AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
JUAN ACUNA: Thank you Cassie. Thank you very much. It is a real pleasure for me to be here today because of many reasons. First because, I don’t know, maybe those things of fate and destiny, I ended up substituting somebody that is very dear to many of you guys, a bit taller. You know who that is. Skinnier. Little bit less hair but I’m heading that way. So, he couldn’t be here. He was going to be here, Bill Sappenfield and I think that it was great to inherit his job here because of two reasons. First because I have been part of that program for the past five years since I pretty much started working on MCH and public health here in the United States. And second because I think that Bill created or helped create it because he inherited as well from Harriet Rush and a great person and he did a great job bringing the program, not to like next but to the next to the next levels. So, I think that I’m up for a big challenge here. And just keeping going with the program is a challenge to try new things is very, very challenging. But I guess that the fact that I’m here means that I am up for the challenge. So, so here I am to try to help you the best possible way that I can.
Making MCH Data Count, that is the title of this session. Sometimes we put titles to the sessions that are colorful, attractive. But that’s my question to you. How do you think that you could do that? How do you think that you could make MCH data count? How do you do it in your own shop, from your own perspective, with your own population? How do you make changes in times of great challenges? Who has heard recently the term 'budget cuts?' Okay. So I guess that we all do. That’s, those are the times. I mean, those times are not likely to fade away soon. Why? Because we have other challenges. We had September 11, which puts us all to the chase of ghosts that might happen again. And chasing such ghosts, even if they are real, is extremely expensive and the pot of money is the same one. I mean, there is not, there is no more money so, when you decide that your priorities change, you have to take away from some and put to another.
Now we had Katrina, so this is a very interesting meeting as I was discussing with the Board of AMCHP because we come after two major challenges. The first one Katrina, big, big, costly, expensive disaster. And the second one less money, less money for all of us from the state perspective, from the federal perspective, from every single perspective. And the problem is that we end up seeing those things and many more because I have not started talking about challenges. Challenges to get those rates or indicators that are bad and make them go lower. And those that are good and try to make them higher. And probably you, many of your have been filling up those nice, wonderful forms for the Title V keep seeing many of those as flat lines. It doesn’t mean that we’re all dead. It means that there are things that are really difficult to change. So we are up to wonderful challenges.
So then how do we play this game with less money, less resources, bigger challenges, and in times of greater difficulties where allocation of money is changing towards sides that, many of those away from the field of MCH. Well, we have to become very creative. We have to improve efficiency, which translates into doing more, doing better, with less money and less resources. And we have seen that there is not a single scenario even using a very user-friendly mechanism as Google. So we Googlize the term of MCH and evidence-base and you find grants, programs, PowerPoint slide presentations, aids, fellowships, everything is there under just that term, MCH evidence-based. And the problem is when we are asked to become evidence-based, to become more efficient and more effective in our programs, to be able to do much more, much better, with much less.
The first question that we have in our minds is how do I do it? I have no clue. I have no idea. I have a few ideas but are those ideas right? Are they the proper ones? Who knows how to do that? Who can help me improve my efficiency given that we are working throughout those times? Well, we are not in a different boat, not at CDC, not at HRSA, not at the federal or state systems, nobody. We’re all in the same boat. We have less money. And we have to allocate money cleverly.
Recently I jumped into a--bumped into a paper. Wonderful paper. You have to read that paper. And that paper was published in the Royal Academy of Medicine Journal, Journal of Royal Academy of Medicine and is written by Sackett and Cox and if you are close to the field of evidence-base in medicine, you will recognize the last names. Very clever people, been around improving efficiency on how we do and practice medicine for probably around two decades. Pioneers on changes that have really transformed the field of direct services. And those guys write a paper that is called “The Mega Analysis of Re-Disorganization”. And you start reading the paper and you say, "Oh my God, you have to be really clever or have really good leverage or have really good publication history to be able to pull up the challenge of writing this type of paper and actually getting it published in a very reputable Journal." And the paper starts saying something like we started evaluating the organizational techniques that everybody is using to reorganize their institution and we basically got bored. We didn’t find anything we really didn’t do anything over here. We are proposing stuff. And its actually pretty good stuff, pretty clever stuff. You will laugh a lot reading that paper. But you will start questioning the way that we think.
