Model Practices Database View

Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:

• Size of population in your health department’s jurisdiction
• Who is your target population/audience, for this practice
• Size of target population/audience, if applicable
• The number or percentage of the target population/audience reached, if applicable
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing. Briefly indicate what the practice intends to accomplish overall.
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met?
• What specific factors led to the success of this practice?
• Lessons learned from the practice

San Joaquin County (SJC) Public Health Services (PHS) serves a demographically diverse population of 685,306 in the agriculturally-dense Central Valley of California. The population targeted for this project was the 136,000 school-aged children, many with limited access to services. Unreliable funding for public health services affects the resources available to fulfill PHS’s mission in the community, and to address emergent public health threats such as an Influenza Pandemic and ongoing threats like a pertussis epidemic. PHS has a long-standing relationship with school districts in addressing communicable disease issues and has nurtured this relationship, recognizing school health services as a valuable resource to support the PHS mission to the community. This practice focuses on enhancing PHS communicable disease control efforts by expanding the scope of the school’s partnership to include PHS providing training on conducting school-based vaccination and/or prophylaxis clinics and opportunities to exercise these skills on an ongoing basis. The objectives were to facilitate administration of influenza and pertussis vaccine to students at school sites, to assist and prepare school nurses to implement mass vaccination clinics at schools, and to build-in strategies to provide sustainability.

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Implementation of this practice began in 2009 with confirmation of the H1N1 Influenza Pandemic and extended into 2010 when significant increases in pertussis cases were identified. Framework for this practice was established in 2006, fueled by the shift in recommendations to vaccinate school-aged children against influenza and the increasing emergency preparedness responsibilities of health departments. PHS staff met with local and county school health staff to plan for the training of school nurses to set up and implement school site mass vaccination clinics in response to public health communicable disease threats. PHS provided school nurses with standing orders and training on vaccination administration and handling, and clinic set up and activation including utilizing the Incident Command System organizational structure. PHS also provided ongoing opportunities to practice these new skills. As a result of these preparations, school-based clinics to administer influenza vaccine during the Influenza Pandemic were highly successful in reaching the target population. SJC/PHS received a commendation from the California Department of Public Health for having administered 17,849 doses of FluMist (the most in California) in collaboration with the school nurses. Additionally, 1,237 doses of injectable vaccine were administered.

Describe the public health issue that this practice addresses. (350 word limit)

Funding for public health services is not a continuous, ongoing, guaranteed stream of funding. It comes and goes depending on the economy. Consequently, staffing to provide needed public health services is not stable either. In planning and preparing for reductions in funding and staffing, SJC/PHS recognized early the schools were a key component in helping to extend and expand its services in the community. Public Health Services had the foresight not only to nurture and foster the relationships with the school nurses on an ongoing basis, but to look at what was going on in the community and public health in general, share that information with the school health programs and provide training to the school nurses to support PHS in the provision of needed services, including, but not limited to: administering influenza vaccines, conducting mass vaccine clinics, and functioning under Health Officer’s Standing Orders to improve immunization rates. When the Influenza Pandemic and the pertussis epidemic occurred, the economy had adversely affected PHS resources. The existing partnership with the school nurses provided an opportunity for PHS to utilize this resource to support Pandemic and disease control efforts in the community. Vaccines are the most effective strategy for dealing with influenza and pertussis. PHS supplemented existing resources available through the school nurse partnership with Health Officer Standing Orders for vaccine administration, additional training, and vaccine and immunization supplies in order to facilitate participation of the schools in PHS disease control efforts. When the Influenza Pandemic and the pertussis epidemic became health threats, PHS was able to expand the role of school nurses fairly easily due to the flexibility and sustainability of the already existing partnership.

What process was used to determine the relevancy of the public health issue to the community? (350 word limit)

The three (3) Core Functions of Public Health Services are: Assessment, Policy Development and Assurance. Public Health agencies in the United States are charged with providing the following 13 essential services: monitor health status; diagnose and investigate; inform, educate, and empower; mobilize community partnerships; develop policies and plans; enforce laws and regulations; link people to needed services / assure care; assure a competent workforce; evaluate health services; and research. In so doing, it is customary for PHS to be aware of public health issues that are happening in the community and project what the impact may be on the community. For several years, PHS has been working on plans to have in-place for responding to emergency situations. These plans are practiced and exercised on a routine basis. In the past few years PHS has established committees of key players to discuss strategies and implement the PHS response plan for the emerging threats including H1N1 influenza spread into California and the county, and the increase of pertussis cases in California and the county. The process for H1N1, was to follow the established Pandemic Plan for a new strain of Influenza that had high rates of morbidity and mortality, which included utilizing existing partnerships in new or expanded activities. In regards to the pertussis epidemic, the process was to work closely with the schools to design outreach and vaccine distribution strategies that address the new California mandate that all students in grades 6-12 are required to have a Tdap booster shot in order to attend school.

