June 14, 2018
The agenda has been released for the 2018 Healthy Students, Promising Futures Learning Collaborative. Click “View the full story” to read it.
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Healthy students are better learners, yet many schools are not able to deliver the conditions that support student health – conditions such as access to in-school health services, a clean and safe school building, nutritious food, and time and appropriate space for physical activities.
Delivering health services in schools is a key strategy for improving access to healthcare for children, including those in underserved populations. Furthermore, incorporating health and wellness into schools’ culture and environment will help close the educational achievement gap and put today’s students on a path to healthy and productive lives.
December 22, 2017
Washington, D.C., December 22, 2017 –It is a serious mistake to cut $750 million from the Prevention and Public Health Fund to provide very short-term funding for the Children’s Health Insurance Program (CHIP) and community health centers. The below is a statement from the American Public Health Association, National Association of County and City Health Officials, Prevention Institute, Public Health Institute, and Trust for America’s Health:
“The Prevention Fund supports critical public health activities—including lead poisoning surveillance, vaccination initiatives and other programs—in every state and community across the country. Cutting this significant funding source would leave communities without the vital resources needed to keep children and families happy, healthy and safe.
It is even more alarming and contradictory that this cut will be used to provide very short-term funding for CHIP and community health centers. Our organizations are united in support of CHIP and community health centers, which are vital to improving children’s health. But losing the Prevention Fund would just create another hole in the public health support children need.
The Prevention Fund is supported strongly by national, state and local groups alike—indeed to-date 1,142 have joined the Prevention Fund supporter’s list. They know the value of the $630 million annually that goes directly to states and communities to prevent illness and disease.
A strong public health system makes the difference between health and illness, safety and injury, life and death.
We urge Congress to oppose any and all future cuts to the Prevention Fund and to begin the long-overdue process of increasing support to CHIP, community health centers, CDC and other public health agencies so today’s children can be our healthiest and happiest generation.”
John Auerbach, President & CEO, Trust for America’s Health
Georges C. Benjamin, MD, Executive Director, American Public Health Association
Larry Cohen, Executive Director, Prevention Institute
Laura Hanen, MPP, Interim Executive Director and Chief of Government Affairs, National Association of County and City Health Officials
Mary A. Pittman, President & CEO, Public Health Institute
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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. www.healthyamericans.org
The American Public Health Association champions the health of all people and all communities. We strengthen the public health profession. We speak out for public health issues and policies backed by science. We are the only organization that combines a 145-year perspective, a broad-based member community and the ability to influence federal policy to improve the public’s health. Visit us at www.apha.org.
The National Association of County and City Health Officials (NACCHO) represents the nation’s nearly 3,000 local governmental health departments. These city, county, metropolitan, district, and tribal departments work every day to protect and promote health and well-being for all people in their communities. For more information about NACCHO, please visit www.naccho.org.
The Public Health Institute, an independent nonprofit organization, is dedicated to promoting health, well-being and quality of life for people throughout California, across the nation and around the world.
Prevention Institute is an Oakland, California-based nonprofit research, policy, and action center that works nationally to promote prevention, health, and equity by fostering community and policy change so that all people live in healthy, safe environments.
Early in 2000, state public health surveillance identified a surge of deaths in North Carolina. The Centers for Disease Control and Prevention conducted an investigation into the increase, finding the main driver was unintentional drug overdoses from prescription drugs.
In 2003, the Governor created the Task Force to Prevent Deaths from Unintentional Drug Overdoses, which helped establish the North Carolina Controlled Substances Reporting System (CSRS), which was the state’s prescription drug monitoring program (PDMP).
Since then, North Carolina has implemented a variety of measures to prevent deaths from drug overdoses. With increased access to data from the PDMP and a brighter light shined on the issue, public health continued to collect data, finding, in 2007, that Wilkes County, in the northwest part of the state, had the third highest drug overdose death rate in the country.
Child Fatality Task Force
North Carolina’s Child Fatality Task Force (CFTF)—a standing committee of the general assembly that is composed of 10 legislators and numerous technical advisors—is essentially the policy component of the state’s child death review system.
