New Hampshire

Quality Improvement Learning Teams

Reducing Preventable Risk Factors that Predispose to Chronic Disease

*Focus on reducing childhood obesity*

Existing NH Public Health Infrastructure

• 234 cities and towns – Health Officer required by statute

• 5 communities with public health departments • No county health departments• State level:

– DHHS (lead agency), – Department of Environmental Services– Department of Education– Department of Safety

• Strong community-level informal public-private partnerships

• Currently engaged in a regionalization process

Selection process:Mini-Collaboratives (QuILTs)

• RFP

• Ranked target area: • Reducing Preventable Risk Factors that

Predispose to Chronic Disease – Focus on reducing childhood obesity

• Formal proposal review process

• Aligned with state health priorities and strategic plan

QuILTs• Currently: 1st of 2 cohorts, 3 each, 15 months

– Caring Community Network of the Twin Rivers– Lakes Region Partnership for Public Health – Mascoma Valley Health Initiative

• Content experts– Regina Flynn, Health Promotion Advisor - KidPower! Program, NH DHHS -

Nutrition & Health Promotion– Mindy Fitterman, M.Ed., R.D., Nutrition Consultant, NH Fruit and Vegetable

Program DHHS, Division of Public Health Services

• Timeline – Kickoff 9/08 – Monthly meetings – conference call, LiveMeeting, in person– Mid session: 4/09– Completion 11/09– Mentors to Cohort 2 through 4/2011

• Lead: Susan Laverack

• Identify an Opportunity: Obesity• Belknap County:

• One of top 4 health issues• Greatest % overweight and obese WIC enrolled children • 75% of residents consume < 5 servings fruits &

• Assemble a Team: • Lakes Region Physical Activity and Nutrition Committee

(PAN)• LRGHealthcare (Dieticians, Education and Outreach), Parks and Recreation

Director, UNH Extension Specialist, Belknap-Merrimack CAP Laconia Child Care Director

– SAU Superintendent – Pleasant Street School Staff

– Principal, nurse, teachers, SAU food director, guidance counselor

Examine Current Approach & Identify Potential Solutions

2nd grade students at Pleasant Street School do not each enough fruits and vegetables at snack time.

Lack of Resources Environment

Incentives/MotivationLack of Knowledge

Parents may be unaware of or lack access to healthy resources

Fresh F/ V may be inconvenient for families to keep in stock.

Prepackaged foods are moreconvenient.

Sweets and junk foods given as rewards.

F/ V expensive, short shelf life.

School not eligible for USDA F/ Vsnack program.

Students: not cool to bring a healthy snack.

Curriculum full, little room to addtopic areas.

Students unaware ofthe benefitsof fruits and vegetables.

Parents may be unawareof the nutritional benefits of fruits and vegetables

Teachers may be unaware of theresources available tosupport teaching.

9.4% or residents in Laconia below poverty level

2nd grade students at Pleasant Street School do not each enough fruits and vegetables at snack time.

Lack of Resources Environment

Incentives/MotivationLack of Knowledge

Parents may be unaware of or lack access to healthy resources

Fresh F/ V may be inconvenient for families to keep in stock.

Prepackaged foods are moreconvenient.

Sweets and junk foods given as rewards.

F/ V expensive, short shelf life.

School not eligible for USDA F/ Vsnack program.

Students: not cool to bring a healthy snack.

Curriculum full, little room to addtopic areas.

Students unaware ofthe benefitsof fruits and vegetables.

Parents may be unawareof the nutritional benefits of fruits and vegetables

Teachers may be unaware of theresources available tosupport teaching.

9.4% or residents in Laconia below poverty level

• Current approach • School w/ high interest level,

fragmented coordination– Nurse and Guidance Counselor teach a

4-wk Wellness Curriculum for 5th grade

– Few healthy eating/active living activities

• Potential Solutions• Interventions based on 5-2-1-0 w/ focus

on the “5” in one 2nd Grade classroom

– Consulted with DHHS and local nutritional experts

– Determined all possible ways food is consumed by students before, during and after school - greatest potential to impact improvement at snack time

Develop an Improvement Theory

Through multi-component nutritional intervention the % of 2nd grade students who bring a fruit or vegetable for snack will increase.