How does the practice address the issue?

Vaccination is the most effective way to prevent and reduce the risk of influenza and pertussis. Lack of adequate funding for public health services and staff, restricts Public Health’s ability to fulfill its mission to the community. PHS recognizes that partnering with the schools and utilizing school nurses to administer vaccines at the school site under the standing orders of the Health Officer, will improve the community’s access to vaccines and significantly assist PHS in its efforts to control and prevent communicable diseases in the community. Developing partnerships that focus on the current health needs of the community and that utilize strategies that incorporate flexibility and provide for sustainability, allow local health departments to mobilize community resources to help meet emergency or newly identified health threats.

Is the practice new to the field of public health? If so, answer the following questions.

What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review.

How does this practice differ from other approaches used to address the public health issue?

Is the practice a creative use of an existing tool or practice? If so, answer the following questions.

Yes

What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice? (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population?

Yes, NACCHO’s toolbox included MAPP.
The MAPP process is a framework for creating new collaborations to meet identified needs in the community. This plan incorporates: an organized, formal process; broad representation from local health system partners, community organizations and residents; a leadership committee to provide oversight; and subcommittees to carry out specific duties and activities. PHS utilized the MAPP framework to formalize and expand upon an existing informal relationship between PHS and San Joaquin County Public Schools. After assessing areas in which school health programs could support PHS in its broader communicable disease control responsibilities (for example, emergency response activities) or provide a means to access hard to reach populations to improve ongoing disease control efforts (for example, increase influenza and Tdap vaccine usage in the school age population), PHS staff identified School Health Program Administrators from six schools districts as the target participants. Staff from PHS set up ongoing meetings with the school district health administrators to identify and discuss areas and inventive ways in which collaboration could support the needs and missions of both groups. PHS provided the ongoing leadership and guidance for this process, and the tools, training and other support needed to achieve the agreed upon goals of this collaborative effort. PHS utilized the MAPP tool as a guide to creating its own “map,” making an existing collaboration more structured and formal, expanding the scope of activities of that collaboration, and preparing the participating members to perform the new activities. The process also included the creation of an MOU between the school health programs and the County Health Officer, allowing the school nurses to administer immunizations and vaccines to their students under Health Officer standing orders. This innovative practice has proven to be extremely effective.

What process was used to determine that the practice is a creative use of an existing tool or practice? Please provide any supporting evidence you may have, for example, literature review.

PHS utilized the MAPP tool in an innovative manner to expand the scope and activities of an existing partnership in an effort to meet identified community needs. Literature review documented the value of partnerships between local health departments and schools, but did not discuss processes for the development of these partnerships. PHS has a long history with the California Immunization Coordinators group. The meetings of these county coordinators and state personnel present opportunities for SJC to share its practices and to learn about other counties. It is not unusual for health departments to have some relationship with schools; however, using the MAPP process to formalize and support expansion of an existing relationship has not been mentioned by our counterparts. Additionally, many counties have collaborations with schools as part of their emergency preparedness planning process, as opposed to expanding existing collaborative efforts. Most school districts also do not have a physician for nurses to work under. The PHS use of the MAPP process was specifically designed to allow for greater collaboration between health partners who provide services to similar populations or whose service goals overlap. The California Department of Public Health, recognizing the need of this type of collaborative effort and wanting to promote its growth, created a guidance document on Strategies for Improving Communication and Collaboration Between Local Educational Agencies and Local Health Departments. Input from SJC was included and acknowledged as being helpful to this effort by providing practical information on how to facilitate this type of partnership.

How does this practice differ from other approaches used to address the public health issue?

Other approaches focus on the creation of new, formal, broad-based community partnerships functioning under the “emergency preparedness” umbrella, or non-formal partnerships with limited activities, such as doing “flu clinics” at a school site, with or without school nurses. This practice focuses on building upon an existing partnership utilizing an individualized process based upon the MAPP tool. The concept of a vital link between the missions of the schools and the local health department is one that is currently being promoted and activities that facilitate this type of partnership are not only being encouraged but are being studied in order to develop guidelines to assist local health departments in their efforts at collaborations with the schools. The utilization of MAPP concepts and process to develop an individualized plan for the creation of partnerships between local health departments and the schools supports and facilitates the development of partnerships specific to the goals and needs of the local community in an efficient and organized manner.