How many of you have gone into deep reorganization in the last five years? Probably everyone. How many of you have used expensive contracts and contractors to actually do that? How many of you within the process actually thought, "My God, this is common sense. I mean, do we really, really, really need to pay for somebody to make us think about the things that we do everyday?" And, at the end we have not even finished the process, when we were thinking, "Oh, my God, we need to reorganize again." So that’s why this is not called “The Make Analysis or Reorganization but Re-Disorganization” because it is such circumstance that resembles those diseases that sometime people have, bulimia and anorexia nervosa, one of those where you have the mental perception that you are really fat even if you are very skinny.
So are we triggering, these days, to improve efficiency through a perception that we are disorganized when we are not? And this is one of the major questions that these guys put there and it really makes us think. If those dollars that we are spending are really actually dollars well spent or if we needed to spend them or not, at all. But that’s the question that I give you that I will leave to you and to your systems, big, small, local, state, federal, whatever.
We have such circumstances it’s easy. I mean, it was fruitful to a lot of extent because then the organization strengthened as one of the results our state programs. So we are walking good days for state programs with NCDC. State programs didn’t have--it’s not that they didn’t have a lot of support, it’s that they didn’t have a lot of special support. And we were focusing our efforts in trying to know more about a lot of things that were each time more focus and more focus and more focus. To a point where we have produced a lot of knowledge that nobody has used. So we have journals and journals and journals and papers published everywhere that nobody has actually put to use.
So the next question is, how much of that money could we have saved to actually take one of those that was relevant and make it into an evidence-based program that actually would have worked and could have saved a couple of lives? A couple of years of quality life, disease, et cetera. And the answer has been many. So that’s why right now CDC is committed to support things that work. And it is very clear that pure research, per se, doesn’t work. So that’s why I started with the question about the title of the session, “Making MCH Data Count.” How do you do it? You have the information. You have the data. Do you know how to deal with it? And maybe the answer many times is no. I really do not know. I have an idea, but I really might not know.
What we have done within one of those state programs, that is the MCH HIPAA program, has been for two decades to try to make that data count. Improve the efficiency of MCH programs, people, systems within a couple of states where we have been able to put assignees work with, provide TA's because there are many mechanisms that we use to work with some programs in the states to try to make the change. And that’s what I am trying to show to you today, in a very brief format. We will have, I have another session Sunday from 4:00--tomorrow, from 4:00 to 6:00 where I will be presenting a lot of what I will be presenting today, a little bit more, and trying to get to, okay.
So I can help you guys given that you will have to help me and you will see how because this has to become a partnership. I cannot do it alone. Maybe you cannot do it alone. The only thing that we can do is build a partnership and make it work for the sake of those that we are trying to save or protect or work with. So we start with these, healthy women, healthy children, healthy families through leadership for healthy positions. That’s how we think that our core strategies work. So what is our program’s mission? Well, you have it there. And it took some of those, one of those re-organizational, you know, times to come up with something that would make sense for us. And I think that for our program and for our perspective, it was helpful. It clarified the fact that that is what we want too. How do we do it was another business. But that’s at least what we would like to.
So the first piece is to promote and improve the health and well being of women, children and families, which makes sense. That is the MCH part? And that is the count part that we are trying to cover within this session. Building MCH epidemiology and that of capacity of the state, local, and tribal levels. That’s how we do it. So if you would be a partner in this enterprise, would you want to get out of that partnership? It’s exactly that. What we try to do is take places to the next level. We try to build something and build something that is not going to disappear later. Something that is there to stay. Sometimes we have been successful. Sometimes we have not. Sometimes DSI need to leave because we all live with time. You know, we don’t stay at the same place forever. And we actually leave a place that is a notch or a couple of notches upwards of where they were. And it’s not that we did it. It is that we just provided the oil so the machinery would work better. So the machinery would find the next notch and the next level and that’s what we try to do. And we try to do it all across the board, domestic and now we’re thinking on expanding these internationally. Why? Because we have two decade of know how, so to speak.
