Building Epidemiologic Capacity in Kentucky: Collaboration and Communication, 2005-2011

1. Building Epidemiologic Capacity in Kentucky: Collaboration and Communication, 2005-2011 Council of State and Territorial Epidemiologists June, 2012 Doug Thoroughman, PhD, MS CAPT, USPHS CDC Career Epidemiology Field Officer Kentucky Department for Public Health

2. Today’s Talk • Background on Kentucky and Public Health • Building Epi Capacity in Kentucky (BECKY) • University collaboration • Epi Rapid Response Team (ERRT) Program • Training to increase capacity

3. Kentucky Background • Mid-size state • 4.3 million people • 26th state in terms of population • Geographically diverse state • Appalachians to Mississippi River • 7 border states • HHS Region IV: Southeast • Racially/ethnically non-diverse • 90% white, 8% black, 2% Hispanic • Economically challenged • Bottom 5 in per capita income

4. Population Concentration 4.3 million people: about 50% live in the “Golden Triangle” Ohio Northern KY Indiana West Virginia Louisville Frankfort Illinois Lexington Missouri Virginia Tennessee

5. State PH Infrastructure in Kentucky • Kentucky Department for Public Health • Located in state capital: Frankfort • MCH, Lab, Epi, Women’s Health, Env, Chronic Health Divisions • Public health climate • 950+ employees in 1992 • 425 mandated cap in 2004 • Current cap: 358 (351-FT, 4-PT) • 90 “FFTL” positions (72-currently hired) • 54 contractors recently moved into state employee column so net loss of 54 positions

6. Local Public Health Delivery • Local Health Departments • 58 LHDs – some district, some county • About 4000 employees; all 120 counties covered • Main focus on service delivery - $$ • Home Rule “Hybrid” model of governance • Local health departments answer to independent local Boards of Health • Strong ties between state and local HDs • Local employees part of state personnel system • 40% - 50% of LHD funding: state & fed. sources

7. 2002 Epi Capacity in Kentucky • State level epidemiologists • 13 MPH (2 MD, 2 Vet, 2 CDC-assigned) • 1 doctoral level • 2 Infection Control Nurse Epi’s • Regional Epidemiologists (PHP funding) • 17 total positions • Mixed training/experience • University schools of public health • Little historical relationship with PH agencies

8. Career Epi Field Officer Program • Main mandate: Build public health preparedness through increasing epidemiologic capacity • Three primary CEFO initiatives • Syndromic Surveillance • Outbreak Management System • Building Epi Capacity

9. BECKY • Building Epi Capacity in KY • Annual meetings started in 2005 • “Independent effort to increase Kentucky’s capacity to identify, investigate, respond to, and evaluate control measures for public health events and crises” • Included state, local, and federal public health (PH), hospitals, academia, other groups • Method – cross pollination and brainstorming • 90 invitees in 2005, ≈150 by 2011

10. Building Epi Capacity • Statewide meeting November 30, 2005 • Attempted to be all-inclusive • Regional and state epi’s • Universities (Schools of PH) • Hospital ICPs • Department of Agriculture/USDA • Epi Rapid Responders • Public Health Preparedness Planners • Bioterrorism Training Coordinators

11. Epi Capacity Meeting 1 • Goals • Brainstorm specific ways to build epi capacity given: • Current budget constraints • Personnel limitations • Facilitate networking of KY epi personnel • Follow community planning model • Meeting format • “Like” small groups  Full Group • “Mixed” small groups  Full Group • Synthesize common themes into action items

12. Like Groups Key Questions: • What are the primary things you see your institutions doing in or with epidemiology? • What specific areas involving epidemiology do you see in your agencies/institutions that need improvement or haven’t even been developed? • What kinds of things do you do well/are you strong in, in epi? • What resources can you offer to other epidemiologists in the state (think in and outside of the box)? • What are the top three things that would help you to improve your epidemiologic capacity and in what realm of epi is it (e.g., teaching, research, response, prevention, etc.)? • Who would you envision forming greater collaborations with to strengthen or improve your epidemiologic capacity? 

13. Multidisciplinary Groups Key Questions: • What does this group think are the major needs for building epi capacity in KY (think big – anything!)? • Prioritize those needs. • Offer two or more alternative methods about how to address each of those needs (or at least the top three priorities). • Come up with at least one creative strategy (but as many as possible) that your group thinks is do-able, which will increase epi capacity in a specific, identifiable way, and the results of which are measurable. • Identify key collaborations that you think could be created or significantly strengthened to increase epi capacity in KY.

14. Six Primary Initiatives • Assess baseline epi capacity • Standardize existing epi programs • State level epidemiologists • Regional Epidemiologists • Epi Rapid Responders • PHP Planners • Training Coordinators • Build collaboration with universities • Internships, thesis, dissertation projects • Teaching opportunities for PH staff • Educational opportunities for PH staff • Sharing of practical field experience with universities (add field epi options to MPH coursework)

15. Six Initiatives (cont.) • Mentoring – Epi’s to Epi’s • Expand epi capacity building using HRSA (now ASPR) networks to bring in non-ID epi groups • Get Electronic Disease Surveillance Module (DSM) working correctly

16. Epi Capacity Meeting 2 • March 24, 2006 • Video Cast across state – 10 sites • Successful • Workgroups reported progress • More ideas generated • Subcommittees formed • Meeting/Training model introduced • Food and Water Collection Training • Offered CE for something we needed to improve • Kept many LHD staff from double travel

17. Epi Capacity Meeting 3 • November 17, 2007 • Additional initiatives arise: • Public Health Advocacy • Cross-pollination of KY epidemiologists • Research collaboration with universities • Certification of epidemiologists • Workgroups to be formed around these and previous initiatives • One problem – CEFO over-extension!

