Addison County: Year in Review

Looking back over my posts from the previous year, I noticed that the many of the news items that ended up on my blog reported good things happening Addison County.  The Open Door Clinic shows the community's commitment to the health of uninsured and underinsured patients.  Recently reported health statistics attest to the fact that Addison is one of the healthiest counties in one of the healthiest states.

Despite the high rankings, Addison County still faces important health challenges and looming economic uncertainties.  Smoking rates remain high and binge drinking continues to be a problem throughout the state.  Addiction care is sorely lacking throughout the region, with patients seeking abuse treatment having to travel many miles to find services.  Another challenge, in addition to lifestyle choices and access to care, are various financial barriers. For example, a promising palliative care program begun by a team of family physicians in Addison County to better meet the needs of a patients requiring palliative care who did not qualify for Hospice was recently eliminated due to lack of financial support.  This story highlights the fact that even a relatively prosperous rural community still faces a great deal of financial uncertainty that can become a barrier to care.

The Blueprint for Vermont medical home model promises to help communities to provide quality health care while controlling rising costs.  While these programs are still in their initial stages, I am hopeful that in a small and relatively low-bureaucracy state like Vermont that these improvements can be expanded to reach communities like Addison County and many other even needier counties in the state.

However I am sure any progress will be met with many difficulties and unanticipated setbacks.  Thinking back on Vermont's tremendously successful universal vaccination program, it would have been difficult to anticipate the vocal and impassioned anti-vaccine movement that has taken firm hold in Vermont.  Hopefully state lawmakers can learn from these experiences and work to craft laws in ways that do not create push-back, but rather unite communities in protecting the health of their citizens.

Supporting student athletes

Thinking about health care needs of student athletes sent me to the Health Center website of Middlebury College in Addison County to see what issues were mentioned.  While there, I noticed a number of links to student life policies and the Hazing Policy caught my eye.

I've always been fascinated and repulsed by the idea of hazing.  I remember hearing stories from my freshmen year roommate who was on the swimming team.  While it seemed innocent enough at the time, it isn't hard to find stories of hazing rituals getting out of hand and causing serious injury and loss of life.  Of course alcohol represents a major threat in these settings, as well as assault, not to mention psychological trauma.  ESPN.com outlined a variety of sports-related hazing stories from 1980-2000 drawn from around the nation from high school, college, and professional sports teams.

Reading through Middlebury College's Hazing Policy made me feel better that the issue was being addressed in a more direct way than perhaps it was five years ago.  I think these traditions are still intrenched in various sporting cultures and it will take a lot of education and support to remake those experiences into something healthier and more positive for student athletes.

Vermont Blueprint for Health

The medical home model is being tried out, studied, and expanded throughout the state of Vermont.  I found this series of video clips that were produced by the Agency for Healthcare Research and Quality Health Care Innovations Exchange in September 2012 as part of a webcast.  The format is a series of three short informational documentary-style clips explaining the Vermont Blueprint for Health, a medical home model that started about five years ago.  In between the video clips there is a panel of professions in the industry talking about their first-hand experiences in transitioning into the medical home model.

The entire webcast is nearly an hour long- so I focused on the documentary-style clips.  I found them to be a bit rambling and low on detail, but overall I think they capture the spirit of the medical home and the promise that it brings.  Much of it is similar to Dr. Singerland's presentation from last session.  The main difference is this presentation focused on specific patients and how their care was improved, and focused less on the details of how the system functions and how reimbursement works.

I found it interesting that the two communities depicted in the clips represent two different spectrums of Vermont life.  St. Johnsbury is a small, rural community with an older population.  Burlington is a densely populated urban center.  There is definitely a sense throughout the presentation that this program is intended to be a blueprint for other communities to follow- both within Vermont and beyond.

One other comment I found interested was from one of the program workers in St. Johnsbury.  She described the community there are poor in financial resources but rich in, "people who care".  The medical home model seems unique in it's ability to tap into these human resources and add quality to their medical care while minimizing financial burden to the community.

Finally, I liked the concept brought up by one of the speakers that the medical model offers the perfect bridge between primary care and public health.  I think this collaboration is critical if we want to get the most value out of our community dollars spent on health care.

If you are interested there is a lot more detailed information on Vermont's Blueprint for Health at the Vermont State website.

It takes a village

Addison County's Open Door Clinic embodies the values of teamwork.  It showcases a diverse mix of medical professionals, including 16 physicians, four nurse practitioners, 15 registered nurses, three physical therapists, five emergency medical technicians, a dietician and a pharmacist.  Furthermore, it coordinates a team of over 130 volunteers, and many community players.

The program is not the work of one person- instead it the successful collaboration of the entire community.  A retired family practitioner donates time as medical director.  Porter Hospital extends free services to patients.  University of Vermont College of Medical residency in family medicine rotates residents through the clinic twice a month.  Funds come from state and federal government, the United Way, foundations, town municipalities, and private donors.

The free clinic serves many Vermonters who are underinsured or uninsured.  Migrant workers also use the clinic.  The clinic is open two nights and one morning each week.

Living without health insurance is scary and can mean going without needed care.  This is a complex social problem that no one person alone can solve.  However, with commitments from many sides, a community can come together to improve health care access for its most vulnerable members.