I think that we are ready to franchise the product because we think that what we’ll hear we could replicate and do better some other places. Better why? Because the less the resources the best we can do our job. I really enjoy working in Louisiana because it’s very hard in the MCH arena to find a place with less resources and bigger problems. It’s really, really hard. Probably you won’t find another place with such correctiveness in the whole United States. So I had a great time there. Why? Because there was a lot to do. Because only you couldn’t go wrong because any idea would crystallize on somebody having a better life, better status. Maybe a few kids dying less every year, et cetera. And, of course, if we are going to promote evidenced-based decision making programs and policies to effectively use information for public health actions. Well that’s what we do. So if we commit to a partnership, that’s what you get out of it. And my question is, does it sound good? Maybe. So how do we do that?
Well, there are, we’re just going to follow one of those models that are out there and this is actually the model of our branch, which is called the Applied Science Branch. So as we have to honor our name, we need to develop the know-how to practice applied sciences. So we pretty much perform, work everyday, with the focus of keep the loop rolling, not let it stop. This is a circle that we do not want to break because we think that this circle, if it keeps going, is the one that will make public health progress. And if we progress of public health practitioners, somebody’s life is going to be better. So we gather information, conduct research, design and evaluate programs, develop uninformed policies, communicate findings and, of course, if we communicate findings and do all of those successfully, the information, the modifiers, the modifiable risk factors are going to change.
The population at the end of each one of these circles has to be different. If it’s not different, we have failed. So as it is different, we need to restart the process again. So we’re going to start again. A few examples of how we do it and where we do it. We’re going to start with the where. These have been the states where we have placed and assignee, at some point in time, or one of our fellows that we support, at some point in time, and those that we have supported or where we have been in the past. So you see that what is notorious here is that we have covered less states than those that there are to cover. And a question would be, why?
Well, one of the issues that we have is we don’t have enough money to put an assignee in each state. Nor, there might be a need for an assignee in each one of the states. Why? Because there are states that do have the MCH capacity to do these. And the second reason is because there are states that really do not need and MCH assignee because they are such low risk populations that they don’t need an MCH leader to try to oil those systems, because they function quite well.
Now, if in your minds you have or you have had the issue of, "Oh, my God, I would really like to get a handle on information and data to do my job better and to impact better given the resources that I have are these," then you might be able to place. And I have not spoken to any place that has not that issue in mind so far. So we have had usually around nine to 10 assignees at a given point in time. If we have not covered the whole United States, it means that those assignees do not change, which means we support the assignees as long as they want to be in the states. And we support states as long as they would like to have an assignee. So it is an endless partnership if the conditions are given. So we don’t move around a lot. When we come we usually stay for quite a long time. The last example, myself. I stayed five years and a half in Louisiana.
So, we have few FT’s. And usually FT’s in these days do not appear out of the blue. Well, the reason why I’m here is because we had some FT’s that actually appeared out of the blue. So having had 10 assignees, I was given, in a way that exemplifies that support that upper spheres have for state programs, I was given five more. And I might be given another five, which means that the program is going to duplicate in size. Which means that I could potentially have maybe as many as 20 states, almost half of the states covered with assignees. So, those are the times. Why can I do that? Because we got some money, so despite the fact that the budget was cut, our programs was considered one of the important programs and the states are considered an important partner.
So, two things happened. First, we got the offer of the FT’s, some money to support them, which means that they are not fully supported by the CDC. Remember, this is a partnership. And believe me, the partnership means first that we have to put money, both of us. Of course, we will put and have some fun together and, you know, that’s part of the partnership as well. But we have to make it happen together. And third, the cap that limits the number of FT’s per program was released for state programs. So theoretically, that gives the grant for unlimited number of assignees if the circumstances and the partnerships all come together.
How do we do this? I will give you some examples. Gather information. These are some of the most recent projects. Five years needs assessment, MCH needs assessment. Do you remember it? Ah. It’s still too painful to forget. So all the assignees that work at the state level were strong partners in developing the MCH EPI needs assessment for their state. Surveillance such as developing planned supporting plans or analyzing plans BRFSS, birth defects, vital stats, et cetera. Mortality reviews, establishing fetal infant child/mother mortality reviews. Those are some of the examples of things that have not been in place in some of the states where we have worked that have been developed because of this partnership.
