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					DPH PROGRAM UPDATES
   (Staff who will be negotiating contracts are listed by program)



   Childhood Lead Poisoning Prevention Program
          Margie Coons, Amy Hill, Meredith Lins, Reghan Walsh

   Family Planning/Reproductive Health Program with EIDP for LHDs
          Millie Jones, Mike Vaughn

   Immunization Program
          Jeff Berg, Jerry Gabor, Dan Hopfensperger

   Maternal and Child Health Program
          Joyce Andersen, Claude Gilmore, Mary Gothard, Terry Kruse, Ann Stueck

   Oral Health Program
          Warren LeMay

   Preparedness Program
          Billie Bayou

   Radon Protection Program
          Perry Manor, Conrad Weiffenbach

   Tobacco Prevention and Control Program
          Tana Feiner, Vicky Stauffer

   Well Woman Program
          Gale Johnson, Courtney Newman




                                                19
CHILDHOOD LEAD PROGRAM – 2008
  Program Boundary Statement

  Program Quality Criteria

  Program Objectives




                               20
                   Wisconsin Childhood Lead Poisoning Prevention Program
                              Program Boundary Statement
For each performance-based contract program, the Division of Public Health has identified a boundary
statement. The boundary statement sets the parameters of the program within which the
LPHD/tribe/agency will need to set its objectives. The boundaries are intentionally as broad as federal and
state law permit to provide maximum flexibility, however if there are objectives or program directions that
the program is not willing to consider or specific programmatic parameters, those are included in the
boundary statement.

LPHDs/tribes/agencies are encouraged to leverage resources across categorical funding to achieve
common program goals. The Wisconsin Childhood Lead Poisoning Prevention Program (WCLPPP)
aligns well with the boundaries of the Prevention and Maternal and Child Health programs, in particular,
the Prenatal Care Coordination program. Objectives that address common goals of these programs can be
funded by combining program allocations.

Program Boundary Statement:
Local childhood lead poisoning prevention programs are to implement objectives that will protect children
against lead poisoning and eliminate it as a major childhood disease by the year 2010. The impact of
LPHD/agency activities should result in decreasing lead hazards in the environment(s) of children and
increasing early detection and treatment of lead poisoning in high-risk children. High-risk children
generally include those 0-5 years of age who are enrolled in Medicaid and/or WIC or live in housing built
before 1950. Education activities are to be targeted at community members who play a role in eliminating
lead hazards, preventing lead exposure, providing blood lead testing, or providing medical or
environmental follow-up to children who are lead poisoned.

Long-term Program Goals:
To eliminate childhood lead poisoning in Wisconsin by 2010.

Annual Program Goals:
• Increase the involvement of community members in childhood lead poisoning prevention activities
• Increase the availability of lead-safe housing for families with young children
• Educate parents so they have the knowledge and skills necessary to protect their children from lead
  hazards
• Increase blood lead testing of children who are enrolled in the Medicaid or WIC Program.
• Provide early intervention for children with low level lead poisoning

Target Populations
High-risk children include those 0-5 years of age who:
   • live or spend significant time in pre-1950 housing,
   • live in pre-1978 housing undergoing renovation or remodeling,
   • are enrolled in the Medicaid or WIC program,
   • have a sibling who has lead poisoning.




                                                    21
References:
Federal Regulations/Guidelines:
• CMS (Centers for Medicare and Medicaid Services) State Medicaid Manual, Part 5 – Early and
Periodic Screening, Diagnosis and Treatment (EPSDT), section 5123.2, page 5-15
• CDC - “Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health
Officials” (November, 1997)
• CDC - “Managing Elevated Blood Lead Levels Among Young Children” (March, 2002)
• HUD (U.S. Dept of Housing and Urban Development) - Guidelines for the Evaluation and Control of
    Lead-Based Paint Hazards in Housing; available at
    http://www.hud.gov/offices/lead/guidelines/hudguidelines/

State of Wisconsin Statute and Administrative Rules:
• WI Statute Chapter 254, Environmental Health
• WI Administrative Rule HFS 163, Certification for the Identification, Removal and Reduction of
Lead-Based Paint Hazards
• WI Administrative Rule HFS 181, Reporting of Blood Lead Test Results

Program Policies:
• WI Blood Lead Screening Guidelines for Children (1998)
• WCLPPP Handbook for Local Health Departments (2002)
• A Wisconsin Physician’s Guide to Blood Lead Screening and Treatment of Lead Poisoning in
Children (October, 2000)

Optimal or best practice guidance:
  Objectives that involve blood lead testing at WIC for uninsured children. Local health departments
  should seek Medicaid reimbursement for blood lead testing of Medicaid-enrolled children. This may
  require establishing contracts with the managed care organizations within their community.

