Lake Cumberland District Health Department using polls in an effort to get school boards to make campuses tobacco-free

Countywide smoking bans are unlikely to pass anytime soon in most of rural Kentucky, but more county school districts are making their campuses tobacco-free. Now a multi-county health department is trying to get rural school boards to do that, with public-opinion polls showing that county residents overwhelmingly favor the move.

Department logo has been altered to
show Clinton County in yellow.

The Lake Cumberland District Health Department conducted the poll in Clinton County, and said it found that 86.55 percent were in favor and 7.16 percent were opposed. The rest had no opinion.

Making a campus tobacco-free means that members of the public are not free to smoke at school athletic events, so the poll also asked, “Would you like to see our school become tobacco-free at all events?” The results were virtually the same: 85.3 percent answered yes and 8.7 percent answered no, even though one-fourth to one-fifth of the county's residents smoke and it has a long history of raising tobacco.

"The results are perhaps surprising to some, considering the rate of tobacco usage in the county," reports the Clinton County News. The poll of 749 residents has an error margin of plus or minus 3.6 percentage points.

The department also surveyed 100 teachers in the school system and found that 77 percent would "definitely" support making the schools 100 percent tobacco-free.

The health department presented the survey and other findings to the Clinton County Board of Education June 15, but the board took no action. The department noted that a recent survey found that 28 percent of the county's students in eighth through 12th grades had used smokeless tobacco in the previous 30 days. "That level was the highest in the Lake Cumberland District," the Clinton County News reports.

The Casey County Board of Education adopted a smoke-free policy after a poll by the health department showed 70 percent of the county's residents favored it, the Casey County News reported.

Health department urges Kentuckians to walk regularly; state ranks high in obesity, low in physical activity

With summer here, the state health department is urging Kentuckians to adopt a regular walking schedule to connect with friends and neighbors and improve health and fitness in a state that ranks high in obesity and low in physical activity.

“Summer is the perfect time to renew your commitment to get outdoors and take a walk,” Health Commissioner Stephanie Mayfield, said in a news release. “We all know walking is healthy, but it’s also fun, relaxing, and a great way to connect with others. You can invite a friend or loved one out for a nightly walk after dinner, take care of weekend errands on foot, or invite neighbors or co-workers to start a regular walking group. The more you walk, the more you’ll connect and be part of building a stronger, healthier community.”

In Kentucky, 31.3 percent of adults are obese. “Obesity is linked to multiple chronic conditions, including diabetes, heart disease and stroke – and is one of the major chronic conditions affecting the health of Kentuckians,” said Elaine Russell, the Department for Public Health's obesity-prevention coordinator. “Regular walking could greatly reduce our state’s obesity burden.”

Russell's program and the Partnership for a Fit Kentucky have created a guide for obesity prevention and health policy for Kentucky communities, at http://www.fitky.org/wp-content/uploads/sites/2/2015/04/PA-Vision-Slidedoc.pdf. ). Kentucky is one of four states that will get technical assistance from America Walks to improve walkable community design, such as complete streets, lower traffic speeds, livable communities and economic benefits.

“We’re also working directly with communities and funding projects through a public health grant program to help cities and towns across Kentucky develop pedestrian plans,” Russell said. The department selected 11 communities for funding to start work on a pedestrian plan.

“We’re very excited about recent developments in obesity prevention and increasing physical activity in the commonwealth,” Russell said. “We hope everyone will not only become more physically active, but take some time to learn more about our vision and support our communities in their work to become more active, healthier places to live, work and play.”

Louisville opens first needle exchange in state; officials predict rural counties will be slow to follow

Photo by Scott Utterback, The Courier-Journal

Louisville Metro Public Health & Wellness opened its mobile needle-exchange program Wednesday, June 10, making Louisville the first place in Kentucky to implement such a program.

Lexington and Northern Kentucky are expected to follow soon, but officials say that establishing needle exchanges in much of Kentucky will be "more politically complex," Mike Wynn reports for The Courier-Journal.