If this practice is similar to an existing model practice in NACCHO’s Model Practices Database (www.naccho.org/topics/modelpractices/database), how does your practice differ? (if, applicable)

Who were the primary stakeholders in the practice?

The major entities from Public Health Services (PHS) are the County Health Officer and the Immunization Program Coordinator who serves as a liaison between the schools and state and local public health agencies. In addition, coordinators for the Communicable Disease and Prevention Program and the Emergency Preparedness Program are key contributors to successfully developing and implementing this practice. Primary partners from the educational agencies include the County Office of Education’s Comprehensive School Health Program Coordinator, the Superintendents of the School Districts, the lead Health Administrators of each School District’s Health Services and the school nurses. Without the commitment and participation of all these stakeholders, the practice would not be as effective.

What is the LHD's role in this practice?

Public Health Services (PHS) has the crucial role of providing leadership in defining the problem to the stakeholders and in developing a plan with effective strategies to address the given public health issue. For this practice, it starts with engaging school districts to become part of the process of setting up vaccination clinics onsite. The County Health Officer is key in advocating for and developing appropriate protocols for school nurses to work under the health officer’s standing orders. The Health Officer presents the specific policy to the county counsel for review and approval. The PHS Immunization Program Coordinator serves as a “liaison” between the schools and the county and state public health agencies. This position is the PHS contact for schools to get necessary support, consultation and guidance, training on administering and proper handling of vaccine, coordination of vaccine allocation, delivery, management, storage and reporting to ensure compliance. In addition, PHS provides the school nurses with training and exercises on emergency preparedness planning and response for setting up a mass vaccination clinic.

What is the role of stakeholders/partners in the planning and implementation of the practice?

Initially, the county and district school health program coordinators meet with Public Health Services to discuss the given public health issue, provide input from the schools’ perspective, and agree to be part of the process. Then the health coordinators present information to the school district superintendents about the need, importance, and benefits of providing on site vaccination clinics to keep their students, staff and community healthy, and to meet their health mandates and educational goals. After the Health Officer’s standing orders have been reviewed and approved by county counsel and the superintendents, all the participating school nurses review, sign and date the protocols they will follow. The school district nurses inform the parents about the situation and the plans to provide vaccinations at the school. The schools provide vaccine information sheets and permission slips for the parents to sign for their consent. School districts also utilize their automated notification systems to emphasize key messages and to inform and remind parents of available health services. The schools physically set-up and implement the vaccination clinic onsite and administer vaccine according to the Health Officer’s standing orders. The schools also make the appropriate documentation and provide report to the PHS Immunization Program Coordinator.

What does the LHD do to foster collaboration with community shareholders?

Describe the relationship(s) and how it furthers the practice's goals.

The working relationship between PHS and the school nurses has been functioning since the seventies. This relationship continues to grow and evolve. The long-standing collaborative efforts between the school nurses and Public Health Services’ immunization program and the communicable disease and tuberculosis programs laid the groundwork for trust, respect, and communication, and a spirit of team work. The school nurses can function as an extension of PHS and help to expand its delivery of services and efforts to control disease transmission in the community. PHS provides over-all leadership and direction for the practice; the school health administrators are the lead within the school system, with approval and direction from the district superintendants and school principals. The relationship is two-way, with all partners having the opportunity for input. PHS ensures that the school health program staff from the participating school districts, receive feedback on and acknowledgement of their contributions and that the schools also have the opportunity to provide feedback to PHS.

Describe lessons learned and barriers to developing collaborations

The barriers are listed below along with the valuable lessons learned from this collaborative working relationship: 1) Lack of Communication – a. Identify key contacts at the schools and at PHS that will be committed to be responsive to needs of the other b. Develop email and phone lists of the stakeholders and appropriate contacts c. Invite the stakeholders to “the table”, to meetings and trainings that will benefit each other d. Establish a PHS Liaison to coordinate communication, consultation, training and vaccine supply distribution, management and reporting (for SJC/PHS this position was the Immunization Program Coordinator) 2) Hesitancy to participate – a. Clarify and understand the need, importance, benefits, and commonality of purpose in these joint efforts b. Assure school leadership that they will have the lead on issues related to school sites, staff and supplies c. Consult county counsel on the legal and liability issues 3) Turf issues - a. All partners need to be heard, be part of the process, provide input, be part of decision making, and agree the collaborative’ s commonality of purpose is a priority b. Clarify roles and responsibilities c. Provide leadership to monitor and keep the project on track d. Foster an environment that promotes positive working relationships and outcomes 1) Lack of Communication – a. Identify key contacts at the schools and at PHS that will be committed to be responsive to needs of the other b. Develop email and phone lists of the stakeholders and appropriate contacts c. Invite the stakeholders to “the table”, to meetings and trainings that will benefit each other d. Establish a PHS Liaison to coordinate communication, consultation, training and vaccine supply distribution, management and reporting (for SJC/PHS this position was the Immunization Program Coordinator) 2) Hesitancy to participate – a. Clarify and understand the need, importance, benefits, and commonality of purpose in these joint efforts b. Assure school leadership that they will have the lead on issues related to school sites, staff and supplies c. Consult county counsel on the legal and liability issues 3) Turf issues - a. All partners need to be heard, be part of the process, provide input, be part of decision making, and agree the collaborative’ s commonality of purpose is a priority b. Clarify roles and responsibilities c. Provide leadership to monitor and keep the project on track d. Foster an environment that promotes positive working relationships and outcomes.

Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.

Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).

List up to three primary objectives for the practice. For each objective, provide the following information: (750 word limit per objective)

This practice was not set up as a pilot project, but as a response to various emergent public health issues. The local strategies and policies are developed and applied to our community with consideration of current research and recommendations from the experts such as Centers for Disease Control and Prevention (CDC).

• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation. Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback: List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.

Besides acknowledgement from the State for the most doses of FluMist administered in the state, the Health Plan of San Joaquin ran a daiaanalysis. The tables below list hospital inpatient bed day rates (bed days/1000members/year) at the Health Plan of San Joaquin for the winter months of 2008-2011. Of note is that the bed days decreased in 2010 (year that H1N1 immunization was first given) and was also better this year. The HPSJ Medi-Cal total population is around 75,000 and population of all lines of business around 100,000. Note our average bed days rate for the 4 year period on Medi-Cal was around 250. Medi-Cal Year Jan Feb Mar Average 2008 321.78 274.03 308.07 301.29 2009 284.17 263.26 315.14 287.52 2010 224.00 244.53 243.77 237.43 2011 255.72 221.32 209.70 228.92 All Lines of Business (Includes Healthy Families—Children) Year Jan Feb Mar Average 2008 278.60 239.27 266.12 261.33 2009 243.98 206.56 244.68 231.74 2010 187.51 205.62 210.07 201.06 2011 206.97 181.25 172.61 186.95

Objective 1

Objective 1 is to facilitate vaccine delivery to school-aged children during the Influenza Pandemic and in response to the upsurge in pertussis morbidity and mortality. The immunization program had always conducted community influenza clinics but the focus was the elderly and the high risk in the community. When the state extended the guidelines for vaccination to include school-aged children one of the strategies to access this group included providing clinics at school sites. School sites in areas housing populations with limited access to health care services were identified and targeted for these special clinics. School Health Services staff notified families of the clinics and the importance of obtaining the recommended/required immunizations, obtained parental permission slips, and set up, staffed, and supplied the clinics. These clinics were determined to be successful based upon the turnout, the after action evaluations on the clinic set up and implementation and parental validation that these clinics made it easier to ensure that their children received the immunizations. School superintendents, school health administrators and the school nurses involved felt validated by their ability to demonstrate the potential of schools to enhance and protect the health of their students while providing an important community service. PHS received a commendation from the California Department of Health Services for providing the most influenza vaccinations in the state, as well as the most FluMist administrations given.

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Objective 2

Objective 2 is to assist and prepare school nurses for implementing "mass vaccination clinics." Prior to actually utilizing school-based immunization clinics as a strategy to reach a targeted population during a public health emergency, PHS had partnered with school nurses to train them in vaccine administration, provided guidance on setting up and implementing school site clinics, gave them an overview on the use of the incident command organizational structure, and utilized them to help staff public health influenza vaccination clinics. When the decision was made to expand this activity to include provision of school-based clinics in a response strategy to an identified communicable disease threat, additional issues needed to be addressed. These included the development of an MOU to allow school nurses to provide immunizations under the auspices of the Health Officer and providing training to the nurses on the provisions of the MOU and their responsibilities when functioning under the authority of the Health Officer. The MOU was developed, and approved by the County Counsel and the local School Superintendents. PHS staff provided several sessions for training on the MOU that were well attended. After action review of the clinics did not identify any problems with compliance with the requirements of the MOU and the school nurses did not give any negative feedback on functioning under the MOU. The school health administrators expressed appreciation for the MOU as it allows them to provide on-site immunization clinics, which can ultimately help them, facilitate compliance with California immunization requirements in schools with poor compliance as well as validate their ability to contribute to ongoing as well as emergency response activities of PHS.

