.  When someone is ready to enter treatment, they turn to our staff for guidance. National studies have shown that syringe exchange participants are five times more likely to enter drug treatment than drug users who do not use a syringe exchange.

Our Syringe Exchange program was also a valuable resource in fighting Louisville’s recent hepatitis A outbreak. People who were homeless as well as people who used drugs were at highest risk and much of our vaccination efforts was focused on them. Hepatitis A is not a blood borne pathogen that is spread by needle sharing as is HIV or hepatitis C, but the unsanitary conditions that drug users often find themselves in greatly increased their chance for contracting and spreading the disease during last year’s outbreak. Using our syringe exchange program combined with outreach to homeless camps and shelters, we gave more than 25,000 hepatitis A immunizations to these high-risk groups.  More than 100,000 immunizations were given throughout the city.

Since it began in 2015, Louisville’s Syringe Exchange program has expanded from a mobile unit parked outside of our headquarters to a site inside the building that is open six days a week. The program now also operates seven additional satellite sites at various locations throughout the city.

The numbers point to our success. Since it was created in June 2015 the program has served more than 20,000 unique participants with nearly 115,000 visits and has distributed more than five million sterile syringes. It has tested more than 3,500 people for HIV and referred 29 for treatment. The program has also tested more than 4,800 people for hepatitis C and referred nearly 700 for medical treatment.

We’ve also referred 719 people for drug treatment and more than 300 have been connected to other community services.

Louisville has averted the catastrophic rise in new HIV cases that Austin, Indiana experienced in 2015.  Rates of new HIV infection in Louisville have stayed steady. In 2014, the year before our syringe exchange opened, the rate of new HIV infection for the five-county area which includes Louisville, stood at 15.3 per 100,000. In 2017, the last year for which data is available, it stood at 13.9.

There has also been a glimmer of good news regarding the city’s opioid epidemic. According to the Kentucky Office for Drug Control Policy and the Jefferson County Coroner’s Office, overdose deaths in Louisville fell 21% last year, the largest decrease of any county in the state.

In 2017 the Department of Public Health and Wellness convened a wide-ranging group that included people in recovery, leaders of nonprofits, law enforcement, healthcare institutions, experts of social work, school officials, concerned parents and scholars. The resulting report, Coming Together for Hope, Healing and Recovery called for implementing specific science-based, best practice strategies to respond to substance use disorder in the city.  It is encouraging to see that some of our efforts are now beginning to bear fruit.

Louisville’s Syringe Exchange program is preventing the spread of HIV and other blood-borne diseases in while pointing program participants toward recovery. It has proven vital to keeping the city safe from infectious disease, while helping to control Louisville’s epidemic of opioid use disorder epidemic.

Tackling the Opioid Epidemic: The Unintended Consequences

(Note: This guest piece was written by Lori Earnshaw, MD FAAHPM HMDC, Senior Hospice and Palliative Medicine Physician, Associate Clinical Professor, University of Louisville Department of Medicine. All opinions are the author’s own.)

Every day, I think about the patients I have seen in my practice of hospice and palliative care. You may be surprised to learn that most of them wish they had met me sooner. Their reflections are based on years of suffering in pain that was not adequately addressed by our healthcare system.

I remember a single mom who was one of my first patients. She had juvenile rheumatoid arthritis that caused joint destruction and resulted in chronic pain. Her primacy care provider prescribed methadone to treat her pain, and her rheumatologist managed her disease with methotrexate. She was able to enjoy a productive and relatively pain-free life, while she worked two jobs and supported her son.

House Bill 1 passed in Kentucky in 2012. While it targeted pill mills and attempted to shape safer prescribing practices, the unintended consequences were soon obvious. Prescribing opioids became more challenging.

My patient’s PCP moved out of state but assured her that her colleague would prescribe methadone for her. This promise would not be fulfilled. Her pain escalated, and she struggled to work and care for her son. A friend told her about a methadone maintenance clinic, where she went to find relief. The problem was that she did not have a substance use disorder and was turned away. She was wiser by the time she attended the second clinic, where she obtained methadone after claiming addiction in order to relieve her pain.

After a screening mammography demonstrated a suspicious mass, she received a new diagnosis: breast cancer. The pathology report identified triple negative breast cancer, which is one of the most aggressive types. She met me in the hospital after her first chemotherapy caused complications, and my colleagues weren’t sure what to do about her pain management, given her methadone treatment.

My consultation resulted in a year-long relationship with her as she rotated from hospital to clinic. One of the nicest complimentsI received from her was also one of the most heartbreaking: “I guess something good came out of my cancer diagnosis.” She was referring to the effective pain treatment and support she received from palliative care and later hospice care.

What makes patients so desperate for pain relief that they would view having cancer as a positive? As lawmakers, policy makers, healthcare professionals, insurance companies, healthcare organizations, and law enforcement attempt to tackle the opioid epidemic, they create a stigmatizing and inefficient labyrinth that is nearly impossible to navigate.

The problem seems to get worse, not better. When the CDC came out with their 2016 “guidelines for prescribing opioids for chronic pain outside of active cancer, palliative, and end-of-life care,” they triggered a cascade of poor decision-making from the C-suite to the bedside. Kentucky adopted one of the recommendations in April 2017, which limited opioids for acute pain to a duration of three days, with the same exceptions listed above.