CFTF provides a unique opportunity for the public health community to present data and bring in outside experts, including law enforcement and subject matter and harm reduction experts. Everyone sits in a room, discusses policies and gets on the same page. Most bills addressing the overdose epidemic since 2010 have come from CFTF, including revisions to CSRS and increasing/improving naloxone access laws.
Project Lazarus
Established in 2007, Project Lazarus— a public health model based on the twin premises that overdose deaths are preventable and that all communities are responsible for their own health—was one of the first initiatives designed to respond to the extremely high overdose mortality rates in Wilkes County.
“Project Lazarus Offers Communities & Individuals Access To:
The University of North Carolina Injury Prevention Research Center (UNC IPRC) evaluated Project Lazarus and found an initial drop in the overdose death rate of 40 percent, which grew to a 69 percent decline in 2011. The program has since be brought statewide.
University of North Carolina Injury Prevention Research Center
The University of North Carolina Injury Prevention Research Center (UNC IPRC) is a key partner in addressing the overdose epidemic. UNC IPRC provides evaluation, research, training, and technical assistance to partners and programs working to combat the opioid epidemic.
Drug Takebacks
In 2009, Safe Kids North Carolina, located in the Office of the Chief Fire Marshall worked with the State Bureau of Investigation and a diverse group of partners to develop Operation Medicine Drop. Since its establishment, Operation Medicine Drop has collected and safely disposed of 89.2 million pills at more than 2,000 events and established a network of permanent drop boxes that serve most counties in the state.
NC DHHS noted that drug takeback programs are a great way to get the community involved and raise public awareness of the issue—it gives everyone a little skin in the game when they realize that items in their medicine cabinet could be fueling the drug epidemic. This process helped move the conversation upstream to ensuring people knew of the problems and the steps they could take to prevent people from developing a substance use disorder.
PDMP
North Carolina has worked to improve CSRS to be a valuable tool to prescribers and dispensers to better manage pain and appropriate prescribing. In 2012, the Child Fatality Task Force convened a study group that resulted in the Revision to the CSRS Law in 2013. They added delegate accounts, shortened the time dispensers have to report data, and enabled proactive reporting from CSRS to licensing boards and prescribers.
In 2014, the Program Evaluation Division of the General Assembly conducted an extensive evaluation of CSRS, concluding that further funding and improvements of CSRS should be included in the state budget bill of 2015.
In 2017, the STOP Act— the most comprehensive bill in the state to address the opioid epidemic—became law. The Act includes mandated use of CSRS, limits on prescribing opioids in line with CDC’s Prescribing Guidelines, expansion of naloxone distribution, and numerous other provisions to address the opioid epidemic.
To develop the Act and identify evidenced-based strategies, NC DHHS worked with UNC IPRC, CDC’s Prevention for States Program, and national experts, including Corey Davis at the Network for Public Health Law.
The 911 Good Samaritan Law/Naloxone Access Act
Expanding access to naloxone has been an important part of North Carolina’s strategy to address the overdose epidemic and was a founding principle of Project Lazarus. The North Carolina Harm Reduction Coalition (NC HRC) has worked with the Law Enforcement community to gain their support for enactment of a series of naloxone laws since 2013.
Since the successful passage of naloxone-related legislation, NC HRC distributed more than 41,000 overdose rescue kits and confirmed 7,408 overdose reversals in North Carolina. Working with law enforcement agencies to develop naloxone programs has resulted in 164 law enforcement agencies with officers carrying naloxone and 403 reported law enforcement reversals by naloxone.
In 2016, the Naloxone Standing Order Law—enables any pharmacy in the state to offer naloxone without a prescription under the state health director’s standing order—Became law. The Standing Order Law was developed in response to requests from the retail pharmacy industry, which wanted to easily offer naloxone in their pharmacy outlets across the state.
After passage, DHHS developed a resource web site with UNC IPRC that contains technical resources on how to use the standing order. Nearly 1,400 pharmacies in the state offer naloxone under the standing order law.
The 911 Good Samaritan Law waived prosecution for individuals experiencing or witnessing an overdose who seek help by calling 911. The law also removed civil liabilities for doctors who prescribe naloxone and bystanders who use naloxone to attempt to save someone’s life and allowed community organizations to dispense naloxone with medical provider oversight.
