Statewide Health Improvement
Program in Rural Communities
Cara McNulty, MS
MDH, Office of Statewide Health Improvement
Initiatives Manager
Marion Kershner, RN, PHN, MS
Family Health Nursing Supervisor
Otter Tail County Public Health
Kristin Erickson, RN, BSN, PHN
SHIP Health Care Intervention Coordinator
Otter Tail County Public Health
SHIP Background
 SHIP is a key public health component of the historic
health reform bill passed into law May 2008
 SHIP aims to reduce obesity and tobacco use and
exposure through evidence-based systems change
strategies
 $47 million appropriated for SHIP for
fiscal years 2010 and 2011
 Competitive grants to Community Health Boards and
tribal governments rolled out beginning July 1, 2009
SHIP Grants Overview
SHIP funding has an impact on the majority of the
state
 40 grants cover all 87 counties and eight of 11 tribal
governments in Minnesota
SHIP grants have facilitated unprecedented
collaboration across the state
 38 of the state’s 53 CHBs are working collaboratively
with other CHBs
 Seven tribal governments are working collaboratively on a
unified SHIP project
 Over 600 community partners are actively engaged in SHIP
work across Minnesota
Importance of a Systems Change
Approach
 SHIP grantees implement evidence-based systems change
strategies to reduce obesity and tobacco use and exposure
 Major health problems will not be solved solely by individual
actions and choices
 Health problems are influenced by societal policies and
environments that in some way either sustain behaviors or
fail to foster healthier choices
 By moving “upstream” to address fundamental causes or
poor health, and by improving environments where we live,
work, learn, play, and receive health care, we can prevent
many people from becoming chronically ill
Impact of SHIP Interventions
As a result of the systems changes that will be
implemented through SHIP interventions:
 Individuals will have increased access to healthy food,
opportunities for physical activity, and spaces that are
tobacco free
 More people will meet healthy eating guidelines, get the
recommended amount of physical activity, and will stop (or
not start) using tobacco
 Fewer Minnesotans will be overweight, obese, or use tobacco
 Health care costs will decrease
Achieving SHIP Goals
In many ways, SHIP grantees have only just started
their work, yet results they have already
accomplished show tremendous promise for future
success
It will take time and sustained effort throughout our
communities to achieve reductions in tobacco use
and exposure and obesity that can lessen burden of
chronic disease in Minnesota
SHIP is on path to reaching those goals by making
healthy choice the easier choice for all Minnesotans
Golden Start Initiative
Nine County Single Intervention SHIP
Grant to Promote Breastfeeding
Roseau
Kittson
Lake of
the Woods
Marshall
Koochiching
Pennington
Beltrami
Red Lake
Clearwater
Polk
Cook
Lake
St. Louis
Itasca
Mahnomen
Norman
Hubbard
Cass
Becker
Clay
Becker, Clay,
Douglas, Otter Tail,
Pope, Grant,
Stevens, Traverse
and Wilkin Counties
Aitkin
Wilkin
Crow
Wing
Wadena
Carlton
Otter Tail
Mille
Lacs
Todd
Grant
Pine
Morrison
Douglas
Kanabec
Benton
Traverse
Pope
Stearns
Isanti
Sherburne
Swift
Anoka
Kandiyohi
Wright
Hennepin
McLeod
Washington
Meeker
Chippewa
Lac Qui
Parle
Chisago
Stevens
Big
Stone
Ramsey
Minneapolis
Carver
Renville
Yellow Medicine
Dakota
Scott
BloomingtonEdina-Richfield
Sibley
Lincoln
Lyon
Redwood
Le
Sueur
Nicollet
Rice
Goodhue
Wabasha
Brown
Pipestone
Rock
Murray
Nobles
Cottonwood
Jackson
Watonwan
Martin
Blue
Earth
Faribault
Waseca
Steele
Freeborn
Dodge
Mower
Olmsted
Winona
Fillmore
Houston
Partners – Otter Tail, Traverse
and Pope Counties
Otter Tail
 Lake Region Healthcare Hospital and
Clinics (Fergus Falls and Battle Lake)
 Perham Memorial Hospital
 Merit Care Clinics (Pelican Rapids,
Perham, New York Mills, and Ottertail)
Traverse
 Wheaton Community Hospital and Clinic
Pope
 Glacial Ridge Health System Hospital and Clinic
Partners – Becker and Clay
Counties
Becker (All in Detroit Lakes)
 Merit Care Hospital
 Innovis Health
 St. Mary’s Innovis Health (hospital)
Clay (Clinic connection via hospital in
Fargo, ND)
 Merit Care Hospital
 Innovis Health
Partners – Wilkin, Douglas and
Stevens Counties
Wilkin
 St. Francis Hospital (Breckenridge)
Douglas
 Douglas County Hospital
 Broadway Medical Clinic
 Alexandria Clinic
Stevens
 Stevens County Medical Center Clinic and
Hospital
Leadership
 Otter Tail County Public Health
 Grant Management
 Grant Coordinators: contract with Lake Region
Healthcare
 Fiscal host
 Brainchild
 Community Leadership Team
Evidence Basis: Golden Start
Intervention and Initiative
Two key sources:
 Meier PP, Engstrom JL, Mingolelli DJ, Miracle DJ,
Keisling S. Journal of Obstetrical Gynecological
Neonatal Nursing. The Rush Mothers’ Milk Club:
breastfeeding interventions for mothers with verylow-birth-weight infant. 2004 Mar-Apr 33(2):164-74.