"We're going to see some parts of our state where this is available and others where it is not," Scott Lockard, president of the Kentucky Health Departments Association, told Wynn. "Rural areas are opting for a slow and deliberate approach, heavy on education and dialogue," he said, and some communities won't even consider a exchange because of "seemingly endless hoops to jump through."

Bullitt County, south of Louisville, is a prime example. There, officials told Wynn that they plan to do a needs assessment and host a community forum with input from law enforcement and mental health experts.

"It's a work in progress," Public Health Director Andrea Renfrow told Wynn. "We are not able to go as quickly as Louisville Metro."

One critic, Magistrate Joe Laswell, told Wynn that he had talked to many voters who are against the exchanges and want to know why police wouldn't arrest addicts when they show up to swap out dirty needles. "I believe in charging and incarcerating," he said, apparently unaware that the addicts would need to have drugs in their possession to be charged.

Lockard, who heads the Clark County Health Department, told Wynn that he won't ask his board to take a vote until August and that he can't predict the political outcome when it goes to city and county officials.

In three other Bluegrass counties, Scott, Harrison and Nicholas, the board of the Wedco District Health Department wants to start a needle exchange, reports The Cynthiana Democrat, but can't proceed in any of the counties without approval of the fiscal court.

So, despite the two-year debate that just ended in Frankfort over the law, it's not really over.

Democratic state Rep. John Tilley of Hopkinsville, the legislature's biggest proponent for needle exchanges, told Wynn that giving city councils and fiscal courts final authority over the programs was necessary to sooth critics and pass a comprehensive heroin bill this year.

Opponents of the law say the exchanges promote drug use, while proponents cite evidence that doesn't support those claims, but instead "help prevent the spread of deadly and expensive diseases and pull addicts into treatment programs while keeping dirty needles out of parks and off the streets," Wynn writes.

A Lexington Herald-Leader editorial wrote about needle exchanges: "Congressional critics rely on a gut feeling that providing needles endorses drug use, but 20 years of research argues otherwise." Listing that where there are syringe exchange programs:

• Participants are five times more likely to get treatment.
• HIV and hepatitis C declines among drug users.
• Participants can get referrals to substance abuse treatment, disease prevention education, vaccinations, condoms, counseling and testing for communicable diseases.
• Costs are more than recaptured. A 2011 European study found that $1 spent on needle-exchange programs yielded $27 in health-care cost savings, prompting an international report to call needle exchanges "one of the most cost-effective public health interventions ever funded."

The federal Centers for Disease Control and Prevention recently reported that new cases of hepatitis C more than tripled in Kentucky, Tennessee, Virginia and West Virginia between 2006 and 2012, mainly from the use of dirty needles. Officials fear an outbreak of HIV and AIDS will follow.

Ten-county Lake Cumberland District Health Department is the latest to ask schools to foot more of the bill for school nurses

The Lake Cumberland District Health Department told school districts in its 10-county area in December that it would no longer be able to pay for nurses for each school, setting off negotiations with the districts.

Somerset Independent Schools Supt. Boyd Randolph said one option would have the schools employ the nurses but contract them back to the health department in order to bill for the full extent of Medicaid services, Chris Harris reports for The Commonwealth-Journal.

Health Department Executive Director Shawn Crabtree told the Somerset newspaper that his agency was "running a deficit" because it wasn't being paid as much for treating Medicaid patients. 

Schools all over Kentucky have been faced with this "unfunded mandate," as Editor Stevie Lowery called it in an article for the The Lebanon Enterprise. If a student requires medical care in order to attend school, state law requires school districts to provide the care, but doesn't necessarily provide a way to pay for it.

The dwindling number of school nurses last year prompted a new law to allow school personnel who aren't licensed health care professionals to administer or help a student self-administer insulin and otherwise treat diabetes symptoms if they take certain training.

Surrounding Somerset, each school in the Pulaski County School District has its own in-house nurse, as does every school in the regional health department's coverage area, with the cost shared by the school system and the health department, Harris reports. Asst. Supt. Sonya Wilds told the Commonwealth Journal last month that the schools pay approximately $20,000 per nurse.