Syringe Exchange
In 2016, North Carolina became the first state in the south to legalize syringe exchanges with passage of House Bill 972.
The years of work on harm reduction and everyone working together broke down the historical resistance of syringe exchanges and they were able to decriminalize needles. Advocates performed demonstration projects and worked with law enforcement early to identify legislation that the law enforcement community would find acceptable and help them in their daily work.
In addition, the argument was made that needle exchanges could save the state money—DHHS noted that Medicaid charges for Hepaticas C treatment went from $3.8 million in 2011 to $85 million in 2016
Following the legalization of the syringe exchanges, DHHS developed the Safer Syringe Initiative and registered 22 syringe programs in the first year of the law—reaching 19 counties.
Initially, to pass the Bill, language was included that prohibited the use of public funds to support exchanges. When the STOP Act passed, it included provisions that only prohibited the use of “State Funds,” enabling local health departments and other governmental units to use local funds to do needle exchange.
The DHHS sees needle exchanges and drug take programs as a way for communities to take direct action in the overdose epidemic.
Background
The District of Columbia is at the national forefront of efforts to reduce childhood lead poisoning, enacting several prevention-focused laws. Reflecting a long legacy of lead usage – an estimated 75 percent of housing predates the 1978 ban on residential use of lead-based paint – the District also mandates universal screening, requiring two lead tests for all children by age two.
The law at the center of the city’s efforts to combat lead poisoning is the District’s Lead Hazard Prevention and Elimination Act of 2008, amended in 2011 (D.C. Official Code § 8-231.01 et seq.). This law prohibits the presence of a lead-based paint hazard in dwelling units, common areas of multifamily properties, and day care and prekindergarten facilities constructed before 1978. Under the law, any paint in or on a pre-1978 dwelling unit or “child-occupied facility” that is not intact is automatically considered hazardous.
Clearance Examination
A key preventive provision in the District’s lead law (see implementing regulations) is the required clearance examination whenever a pre-1978 residential rental property is about to be occupied by a pregnant woman or a child under age six. Specifically, the property owner must furnish a passing clearance report, issued within the previous 12 months, providing documented proof that the individual rental unit contained no lead-based paint hazards, including deteriorated lead-based paint or lead-contaminated dust or soil. This information must be disclosed before a buyer or renter is obligated under contract to purchase or lease the unit.
A related provision extends this requirement to units occupied or visited by a child or pregnant woman. Additionally, if owners discover lead-based paint in their properties, they must disclose it to their tenant within 10 days.
Lead-Based Paint Presumption
The District’s lead law also expands the definition of “lead-based paint hazard” to presume that any paint in or on a pre-1978 residential or child-occupied facility is lead-based. Any paint that is peeling, chipping, cracking, flaking, or otherwise not intact is automatically considered to be a lead-based paint hazard, unless proven otherwise.
This broader definition facilitates the District’s proactive approach to lead-based paint hazards. Any time there is a “reasonable belief” that a lead-based paint hazard may be present, the Government of the District of Columbia is empowered to inspect residential housing or child-occupied facilities (DC Official Code § 8-231.05(a)). Under this authority, inspections can take place for a variety of reasons, including a tenant complaint or knowledge that a particular neighborhood has a higher prevalence of lead hazards.
The law allows the Government of the District of Columbia to enter a property and conduct a lead risk assessment to determine if lead-based paint hazards may exist. If a lead hazard is found, the property owner may be issued an Administrative Order to Eliminate Lead-Based Paint Hazards. The order specifies the type and location of the hazard and how and when it must be eliminated. Additionally, the property owner is charged for recovery of costs associated with conducting the risk assessment.
Eliminating the lead-based paint hazard must follow specific safe practices. Once the work is complete – to ensure that no lead-based paint hazards remain – the owner must hire a District-certified risk assessor to perform a clearance examination.
The law also states that contractors that disturb paint during work in a pre-1978 property must use lead-safe practices, which includes containing the immediate work area to protect the occupants. A Cease and Desist Order, a Notice of Violation, and/or a Notice of Infraction can be issued to any contractor who fails to do so.