I have been in healthcare long enough to know that “guidelines” often become “standards” and “policies” from which prescribers are fearful to waiver. I can assure you that the 90-year-old grandmother who falls and sustains a compression fracture from osteoporosis will not make a full recovery in three days, nor will the trauma patient who suffers an amputation. Chronic pain is created from inadequate treatment of acute pain. Common sense and experience make these “guidelines” seem absurd when interpreted rigidly.

More Americans suffer from chronic pain than heart disease, diabetes, and cancer combined. Chronic pain is the number one reason that Americans seek medical care and impacts 11% to 40% of the U.S. population. Chronic pain is a complex biopsychosocial phenomenon and is labeled as “chronic” when it occurs at least half of the days for six months or more.

While the use of opioids in treating chronic pain has been blamed as contributor to the opioid crisis, the evidence suggests that opioid use disorder in chronic pain patients is not as pronounced as one may expect.

In one analysis, consistent exposure to opioid therapy in chronic pain patients led to addiction in 3.27% of patients. In patients who did not have a current or past history of use, abuse, or addiction, the rate of abuse was only 0.59%. Of 801 patients treated with prescription opioids in a primary care setting, only 3.8% met the criteria for opioid use disorders. My patient belonged the majority of chronic pain patients who do not have or develop an opioid use disorder because they are using opioids appropriately to treat their pain.

What the opioid epidemic should highlight for all of us is the elephant in the room: substance use disorder. Restricting access to opioids cannot be the sole focus of curbing the opioid epidemic, and this strategy fails to make a significant impact.

The national CDC data on overdose rates involving opioids mirrors that of Kentucky. Despite the efforts of House Bill 1, there was an increase in overdose fatalities in 2016, with the largest demographic of opioid deaths being adults ages 35-44. Autopsy and toxicology reports from 2016 showed that 47% of overdose deaths involved fentanyl (up from 34% in 2015) and 34% of overdose deaths involved heroin (up from 28% in 2015).

A University of Kentucky study found that individuals in state-funded treatment had an increase in heroin use of 2.4% per year after House Bill 1 was passed. Until the same fervor that prompted us to address the opioid epidemic is applied to substance use disorder, we will continue to inadequately impact the suffering of both patients with pain and those with addiction.

I hope that we are open to learning the important lessons that my patients have taught me. While we must take action in curbing opioid abuse and deaths, we must also compassionately treat those with pain and substance use disorder. The approach must be multi-faceted and acknowledge the uniqueness of each population and practice setting.

Solutions should include:

  1. Identifying and mitigating individual risk factors
  2. Identifying patients eligible for palliative care and hospice much sooner
  3. Utilizing available resources for treatment of both pain and substance use disorder
  4. Improving education for pain treatment and referral to specialists
  5. Providing funding for research and training of pain, addiction psychiatry, and palliative care specialists
  6. Advocating for a holistic, team-based approach that includes social determinants of health and the value of all health profession disciplines

Congress has markedly increased funding for research into opioid misuse and pain, with the National Institutes of Health nearly doubling its investment in finding solutions. When approaches are tried and fail to demonstrate an impact, they should be phased out. I would recommend starting with onerous insurance prior authorizations and restrictions on the prescribing of opioids that consume resources in already stretched-thin physician practices.

The unintended casualties of tackling the opioid epidemic are people. They are our brothers, neighbors, mothers, grandmothers, and coworkers. I have met many of them in my practice of hospice and palliative care, and I hear the disappointment and anger that they feel in not being treated with compassion, not being heard, and suffering without relief.

We must change our approach to the opioid epidemic. Unnecessary pain and suffering are the enemies.

National Diabetes Month 2019 – “Take Diabetes to Heart” by Promoting Diabetes Self-management Education and Support

(Note: This guest piece was written by Reita Jones, RN, KY Department of Public Health, Diabetes Prevention and Control)

According to the Centers for Disease Control and Prevention and the Kentucky Department for Public Heath, nearly 600,000 Kentucky adults are estimated to have diabetes. Of these, one in four don’t know they have it. Additionally, adults with diabetes are nearly twice as likely to die from heart disease and stroke. And for women with diabetes, the risks for cardiovascular disease are three to seven times greater compared with women who do not have diabetes. Thus, the 2019 theme for National Diabetes Month is “Take Diabetes to Heart”. This November and in the year ahead, you are encouraged to join organizations and communities across Kentucky to raise awareness about risk for this serious chronic health condition and the strong link between diabetes and risks for heart disease. You are also encouraged to share resources from links in this article and engage in discussion and action to make a difference in your client population and in the lives of people with diabetes.

Early Detection is Critical

First consider, could members of your family or client population be one of the four adults who have diabetes and don’t know it? Early detection and appropriate management are key in preventing or delaying devastating complications of poorly managed diabetes. How many times have you known of individuals seeking medical attention for a health problem that turns out to be a complication of diabetes and the diabetes had likely been present but undiagnosed for several years? Take steps now to engage and screen your client population at risk for diabetes or prediabetes, especially those who have not been seen for some time. See page 3, section 2 in the Standards of Medical Care in Diabetes – 2019, Abridged for Primary Care Providers for screening guidance. If you are not in a clinical setting, it is also a good choose to share the diabetes risk test with your network of influence, community and family.