   Objectives that involve direct provision of services to families with children at high risk for, or with,
   lead poisoning. In particular, objectives that involve best practice following the WCLPPP Standard for
   Home/Childcare Site-based Intervention to Address Lead Hazards.

   Objectives that build capacity in a community to increase the availability of lead safe housing to
   families of young children, and to prevent childhood lead poisoning. This involves going beyond the
   one-to-one transfer of information to building coalitions and partnerships with targeted
   organizations/groups that can assist in maximizing community resources to meet the goal of
   eliminating lead poisoning.

Unacceptable Proposals:
When using WCLPPP General Purpose Revenue funds, the following activities are non-allowable:
• Educational objectives that do not include a behavior change component.
• Objectives for health fairs.




                                                    22
Relationship to State Health Plan: Healthiest Wisconsin 2010:
State Plan System Priorities:
• Community health improvement processes and plans
• Sufficient, competent workforce

State Plan Health Priorities:
• Access to primary and preventive health services
• Environmental and occupational exposure
• Social and economic factors that influence health

Essential Public Health Services:
• Monitor health problems to identify community health problems.
• Identify, investigate, control and prevent health problems and environmental health hazards in the
   community.
• Educate the public about current and emerging health issues.
• Promote community partnerships to identify and solve health problems.
• Create policies and plans that support individual and community health efforts.
• Enforce laws and regulations that protect health and insure safety.
• Link people to needed health services.
• Assure access to primary health.
• Foster the understanding and promotion of social and economic conditions that support good health.




                                                  23
            Wisconsin Childhood Lead Poisoning Prevention Program (WCLPPP)
                               Program Quality Criteria
Generally high program quality criteria for the delivery of quality and cost-effective administration of
health care programs have been, and will continue to be, required in each public health program to be
operated under the terms of this contract. Contractees should indicate the manner in which they will
assure each criterion is met for this program. Those criteria include:

1. Assessment and surveillance of public health to identify community needs and to support systematic,
   competent program planning and sound policy development with activities focused at both the
   individual and community levels.

   a. Contractee must assess local surveillance data for lead poisoning risks and known prevalence.

2. Delivery of public health services to citizens by qualified health professionals in a manner that is
   family centered, culturally competent, and consistent with the best practices; and delivery of public
   health programs for communities for the improvement of health status.

   a. Contractees must provide services that support the elimination of childhood lead poisoning, and
      the early detection and treatment of children with lead poisoning including compliance with WI
      Stat 254 (Environmental Health), WI Admin Rule 181 (Reporting of Blood Lead Test Results), WI
      Admin Rule 163 (Certification for the Identification, Removal and Reduction of Lead-Based Paint
      Hazards), and the practice standards presented in the Wisconsin Childhood Lead Poisoning
      Prevention & Control Handbook (2002) and in Managing Elevated Blood Lead Levels Among
      Young Children (CDC, 2002).

   b. Contractees must assure the availability and accessibility of blood lead tests for children ages 0-5
      years at high risk of lead poisoning.

3. Record keeping for individual focused services that assures documentation and tracking of client
   health care needs, response to known health care problems on a timely basis, and confidentiality of
   client information.

   a. Contractee must maintain a central case registry to track follow-up of children with BLLs
      >10 mcg/dL and of properties where a lead hazard investigation was performed, including
      findings, interventions and outcomes.

4. Information, education, and outreach programs intended to address known health risks in the
   general and certain target populations to encourage appropriate decision making by those at risk and to
   affect policy and environmental changes at the community level.

   a. Contractee must provide information to one or more target audiences within the community about
      lead hazards, lead hazard reduction methods, primary prevention of lead poisoning, and blood lead
      testing as referenced in the boundary statement.