The District may require landlords to arrange and pay for temporary relocation of tenants whose homes contain lead-based paint hazards. In addition, the landlords must make all reasonable efforts to relocate tenants in the same school district or ward and near public transportation.
The law also includes tough disclosure requirements. Owners are required to disclose any “pending actions” ordered by the District and any reasonably known information about the presence of lead-based paint or lead-based paint hazards.
Renovation, Repair and Painting Permitting Requirement
Another preventive measure applies to contractors seeking renovation permits. They must provide proof of training as required under EPA’s Renovation, Repair, and Painting Rule to the permitting office at the District’s Department of Energy and Environment (DOEE). DOEE provides a list of individuals and business entities certified by DOEE to conduct lead-based paint activities in the District.
Universal Lead Screening and Reporting
The District also passed the Childhood Lead Screening Amendment Act of 2006 (D.C. Official Code § 7-871.01 et seq.), mandating that all District children be tested twice by the time they are two-years-old, once, between 6 and 14 months, and the second time between 22 and 26 months. Additional screening is required up to age six if the child has received no prior screening and whenever there are other risk factors. Laboratories must report all test results to DOEE’s Childhood Lead Poisoning Prevention Program. Similarly, health care providers must notify the DOEE about lead-poisoned children within 72 hours.
To increase compliance with the District’s lead screening and reporting law, DOEE provides education to health care providers and builds community awareness, especially among at-risk populations. DOEE has also created formal data-sharing agreements with several District agencies to identify and reach out to families who need to update their children’s screenings.
DOEE provides case management to families whose child has an elevated blood lead level, including help with follow-up testing, education, and referrals. In addition, a DOEE lead inspector conducts an environmental investigation and provides a risk assessment report detailing where lead-based paint hazards were found, with instructions for the property owner about necessary steps to eliminate the hazards. The law also allows DOEE to be reimbursed by the District’s Medicaid agency for lead risk assessments it conducts in the homes of Medicaid-enrolled, lead-exposed children.
Lead-Safe and Healthy Homes
In 2011, DOEE published a Strategic Plan for Lead-Safe and Healthy Homes, the first-ever District-wide agenda for maintaining homes free of lead hazards, asthma triggers, and other environmental health threats. The plan was developed with extensive input and feedback from community groups, providers, environmental experts, and sister agencies.
In 2012, DOEE launched the District’s first full-fledged Healthy Homes program. Local health providers and social service agencies identify families with children or pregnant women in distress due to lead exposure, poorly controlled asthma, or hazardous conditions, and refer those families to DOEE. Participants receive a comprehensive home environmental assessment, family education, an asthma management diagnostic, and case management coordination. Once health and safety threats are identified and systematically documented, DOEE issues a technical assistance report to the property owner to help them correct the identified hazards. The agency also provides a customized care plan to help clients avoid additional exposure while waiting for hazards to be addressed. DOEE’s case managers monitor progress as the identified hazards are eliminated.
DOEE also designed the District’s Lead-Safe and Healthy Homes Hub to help teach residents about possible health risks at home. This interactive site features a variety of healthy homes topics, including lead, mold, secondhand smoke, pest infestations, and radon, and describes how residents can help prevent exposure to these hazards.
Results
For Fiscal Year 2015, the District reported that it had 196 new confirmed cases of children below age six with a blood lead level at or above CDC’s reference value of 5 µg/dl. Overall, District data suggest a downward trend in children’s lead exposure, with approximately 98 percent of children under six testing below the 5 µg/dL action level. DOEE’s Healthy Homes documented improvements in 80 percent of the 137 homes it managed in 2012, the program’s first year. Over time demand for the Healthy Homes program has grown, with 202 households served in Fiscal Year 2016.
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In August, 2017, the Health Impact Project, a collaboration between the Robert Wood Johnson Foundation (RWJF) and Pew Charitable Trusts released: Ten Policies to Prevent and Respond to Childhood Lead Exposure. The Trust for America’s Health (TFAH), National Center for Healthy Housing (NCHH), Urban Institute, Altarum Institute, Child Trends and many researchers and partners contributed to the report. TFAH and NCHH worked with Pew, RWJF and local advocates and officials to put together the above case study about lead poisoning and prevention initiatives.