*****AIM: 2nd Grade Students will bring fruit and/or

vegetable for snack at least 60% of the time by 6/09*****

• Multi-component nutritional information and activities to 2nd grade students

• Taste Testing • Visit to grocery store• Design bulletin board • Prepare & serve healthy foods to 5th grade “Book Buddies”• Integrate project into school’s Wellness Committee

Check the Results

• ↑ Fruit/Vegetable ID and understanding of nutritional benefits (pre-post test)

• Cycles of Change– Dec: Taste Tests– Feb: Trip to Grocery Store– April: School-Wide

Principal’s Tie Challenge– May: Prepare & serve

healthy snacks to 5th graders

– ↑ awareness and enthusiasm across the school

Percentage of 2nd Grade Students Consuming F/V at Snacktime

25

52

63

77

0

10

20

30

40

50

60

70

80

90

Dec Feb Apr June

Months of Measurement M

ean

Per

cen

tag

e

Establish Future Plans

• Improve processes for working with QuILT members

• Broaden successes to fifth grade • Developmentally-appropriate activities (e.g., student

involvement in tracking tools and data collection)

• HEAL funding source to broaden initiatives to other schools within region

• Explore Snack Policy (informal) • create school-wide practice “this is how we do it”

Mascoma Valley Health Initiativein partnership with

Canaan Elementary SchoolLead: Susan F. Houghton, MA, PhDc., ED, MVHI

Improve Nutrition Literacy and Food Choices in

ElementaryStudents and their Families

Improvement Theory/ Assemble Team

• Improvement Theory• Rates of overweight and

obesity, and obesity-related chronic disease, can be positively impacted through nutrition education that:– Integrates hands on

learning– Involves the family– Results in an increase in

healthy food choices

• Building the Team– Elementary school

Guidance Counselor– Elementary Principal– SAU Superintendent– Pediatrician– Pediatric NP– Community Health

Manager, Alice Peck Day Hospital

– MVHI Project Coordinator

Mascoma Valley Health Initiative

Current Approach/Potential Solutions• Current Approach

– A faculty-developed nutrition curriculum

– “Big 3” macro-nutrients

• Environmental Challenges

– Food Desert

– Socieconomics

• Intervention

– Target: 4th grade students (n=50)

– Teach new food pyramid, macro- and micro-nutrients, focus on Calcium

– Nutrition literacy: reading food labels

• Snack packing literacy: What’s in your snack?

• Calcium and bone density: how do beverages matter?

• “Find the Fiber” in food labels – how “special” is Special K?

• Healthy eating! Popcorn, salsa, vegetables.

• Posters based on new food pyramid

• Family night and poster show

• Family quiz game

• 4-Ingredient Trail Mix: Cheerios, Dried Cranberries, Raisins, Chocolate Chips

• Group work: benefits of nutrients

Check the Results

Pretest: Number of Students Able to Name Between One and Five Food Groups (n = 50)

9

14

10

15

2

0

2

4

6

8

10

12

14

16

1 2 3 4 5

# of Food Groups

• Measurements: Food Knowledge and Family Participation

• Family night drew more than 75 people

• 40 copies of 4-Ingredient Trail Mix recipe distributed

• New School-wide Wellness Policy developed, Approved by School Board and Implemented Fall 09

• QuILT leader member of Wellness Committee

Next Cycles of Improvement

Mascoma Valley Health Initiative

• Increase focus on food choices:

– Measuring snacks brought from home

– Increase in-school and take-home messaging about snacks

• Follow current 4th graders to Middle School next year

• Incorporate food preparation (classroom kitchen)

• Integrate other activities to teach a “healthy food environment” curriculum:

– Physical activity – energy balance

CCNTR Caring Community Network of the Twin Rivers Working Together for Healthier Communities