Gaps in Diabetes Control and Cardiovascular Risk Reduction

Second, in bringing awareness around the strong link of diabetes and risk for heart disease, it is important to acknowledge that managing diabetes is much more than meeting blood glucose targets. Blood pressure and lipid management are equally important for reducing cardiovascular risks related to diabetes. However, despite many advances in therapies over the past 30 years, large gaps persist in cardiovascular risk reduction and heart disease management in people with diabetes. A January 2019 article with analysis of data in the U.S. Collaborative Diabetes Registry shows that only one in five individuals with diabetes meet appropriate targets for comprehensive cardiovascular risk factor control (ABCs – A1C, Blood pressure, LDL Cholesterol and non-Smoking status). Even fewer meet the recommendations for physical activity, healthy eating and body mass index.

Opportunity for Diabetes and Cardiovascular Improvement with DSMES

This low baseline, presents a tremendous opportunity for improvement in cardiovascular outcomes among individuals as well as populations of people with diabetes. Lifestyle management is a fundamental aspect of diabetes care and diabetes self-management education and support (DSMES) is the most comprehensive evidence-based intervention recommended in the latest American Diabetes Association standards of care for lifestyle management. It is an underutilized intervention which can be very effective in addressing the achievement gap for diabetes ABCs goals, especially considering that at least 90 percent of diabetes care is carried out by the person with diabetes or a family member.

DSMES services are an ongoing process to facilitate the knowledge, skill and ability necessary for optimal diabetes self-care. They include activities and tools that assist in implementing and sustaining the behaviors needed to manage diabetes. DSMES services incorporate the needs, goals and life experience of the person with diabetes and support informed and shared decision-making for active collaboration with healthcare teams to improve clinical outcomes over the course of a lifetime. DSMES services are provided by licensed/certified diabetes educators and are recommended at diagnosis, annually (based on assessment of education, nutrient and emotional needs), when new complicating factors arise and when transition in care occurs.

Benefits DSMES

Studies have found that individuals who attend ongoing DSMES are more likely to use primary care and preventive services or follow-up on treatment recommendations. DSMES attendance is also associated with improved self-care behaviors; lowered A1C, blood pressure, and cholesterol levels; lower self-reported weight; healthy coping; improved medication adherence and quality of life; and reduced hospital admissions, readmissions and healthcare costs. It is also important to note that outcomes associated with DSMES services have been shown to be dose responsive in that more DSMES leads to better outcomes. It may also be helpful to look at the benefits rating for diabetes education with the parameters utilized to evaluate medications.

Despite the well documented benefits and reimbursement for the service, reports indicate that only 5-7% of individuals eligible for DSMES through Medicare or a private insurance plan actually receive it. In addition, licensed/certified diabetes educators, who deliver the services (within an organization or in the community), are seldom included on the multidisciplinary care team that plays a critical role in managing diabetes and all the relevant risk factors.

Everyone Can Play a Role to Increase DSMES Participation

During National Diabetes Month and in the year ahead “Take Diabetes to Heart” by taking steps to become familiar with the accredited and recognized DSMES programs in the Kentuckiana region and your community. The Kentucky Diabetes Resource Directory is an easily accessible source to search for programs by county and surrounding counties in the state. All public and private insurance plans in Kentucky cover the DSMES service although, provider referral, deductibles and copayments may apply. Access to diabetes education is less abundant, and in some cases non-existent, in rural areas of the Commonwealth. To address this gap, the Kentucky Department for Public Health’s accredited DSMES program (Healthy Living with Diabetes), services 58 counties across Kentucky through 16 local or district health departments.

And lastly, you are encouraged to take action on the steps below, as applicable, to promote DSMES access and participation in your network of influence. Health systems, employers, health plans, public health, academic organizations, consumer advocacy groups, local pharmacies, diabetes sales companies, communities and individuals can all play an important role to help drive improvement in diabetes ABCs and cardiovascular outcomes.

Spotlight: Get to Know KHC’s Newest Employee

As the Kentuckiana Health Collaborative continues to add projects that drive health and healthcare delivery in the region, the coalition has hired a part-time staff member to support various projects. Emily Divino, the KHC’s new Project Administrative Assistant, was added to develop marketing and communication materials, support event planning, and provide administrative support to any ongoing projects of the KHC.

Emily, a Louisville native, earned a degree in Health Sciences from DePaul University in Chicago, but she has returned to the region and is currently pursuing a Master of Public Health at the University of Louisville, with a concentration in Health Promotions and Behavioral Sciences.

“I’m excited to support the efforts of the opioid employer cohort that is about to begin,” Emily said. “It will be interesting to see what results and future directions it will produce. Additionally, I’m interested in supporting future collaborative work between our members that will hopefully lead to some great new health initiatives to implement in the community.”

Related to healthcare, Emily is interested in reducing health disparities in marginalized communities, community engagement, program planning and women’s health and wellness.

A Little More About Emily

What do you like to do in your spare time?

I love listening to music, kayaking, hiking, and playing with my cat even though she hates me.

What is something people might find surprising about you?

I can juggle.

What are your favorite places to travel?