The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.
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“While no imminent public emergency has been discovered, recent detections of lead in some water systems are highlighting the important roles our water utilities, schools, public health departments and the state play in ensuring we all have access to safe, clean drinking water. This directive will better ensure we’re working in coordination and leveraging resources effectively to tackle lead at all its primary sources, whether it’s water, paint, or soil.” – Governor Jay Inslee |
Background
In May 2016, in the wake of recent detections of lead in drinking water systems in the state, Governor Jay Inslee issued a directive to the state Department of Health and partner agencies to reduce lead exposure in Washington State. The directive instructs the Department of Health to take a series of actions to reduce lead exposure and help those with lead poisoning. It calls for additional investments in and funding for foundational public health services and infrastructure to help prevent, reduce, and remediate lead from water as well as other sources, such as paint.
The governor’s instructions focus on reducing environmental exposures to lead and making sure that children with lead poisoning receive all necessary case management and public health services. It directs the state Department of Health to take the actions and report back to the governor on budget and policy recommendations relating to these actions.
Partner with Other Sectors to Prevent and Reduce Lead Exposure
Governor Inslee’s directive instructs the Department of Health to work with schools, child care facilities, residential landlords, and public water system operators to prevent and reduce exposure to lead.
Key Partner: Schools
The directive instructs the Department of Health, the Washington State Board of Health, and the Office of Financial Management to review and update school health and safety regulations as needed (also known as the “School Rule”). They also should compile a budget decision package to put the regulations in place, beginning with those that pertain to lead exposure.
The Department of Health must continue providing technical assistance and guidance related to voluntary water quality testing schools can perform. This will help ensure that testing meets water sample collection protocol standards. In addition, the Department is asked to conduct workshops for schools that will heighten awareness about water quality and how to correctly test and repair any problems they find.
Key Partner: Child Care Settings
The directive instructs the Departments of Early Learning and Health, in collaboration with the Office of Financial Management, to determine the need for and feasibility of requiring child care providers located in buildings constructed before 1978 to complete an evaluation for potential sources of lead exposure. This includes drinking water testing.
Key Partner: Residential Landlords
The directive instructs the Department of Health to assess the feasibility of possible policy changes associated with developing a Lead Rental Inspection and Registry program. This step would require residential rental properties built prior to 1978 to register and complete a lead inspection and show proof of safety every time new tenants move in.
Key Partner: Public Water System Operators
The directive instructs the Washington State Department of Health to work with large public water system operators (those with more than 15 home/business connections or that serve 25 or more people per day for more than 60 days annually) to identify within two years all lead service lines and lead components in water distribution systems.
The directive also instructs the health department to make the removal of lead service lines and other lead components a top priority when it provides low-interest loans to eligible public water systems to address public health concerns. The department is also directed to work with stakeholders to develop policy and budget proposals, with the aim of removing all lead service lines and lead components in large public water systems within 15 years. This would make Washington State the first state to set such a goal.
Improve Lead Screening Rates and Provide Case Management and Remediation Services
To help those who already have lead poisoning, the governor has asked the Department of Health to work with the Healthcare Authority and the Office of the Insurance Commissioner to increase lead screening rates for the children on Medicaid at highest risk, provide case management services to children with lead poisoning and their families, and determine whether private payers provide coverage for lead screening and case management services or if further coverage policy change is called for.
Governor Inslee also asked the Department of Health to work with stakeholders and other partners to make the blood level monitoring system more efficient. This step entails transitioning the Child Blood Lead Registry to a fully electronic reporting system–and developing an adequate funding mechanism so that local health departments can fully implement home visits and other investigative work necessary to identify and remediate lead exposure.