841 Central Street, Franklin, NH 03235 Telephone (603) 934-0177 Fax (603) 934-2805 website www.ccntr.org

Childhood Weight Management and Obesity Prevention Quality Improvement

Serving a Population of over 34,000

Michael Loomis, MPH

Community Program Specialist

Team Members

• Rick Silverberg, LICSW (CCNTR)

• Michael Loomis, MPH (CCNTR)

• Sally Minkow, BSN, CHES (LRGH)

• Rick Wilson, MD (LRGH)

• Melissa Rizzo, M.Ed (LRGH)

• Wendy Pavnick, PA-C (Health First Family Care Center, FQHC)

2007-2008 Age/Gender Specific Body-Mass-Index (BMI) Percentile for Franklin School

District Kindergarten-4th Grade

0%

10%

20%

30%

40%

50%

60%

HealthyWeight

Overweight Obese

BMI Percentile Risk Rating

Perc

en

t of

Stu

dents

in

Ris

k

Rati

ng

Students (n=496)HEAL Goal*

Assessment of Need

• Upon notice to parent from school nurse of overweight or obese status and health risks related, parents respond with negative feedback with noted reflection to absence of discussion during primary care visit

• Run report at 3 local primary care practices of children ages 2-19 with a well-child visit in 2007 fiscal year with a documented BMI or BMI percentile

• Focus on Primary Care Setting and how weight related risk and behavioral assessment is being delivered to youth

PLAN

• Documentation Rates Baseline:– BMI documentation rates in 2-19 year olds with a

well-child visit between 7/1/07-6/30/08 among 3 local primary care practices vary (12.6-90%)

• EMR well-child vital sign template with BMI risk rating calculator identified and uploaded

• PCP “Wellness Champion” to test QI in clinic

CHRONIC CARE MODEL!

PLAN• To begin process, educate providers on BMI

measures, community profile, available referral resources

• Update Medical staff on research identifying weight-related health as an indicator for chronic disease risk

• Motivational Interview training

• BMI behavioral risk screening tool

• EMR technology that auto-calculates BMI risk rating at well-child office visit

Improvement Theory• The team will improve health care provider

access to timely BMI risk rating analysis through redesign of clinical flow to assess behavior, provide effective communication strategies and referrals, and interpret weight related health into diagnosis and treatment

• Goal of all 3 Primary Care Practices documenting at least 65% of children’s BMI seen in the following year

DO

• Review evidence and recommendations for increasing assessment, prevention, treatment and clinical guidelines

• Identify EMR BMI risk rating tool and upload for prompt evaluation at time of visit

• Designate a “Wellness Champion” in clinic

• Create and educate medical staff on clinical office flow for weight-related health risk factor assessment

• Document SM goal in pt’s chart as a measurable health indicator

• Educate providers on referral resources to community HEAL interventions

• Identify locations suitable for outreach activities to distribute printed materials to community members

STUDYGOAL REACHED!

• After 1 year of new EMR applications and provider education, all three Primary Care Clinics were documenting at least 65% of children’s BMI and using EMR 5210 tab to discuss weight related health by focusing on preventing the risk factors (72%, 89%, 92%)

• Promote routine calculation of BMI risk rating at each clinical encounter as a VITAL SIGN to encourage weight-related health and its impact on the patient’s overall health and well being as well as its impact on public health

ACT

• Continue to educate and promote the importance of daily behaviors related to 5210 Healthy NH

• Continue to foster collaboration between CCNTR and local PCP about referral for local nutritional and physical activity resources

• Continue to utilize QI tools in day-to-day activities

• Continue broad community outreach to target population

Establish Future Plans:

• Continue familiarizing CCNTR staff with QI concepts, tools and methods with particular evidence on evidence-based interventions

• Relay obesity statistics, trends and health indicators to health care partners to further develop QI echoing community efforts

• QI will be expanded to other Healthy Eating Active Living (HEAL) sectors in the region (worksites & workplaces, schools, food & recreation industries, communities & municipalities

Each partner brings their own influence on the community to the table. When we put them together it

creates a “Quilt” covering our community with a universally delivered message