“I love exploring cities so travelling to New York City or Chicago is always fun. Hopefully I will be lucky enough to visit Tokyo one day!”

What is your favorite quote?

“Don’t count the days; make the days count.” – Muhammad Ali

If someone wrote a biography about you, what do you think the title should be?

“The True Life of a Punctual Procrastinator”

If Hollywood made a movie about your life, who would you like to see play you?

Sandra Oh because she is great in everything she does.

I used to scoff at breast cancer “awareness” activities. That was before I worked in healthcare.

I have a confession to make. One that I’m embarrassed about.

October is breast cancer awareness month, a month where we see more pink than usual – on everything from cereal boxes to athletes’ gloves and shoes on the football field. And I used to roll my eyes at all of it. I mean, all of this money being spent on pink accessories that raise “awareness” but don’t necessarily raise money for research or treatment! What a waste!

That was before I worked in healthcare.

I joined the Kentuckiana Health Collaborative four years ago as the data scientist, and as a result, I’ve learned that with appropriate screening according to clinical guidelines, certain cancers, including breast, cervical, and colorectal, can have better chances for survival or even be prevented completely. “Awareness” isn’t some fluffy idea without true impact. It can save lives.

EARLY SCREENINGS RECOMMENDED FOR HIGHER RISK GROUPS

Approximately one in eight women will develop breast cancer in her lifetime, according to the American Cancer Society. Breast cancer is the second most common newly diagnosed cancer and second leading cause of cancer death among women in the U.S. Many factors play into an individual’s odds of developing breast cancer, including genetics, diet, age, and more.

There is a special emphasis on appropriate screening and early detection of breast cancer, because when breast cancer is detected early, there are more treatment choices and better chances for survival. The five-year survival rate for women who are diagnosed at Stage 0 or Stage I cancer is nearly 100 percent, while women who aren’t diagnosed until Stage IV only have about 22 percent five-year survival rate.

Current screening guidelines dictate that women ages 50 to 74 should have a mammogram at least every two years. But screenings are recommended earlier than 50 for certain groups, such as African-American women or women with a gene mutation known as BRCA.

BREAST CANCER AWARENESS TAKES MORE PERSONAL MEANING THIS YEAR

You’ve probably heard of the BRCA gene mutation, even if you didn’t know that that’s what it is called. Actress Angelina Jolie put the national spotlight on this mutation in 2013, when she announced that she had the BRCA gene mutation and, as a result, underwent a double mastectomy to reduce her chances of developing cancer. Approximately 1 in 500 women has the mutation, which makes them much more likely to develop breast cancer – estimates range from 55 percent to 85 percent lifetime risk for breast cancer for women with the mutation.

And these women with the BRCA gene mutation often develop cancer much earlier than the typical minimum screening age guidelines of 50 years old. Earlier this year, my dear friend, at just 33 years old, experienced a bit of pain when her kids laid on her chest. Even with no other symptoms, her healthcare provider recommended a screening, and they found a nine-centimeter tumor in her breast. She was found to have the BRCA gene mutation, and since then, two of her sisters have also tested positive for the mutation. By taking the proper steps, her sisters can drastically reduce their chances of developing breast cancer.

Breast cancer awareness month this year takes on a special meaning for our friend group, as she starts chemotherapy next week after having a double mastectomy in August. I’ve read more books and articles on cancer and chemotherapy than I ever thought I would, and much of our time is spent coordinating transportation, meals, donations, and distractions. There are lighter moments, too, spent laughing about the more outrageous aspects of cancer.

No longer do I eschew breast cancer “awareness,” now that I’m more informed about the impact that early intervention has on outcomes. This month, and in the following Octobers, count me in for awareness efforts.

Children’s Seven-County Health Initiative Serves as Model for Entire State

(Note: This guest piece was written by Ben Chandler, President and CEO, Foundation for a Healthy Kentucky)

Ben Chandler

A Foundation for a Healthy Kentucky community-driven children’s health initiative called “Investing in Kentucky’s Future” (IKF) strengthened cross-sector coalitions in seven Kentucky counties. The initiative also improved student eating habits, increased youth physical activity, trained teachers to support students experiencing trauma, and increased youth resilience. The six-year, $2.4 million initiative also led to the adoption of 38 local ordinances and policies to help sustain the improvements and promote health equity long-term.

The IKF initiative supported demonstration programs in seven Kentucky counties and was designed to reduce the risk that school-aged children will develop chronic diseases later in life. The communities contributed another $1.7 million in matching funds under the initiative, which reached nearly 13,000 students in 28 participating schools.

Unlike most philanthropic grants, the IKF initiative’s community-driven approach allowed the local coalitions to choose the topic on which they wanted to focus, and then funded a one-year planning phase during which the Foundation also provided training and technical assistance in the development of a business plan. This made the grant program more accessible to small communities with fewer resources. The Foundation also required Coalition members to attend twice-yearly trainings it provided with national and state experts in areas such as youth engagement, health equity, developing policy and influencing policymakers.

