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Office of Policy and Planning

State: TX Type: Promising Practice Year: 2019

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Harris County Public Health
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Office of Policy and Planning

Detroit has a rich history, expanding in the mid-20th century to one of the largest cities in the US with roughly 1.8 million people, spread out over 139 square miles. The city was constructed with multiple highways, large single-family homes and no true public transportation infrastructure—predicated on the booming automobile industry and the premise everyone would own cars. The decline of the automobile industry and racist federal urban policies such as redlining created an accelerated decline in the population (now 673,104 with 79.1% African-American), leaving extreme pockets of low density, blight, concentrated poverty (37.9%), and a vastly spread out population without transportation modalities needed to sufficiently access services and employment. Taken altogether, these factors indicate a population with high levels of isolation, entrenched barriers to opportunity, and significant health inequalities. As a health department, this creates significant challenges to reaching people and improving health outcomes, and has required innovative and neighborhood-based approaches to service provision.

In the summer of 2018, the Detroit Health Department launched the Lead Primary Prevention Pilot Project (Pilot”) as a proactive measure to end childhood lead poisoning in Detroit through education, blood lead level testing, testing for lead paint, and by providing lead-safe cleaning kits. The scope of the project is focused on door-to-door outreach performed by Community Health Workers in the five zip codes with the highest rates of childhood lead poisoning: 48202, 48204, 48206, 48213, and 48214.  We also have a field liaison to oversee the on the ground work, and a social worker and nurse manager that assists with follow up for case management. The goal of the Pilot is to reduce lead poisoning in children, who are developmentally the most vulnerable to the harmful effects of lead exposure, before they are exposed.  This goal will be achieved by increased testing of children for lead, education, and lastly, getting families with young children into the pipeline for having their homes abated for lead hazards.

The Detroit Health Department (DHD) started the pilot by collecting addresses for every parcel in each of our target five zip codes, a total of over 37,000 parcels provided by post office records. We dispatched our Community Health Workers to knock on every door starting out in zip code 48202, and later moving into 48204 and 48213.  Through our partnership with Wayne State University, who replicates our efforts in 48206 and 48214, we have created a referral pathway directly to DHD for any in-home child lead testing that is requested.

We are close to completing a door knock in each single family home in our target zip codes, and successfully completed outreach to over 17,000 occupied homes.  Of those homes, we were able to provide education to over 1,000 families, and completed full home assessments to almost 50 homes, and lead testing for 35 children ( 4 of which were not previously tested and were found to have elevated levels).  80 lead-safe cleaning kits were distributed to families in our target demographic and target zip codes.  The Pilot tested a total of three pregnant women and detected zero with elevated blood lead levels.

We were able to meet our objectives of providing resources and education to the community, increasing knowledge and education, testing children who previously had not received a test, and increasing the number of homes placed in the housing abatement pipeline. We were able to meet these objectives by being proactive, flexible, and creative and bringing our services and resources into neighborhoods. 

The public health impact from this pilot is that more children are prevented from being exposed to lead hazards, testing increased, and long-term fewer children will be impacted by the negative impacts of lead exposure.  

Our website is located at:  https://detroitmi.gov/departments/detroit-health-department/programs-and-services/lead-program

Lead poisoning continues to be a scourge in Detroit, primarily because the majority of housing stock in the city was built prior to 1978 when lead paint was banned.  MDHHS has reported an increase in lead poisoning of Detroit children from 7.5 percent in 2015 to 8.8 percent in 2016.  In 48206, one of the most lead poisoned zip codes in Detroit, 22 percent of children tested in 2016 were considered lead poisoned. Detroit has the highest percentage of children poisoned by lead than any other city in Michigan, including Flint.  Furthermore, only 40% of children under 6 in Detroit are tested for lead, a concerning number given the known risk based primarily on aging housing. Thus, a proactive strategy that brings public health services into neighborhoods most at risk is urgently needed. The Pilot has lead to increased lead testing,  awareness of environmental lead hazards, and identification of household lead hazards. 

The Lead Primary Prevention Pilot Project was developed as a partnership between the City of Detroit's Housing and Revitalization Department (HRD) and the Detroit Health Department (DHD). DHD completes the door-to-door outreach while HRD receives abatement referrals from the families in our target population (pregnant women and children under six years old) who are also in our target zip codes. By creating a pipeline for families who have young children most at risk of lead poisoning, but have not yet been lead poisoned, we strive to eliminate childhood lead poisoning in Detroit. This was a way to carve out the primary prevention abatement efforts and build up cases in the queue for HRD to meet their required abatement numbers. Currently, DHD has referred 30 homes to HRD for abatement.

The overall goal of the Lead Primary Prevention Pilot is demonstrate the feasibility of door-to-door outreach and testing strategies to reduce lead hazards in households that pose a risk to pregnant women and children under the age of six years old. During the early stages of program development, DHD partnered with and expanded upon the Lead Safe Blocks (LSB) Project, a project of CLEARCorps Detroit and Wayne State University's (WSU) Center for Urban Studies. This pilot targets high-risk homes with a comprehensive healthy home assessment ( including lead hazards) in one of the target zip codes, 48214. DHD, in its case management and coordinating capacity, builds on these existing partnership with the LSB project for data sharing and case referrals.  Our primary prevention pilot was able to scale this effort and expand it to create in-home lead testing of children and pregnant women.