 DiGirolamo AM, Grummer-Strawn LM, Fein,SB. Effect
of Maternity Care Practices on Breastfeeding.
Pediatrics. Supplement 2008 OCT Vol. 122:S43-S49.
SHIP Golden Start Initiative
 Training
 Assessment and Policy Change
 Golden Start Intervention
 The Business Case for Breastfeeding
 Worksites
 Daycares
 Sustainability Project
Lactation Training
 Two 3 day trainings were held in March and May,
2010
 120 public health and hospital nurses trained
 Train the Trainer training in August, 2010
 Molly Pessl, Evergreen Perinatal
 Sustainability project
Assessment and Policy Change
 All participating hospitals completed Baby
Friendly Hospital Assessment
 All nine public health departments have
completed the Wisconsin Breastfeeding
Friendly Health Department Assessment
 All are committed to at least two policy
changes in support of breastfeeding
Golden Start Intervention Goal: A
commitment to mother’s milk for the first
four weeks of a child’s life
 Prenatal intervention: WIC & medical clinics
 Brochures and motivational interviewing
 Postpartum PHN follow-up
 Phone calls, home or office visits
 Lactation trained nurses in participating
hospitals, clinics, and public health
departments
Worksites and Daycares
 Project Coordinators have attended Business
Case for Breastfeeding Training
 Public Health Departments will be trained
 Two worksites and 2 daycares in each county
will receive training
 Partnerships will be fostered
Outreach to medical clinics
 Data has been collected in seven medical
clinics
 Golden Start Intervention will spread to clinics
 Training of clinic staff will proceed in year two
of the grant
 Partnerships between public health
departments, clinics and hospitals will be
fostered
Evaluation
 Two year work plan is in place
 Evaluation measures are identified
 Clinics have surveyed mothers of infants, to be
repeated at the end of the grant cycle
 Assessments of hospitals and public health
departments are completed
 Training conducted
 First focus group conducted
 GS Intervention will begin by July 1, 2010
Sustainability Project
 Concordia College Nursing Department
 Goal: Promote breastfeeding by providing
evidence based lactation education to
practicing healthcare providers
 Assessment and development will start in
the summer of 2010
Community Leadership Team
(CLT): Partners and Role
Partners




Hospitals and Medical clinics
Public Health departments
Concordia faculty member
Grant manager and coordinators
Role of CLT:





Communication
Shared decision making
Relationship building
Collaborative approach to patient care
Hope for the future
Lessons Learned
 Funds to be able to sponsor training
instrumental in engaging partners
 All partners have valuable insights
 Developing an evaluation plan early has many
rewards
 Everything takes a little longer than you
expect
Carpe Diem!
Becker, Clay, Otter Tail, and
Wilkin Counties
SHIP HEALTHCARE INTERVENTION
Policy, Systems and Environmental
Change to Reduce Obesity, Tobacco Use
and Tobacco Exposure
MN Rural Health Conference in Duluth, MN
June 29, 2010
THE FACTS
 Chronic diseases such as heart disease,
cancer, stroke, diabetes, and obesity
share four root causes:




physical inactivity,
poor nutrition,
smoking, and
hazardous drinking.
 These diseases account for roughly 40% of
all deaths in the U.S. (Vinz & Marshall 2008)
AND, WHO SHOULD ADDRESS
THESE ROOT CAUSES?
Healthcare Settings? Perhaps.
But…
“High quality prevention cannot be
accomplished in the medical clinic
alone.” (Vinz & Marshall 2008).
SO…IT COULD BE HEALTHCARE?
Yes, but not
alone.
Others also
need to be
encouraged to
focus on
prevention.
THUS…
… if healthcare
can play a part in
preventing
obesity and
tobacco use…
 Is this already
being done?
 If so, is it
working?
NOT REALLY
“It is clear that clinical systems must
tackle chronic disease in a new
fashion to reduce the social and
financial burden of chronic disease”
(Vinz & Marshall 2008).
If a new fashion should be used,
does that new fashion exist?