Conduct research, assessment of tribal MCH programs monograph on research in American Indian communities, factors related to breast-feeding duration. Just to give you an idea, those nine MCH assignees present around 20 to 22 abstracts yearly, at several different meetings. And you have to consider that these presentations obey the fact that they have been working on these projects and the main focus of those projects has never been either a peer review publication or actually presenting an abstract. Those are extras. After doing these, or before doing these, that information, those projects, that research has been first applied at the state level or at the tribal level or at the local level to make things work better. So that’s what we seek. We seek first to apply research, to move programs forward, to improve the efficiency and efficacy of programs. Then if we publish, great.
Design and evaluate programs. Electronic versus manual breast pumps and breast-feeding duration, one of the projects facilitates management and pre-maturity, high-risk infants and early intervention services and many more. Each one of us usually, not only designs but promotes or carries out large, a large evaluation program or as within Louisiana, we helped to institute the evaluation component for every single grant that the Title V supports within the state. So it’s not only the performance measures but actually for state accountability, each one of those programs that we contract or we build at the state level are supported by an evaluation component. Why? Because we need to learn more about those things where we cannot find evidence. So many of you might be in programs, paying them with Title V or state funds or other funds and you really do not know whether those programs work. You know that those programs are being done and are being done well, but whether you’re producing an impact, you have no idea, many times.
Development in foreign policies. Evaluation of high-risk prenatal services to change the prenatal classification of hospitals in states. Former versus current Medicaid recipients and pregnancy outcomes. Extremely popular if you want to piggyback on Medicaid funds and partner with established partnerships within the state with Medicaid, which has a lot of money. Insurance status of entry into prenatal care sometimes, same reasons. Communicate findings. Publications, Journals, or Board briefed Web sites, presentations, conference meeting, media, planning et cetera, et cetera, et cetera.
So I guess that what we do overall surrounds the fact that we work mainly on MCH and reproductive health. In many of the states we do not support only the MCH program, but the family planning programs, children with special health care need programs and many times others. So really the structure that we work with at the state level doesn’t really matter. What matters is that our mission is to make that system better. So that’s why most of what we do is based on the fact that we are able to recruit and maintain senior MCH epidemiologist at the doctor level. You and I know that trying to recruit a doctoral level epidemiologist, MCH epidemiologist at the state level is between impossible and non-doable because nobody has a mechanism to pay a doctoral level salary. And we all know that a Masters Degree Epidemiologist that goes out of the school will work in our system and I believe that the average stay in our state was like 1.2 years at the most. I mean they stay for a while until they find a better salary. And better salary for a MCH level epidemiologist could be $3,000. They are not willing because that’s the nature of the age range and the commitments that they have as a person. They cannot afford to lose $3,000 per year of salary. So they shift.
So we can never build a place that will learn upon our mistakes and experiences and build a senior MCH epidemiologist that is going to drive all our funding, scatter, shorten, in these times are with high need, with more efficiency. Why? Because we just focus on filling up the blanks, filling up the numbers, and then keep going with life. How efficient is that? Very inefficient. So even if there would not be an assignee from the program in your state, there are mechanisms that we can use to support your state if you feel that your state, that would really like some TA for now while you build the system that is going to be able to support on of these assignees, for example. Or build upon the system so you can form those leadership positions that are going to build your capacity in MCH epidemiology to support and make evidence-base your programs.
I would like to stop at this point and thank you all for being here and if you have any questions at this point, please feel free. Remember that there will be a session to discuss this program, this topic and more the whole core philosophy and way to do things that the program has used in the past so that it gets to actually build that MCH epic capacity if you want to go on Sunday. Thank you very much and if there are questions, please. Thank you. Any questions?
UNKNOWN SPEAKER: I have just one question. I was wondering if traditionally your organization has focused on the medical and biological determinants of health or if you are now starting to get into more in the social determinants for this population.
JUAN ACUNA: That’s a good question and you know that there are two institutions that fund, so to speak, research in within the federal government, NIH and CDC. Of course, many of the others, HRSA has a research component, et cetera, et cetera. But, those others usually are split into that research that is going to be more medically and biologically oriented, and those are supported by NIH, traditional. And those that are public health oriented go towards other institutions such as CDC and other parts of HRSA. But that has been the traditional split. Not to say that, of course, biology and public health or social, psychosocial determinants or risk factors, how we know sometimes are not becoming pretty much confluent in the mill and are becoming part of the same causal pathway. So you see more and more NIH supporting things that are public health and CDC working and some that are more biology or disease oriented. Okay?
Well, thank you very much.