Six of the Foundation’s IKF grantees – in Breathitt, Clinton, Grant, McLean, McCracken and Perry Counties – selected childhood obesity prevention as the issue they would address through the initiative. The Jefferson County coalition focused on Adverse Childhood Experiences (ACEs) and building resilience in children who have faced trauma. Both issues are complex and influenced by a variety of biological, behavioral, social and environmental influences, so they require the cross-sector approach that coalitions can bring. Participants told the Foundation that identifying a local champion and engaging the school system were critical to success in each of the counties. But by far the most decisive factor was ensuring that the local health coalition included multiple members from a broad range of community organizations – schools, hospitals, elected officials, youth groups, and businesses. It takes more time to get everyone aligned but the resulting collaboration makes all the difference in creating long-term change to improve health.

School-based interventions were ideal for both obesity prevention and ACEs because kids spend more than 1,000 hours a year and consume up to half their daily calories at school. The Foundation has now launched a statewide school-based health coalition to share and implement some of the lessons learned in the IKF initiative; the steering committee for that coalition will begin meeting soon.

Among the IKF initiative’s successes:

  • Policy change: A total of 38 local policies were adopted by the communities at the county, city and organizational levels.
    • Policies related to childhood obesity prevention expand physical education in middle school, require future streets to be usable by walkers and cyclers as well as cars, allow school fitness equipment to be used by the community after school, and make healthier foods available in schools and park concession stands.
    • Policies that support resilience in children include requiring trauma-informed training for all Jefferson County Public Schools (JCPS) and ACEs training certification for out-of-school youth care workers and agencies that receive funding from Metro Louisville’s Office of Youth Development.
  • Built Environment: Additions including new parks, fitness equipment, sidewalks and walking paths, playgrounds, filtered drinking water fountains, community trails and standing desks in schools. Many communities leveraged the Foundation grant to secure additional funding. For example:
    • Purchase Area Health Connections-Paducah Chapter secured another $400,000 Rotary Club grant to build a playground at the health park developed with IKF funding, and then another $500,000 donation to build a second phase of the park.
    • Sidewalks to school that were built in Grant County will be included as part of a 48-mile trail system under development thanks to a follow-up grant from Interact for Health.
    • FFLAG in Grant County also worked with five elementary schools to win another grant to fund additional outdoor play equipment for students.
  • Expanded Engagement by youth, parents and members of the community in health coalitions that develop health events, farmers markets, and school-based clinics. Several coalitions incorporated youth as members or established youth councils.
  • Increased Physical Activity and Improved Nutrition for more than 90 percent of the students in participating elementary and middle schools in the counties where obesity prevention was the focus. Among the programs:
    • Many schools incorporated classroom movement activities and standing desks.
    • Many schools eliminated deep fryers in their cafeterias, installed filtered drinking water fountains, and partnered with local farmers’ markets in farm-to-school programs that brought fresh produce to students.
    • All six coalitions began or expanded student food programs over the weekends or the summers.
    • Most students reported that school was their only source for fruits and vegetables; offering produce at snack time “appears to be a successful strategy” to increase consumption, the report found.

Additional gains specific to the trauma resilience-building model program implemented by the Bounce Coalition in Louisville, included:

  • A 56 percentage-point improvement – from 30 percent to 86 percent – among participating Jefferson County Public Schools teachers and staff who felt they could be effective in supporting students who are experiencing traumatic events in their lives.
  • Improved school climate in all nine areas measured
  • Parent conferences increased 195 percent from 2014 to 2017.
  • Teacher retention improvement, from 87.8 percent in 2014 to 90.2 percent in 201

Bounce also leveraged the Foundation grant to gain support from the Kentucky Department for Public Health for gatherings with community leaders to discuss ACEs and practical strategies for building resilience and provide training for healthcare providers and other organizations to foster resilience-building practices in several neighboring communities.

A full report regarding the Foundation’s IKF initiative is available on its website. Two videos produced by the Foundation also are available: the obesity prevention video can be found here and the ACEs video can be found here.

Measurement Alignment Efforts First Step Towards Driving Health Improvements in the Commonwealth

Stephanie Clouser

Healthcare quality measurement is not sexy. Or at least that’s what my boss, KHC Executive Co-Director Randa Deaton, has said.

As the KHC Data Scientist, I disagree. And judging by the attendance at this month’s KHC Community Health Forum, “Driving Health Improvements Through Measurement Alignment,” I’m not the only one who disagrees. On September 10, we spent the morning with a full house of attendees to learn from national and local experts in healthcare measurement and measurement alignment.

The two-hour Forum highlighted national and local measurement alignment efforts aimed at reducing measurement burden, improving focus, and ultimately measuring what matters most to patients. This included:

  • The Core Quality Measure Collaborative (CQMC), a broad-based coalition of health care leaders convened by America’s Health Insurance Plans, Centers for Medicare and Medicaid Services (CMS), and the National Quality Forum (NQF)
  • Louisville-headquartered Humana’s journey to align their measures across product lines
  • The Kentucky Core Healthcare Measures Set, convened by the KHC
  • A panel of regional experts on the current landscape and future of healthcare measurement in the Commonwealth

Packed Agenda Highlighted Measurement Alignment Opportunities and Challenges

Norton Healthcare’s Dr. Joshua Honaker, Chief Medical Administrative Officer for Norton Medical Group, kicked off the morning with an introduction to the “measurement mayhem” that contributes to physician burnout and high administrative costs, highlighting the need for the streamlining of measures and incentives.