18. Epi Capacity Meeting 4 • July 29, 2009 • Added initiatives • Environmental public health tracking • Outbreak investigation protocols • Formation of working subcommittees • Core Public Health • Assessment/Policy Development/Advocacy • Career Development • University Collaboration • Membership/Administration

19. Epi Capacity Meeting 5 • February 17, 2011 • (Rescheduled from 2010 due to weather) • Reinforced Subcommittee Structure • Subcommittees met ½ day • Elected leaders • Formed goals and objectives • Reported to group • Added funding for subcommittee meetings • Created Advisory Board • Based on subcommittee leadership • Supposed to operate independently of CEFO

20. BECKY Results • University collaboration! • Create/improve PH internship process • University affiliation agreements • Coordinator • Standardizing and cataloguing opportunities • Research/teaching opportunities • Adjunct Faculty appointments • Summer Institute/continuing education for PH staff • Inject field epi into curriculum at universities

21. Internship Process • Affiliation Agreements in place with 4 universities as of 2011 • Internship coordinator (on and off) • Focused paperwork process • Memorandum of Understanding (MOU) template • Business Associate Agreement (BAA) for use with Protected Health Information slots • Internship Opportunity Description Sheet • Allows for standard description • Helps match students to opportunities • Nudges DPH staff to identify project areas that students could fill

22. University Coordinator • Forwarded Idea in 2005 • Focal point for all university interactions • Could identify and facilitate research collaborations • “Work” the DPH system for internships • Establish a faculty-sharing program • Coordinate continuing education programs for state staff • Continue to promote this idea • Got part-time person to coordinate practicum placements in 2007

23. Applied Epi for Students Getting students more relevant exposure to what epidemiologists do in health departments • Increasing HD practicum placements • Encouraging collaboration between university researchers and public health data resources • Including students in special projects and public health responses • Ice Storm • Coal miner’s survey • Tornado response • Applied Epi class at EKU • UK Practice and Service Committee

24. BECKY Results (cont.) • Epi Rapid Response Team program • Improving Disease Surveillance Module • Epi Competencies and Epi Capacity Assessment • Beginnings of mentoring process for epi’s • Advisory Board and Subcommittees • Increased collaborations and relationships across the Commonwealth

25. Epi Rapid Response Teams • ERRT Program begun in 1980’s • Trains local health department (LHD) staff in field epi investigation • Any type – infectious, foodborne, waterborne, environmental, etc. • Encourages team structure – Epi, Nurse, Env • Program languishing by 2003-05 • ERRT coordination not consistent at KY DPH • No assessment of need at LHD level

26. ERRT Revitalized • Asked LHDs if they wanted ERRT – Resounding “YES!” • Formed Steering Committee • Membership requirements set • Training reworked • Restructured curriculum • DPH staff and CEFO teach • All-day exercise/refresher added based on CDC case studies • Five trainings & conferences since 2006 • > 200 trained since late 2006

27. Epidemiologic Trainings • Epi Ready Training – May, 2007 • NEHA/CDC foodborne outbreak investigation • KY one of five sites chosen nationally • KY filled 90% (47 of 52) slots • Avian Influenza Rapid Response Team Training – Oct., 2007 • CSTE/CDC national T-T-T workshops • Funding for local training offered (KY matched with Pandemic Influenza funds) • 170 attendees (194 invited) • KY DPH, LHD’s, Hospital ICPs, Ag, Fish & Wildlife, Poultry Industry (commercial and backyard), EM

28. Epidemiologic Trainings • Food and Water Sample Collection and Submission – March, 2006 • PHN/Epi Handheld Data Collection During a Disaster – May, 2008 • Foodborne/Waterborne Outbreak Investigation – January, 2009 • Forensic Epidemiology – February, 2009 • UK Summer Institute (Still in planning)

29. Tie-in with National Initiatives • Epi Competencies • Standardizing roles of different epi groups • Pilot Testing CDC/CSTE Epi Competencies • Field (Applied) Epi Competencies • CDC workgroup • Dovetailed with our efforts to standardize roles • Will facilitate appropriate training • Epi Preparedness Competencies

30. Workforce Building and Mentoring • 2010 State level epidemiologists • 19 MPH (3 MD, 1 Vet, 0 CDC-assigned) • 2 PhD level • 5 Infection Control Nurse Epi’s • Regional Epidemiologists • Still17 total positions • Much improved training/experience • Many KY grads now

31. Conclusions • Multifaceted approach used • State’s commitment  Long-term growth • Federal funding crucial to KY • Directly increased capacity – Regional Epidemiologists, CEFO’s • Allowed for capacity-building process to arise • CEFO’s effective use of PHP Cooperative funds • Epi capacity ↑ in creative ways

32. OMB Disclaimer The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention

33. THANKS! Doug Thoroughman, PhD MS CAPT, US Public Health Service CDC Career Epidemiology Field Officer Kentucky Department for Public Health 502-564-7243 x3562 douglas.thoroughman@ky.gov dat4@cdc.gov

34. Cabinet for Health and Family Services

35. Internship Opportunity Description Sheet Internship Process

36. Internship Process Internship Opportunity Description Sheet – Page 2