The department has proposed that the schools pay the full cost of employing 12 nurses, which will fall "in the neighborhood" of $750,000, about three times what they pay now, Supt. Steve Butcher told Harris. “Of course, we would receive money back from the health department on Medicaid claims, but . . . it’s hard for me to wrap my head around how much that would be worth to us,” he said.

As school officials consider all of their options, they are also looking at the individual needs of schools, with the understanding that these needs constantly change and are like a "moving target."

“We’ve got some schools that have kids with feeding tubes, and some schools that are heavy on [students with] diabetes,” Butcher told Harris. “It’s not necessarily bigger schools that have more issues, it’s just schools have specific kids that have got needs that we can’t do anything about and need additional help."

New rule will improve reporting of antibiotic-resistant infections in health-care facilities, which are getting worse in Kentucky

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. — Kentucky will have a new weapon, in the form of data, to fight infections acquired in hospitals and other health-care facilities, with legislative approval of a regulation that changes the way antibiotic-resistant infections such as MRSA and C. difficile are reported.

Health Watch USA chart, Centers for Disease Control data

The new rule comes at a time when Kentucky has the third highest rate of MRSA bloodstream infections in the nation, according to the National Healthcare Safety Network. The state was ranked fourth last year.

Kentucky hospitals are 27 percent worse for MRSA (methicillin-resistant Staphylococcus aureus) and 21 percent worse for catheter-associated urinary tract infections than they were two years ago, according to the federal Centers for Disease Control's National and State Health-care Associated Infection Progress report.

The legislature's Administrative Regulation Review Subcommittee approved the regulation, which has been in the works since 2008, at its Jan. 13 meeting. In the meantime, hospitals have succeeded in changing the term "hospital-acquired infections" to "healthcare-associated infections" to indicate that not all such infections occur in hospitals.

"The emergence of these dangerous organisms is really a problem of our entire heath care system and it can't be fixed by any single facility or facility type," Kevin Kavanagh of Somerset, chairman of Health Watch USA, a non-profit organization that promotes health care transparency and patient advocacy, told the committee. For his testimony, click here.

The regulation redefines HAIs and HAI outbreaks for infections, and requires simultaneous data reporting to the CDC and the state Department for Public Health. The CDC already has the data, but has "no authority" to act on it, while the state health department has the authority but not the data, Kavanagh wrote in an opinion piece for the Lexington Herald-Leader. "It is imperative that we know what is happening and where, so effective action can take place."

He told the committee, "Data for action is critical. It is the first step to confront these dangerous organisms."

The regulation also will require electronic reporting via the Kentucky Health Information Exchange beginning 2016. It now goes to Gov. Steve Beshear for final approval, which is expected.

Rep. Tom Burch, D-Louisville, chair of the House Health and Welfare Committee, told the joint House-Senate regulations committee that he had worked on the regulation for many years and that the Kentucky Hospital Association supported it. It had lobbied against such regulations. "There is nobody against it right now," Burch said.

However, Sen. Alice Forgy Kerr, R-Lexington, said "This regulation seems to have caused a lot of indigestion for a lot of people," and asked for a "statement of confirmation" from someone representing a group that might have opposed it in the past.

The hospital association's vice president of government relations, Sarah Nicholson, was at the meeting but didn't speak. Dana Stephens, director of infection prevention and control at St. Joseph East Hospital and St. Joseph Jessamine, told the committee, "I have had the great pleasure and honor of working with this multidisciplinary team for the past many years to really develop legislation and regulatory language that will provide information that will improve the health of those citizens we serve."

Kerr commended the groups on reaching a compromise, but the elements of the compromise were unclear. Nicholson declined to comment after the meeting.

Kavanagh said afterward that the regulation is needed to reverse the apparent increase in hospital infections, based on the CDC data from 38 of the state's 93 hospitals. "We are going in the wrong direction, with Kentucky 27 percent worse than it was two years ago," he noted. "This regulation will help with that."

Centers for Disease Control graphic reports Kentucky data on health-care-associated infections

The regulation is expected to improve the accuracy of Kentucky's HAI data because it requires all health-care facilities to submit reports and more clearly defines HAIs, which Kananagh said will help with under-reporting of infections.