Federal Funds to Expedite Lead Removal in Drinking Systems
Finally, the governor has asked the Department of Health to partner with the Department of Ecology and the Environmental Protection Agency to seek federal funds to expedite lead removal in drinking systems, require lead testing in childcare settings, and support revisions to the federal Lead and Copper Rule. The rule requires water utilities to monitor drinking water, control corrosion, and inform the public when lead or copper concentrations exceed a designated threshold.
| “Lead is all around us, and the governor’s directive is a positive step in the right direction of reducing lead exposure.” |
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In August, 2017, the Health Impact Project, a collaboration between the Robert Wood Johnson Foundation (RWJF) and Pew Charitable Trusts released: Ten Policies to Prevent and Respond to Childhood Lead Exposure. The Trust for America’s Health (TFAH), National Center for Healthy Housing (NCHH), Urban Institute, Altarum Institute, Child Trends and many researchers and partners contributed to the report. TFAH and NCHH worked with Pew, RWJF and local advocates and officials to put together the above case study about lead poisoning and prevention initiatives.
The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.
Background
In June 2016, the Rhode Island General Assembly passed the Lead and Copper Drinking Water Protection Act, requiring schools, day care facilities, public playgrounds, shelters and foster homes with children under six, and other state facilities to certify that drinking water conduits are lead-safe. It also directs state inspectors to conduct an annual lead and copper test at these facilities. In conjunction with the law, which will be implemented once regulations are promulgated, the state created a commission to study lead in the water system.
Documentation of Lead-Safe Remodeler/Renovator License Required to Receive a Building Permit to Complete Housing Renovations
In 2011, the City of Providence began requiring applicants for building permits at pre-1978 homes to provide proof of training and licensing in lead-safe work practices. The state of Rhode Island requires all construction contractors working in homes and child care facilities built before 1978 to hold a Lead-Safe Remodeler/Renovator License or a higher level of lead hazard control certification. The lead-safe remodeler/renovator program has been overseen by the state since 2001. It is authorized by the U.S. Environmental Protection Agency to administer the federal Renovation, Repair, and Painting rule in Rhode Island. To increase compliance with the state remodeler/renovator law, the City of Providence will issue permits for construction work at properties covered by the law only if proof of licensure is provided. In January 2015, the City of Pawtucket put in place a similar requirement: contractors must document their training and licensure to receive a building permit for renovations.
Use of Local Housing Officials to Enforce Lead Hazard Mitigation Law
The state of Rhode Island passed the Lead Hazard Mitigation Act in 2002 and implemented regulations in 2004. Under the law, rental property owners are required to attend a training on unsafe lead conditions, inspect/repair any lead hazards at their properties, make residents aware of their findings and actions, address residents’ lead-hazard concerns, use lead-safe work practices during maintenance, and verify each unit’s compliance through a lead inspector. Typically, the owner must have the property inspected every two years and prove its safety for children by showing a Certificate of Conformance (COC) or a Lead-Safe or Lead-Free Certificate. Owners of two- and three-dwelling properties who live onsite are exempt from the law.
Since the law’s enactment the state has been challenged by compliance. In 2014, when the Providence Plan completed an evaluation of the Lead Hazard Mitigation Law, it found that only 20 percent of the covered properties had complied with the regulations within the first five years of implementation. Several cities have taken steps to improve enforcement. Providence, for example, created a separate division of Housing Court to address lead violations.
The Inspection and Standards division reported that of 537 lead violation cases filed over the first four years, 484 resulted in corrective action. An analysis conducted by the Rhode Island Department of Health discovered that between 2012 and 2013, there was a significant decline in children with elevated blood lead levels in Providence. Notably, the declines coincided with the implementation of the building permitting requirements and the lead docket.
Medicaid Reimbursement for Lead Follow-Up Services and Lead Centers and Reimbursement
Rhode Island Medicaid, which covers nearly 40 percent of children in the state and roughly half of children below six with elevated blood lead levels, provides reimbursement for lead follow-up services under its 1115 demonstration waiver (known as the Rhode Island Comprehensive Demonstration). The waiver gives Rhode Island the flexibility to “redesign the state’s Medicaid program to provide cost-effective services that will ensure beneficiaries receive the appropriate services in the least restrictive and most appropriate setting.”
Lead follow-up services eligible for reimbursement in Rhode Island are provided through four “lead centers” certified through the state health department. Because the services are offered under specifications of the contract with Rhode Island Medicaid, the centers have the flexibility to hire a range of personnel to deliver in-home lead services. These include community health workers, nurses, and certified lead inspectors.