The morning’s keynote speaker, Chinwe Nwosu, America’s Health Insurance Plans, discussed the advancement of quality measurement and improvement through core measures sets. Nwosu, the project manager for the Core Quality Measures Collaborative (CQMC), a broad-based coalition of health care leaders convened by AHIP, CMS, and NQF. In her talk, Nwosu noted several challenges to the adoption of national core measures sets, including lack of interoperability, small sample sizes, and lack of alignment with state Medicaid and commercial measurement efforts. Some proposed strategies included standardization of measure implementation across payers, alignment of CMS reporting requirements with the core measures, identification of high-impact measures with strong relationships to outcomes, and increased data capacity of electronic health records and interoperability between registries.

Faith Green, Humana, talked about her organization’s journey to align their measures across product lines, including the lessons learned from their process, which reduced their number of metrics from 1,116 to 208. I then talked about the 2019 Kentucky Core Healthcare Measures Set (KCHMS), created by experts across the Commonwealth of Kentucky and convened by the KHC. The 2019 KCHMS, the second iteration of the core measures set, was released in August. The morning ended with an expert panel discussion about the current landscape and future of healthcare measurement in the Commonwealth.

Path Forward is Challenging but Promising

If the energy at our KHC Community Health Forum was any indication, the future of measurement alignment in the Commonwealth is a promising one. Much like the AHIP/CMS/NQF Core Quality Measures Collaborative, we are now at the point where we have a core set of key quality indicators that is ready for implementation among Kentucky’s various stakeholders.

From the beginning, more than two years ago, we have been truly overwhelmed by the response that we have gotten around this initiative. With the current state of healthcare work today, it is often challenging to get volunteers to commit to “one more thing” in addition to their already overextended workload. However, we were approached – enthusiastically, I might add – by individuals from all backgrounds to serve on this project, which speaks to the importance of this work.

What we have launched is not a small lift. Healthcare measurement alignment is tough work, and it’s not for the faint of heart. It isn’t easy to sift through hundreds of measures to identify the ones that will give us the greatest insight into how our healthcare systems are performing, while also continuing to honor the various reporting standards given by dozens of other organizations. However, while the daunting quality of the work has the potential to be a deterrent, it is important to push for reduction and alignment around meaningful measures that ultimately drive change in our community, reduce measurement burden, and improve adherence to evidence-based medicine and health outcomes.

Creating a core set of healthcare measures to focus and align priorities is just the first step toward aligning incentives around the things that matter. The Kentucky Core Healthcare Measures Set brings together the priorities of consumers, providers, payers, and purchasers specifically with the needs of the Commonwealth in mind. We need to push in the coming months to get this core measures set in use by our payers, providers, and purchasers. I feel a bit like a broken record, but as always, I want to finish with this thought: By focusing on everything, we focus on nothing. But by focusing on the right things, we can drive improvements.

Did you miss the KHC Community Health Forum, “Driving Health Improvements Through Measurement Alignment”? Click here to see the agenda and slide decks from the event.

Kentucky Core Healthcare Measures Set Expands to 38 Adult and Pediatric Primary Care Measures

Stephanie Clouser

After a summer of deliberations by committees, the 2019 Kentucky Core Healthcare Measures Set has been finalized, increasing the number of core measures from 34 to 38.

The final vote resulted in the removal of three measures, addition of seven measures, and the upgrade of two measures from “standard” priority to “high” priority. Measures added include opioid treatment agreement, progress towards depression remission, diabetes blood pressure control, childhood and adolescent well care visits, HPV immunization, and patient experience. Measures related to diabetes and cardiovascular disease medication adherence and bronchitis antibiotic avoidance have been removed.

This year’s update ensures that the measures on the core measures set are current, relevant, and sound. The Kentucky Performance Alignment Committee – or PMAC – and its subcommittees have spent the last months reviewing the current measures set, examining potential measures for addition, and confirming or questioning the current measures’ relevance.

The core measures set was developed and released through a public-private partnership with the goal of creating a core measures set for Kentucky stakeholders to align to. The core measures set is focused in the areas of prevention, pediatrics, chronic and acute care management, behavioral health, and cost/utilization.

MEASURE UPDATES INCLUDE ‘STRETCH’ MEASURES TO DRIVE HEALTH OUTCOMES IN THE COMMONWEALTH

In 2018, the PMAC team chose a few “stretch measures” that might have had a few more challenges to them but ultimately were important to impacting the health of Kentuckians. This year, the committee and subcommittees chose a few more of those stretch measures, including Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents and Depression Response at Twelve Months – Progress Towards Remission. The data extraction required of these measures makes them more challenging to measure.

The full list of changes is as follows:

  • Add Documentation of Signed Opioid Treatment Agreement
  • Add Adolescent Well-Care Visits
  • Add Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
  • Add Comprehensive Diabetes Care: Blood Pressure Control
  • Add Depression Response at Twelve Months – Progress Towards Remission
  • Add CG-CAHPS
  • Modify Immunizations for Adolescents to break out HPV
  • Upgrade Comprehensive Diabetes Care: Eye (Retinal) Exam to high priority
  • Upgrade Comprehensive Diabetes Care: Nephropathy to high priority
  • Remove Medication Adherence for Diabetes
  • Remove Medication Adherence for Cardiovascular Disease
  • Remove Antibiotic Avoidance in Adults with Acute Bronchitis.