New regulations often raise questions about the cost of enforcing them. Kavanagh told the committee that the CDC had told him that it would be allocating "a lot of federal money" to state health departments through grants to confront infectious disease issues, a result of the lessons learned from Ebola. Better HAI data will support Kentucky's need for these grants, he said.

"So, I do believe the state health department, along with other entities, will have access to funds to implement this regulation change,” he said.

If you haven't gotten your flu shot yet, this week is an excellent time to get it, with the holidays coming up

State health officials are encouraging Kentuckians to get a flu vaccination during National Influenza Vaccination Week, Dec. 7-13.

"Getting a flu vaccine is an early holiday gift you can give to yourself and your family,” said Dr. Stephanie Mayfield, commissioner of the Department for Public Health. “As the holidays approach, people will be traveling, and families will gather together, increasing the potential for exposure to the flu. We are strongly urging anyone who hasn’t received a flu vaccine, particularly those at high risk for complications related to the flu, to check with local health departments or other providers.”

National Influenza Vaccination Week is a reminder to those people who have not yet received a flu vaccine that the time to get vaccinated continues into winter – through January or later, when flu season typically peaks. Because it takes about two weeks for the body to develop protective antibodies against the flu following vaccination, Kentuckians who have not had a chance to be vaccinated should seek out the opportunity during this season.

Throughout the week, health departments and the federal Centers for Disease Control and Prevention will highlight the importance of vaccinations for those people at high risk, their close contacts and all those who want to be protected against the flu. In addition, good health habits such as washing hands often with soap and warm water; avoiding touching your eyes, nose or mouth; and staying at home from work or school when sick will also be emphasized.

Kentucky’s flu activity level has recently increased to regional, which indicates an upturn in influenza-like illness or outbreaks of flu in some regions of the state.

The best way to protect against the flu is to receive a flu vaccination. The CDC’s Advisory Committee on Immunization Practices recommends flu vaccine for all individuals 6 months of age and older. People who should especially receive the flu vaccine because they may be at higher risk for complications or negative consequences include:

• Children ages 6 months through 18 years;
• Pregnant women;
• People 50 years old or older;
• People of any age with chronic health problems;
• People who live in nursing homes and other long-term care facilities;

• Health care workers;                               
• Caregivers of or people who live with a person at high risk for complications from the flu; and
• Out-of-home caregivers of or people who live with children less than 6 months old.

Kentuckians should receive a new flu vaccination each season for optimal protection. Healthy, non-pregnant people ages 2 through 49 can be vaccinated with either the flu shot or the nasal vaccine spray. Children younger than 9 years old who did not receive a previous seasonal flu vaccination should receive a second dose at least four weeks after their first vaccination.

High-dose flu vaccine is available for persons aged 65 years and older this year.

The CDC says some of the nation’s circulating flu viruses may not be covered well by this year’s vaccine.  That is not unusual. "Despite the possibility of a poor vaccine match for one of the circulating strains, vaccination still provides the best protection against influenza," a state news release said. "The vaccine appears to be a good match for many of the strains which are being transmitted, and because of antibody cross-protection, should help to reduce hospitalizations and deaths, even in persons who may contract the mismatched strain of influenza."

In addition to flu vaccine, the health department strongly encourages all adults 65 years and older and others in high risk groups to ask their health care provider about the pneumococcal vaccines. These vaccines can help prevent a type of pneumonia that is one of the flu’s most serious and potentially deadly complications. The CDC now recommends that adults 65 years or older receive the pneumococcal conjugate vaccine (PCV13, Prevnar-13) in addition to the pneumococcal polysaccharide vaccine (PPSV23, PneumoVax-23). Getting both vaccines offers the best protection against pneumococcal disease. Between 3,000 and 49,000 deaths are attributed to flu and pneumonia nationally each year, with more than 90 percent of those deaths occurring in people age 65 and older.

Kentucky's health departments are working on changes, to adapt to changing times

By Melissa Patrick
Kentucky Health News

Health departments across Kentucky come in all shapes and sizes, and typically work independently from each other to serve the specific needs of their community within their budgets. But to deal with changes in the health-care system, the Kentucky Health Department Association is working on a strategic plan that will bring even more changes to the departments and the people they serve.