Medicaid reimbursement is currently available to the lead centers for follow-up services provided to Medicaid-enrolled children up to age six who are identified to have elevated blood lead levels. The lead centers bill by the “Current Procedural Terminology” billing code for each service provided to Medicaid recipients. Medicaid reimburses them for an initial visit, a follow-up visit, or to close the case. The lead centers are reimbursed by the state for services provided to non-Medicaid-enrolled children.
Follow-Up Services: Education, Case Management, Assessment, and Inspection
Written Rhode Island Medicaid standards require the lead centers to contact associated healthcare providers when providing lead follow-up services. For each child or family, the lead center identifies a specific case manager who handles all communication and coordination with the child’s primary care provider or treating physician, all treatment providers and community support agencies, and the child’s health plan, when appropriate. When necessary, the lead center case manager also works with the Rhode Island Department of Human Services and Department of Health, serving as the point of contact for the child, family, and all providers and agencies.
Along with case management, other Medicaid-reimbursable follow-up services provided to children under age six with elevated blood lead levels by Rhode Island lead center staff include:
For children with blood lead levels elevated above the designated threshold (as set by the U.S. Centers for Disease Control and Prevention), Medicaid also reimburses for a Comprehensive Environmental Lead Inspection of the home by a Rhode Island Department of Health lead inspector. After the inspection, lead center staff review the results with the family to help them understand sources of lead in their home.
The lead centers provide some education and other services to children with blood lead levels that are high but do not exceed the designated threshold. However, these services are funded by a Rhode Island Department of Health contract, not by Medicaid. The services include an educational home visit to discuss lead poisoning, nutrition, and cleaning practices that can protect children from additional lead risks; a Visual Environmental Lead Assessment by a trained community health worker, which provides education and preventative next steps; and the provision of soil and dust wipes for the home. The Rhode Island Department of Health is also piloting a limited environmental investigation (soil testing only) in partnership with the lead centers for children with lower blood lead elevations that do not meet the designated threshold.
Additional Services: Structural Remediation
While Rhode Island Medicaid can provide some reimbursement for window replacement and spot repair of conditions found to pose a lead-related threat to children with elevated blood lead levels, this structural remediation benefit has been used rarely. The primary reasons include: (1) the current reimbursement rate for window replacements is less than the typical replacement cost and (2) the mechanisms by which lead centers receive this reimbursement are cumbersome. In an effort to increase use, the Rhode Island Department of Health is exploring ways to improve the window replacement program. One possibility may be a revolving loan fund since lead centers must pay for replacement first and seek Medicaid reimbursement later.
In addition, when a lead violation is found and a notice of violation issued, property owners and families are automatically referred to local Housing and Urban Development-funded lead hazard control grant programs that may pay for structural remediation. Access to these grant programs depend on income, the property’s age (pre-1978), and the presence of a child under age six living in or frequently visiting the home or unit. The Rhode Island Department of Health is currently assessing how often cited owners use these grant programs and whether or not there are enrollment barriers.
Use of Medicaid Reimbursement for Lead Follow-Up Services
This table from the Rhode Island Executive Office of Health and Human Services shows the total number of Medicaid-enrolled children who received lead follow-up services from the Rhode Island lead centers and the corresponding amount of total Medicaid reimbursement for selected years between 2006 and 2014.
Rhode Island’s current Medicaid 1115 demonstration waiver is in place through 2018, and there has been consistent support for the continuation of the lead follow-up service reimbursement program in the state. Stakeholders attribute this enthusiasm to the relatively low total cost of the lead program within Rhode Island’s overall Medicaid budget, along with the well-known dangers of lead poisoning.
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In August, 2017, the Health Impact Project, a collaboration between the Robert Wood Johnson Foundation (RWJF) and Pew Charitable Trusts released: Ten Policies to Prevent and Respond to Childhood Lead Exposure. The Trust for America’s Health (TFAH), National Center for Healthy Housing (NCHH), Urban Institute, Altarum Institute, Child Trends and many researchers and partners contributed to the report. TFAH and NCHH worked with Pew, RWJF and local advocates and officials to put together the above case study about lead poisoning and prevention initiatives.
The case study does not attempt to capture everything a location is doing on lead, but aims to highlight some of the important work.
