MODELS FOR PRACTICE

FOCUS AREA: IMMUNIZATIONS AND INFECTIOUS DISEASES

 

Program Name: Communities Caring for Children

Location: Thief River Falls, Minnesota

Problem Addressed: Immunization and Infectious Disease; Maternal, Infant, and Child Health

Healthy People 2010 Objective: 14, 14-26, 16

Web Address: www.ccc-registry.org

 

SNAPSHOT

 

Communities Caring for Children (CCC) is both an immunization registry and a maternal and child health outreach program. Public health nursing agencies in 12 relatively low income and rural counties in northwest Minnesota conduct the program. All of the public health nursing agencies work with various groups within the community including clinics, hospitals, health plans, and schools. The mission of the program is to improve the health of mothers, children, and families through education, outreach, and support to families.

 

CCC began in 1991, when only 58 percent of the two-year-old children in the area were up to date on their immunizations, 17 percent of children zero to five years of age received well-child exams, and approximately 25 percent of pregnant women in the area did not receive prenatal care in the first trimester. CCC has increased the percentage of pregnant women who receive prenatal care and has increased the immunization rates of children through collaboration and cooperation among various entities.

 

THE MODEL

 

Blueprint: CCC serves all children in the area ages zero to 21, pregnant women, and adults who receive immunizations. Currently, 2,886 pregnant women are enrolled, with 61,548 total records in the system. There is no cost to participate in CCC, and families may enroll at any time. In an effort to maintain accurate and up-to-date immunization records, CCC includes an immunization registry that is universal, web based, and includes a reminder system. This is the first web-based registry in the state and now includes 45,703 children ages zero to 21 years old. All participating public health agencies support the registry financially. The registry also tracks well-child exams and other data used for outreach and evaluation. It records who has received or needs newsletters and follow up on immunizations, pregnancy, and well-child care. The system allows summary statistics for each county or the aggregate participating counties to be generated.

 

The outreach component of the program falls under two categories: education and the provision of services. Through public education efforts, CCC seeks to increase community awareness of the importance of prenatal care, childhood immunizations, and well-child care and the barriers that prevent families from receiving such care. Public health nurses accomplish this through presentations to local clubs, businesses, organizations, and state conferences. Other methods the program uses to increase awareness include: publication of articles in newspapers and different agency newsletters, brochures, public service announcements, local radio and TV talk shows, posters, health fairs, mail stuffers, stickers, and activity sheets used for evaluation purposes.

 

The program also provides services to those enrolled in the program. Pregnant women can enroll at local clinics; Women, Infant, and Children (WIC) clinics; local public health agencies; or at the hospital obstetric wards. During the pregnancy, women receive three newsletters¾one each trimester. A public health nurse follows up with women who miss appointments and works with them to reschedule and address any barriers the women may face. After delivery, new mothers receive the newborn “Health Tracks” newsletter whether or not they are already enrolled. This newsletter is sent to enrolled families two weeks before every well-child exam and/or immunizations are due. In addition, follow-up phone calls are made to families four weeks after the two-month, nine-month, and 18-month newsletters are sent; data are collected about well-child exams, immunizations, barriers to receiving care, and ways that barriers can be overcome. Public health nurses use this information as they continue to follow up with families until the child is up to date on immunizations.

 

CCC is an inter-agency agreement between the 12 participating public health agencies. An agency director is appointed as a fiscal agent, and there are several standing committees. During the first three years, a project director worked full time but then changed to two days a week, with a public health nurse coordinator working one day a week. The project director and the public health nurse coordinator met with the agency public health nurses every four to eight weeks. Now that the program is established, administrative coordination is accomplished through the fiscal agent and the chair of the lead committee. Coordination of local staff is combined with regional maternal and child health nurse meetings.

 

CCC attributes its success to many factors, among them:

 

 

Making a Difference: The consortium uses several methods to evaluate the program processes and outcomes, including telephone and mail surveys and survey statistics from the registry. Phases of the evaluation are ongoing.

 

Data from the registry show that 90 percent of two year olds in the program received age-appropriate immunizations compared to the baseline data of 58 percent. At the same time, 91 percent of women in CCC’s prenatal program received first trimester care compared to 75 percent of women before the program began. In addition, only 3.6 percent of participating women had low-birth-weight babies, compared to the state average of 3.8 percent for the 12 counties. Only 4.6 percent of pregnant women had preterm births, compared to 8.8 percent for the state.

 

Public health nurses in CCC conducted more than 10,000 outreach activities including letters (43 percent), phone calls (42 percent), and home visits (15 percent). Often, these activities included discussions about immunizations, well-child exams, prenatal information, and follow-up on missed appointments, among other issues. Public health nurses also referred participants to community resources, including 970 referrals to medical assistance, WIC, public health nursing services, social services and other agencies, and 262 postnatal referrals to similar services as well as to Early Childhood Special Education and Head Start.

 

A survey of 710 participants revealed that 100 percent of participants felt it was somewhat or very important to receive prenatal care in the first three months of pregnancy; 99 percent felt well-child exams were somewhat or very important, and 100 percent felt it was somewhat or very important for children to receive well-child exams. In addition, 85 percent felt the program phone calls were useful, and 93 percent would recommend the program to other families.

 

Beginnings: CCC began in 1991 when the Minnesota Department of Health and 10 public health nursing agencies formed a consortium and applied for and received a $300,000 three-year grant offered through the Office of Rural Health Policy. To determine the needs of the counties, a discussion was initiated among public health nursing directors, public health nurses, local physicians, social workers, early childhood educators, hospital nurses, and others. Data for 1991 in the 13 counties showed:

 

 

The consortium realized these findings called for outreach programs that encouraged pregnant women to seek and remain in medical care, and programs that educated parents about healthy pregnancies, immunizations, well-child exams, and community resources.

 

Grant goals, objectives, activities, and a budget were developed by the consortium between March and December 1992. Funds were allocated for evaluation purposes through the Center for Social Services at Bemidji State University, and the consortium contracted with an independent software developer to create the registry. The fiscal agent developed contracts with the other nine public health agencies, and a public health nurse was hired in each county to conduct the program. An advisory committee was formed, but it was disbanded in the second year of the program after promotional material was developed. It later reconvened as a partnership work group, with health plans and medical providers to develop the immunization registry. The program was fully implemented in 1993.

 

Challenges and Solutions: Maintaining and sustaining the program financially is the largest challenge faced by CCC. After the initial grant ended, it was a challenge for the program to find grants that fund ongoing programs. Fortunately, CCC secured funding through the Medica Foundation (now the Allina Foundation). Beginning in 1995, the Foundation developed a partnership with CCC. This allowed the program to continue, write a manual for replication in other rural communities, and find a stable funding source. Dakota Medical Foundation partnered with CCC with funding to develop the immunization registry. Since 1991, CCC has raised $2 million from grants and foundations to develop the program and become fully operational, in addition to financial contributions of the local agencies.

 

In 1996, CCC received the Governor’s Commendation for a Cooperative Public Service Award. In addition, it was identified as a model program in Shots for Tots Best Practices by the Allina Foundation and the Children’s Defense Fund of Minnesota.

 

PROGRAM CONTACT INFORMATION

 

Susan Olson, Fiscal Agent

Inter-County Nursing Service

318 Knight Ave. N.

Thief River Falls, MN 56701

Phone: (218) 681-0876

Fax: (218) 683-7099