You can find the complete list of 2019 KCHMS measures here. For more information on the core measures set, click here.

COMMUNITY HEALTH FORUM WILL HIGHLIGHT NATIONAL AND REGIONAL ALIGNMENT EFFORTS

The 2019 KCHMS will be rolled out at a KHC Community Health Forum on September 10, “Driving Health Improvements Through Measurement Alignment.” The Forum will highlight national and local measurement alignment efforts aimed at reducing measurement burden, improving focus, and ultimately measuring what matters most to patients.

Chinwe Nwosu, America’s Health Insurance Plans, will discuss the advancement of quality measurement and improvement through core measures sets. Nwosu, the project manager for the Core Quality Measures Collaborative (CQMC), a broad-based coalition of health care leaders convened by America’s Health Insurance Plans (AHIP) starting in 2015. It includes Centers for Medicare and Medicaid Services (CMS), the National Quality Forum (NQF), health insurance providers, medical associations, consumer groups, purchasers (including employer group representatives), and other quality collaboratives. The KHC joined this collaborative in recent months. CQMC members work to identify Core Measure Sets – parsimonious sets of scientifically sound measures that efficiently promote a patient-centered assessment of quality and should be prioritized for adoption in value-based purchasing and alternative payment models.

Faith Green, Humana, will also talk about her organization’s journey to align their measures across product lines. KHC’s Stephanie Clouser will introduce the 2019 KCHMS. The morning will end with an expert panel discussion about the current landscape and future of healthcare measurement in the Commonwealth and will include:

  • Jenny Goins, Commissioner, Department of Employee Insurance, Kentucky Personnel Cabinet
  • Michael Hagen, Professor, Dept of Family and Community Medicine, University of Kentucky
  • Amy Mattingly, Provider Collaboration Director, Anthem Blue Cross and Blue Shield of Kentucky
  • Angela Parker, Director, Program Quality and Outcomes, Department for Medicaid Services
  • Rachelle Seger, Community Health Research Officer, Foundation for a Healthy Kentucky

The Forum will take place from 7:30 a.m. to 10 a.m. on Tuesday, September, 10. As always, registration is free for individuals who work for a KHC member organization and $35 for anyone else. For more information on the Forum, click here.

More information on the core measures set, including future areas of development, will be shared in the future.

HPV Vaccination – An important, but Neglected, Piece to Adolescent Vaccine Series

(Note: This guest piece was written by Elizabeth Holtsclaw, MA, Health Systems Manager, State & Primary Care Systems, American Cancer Society)

Remember in elementary school when one of the first assignments of the new school year was to write an essay titled: How I Spent My Summer? In the spirit of the back-to-school season and recognizing August as National Immunization Month, I’d like to share how I spent my summer: Advocating for the HPV vaccination in Kentucky.

The American Cancer Society, along with the Kentucky Department for Public Health and other stakeholders and health care systems, convened community and healthcare leaders in Paducah, Louisville, Lexington and Somerset for roundtable discussions about the need for increasing HPV vaccination in the state. These HPV roundtables not only served as networking and professional development opportunities, but also helped increase awareness of the issue, and served as a catalyst for best practice sharing and idea generation on ways to close the HPV immunization disparity gap. We’ve challenged each region to develop their own SMART goals that will work in their area to increase HPV vaccination.

And that disparity gap? It’s significant. But first, a little about the vaccine.

HPV vaccination is cancer prevention

The Human Papillomavirus (HPV) is a very common virus that can lead to cancer-causing infections. In fact, every year 33,000 people are diagnosed with HPV cancers. The HPV vaccine prevents six types of cancer – cancers of the cervix, throat, anus, penis, vagina and vulva – and is expected to prevent 90% of HPV-related cancers when given before a child is exposed to the virus. 

The two-shot HPV vaccine series is best given to boys and girls at ages 11 or 12, which is generally before they are exposed to the virus and when their immune systems can provide the most protection. That’s also the age when parents are usually taking adolescents in for their meningococcal and Tdap (Tetanus, Diphtheria and Pertussis) vaccinations, so getting Kentucky adolescents vaccinated against HPV should be simple, right?

So there’s a vaccination that can prevent cancer, but people aren’t getting it

The CDC recently released its latest report from the National Immunization Service-teen (NIS-teen) survey, a national survey which gathers information on vaccination rates of 13-17 year olds in the US. You can find the report in the Morbidity and Mortality Weekly Review. The report shows that the rate of 13 to 17-year-olds with one dose of the HPV vaccine increased slightly, from 65.5% in 2017 to 68.1% in 2018, and the rate for series completion increased from 48.6% to 51.1%. However, these increases were only seen in males.

And here’s the thing about that disparity in Kentucky: Kentucky falls below the national average on HPV vaccination. We know that adolescents are getting their other vaccines (Tdap at 84.9% and meningococcal at 84.4%) but not getting the HPV vaccine (first dose of HPV is 56.9% and up-to-date vaccination is 42.6%. You can view this in the MMWR supplemental table.

