The Chronic Lead Poisoning Team Intervention Model is an innovative approach developed by the Milwaukee Health Department Childhood Lead Poisoning Prevention Program (MHD CLPPP). This approach was developed in response to a subset of lead poisoned children with chronic blood lead elevations who were placing significant demands on program resources and were not responding to standard MHD CLPPP interventions. These children comprise about 25% of the 450 currently active cases of children with elevated blood lead levels. The outcome expected as a result of this approach is to decrease the number of children with chronically elevated lead levels, shorten the length of elevated lead levels, and improve the living conditions that prevent these children from achieving safe blood lead levels.
The entire process of developing and actualizing this Team Intervention model has been the result of the joint efforts of a group of Public Health Nurses, Risk Assessors and related managers. All professionals involved in the management of these families was crucial to success. All team members have had to be open to developing new, creative, and flexible interventions to meet the needs and demands of these high-risk families, as standard approaches were failing this subset of children. New relationships with housing, education and community agencies have extended the ability to meet the planning goals identified with these families.
Desired outcomes are that children’s blood lead levels decrease to a safe blood lead level faster than the previously established baseline of three to four years among chronically poisoned children; that children identified as at-risk for chronic poisoning receive intensive and rapid attention; and that their families remain in lead-safe housing with less frequent moves. Among the 121 enrolled at-risk children to date, lead levels have declined in 93%; and 115 lead-safe housing units have been created or located for these families.
Some children have had lead levels remain higher than 20 mcg/dL for many months or years causing significant demand on program resources, and presumably increasing the risk for these children. The Team Intervention model seeks to reduce the number of children in Milwaukee with such chronic poisoning.
Case review of 20 children who were chronically lead poisoned versus 20 children whose lead levels declined after standard interventions helped to define criteria to identify which children were most likely to develop chronic lead poisoning. A set of criteria was established to identify among Milwaukee children with elevated blood lead levels those who were at highest risk for developing chronic lead poisoning. Children meeting these criteria are enrolled in the Team Intervention program.
A working team of Public Health Nurses (PHN) and Risk Assessors (RA) developed a more inclusive and comprehensive approach to case management and environmental assessment for these children and their households. The basis of this practice is the recognition that the family is key to its own success and that the family must participate in a plan that will recognize its strengths and weaknesses and support a plan that is all-inclusive. The integration of the Lead RA and PHN as team leaders allows for the process development.
This level of intervention looks beyond the singular issue of lead poisoning providing a holistic approach to family case management. The team focuses on underlying obstacles for the family such as housing needs, lack of financial resources, and AODA issues. The interventions are directed to addressing the family needs in an attempt to truly stabilize and empower the families. This multifaceted approach seeks to improve the living conditions that prevent children from achieving safe blood lead levels.
Agency and Community Role:The MHD and the MHD CLPPP supports this innovative approach by providing the necessary resources to the staff to administer such a model. Such an approach reflects the mission of the MHD: to enhance the health of individuals and families, promote healthy neighborhoods, and safeguard the health of the Milwaukee community.
The child’s parent, the PHN, and the RA develop a joint case plan in which the individual roles and responsibilities are identified including the role of external stakeholder such as the child’s Medical Provider, property owner, housing agencies and other related community organizations.
The MHD CLPPP is continually looking to create new and expand current partnerships with community organizations offering the services and resources most needed by these families. Since it can be challenging for families to find lead safe housing in Milwaukee, health department staff have fostered several relationships with organizations that can assist with housing. Additionally, MHD CLPPP has negotiated the Hoover Company to purchase HEPA vacuums for families with lead poisoned children at a reduced cost. For added developmental stimulation and incentives to families with lead poisoned children, a local community based agency has been providing MHD CLPPP with new or gently used books for distribution. The PHNs make referrals to Milwaukee Public Schools (MPS) Headstart program and Curative Care Network Birth to Three Program for further developmental assessments on children identified as having potential developmental delays. Referrals have also been made by the PHNs to the Bureau of Milwaukee Child Welfare, other health care providers including specialists, and other local social service agencies. PHNs and Ras make referrals to the City of Milwaukee-Department of Neighborhood Services for building code violations on properties, as well as to other housing agencies that can offer services to low-income property owners.