For more information:

http://www.addisonindependent.com/node/12588

Addison County by the numbers

Addison County is one of the healthiest counties in Vermont according to data reported by the County Health Rankings (CHR).  Addison is ranked as the number one county in Vermont based on morbidity indicators and number two for mortality.  Compared with the national statistics, according to America's Health Rankings (AHR), Vermont is ranked number one for overall health.  In premature deaths, it ranks number two; in cardiovascular deaths, number nine.  One statistic showing room for improvement is cancer deaths, where it ranks 23rd.  In measures of morbidity, Vermont is 1st for lowest rates of infectious disease, 4th lowest rate in diabetes, and in obesity they are 13th lowest.

Addison County is number two in Vermont in Social & Economic Indicators, according to the CHR data.  Compared on a national level, Vermont ranks 2nd in high school graduation rate, 15th lowest rate of children living in poverty, 3rd in public health funding, and in insurance coverage they are also 3rd, according to the AHR data.

Excessive drinking is one of the few health behaviors in which Vermont lags behind the national average.  According to CHR data, Vermont has an excessive drinking rate of 19% compared with the national benchmark of 8%.  According to AHR data, Vermont ranks 27th in measures of binge drinking.  While the cold climate is thought to play a role in the problem, an article from the boston.com also discussed the permissive environment on Vermont college campuses that is thought to create unhealthy drinking norms for students (http://www.boston.com/news/education/2012/10/09/colleges-health-dept-tackle-binge-drinking/H9QHX1NwIZdX2HgDXOPflI/story.html).

In most of the Clinical Care indicators measured by CHR, Vermont is very close to the national benchmark.  One area for improvement is the ratio of primary care physician per person.  Vermont has a ratio of 720:1, compared with the national benchmark of 631:1.  According to AHR, Vermont is 4th in primary care physicians per 100,000 population.  While is room for improvement in Vermont in terms of reaching the national benchmark, it is clear that the entire country in doing very poorly on this statistic.  

Data cited is from the following sites:

http://www.countyhealthrankings.org/

http://www.americashealthrankings.org/

An Intervention Program for Low Birth Weight Infants

It took me a little searching (and help of google scholar) to find a healthcare intervention study in Vermont.  I discovered this article, which is ten years old- nevertheless, I think it's still relevant to discuss, since the issue of low birth weight continues to impact low-socioeconomic classes throughout the United States.  The study, Nine-Year Outcome of the Vermont Intervention Program for Low Birth Weight Infants, examined the effectiveness of an educational intervention for mothers of low-birth weight babies.  The mothers were visited seven times in the hospital and four times in their homes during which a nurse gave individualized education and instruction and helped the mothers master hands-on baby-care skills.  The intervention stopped at 90 days after birth and this study was done nine years later, comparing the children who got the intervention to those who did not and comparing both with a normal birth weight cohort.  They were compared based on measures of cognitive development, and school achievement.  They found the low birth weight children who received the intervention performed significantly better on both measures and closely resembled the normal birth weight children.

This article is proves the effectiveness of a low-tech, low-cost intervention in significantly improving outcomes for children who are born at a low birth weight.  I am curious what the impact of this study is and what sort of education is routinely given to mothers of low-weight babies.  I did a quick search on UpToDate but couldn't find specific recommendations for caring for low birth weight babies after they are delivered.  UTD did include a good discussion of the various adult diseases that low birth weight babies are at increased risk for.  As far as evaluating intervention, according to the UpToDate article, "excessive or poor postnatal weight gain during the first four months of life appears to have a negative impact on neurodevelopmental outcome".  This made me think that part of the benefit of this intervention is helping babies make appropriate weight gain during the critical first three months of life.

In conclusion, this is a complex topic and I am not really doing it justice in a few paragraphs- however I think this is a very interesting intervention with potentially wide applicability.

The full-text article is available through the Upstate Library website.  The full citation is: Achenbach, TM, et al. 1993.  Nine-year outcome of the Vermont intervention program for low birth weight infants.  Pediatrics 91: 45 - 55.

Palliative Care Initiative Closes

For this month, I would like to discuss an innovative program in palliative care in Addison County that unfortunately was discontinued about a year ago.

The program, called Partners in Palliative and Home Care, was begun in 2009 under the leadership of two family physicians and with support of the local hospital, Porter Hospital.  The concept was to provide comprehensive high quality in-home palliative care for patients that did not meet the requirements of Medicaid for Hospice reimbursement, which include having a prognosis of less than six months to live.  This program in many ways mimicked the Hospice program, with an emphasis on crafting a treatment plan to best meet the patient's goals.

I think this program exemplifies several important features of the patient-practitioner relationship.  First, it shows that the two local physicians who started the program were well-acquainted with their patients and knew that there was a need for this type of service.  Furthermore, they were willing to reshape their practice to go into the patients' homes in order to improve their quality of care.

Unfortunately the program closed about a year ago, not because the need for it disappeared, but because of difficulties in securing reimbursement from Medicaid.

This story reminds me that in a broken system, even good ideas can fail.  I am all but certain that this program reduced hospitalizations, unwanted treatments and promoted the best possible quality of life for the patients.  How ironic that it was found to be financially untenable.

http://vtdigger.org/2011/10/28/palliative-care-program-at-porter-medical-center-in-middlebury-closes/