Here’s a snapshot:

  • According to the Kentucky Cancer Registry, Kentucky has the highest HPV-related cancer burden in the nation
  • The Centers for Disease Control (CDC) National Immunization Survey indicates that Kentucky is 49th in the nation for HPV vaccination
  • Only 42.6% of Kentucky adolescents are up to date on completing the HPV two-shot series, which is below the national average of 51.1% (68.1% of adolescents age 13-17 have received the first dose of the series)

Why the gap?

Reasons for the vaccination gap vary, depending on a multiple factors – parents feel their child isn’t sexually active yet at age 11 or 12 and are not in need of the vaccine, or they aren’t aware of the vaccine at all – but research tells the biggest factor that leads to parents getting their children vaccinated is simply the clinician recommending it. The MMWR data referenced above emphasized the importance of a provider recommendation as HPV vaccination rates for adolescents whose parents reported receiving a provider recommendation were 28 percentage points higher than those who did not.

That’s right: Parents receiving the physician or nurse practitioner’s recommendation of the vaccine – on the same day and in the same way as other vaccines – were more likely to make sure their children were vaccinated. In fact, studies show parents value the HPV vaccine equally with other vaccines … they just need to hear the endorsement of the provider as a prompt to action. Parents need to know that the vaccine is cancer prevention, but they also want reassurances that the vaccine is safe, effective and lasts.

That seems simple enough, right?

Of course clinicians may not be comfortable recommending the vaccine if they have questions of their own, and the HPV Roundtable discussions have shown that even some healthcare providers feel like they need more information about the vaccine. More information about HPV, the vaccine, and guides for healthcare providers can be resourced at cancer.org/hpv.

And I also encourage parents or members of the community who have questions or concerns to visit cancer.org/hpv and get the facts. As a parent, I have one more task on my to-do list this summer: to get my 11-year-old son his HPV vaccination this week, along with his other adolescent vaccines. And I can assure you his passionate mom will be taking photos of him the whole time. These pictures will join the ones I have shared on social media of my 13-year-old daughter who completed the two-shot series, to show Kentucky that I want to protect all of Kentucky’s children as I have my children.

Here’s what you can do

The data is clear that a strong provider recommendation is the key to a successful increase in HPV vaccination rates.

  • Bundle your adolescent vaccine recommendation “Your child is here today for three vaccines. These will help protect her from meningitis, HPV cancers and pertussis.”
  • Engage all office staff in your commitment to increasing HPV vaccines in the office.
  • Let’s be creative in engaging diverse provider groups in this work; Pediatricians, family practice doctors, OB-GYN, dentists, orthodontists, school districts and communities.
  • There are ways to talk to parents, such as motivational interviewing or a presumptive recommendation, that are proven to help them feel comfortable in vaccinating their children.
  • Know your own data! What is our state data? Your county and school system data? Your clinic data as a whole and the individual provider data? Because HPV is not a mandated vaccine, it’s not always a priority for reporting and data collection. We often THINK we are doing better than what’s really happening.
  • Engage in our regional Roundtables and within your networks to make HPV vaccination a priority. Contact me at elizabeth.holtsclaw@cancer.org to find out more.

The opportunity we can’t miss

We have an opportunity in Kentucky and the rest of the nation to see almost immediate reduction in adverse health outcomes related to the HPV virus. Very rarely in public health are we able to see such immediate and dramatic improvements such as is being seen in areas with high vaccination rates. It’s incredibly exciting and I welcome the energy we’ve seen across the state this summer.

As summer winds down, the American Cancer Society plans to keep the conversation about HPV vaccination going, as well as continue the momentum the Roundtables have begun. Additional Roundtables are scheduled for Hazard, Bowling Green and Morehead with other activities in London and Prestonsburg in the coming months. There is an energy and excitement in each of these communities and we sincerely hope it will translate to a healthier future for Kentucky.

Together – as a community, as parents, as healthcare providers – we can truly make this a summer to be remembered in the fight against cancer.

Call for Public Comment: Proposed Changes to KY Core Healthcare Measures Set

2018 KY Core Healthcare Measures Set

Modifications are being made to the Kentucky Core Healthcare Measures Set (KCHMS), and healthcare stakeholders throughout the Commonwealth are invited and encouraged to review and comment on those submissions during a public comment period that will run through August 9.

In 2018, the core measures set was developed and released through a public-private partnership with the goal of creating a core measures set for Kentucky stakeholders to align to. The 2018 core measures set includes 34 unique measures, focused in the areas of prevention, pediatrics, chronic and acute care management, behavioral health, and cost/utilization.

This year’s update will ensure that the measures on the core measures set are current, relevant, and sound. The Kentucky Performance Alignment Committee – or PMAC – and its subcommittees have spent the last months reviewing the current measures set, examining potential measures for addition, and confirming or questioning the current measures’ relevance.

This week, the subcommittees presented their final recommendations to the PMAC Oversight Committee, which will finalize the 2019 KCHMS measures on August 20.

If all recommendations are accepted, the core measures set will increase from 34 measures to 39. Measures that would be added include opioid treatment, depression treatment, diabetes blood pressure control, childhood and adolescent well care, and patient experience measures. Measures related to medication adherence and antibiotic avoidance would be removed.

Any healthcare stakeholder is invited to provide feedback for the PMAC Oversight Committee on these recommendations. The public comment period will close August 9, and you can find details on the proposed changes and public comment form here.