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Acute Care and Preventive Health Services in Public Health--Two Sides of the Same Coin

I delivered this speech at a conference, but I don't recall which one or where it was held.

My name is John Bradley. By profession, I am a health educator and an instructional designer. I work with the Florida Department of Health and Rehabilitative Services. This afternoon, I would like to share how Florida addresses both episodic care and preventive services within its public health system.

I have several objectives for this presentation:

  1. To tell you a little about Florida's primary care system.
  2. To tell you how integration of services is being achieved at the state level.
  3. To describe several projects and initiatives at the state and local level that are improving preventive services.
  4. And finally, to find out what your state public health care systems are doing in the area of preventive services.

What is primary care?

Although there are various definitions, primary care is the first medical care level for both the individual and the family. This includes acute care, preventive services, health education, and referral. A traditional example of primary care is the family practice physician.

During the early 1980s, it became apparent that many low-income Floridians did not have easy access to consistent health care. In Florida, more than two-thirds of low-income people were not eligible for Medicaid. Almost none of them had private health insurance. Consequently, they did not receive preventive services. Whenever a medical problem arose, these people turned to hospital emergency rooms for treatment.

To meet the health care needs of low-income people, the Legislature of Florida began allocating funds in 1984 to provide primary care services through county public health units or contract providers.

This program was implemented over a three-year period. Today, all 67 counties in Florida provide public health primary care. For approximately $___ million a year, over 183,000 people are being reached annually with primary care services that were not previously available.

This new system provides both episodic and preventive health services. There is a long list of mandated services:

  • acute outpatient care
  • STD control
  • HIV testing, control, and treatment
  • tuberculosis control
  • laboratory services
  • radiology
  • pharmacy
  • risk-factor assessment
  • nutrition assessment and counseling (including WIC)
  • family planning
  • prenatal and postpartum care
  • well-adult examinations
  • well-child examinations
  • health education
  • dental care (in some counties)
  • mammography (in some counties)
  • sigmoidoscopy (in some counties)
Eligibility for primary care is based on federal poverty standards. All family members are enrolled at the same time. There is a 24-hour call system, as well as weekend and evening clinic hours. Primary care clinics in county health units must coordinate with existing primary care providers and have referral agreements with specialists and hospitals.

The two adjectives that best describe what is happening in HRS county public health units due to primary care are "comprehensive" and "integrated." The previously separated and fragmented programs are now coordinated to provide total care to the whole person and family.

Do any of your states provide comprehensive primary care to low-income people through county health departments? What have been the results?

In conjunction with this new approach to public health care, there has been a reorganization at the state level of HRS to integrate several programs. Family planning, maternal health, child health, WIC and nutrition, dental, chronic disease, and primary care have been blended into a new Family Health Services office. This office is predominantly organized along functional lines rather than programmatic ones. For instance, one unit is responsible for developing policies and procedures for all of these programs. One unit is responsible for implementing all of these programs in county public health units. Within these units are sub-units for grant administration, contract management, and data management. WIC and dental are still somewhat autonomous because of the unique nature of the services they provide.

This reorganization was instituted in July, so we are still trying to work out the kinks. There is some confusion at the state and county level regarding which units are responsible for which activities. Many of us are having to learn new jobs. However, the new structure appears to be working well. We are confident that it will result in better service to the county public health units and their clients.

Are any of your state health departments organized along functional lines rather than programmatic ones?

Now I would like to tell you about some of the preventive health projects and initiatives that Florida's public health care system is involved with on a state and local level.

One of these is the Comprehensive Health Improvement Project (CHIP). CHIP is funded by the Preventive Health Block Grant and involves two main elements: 1) chronic disease prevention and control activities within county health units and

2) health promotion activities in the host community. The chronic diseases upon which CHIP focuses are cardiovascular disease; hypertension; diabetes; and cancers of the lung, breast, colon, and cervix.

The 14 counties participating in CHIP contain 45 percent of Florida's population. There are CHIP counties in all regions of the state. There are two primary populations targeted by CHIP: 1) all adult HRS county public health unit primary care clients and 2) all adults in the host county.

There is a CHIP coordinator in each of the participating county public health units designated to oversee CHIP activities. The CHIP coordinator must be a qualified health professional (such as a nurse, nutritionist, or health educator).

Each participating county is expected to maintain a CHIP advisory committee composed of key staff members of the HRS county public health unit--CHIP coordinator, CPHU director/administrator, nursing director, nutrition director, primary care administrator, health education director, and business manager. The committee meets at least quarterly to discuss the delivery of chronic disease services and resolve identified problems. The CHIP advisory committee involves health professionals from all major disciplines (physicians, nurses, nutritionists, and health educators), thus facilitating a team approach to care.