The plan will either “succeed or health departments will be privatized; this is our choice,” said Georgia Heise, district director of Northern Kentucky's Three Rivers Health Department and current president of the National Association of County and City Health Officials.

She discussed the plan and the state's health needs at the recent fall meeting of the Friedell Committee for Health System Transformation in Lexington.

One of the biggest changes in Kentucky's health departments is a move away from clinical care toward population health, Heise said. Departments are funded for clinical care, but they were never intended to take care of the sick, contrary to public perception; and Kentucky's shift to managed-care Medicaid no longer makes it feasible for health departments to provide clinical services, she said.

Heise noted that Kentucky's health status is 45th in the nation, so the first priority of the plan is to improve it. She told the Friedell Committee that this goal is timely, since it coincides with Gov. Steve Beshear’s "kyhealthnow" goals for 2019.

Prevention through population health is the key, but prevention takes more than just educating the public; there must be political and social will, Heise said. There are also organizational obstacles.

She said local health departments have spent lots of money just being told what to do, while the health of Kentuckians just got worse. A new strategy will use a data-driven approach toward solutions and require smart goal statements, attaching responsibility to tasks and measuring everything.

The health departments want to develop a shared vision with the state Department for Public Health, which oversees them. “It does us no good to be at odds,” Heise said.

Other goals include serving as a communication tool for private and nonprofit public-health partners, and to assist with local public-health advocacy for all branches of Kentucky government.

The plan also calls for changing laws that govern health departments. “Current statutory obligations do not represent the purpose and scope of public health,” Heise said, calling the laws dated, vague and hard to understand. She said that often there is no consensus about the requirements for a health department, but they are working on that.

Heise said there are limited resources to fulfill the required mandates, and there will be no new money. “We have to do better with what we have,” she said. Kentucky already ranks 15th in per-capita spending for health care among the states.

Barren River Health Dept. accredited; joins 5 others in Ky. (Franklin, Fayette, Madison, Northern Ky. and Three Rivers)

The Barren River District Health Department has joined five others in Kentucky with national accreditation.

The Public Health Accreditation Board announced Sept. 18 that the Bowling Green-based agency and nine other health departments had been accredited, bringing the total number to 54.

Kentucky health departments previously accredited are Franklin County, Lexington-Fayette County, Madison County, Northern Kentucky and Three Rivers (Carroll, Gallatin and Owen counties). The Barren River department serves Barren, Butler, Edmonson, Hart, Logan, Metcalfe, Simpson and Warren counties.

"Public health departments play a critical role in protecting and improving the health of people and communities," the board said in a news release. "Health departments provide a range of services aimed at promoting healthy behaviors; preventing diseases and injuries; ensuring access to safe food, water, clean air, and life-saving immunizations; and preparing for and responding to public health emergencies. To receive accreditation, a health department must undergo a rigorous, multi-faceted, peer-reviewed assessment process to ensure it meets or exceeds a specific set of standards and measures. The peer-review process provides valuable feedback to inform health departments of their strengths and areas for improvement so that they can better protect and promote the health of the people in the communities they serve."

Women leading Kentucky health: State health commissioner sees 'stars aligned' for Kentucky to finally get healthier

Health Commissioner Stephanie Mayfield Gibson

This is the third in a series of stories about four high-ranking female state officials who have guided the state's embrace of the Patient Protection and Affordable Care Act.

By Melissa Patrick

Kentucky Health News

“The stars have aligned” and Kentucky has at last “created an infrastructure” to make the state healthier, says Dr. Stephanie Mayfield Gibson, commissioner of the state Department for Public Health.

“What a great time to be in my position,” Mayfield said in an interview, in which she enthusiastically ticked off a list of aligned stars:

• Her bosses, including the governor and lieutenant governor, who are “extraordinarily supportive of health care;”
• The expansion of the federal-state Medicaid program to households with incomes up to 138 percent of the federal poverty level;
• The Kentucky Health Benefits Exchange, branded as Kynect, where Kentuckians sign up for Medicaid or subsidized private insurance;
• The Kentucky Health Information Exchange, an electronic network that makes a wide range of health information easily available; and
• Programs that enhance the quality of care to get better outcomes and decrease costs, such as the programs to stop over-use of emergency rooms.