The Lead Primary Prevention Pilot was funded by the City of Detroit in the amount of $1.25 million for one year. The original budget marks $611,520 for the salaries of one full-time project manager, one full-time field supervisor, one full-time social worker, one full-time nurse case manager, two part-time nurse case managers, and six full-time lead advocates; $103,958 in employee fringe benefits; $21,120 in travel expenses; $133,676 in supplies and materials, which includes lead care kits, lead testing machines, cleaning kits, lead check swabs, and general office supplies; $315,750 for home inspections and evaluation; $10,560 for cell phone and wifi connectivity; and $53,416 for promotional materials and administrative expenses.

The Lead Primary Prevention Pilot implements on-going process evaluation to improve program delivery and maintain protocol fidelity, evidenced by pre-deployment team meetings where screening and testing protocols are reviewed and questions are addressed before the team goes into the field. Team leaders and/or the program manager monitors operations when a home assessment is being conducted, providing retraining to lead advocates if needed. If there are questions posed regarding interpretations of visual home assessments, the team reviews these collectively to reach consensus. 

At each home assessment, the Lead Primary Prevention Pilot Screening Tool is used to collect information about the structure of the home and household demographics and information, including race and ethnicity, income level, children present under the age of 6, insurance status, home ownership or rental status, rental compliance (if applicable), and other health status information (e.g., prenatal care, past lead testing for children under age 6, WIC enrollment, vision and hearing screening, and chronic conditions) to provide referrals. In additional to the quantitative data collected on the initial screening tool, lead advocates also conduct visual assessment of household lead hazards, lead check swaps for lead paint, and capillary blood tests to test for lead exposure.

In October of 2018, the Detroit Health Department (DHD) also launched a Parent Support Group for parents of lead poisoned children.  These meetings are intended to engage feedback from families about the program service delivery such as challenges with the abatement applications, navigating hospitalizations, relocation and resources to improve programmatic service delivery and maximize our reach.

The Lead Primary Prevention Project was initially funded as a demonstration pilot for a year by the City of Detroit through June 2019. As of 12/05/18, over 17,400 homes have been visited across 3 zip codes, providing same-day lead testing for children under the age of 6 and their homes, as well as information and referrals for lead abatement. A routine household lead-safe visit (intake, visual lead hazard assessment, lead-safe cleaning kits, lead check swabs, and child lead testing)  of a home that includes one child costs approximately $100. In Gould (2009), such investments have a projected $12-$155 return on invest per every dollar spent. Furthermore, MDHHS has reported that the cost of lead exposure in Michigan in 2014 costs nearly $240 million with $112 million of this amount being paid by the taxpayer. Lead testing and hazard removal is imperative for promoting and protecting the health and vitality of Detroit's residents. As our direct outreach continues to successfully yield new clients for lead safe services, the Detroit Health Department has been developing and incorporating sustainability action plans focused on raising lead-safe awareness and building and expanding capacity around the importance of testing city-wide.

Early into the project, our Lead Primary Prevention Project Team recognized a clear need to provide additional support services for families with a child who had tested positive for lead exposure. As a response, the Detroit Health Department (DHD) launched a Parent Support Group for caregivers of lead poisoned children in October of 2018. The support group is modeled after the Children & Families with Special Needs' (CSHCS) family support group and the Lead Safe Parent Support group of Grand Rapids. These engagements provide families social support and have increased their knowledge and self-efficacy around accessing lead safe and other health department programs and services. Parent support group meetings will include presentations on selected topics on how to navigate applications, link to early on, available DHD services, education services, and parent to parent sharing about the testing and case management processes. DHD has connected with the Grand Rapids Parent Support group for sharing of topic areas and best practices and to build in alignment with quality improvement plans for the program. The families who attend the support group have also provided meaningful feedback to aid the pilot's process improvement. They also return to their neighborhoods and other community settings more informed and willing to share information and resources within their networks.

Over the past year, DHD has also undergone transformative reorganization, aimed at integrating its programs and services more seamlessly to capture and increase referrals system-wide. In 2019, the health department will be piloting implementation of customer relationship management (CSR) technology in one of our infant mortality programs. This innovative approach will soon assist the entire department in managing and analyzing client interactions and data at every point of delivery at the health department, including our door knocking programs. The new tools will also improve service delivery, efficiencies, and increase utilization of health department services. Families served in the Lead Primary Prevention Pilot will be entered into the Salesforce platform, which will provide unique opportunities to identify specific health needs, improve referrals across internal and external stakeholders, and increase connectivity with families overall.

Lastly, in response to the Lead Primary Prevention Pilot's capacity to provide high-quality lead-safe service delivery in neighborhood-settings, DHD is developing a proposal to implement school-based lead testing for children under the age of six in the targeted five zip codes. The project, which is planned for 2019, incorporates best practices from the Cleveland Public Schools System and will complement the current neighborhood testing strategy and expand referrals to our household testing and abatement services. 

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