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Objective 3:

Objective 3 is to provide support to the local school districts that will provide sustainability for this practice. In order to sustain a practice, it must continue to have value to the stakeholders, be updated as needed, and be practiced. School nurses and Public Health staff continue to meet on an ongoing basis, PHS continues to provide consultation, updates and training opportunities to school nurses, and the schools are encouraged to provide ongoing immunization clinics on site as needed. The MOU continues to be utilized as an essential tool to allow the school nurses to function as providers of immunizations and is one of the “perks” of the continued partnership for the schools. Commonality of purpose regarding student health remains a common goal for both organizations. Because of the over 40 year relationship between the schools and PHS, the nurturing of this relationship over the years, and the success of the newest collaborative efforts between the two, sustainability has proven to not only be obtainable but invaluable to an ongoing and evolving partnership.

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What are the specific tasks taken that achieve each goal and objective of the practice?

The goal of this practice was to enhance PHS communicable disease control efforts by expanding the scope of the school’s partnership to include PHS providing training on conducting school-based vaccination and/or prophylaxis clinics and opportunities to exercise these skills on an ongoing basis. To achieve this goal PHS and the County Office of Education identified key players in this process and set up an initial meeting during which PHS presented the concept of utilizing schools and school nurses to enhance PHS communicable disease control efforts in the community, both on an ongoing basis and in response to an identified public health threat. The triggers for this concept, the objectives identified to achieve this goal, and the outcomes of this practice that would benefit the school were also presented at this time. Implementation strategies, possible barriers and facilitators for this practice, and necessary tools for implementation were topics for additional meetings, as well as identifying roles and relationships between the two agencies in the planning and implementation process. Objective number one was achieved by developing an MOU allowing the school nurses to administer vaccines under Health Officer auspices, utilizing required protocols and procedures, providing training on vaccine administration and handling to school nurses, and providing opportunities to observe and staff PHS Influenza Immunization Clinics. Objective number 2 was met by providing leadership to the planning and implementation of a mass vaccination clinic, utilizing a school-based community influenza clinic as a way to prepare for the school nurses to performing this action on their own, with PHS acting in a consultation capacity. School nurses were also encouraged to partner with PHS in providing influenza vaccine to school-aged children via school-based clinics. Objective number three is being achieved by providing ongoing PHS communication, consultation, support and acknowledgement to school health administrators and school nurses, updating them on community health issues and enlisting their input to PHS communicable disease control efforts in the community.

What was the timeframe for carrying out these tasks?

Partnering with school nurses has been an ongoing process for a number of years. Initially the relationship consisted of PHS naming a liaison person for school nurses to contact when health questions/issues arose, usually related to communicable disease identification and follow-up. The relationship expanded to include the liaison attending monthly school nurse meetings, assisting school health administrators with trainings for school nurses on communicable disease issues, and inviting school health services staff to communicable disease and administration updates. The Immunization Program staff provided parent education on vaccine preventable diseases for local schools. When emergency preparedness became a PHS responsibility, influenza vaccination clinics were utilized as a way to prepare school health nurses to staff mass vaccination clinics implemented by PHS staff. When the Influenza Pandemic was declared, the existing partnership was utilized to expand the services provided by school nurses. Over a three month period an MOU was developed that allowed school nurses to administer vaccine under Health Officer auspices. This MOU was the only thing missing at that point to allow for the planning and implementation of school-based clinics.

Is there sufficient stakeholder commitment to sustain the practice? Describe how this commitment is ensured.

All the stakeholders participating in this collaborative practice understand their commonality of purpose and recognize it as a “win-win situation”. The partners have worked hard together and agree it is in the best interests of the school, the individual and the public’s health to foster and sustain this practice. Public Health Services and School Health Programs are committed to promoting a healthy future for San Joaquin County residents. One critical factor in achieving this is to reduce the burden and impact of communicable diseases on the individual and the community as a whole through administering vaccinations as needed. Public Health Services understands they cannot do it alone and realizes the importance of supporting and mobilizing community partners, resources and strategies to expand the delivery of crucial services in order to protect, preserve and promote the health of the community. Keeping students in school, healthy and free from disease affects the child’s readiness and ability to learn. This in turn affects the ability of the school to achieve its academic and financial goals and requirements. This practice has proven to be a very successful partnership that benefits all the participating entities. They each understand their own responsibilities contributing to its success. Public Health Services will continue providing the liaison and leadership roles as required. All the participating partners are committed to continue working together, communicating their needs, providing input and support, developing strategies and policies to address the needs, being responsive to each other, keeping each other informed, and offering training updates as needed to be in compliance with the standing orders provided under the county health officer. Public Health and the schools will continue to invite each other “to the table” in order to foster the communication, the working relationship, and the success of their joint efforts.

2012 Model Practice Application (Public)