Mayfield says her top priority is to decrease exposure to tobacco, because so many of Kentucky’s health issues are related to its most famous crop. About 28 percent of Kentuckians smoke, and “The single most important factor that negatively impacts the health of the commonwealth . . . is exposure to tobacco smoke,” Mayfield said. “I want people well.”

She said Kentucky must also address the epidemic of painkiller abuse, which has made it one of the top three states in deaths related to abuse of opioids; and obesity, which is connected to cancer, diabetes and cardiovascular disease. Kentucky ranks in the top five in each of those diseases, and is in the top 10 for child and adult obesity.  

“Who wants the reputation for being number one in cancer deaths?” Mayfield asked. “We know we can do better. These are winnable battles.”

These and other issues are included in Kentucky Health Now, a plan Gov. Steve Beshear has set forth to improve the health of Kentuckians, with specific goals to be reached by 2019, the end of the next gubernatorial term. Beshear’s term ends in December 2015.

Mayfield is vice-chair of the team overseeing the effort, led by Lt. Gov. Jerry Abramson.  She seems to have the full confidence of Audrey Haynes, the secretary of the Cabinet for Health and Family Services, who lit up when asked about her, but Haynes said she had to make sure that Mayfield, a pathologist who ran the state health lab for seven years, was cut out to be the state’s top doctor.

“It’s a job where … you have to kind of have a better understanding of politics,” Haynes said.  “But I wanted her to rise above all that because she is the public health commissioner. Hers is more about the science.  I need her to be honest and tell the truth.”

Haynes said she told Mayfield, “You are going to tell people what they don’t want to hear sometimes, but always stick with science.  You have to rise above the rhetoric, no matter what.”

“And so I recommended her to the governor and they also fell in love with her.” She became commissioner on Oct. 1, 2012.

Kentucky’s health problems have mounted for decades, but Mayfield is optimistic that they can be overcome because of the Medicaid expansion and increased access to health insurance under the federal health-reform law. Thousands of people have sought care for problems that went untreated because they had little or no money or no insurance.

The federal government is paying the entire cost of those newly eligible for Medicaid until 2017, when the state will begin paying 3 percent, rising to the law’s cap of 20 percent in 2020.  Republican legislators and candidates for governor have voiced concern about the state’s ability to pay its Medicaid bills.

Mayfield said the state is working on controlling costs, through the managed-care system that began in 2011.  One target of cost control is the “super-utilizers” of emergency rooms, or those who come to hospital emergency departments 10 or more times per month.

Mayfield, who was put in charge of finding a way to reduce super-utilizers, said 80 percent of them have mental-health issues, so she is working on the problem with Medicare, the state Department of Behavioral Health and Kentucky’s three medical schools. Kentucky is one of six states accepted into the National Governors Association Policy Academy to address super-utilization.

Dr. William Hacker, who preceded Mayfield as commissioner, said her broad training and deep experience in the department uniquely qualified her to succeed Dr. Steve Davis, who was interim commissioner after Hacker retired.

“She is multidisciplinary and thinks beyond the public-health world,” Hacker said. “She has done an excellent job.”

Mayfield, who has been nationally recognized for her contributions to the state’s electronic health information exchange, also stresses the importance of using technology to improve the health of Kentuckians – especially those who live in rural areas, far from specialists.

Mayfield describes her style of leadership as one of action.  “If we say we are going to do something, then let’s build that infrastructure and let’s get it done,” she said.

Hacker said, “Dr. Mayfield is a thoroughbred.  She is on the go at 90 miles per hour.  She is focused on accomplishing goals.”

Haynes said Mayfield “led massive change at the lab” and knows “how to cajole and support and lead” – and when to be firm. “There are times you have to stick to your guns. You have to choose sort of your poison and you have to say ‘I’ll give you this, but I’m not giving this.’ I needed somebody that didn’t feel the political pressure to give in, and that would stick with it. And really just be a great public face of public health.  And she is all of that.”