Costs and Expenditures: Costs for staff time include initial PHN home visit ($395 and each follow-up visit costs $158); and initial risk assessment including RA time, cost of dust wipes, lab support, and other related costs ($565). Costs for other resources included vacuum cleaners ($1,600), cleaning supplies ($500), and donated books if purchased ($200). Outside agencies who supplied in-kind contributions included the Next Door Foundation, Milwaukee Public Schools (MPS) Head Start, Curative Care Network (CCN) Birth to Three Program, and Community Advocates Transitional Living Program. Dollar amounts are unknown for these contributions.
Funding sources included Milwaukee Health Department, State of Wisconsin Childhood Lead Poisoning Prevention Program contracts, Centers for Disease Control and Prevention Childhood Lead Poisoning Prevention Program Grant, Community Development Block Grant funding, Multiple U.S. HUD grants, and Voluntary collaboration by rental property owners, other city departments, Hoover Vacuum Company, housing and child-serving agencies.
Implementation: Tasks include design/develop referral system to identify at risk families/children; identify children who meet referral criteria; refer children to “Team Intervention Program” based on identified criteria; establish joint home visit protocol for PHNs and RAs; initiate contact with family; develop case plan with family and obtain parent/care giver’s signature; comprehensive risk assessment including environmental assessment of primary/secondary addresses, obtaining dust wipes and visual assessment; educate family on lead issues, developmental screening, nutrition assessment and identification of other health and psychosocial needs of family; initiate referrals to collaborating agencies (Section 8, Community Advocates, Head Start and Curative Network Birth to Three Program); discuss status of case plan; distribute of HEPA vacuum cleaners and cleaning supplies to participating families; and contact and collaborate with child’s medical provider.
The timeline for these tasks is as follows. RA initiates contact within one to two days after receipt of referral; dust wipes obtained (initial, clearance, interim and final or as needed). Interior orders completed within 30 days. Exterior orders are completed within 30 days if weather permits. With noncompliant owners, a court order is obtained within one week to complete lead hazard reduction. Contractors’ work is monitored daily. PHNs initial contact depends on child’s blood lead level and based on CDC’s guidelines. Denver Developmental Screening administered at initial visit or as soon as possible and repeated in three months and six months as needed. PHN/RA evaluates effectiveness of Team Intervention Model pertaining to each family every six months.
Multiple criteria are utilized in determining the effectiveness of the strategy such as a decrease in child’s blood lead levels, documented changes in visual assessments which are based on HUD standards for housekeeping and structure of house, lead dust wipes that indicate consistent decline in lead levels, ongoing evaluation of case management plan, goal achievement, case closure criteria, and case closure conference held with family to elicit feedback regarding the process.
Baseline information from multiple years of tracking children with chronically elevated blood lead levels indicated that it took about three to four years for that child’s lead level to decline into a safe range. Since this approach has only been an active intervention since July of 2002, it is too early determine if there has been a decrease in the length of time enrolled children’s lead levels are elevated. Preliminary information, from the 121 children in 100 families who have been enrolled for this intervention, indicates a decrease in blood lead levels in 93% of the children who have been retested. In addition, 71 housing units where the children live or spend time have been made lead safe through compliance with orders, direct abatement, or primary prevention funding and 44 additional units were found to be lead safe. Although complete evaluation has not yet taken place the staff identifies some anecdotal changes that have occurred such as families remaining in the same housing unit after it is made lead safe, regular and frequent follow-up with the Medical Provider, some families actually establishing a better financial outlook, and families having a better understanding of lead poisoning and what can be done to protect children from further lead exposure.
Lessons Learned
In order to achieve the outcomes for this approach program staff have learned that family cooperation and willingness to participate is critical. Families actually become active members of the team. With more intensive services most families have developed a greater trust in the MHD CLPPP.
The entire staff participating in the Team Intervention approach has found the weekly meeting to be invaluable. These meetings allow for the discussion of cases, successes, and failures, which serves to build a sense of collaboration between staff. In addition, the opportunity to collaborate with other programs and housing agencies such as Rent Assistance has added to the success of this approach.