“NEW FASHION”???
Could it be
that…
THE NEW FASHION IS “SHIP”?
SHIP interventions focus on changes not
just in healthcare, but also in school,
community, and worksite settings.
SHIP interventions were created by MDH
to bring public health and healthcare
partners together.
THUS…
Healthcare settings
would not be going at it
alone…and,
Since SHIP
interventions focus on
policy, systems, and
environmental
changes…
THIS IS A NEW
FASHION!
SHIP GRANT in Becker, Clay, Otter
Tail, and Wilkin Counties
 A Becker, Clay, Otter Tail, and Wilkin
County Community Leadership Team
made up of public health staff and
community leaders was formed.
 Healthcare settings were surveyed.
INTERVENTION SELECTION
The Community
Leadership Team
discussed the survey
results and the MDH
menu of healthcare
interventions.
A selection was
made…
Healthcare Intervention
Selected
Support implementation of the
Institute for Clinical Systems
Improvement (ICSI) Guidelines for
“Prevention and Management of
Obesity" and “Primary Prevention of
Chronic Disease Risk Factors” by
health care providers for adults and
children where applicable.
WHAT IS ICSI?
The Institute for Clinical Systems
Improvement (ICSI) is an independent
organization that brings together medical
groups, hospitals, health plans,
employers, and consumers to create
patient-centered, value-driven health
care solutions (Vinz & Marshall 2008).
WHY THIS INTERVENTION?
This intervention seeks to provide
support and resources to
incorporate ICSI Guidelines into
provider systems to reduce obesity,
tobacco use, and tobacco exposure.
SYSTEMS CHANGE
NEXT STEPS
 Meetings were held with MDH, ICSI, and
SHIP Grantees to create an
implementation model.
 An ICSI Collaborative Model was
chosen.
 All healthcare settings in the four
counties were invited to become
partners.
Healthcare Partner Benefits
 Organizational analysis
 ICIS Collaborative training expenses
 CMEs and CEUs for ICSI Trainings
 Possible funding towards modification
of an Electronic Medical Record System
 Access to SHIP and ICSI Staff expertise
and resources
Healthcare Partner
Responsibilities
Complete Baseline Assessments
 Organization Assessment
 Clinical Team Members Survey
 Chart Audit
Complete ICSI Assessments
 Readiness
 Guideline
Healthcare Partner
Responsibilities
Work towards guideline
implementation:
 assessing BMI;
 assessing chronic disease risk factors;
 discussing BMI and risk factors with
patients;
 making referrals to clinic- and/or
community-based resources; and
 follow-up.
Healthcare Partners
 Family Healthcare Center: Fargo
 Migrant Health Services, Inc.: Moorhead
 Orthopedic and Sports Physical Therapy,
Inc.: Breckenridge
 Sanford Health – MeritCare Clinic: Pelican
Rapids
Healthcare Partners
 Sanford Health – MeritCare Regional
Clinics: Hawley, New York Mills,
Ottertail, Perham, and Ulen
 St. Mary’s Innovis Health: Detroit Lakes
 Local Public Health Departments (4);
Becker, Clay, Otter Tail, and Wilkin
Public Health’s Role
Two fold:
 Become a Healthcare Partner in the
intervention – working to implement
ICSI Guidelines in the Public Health
Setting.
 Network with local clinics to provide
resources to the clinic and refer
clients to clinic resources.
Collateral Work
Member of an MDH SHIP workgroups charged
with:
 reviewing the MN Clinic Fax Referral Program
for Tobacco Cessation to see if a similar
program could be offered for weight
management; and
 brainstorming referral and follow-up systems
that would be effective, reimbursable and
efficient for healthcare settings to
incorporate.
Lessons Learned
 Public Health and clinics can benefit
greatly from networking with each other.
 Healthcare settings are eager to
prevent obesity and tobacco use, but
cannot do it alone.
More Lessons Learned
Healthcare
clinicians want
effective and efficient
tools and
mechanisms.
It is good to be
humble.
It is exciting to ask
“What if…?”
Reference
Vinz, C, and M. Marshall. July 2008. Battling the Big
Four of Chronic Disease. The culprits: inactivity, poor
nutrition, smoking, and hazardous drinking. Minnesota
Health Care News 6,no. 7.
http://www.icsi.org/prevention_of_chronic_disease_art
icle/prevention_of_chronic _disease_article_.html
QUESTIONS?
SHIP Website:
http://www.health.state.mn.us/healthreform/ship.html
Cara McNulty, MS
Email: [email protected]
Phone: 651-201-5438
Marion Kershner, RN, PHN, MS
Email: [email protected]
Phone: 218-998-8348
Kristin Erickson, RN, BSN, PHN
Email: [email protected]
Phone: (218) 998-8336