Each HRS county public health unit participating in CHIP is required to submit an annual work plan. The work plan must contain the following elements: a description of the host community's chronic disease problems and resources; an overview of present chronic services in the HRS county public health unit; a mission statement; a narrative of planned activities; measurable, realistic, and time-limited objectives; and a budget. In addition to the work plan, counties must submit quarterly reports describing the status of objectives.

In CHIP counties, adult health department clients are assessed for chronic disease risk factors such as for overweight, smoking, alcohol/drug abuse, stress, diet, abnormal blood glucose, elevated blood cholesterol, high blood pressure, family history, lack of exercise, and appropriate cancer examinations.

Counties maintain a referral system so that clients with risk factors can receive treatment or education to reduce their risks of developing a chronic disease or a chronic disease's complications. A follow-up system ensures that clients with risk factors receive the services to which they are referred.

Client education is provided on the prevention of chronic diseases or the complications of chronic diseases. Education may take the form of one-on-one sessions or group classes. Several counties use "Healthier People" health risk appraisal software as a health education tool.

Several professional education opportunities are provided to county staff on state-of-the-art techniques for preventing morbidity and mortality related to the major chronic diseases. These opportunities include an annual CHIP coordinators' meeting, annual symposia, regional workshops at university medical centers, on-site in-service, and orientations as needed.

The community health promotion component of CHIP extends chronic disease prevention and control beyond the HRS county public health unit to the community at large. This is accomplished through networking with existing resources such as the media, local business groups, civic organizations, private health care providers, and voluntary health agencies to provide special programs, classes, and awareness events. Worksite wellness programs and health fairs for specific populations are common. Several counties have community health councils composed of diverse groups and individuals. Communication and cooperation among agencies and organizations that offer health care and education to the community are essential to minimize duplication and maximize effectiveness. The goal is to increase community-wide awareness about chronic disease prevention and foster social values that promote healthy lifestyle changes.

What kind of preventive health projects are your county health departments involved with?

In addition to CHIP, Florida has a diabetes cooperative agreement with the Centers for Disease Control. The state office is working with 15 county health units to improve diabetes control services. The organizational model for these diabetes cooperative counties is similar to the one used with CHIP counties. There is a diabetes coordinator in each county. There is an emphasis on a team approach to care. Key staff receives training at university-based diabetes centers. Insulin-dependent clients receive insulin on a sliding scale. Clients receive appropriate examinations for complications of diabetes and education on diabetes management. When necessary, clients are referred to specialists for evaluation and treatment. Follow-up is done on all referrals.

One product of the diabetes cooperative agreement is a series of patient education flip charts. The flip charts were developed jointly by Florida and Pennsylvania. They are geared for an audience with a low reading level. Five flip charts are already available: hypertension, sick days, foot care, low blood sugar, and nutrition. Flip charts on eye care and cholesterol are in development.

Our CHIP counties and our diabetes counties are encouraged to use a Chronic Disease Patient Flow Sheet for all adult clients. The flowsheet is designed to summarize all chronic disease information about the client in one place and provide a prompt to the health care provider about the client's services. The flowsheet, which is part of the medical record, contains information on risk factors, cardiovascular disease, cancer, diabetes, laboratory values, referral & follow-up, and client education.

What might be some advantages and disadvantages to using a flow sheet?

In addition to the flowsheet, CHIP and diabetes counties must perform a quarterly chart audit of randomly selected records. A standardized four-page chart review form is used. The completed forms are sent to Family Health Services for data entry and analysis. In turn, Family Health Services provides summary reports to the counties.

How do your county health departments ensure that they are providing quality preventive health services?

Family Health Services has developed the Comprehensive Chronic Disease Protocols. The protocols cover hypertension, cardiovascular disease, cholesterol, diabetes, cancer, adult immunization, and tuberculosis. These protocols are based upon national authorities' consensus, such as the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure and the National Diabetes Advisory Board. All HRS county public health units have been provided with this document and encouraged to implement them as much as possible, given their resources, range of services, and population served.

Have any of your states promulgated protocols for chronic disease services? What was the result?

All HRS county public health units are required to use a standardized Adult and Adolescent Health History Form. The form contains several questions on chronic disease risk factors and covers the subjective portion of patient assessment. The objective physical assessment tool is presently being revised to include chronic disease risk factors.