5. Coordination with related programs to assure that identified public health needs are addressed in a
    comprehensive, cost-effective manner across programs and throughout the community.



                                                     24
   a. Contractee must build partnerships with local health care providers and agencies involved in
      health, social services, housing, and child care to incorporate lead hazard awareness into their
      activities with, or services to, families living in pre-1978 housing.

   b. Contractee must provide information, consultation and technical assistance to health care providers
      or other programs to assure that treatment of children with lead poisoning is efficient and effective,
      and to assure that lead safe environments are available to children with lead poisoning.

   c. Contractee that serves a community receiving HUD Community Development Block Grant
      (CDBG) funds must, in order to accept the additional lead program formula allocation, establish
      and maintain a relationship with the local housing agency that distributes the CDBG funds in order
      to increase the availability of lead-safe housing within the community.

6. A referral network sufficient to assure the timely provision of services to address identified client
   health care needs.

   a. Contractee must assess the need for, and provide referrals for, supportive services to families of
      lead poisoned children.

7. Provision of guidance to staff through program and policy manuals and other means sufficient to
   assure quality client care and cost-effective program administration.

   a. Contractee must assure that local childhood lead poisoning prevention program staff have access
      to, are knowledgeable of and in compliance with the Wisconsin Childhood Lead Poisoning
      Prevention & Control Handbook for Local Health Departments, the Wisconsin Blood Lead
      Screening Guidelines (2002), Managing Elevated Blood Lead Levels Among Young Children
      (CDC, 2002), state statutes, administrative rules, and/or local ordinance.

8. Financial management practices sufficient to assure accurate eligibility determination, pursuit of
   third-party insurance and Medical Assistance coverage of services provided, prompt and accurate
   billing and payment for services provided and purchased, accurate expenditure reporting, and
   appropriate use of state and federal funds.

   a. Contractee must pursue third party payment and/or other funding sources for service provision to
      children who are eligible for third party payment, except when doing so is demonstrated to be not
      cost effective.
9. Data collection, analysis, and reporting to assure program outcome goals are met or to identify
   program management problems that need to be addressed.

   a. Contractee must regularly collect and analyze local data to determine the adequacy of blood lead
      testing for children enrolled in WIC, timely follow-up of lead poisoned children, timely
      completion of lead hazard reduction work, and community lead poisoning prevention education.
   b. Contractee must submit the following forms and documents to the Wisconsin Childhood Lead
      Poisoning Prevention Program by the specified deadlines as stated in the WCLPPP Handbook.
      These forms are available on the Lead-Safe Wisconsin website, dhfs.wi.gov/lead.
      • Nursing Case Management Report (DPH 4771A)
      • Nursing Closure Report (DPH 4771B)
      • Property Investigation Report (DPH 4771C)
      • Property Investigation Closure Report (DPH 4771D)

                                                    25
               Childhood Lead Program - Home/Childcare Site Intervention Objective
    A. Objective, B. Deliverable, C. Context, Data Source for Measurement, E. For Your Information

A. By December 31, 2008, xx pre-1950 housing units or childcare sites located in (insert name of
   jurisdiction) where (choose one or both target groups: children less than 6 years of age without
   an elevated blood lead level and/or pregnant women) reside or attend day care will be assessed
   using the Wisconsin Childhood Lead Poisoning Prevention Program Standard for Home-/Childcare
   Site-based Intervention to Address Lead Hazards.

B. For each property assessed in (insert name of jurisdiction) the “Standards for Home Visitation to
   Address Lead Hazards Documentation” form should be completed. This form is found in the
   Wisconsin Childhood Lead Poisoning Prevention Program Standard for Home/Childcare Site-based
   Intervention to Address Lead Hazards resource kit. It contains these required deliverables: 1) property
   address, 2) year the structure was built, 3) activities conducted – lead poisoning education, visual
   assessment and intervention guidance, sampling via dust wipe samples or lead check swabs,
   demonstration of cleaning techniques), 4) results of dust wipe samples or lead check swabs (positive
   or negative), and 5) date that information was provided to the property owner regarding the presence
   of lead in the property.

C. Acceptable value for this objective is up to $150 per housing unit or childcare site. The protocol to be
   followed is the Wisconsin Childhood Lead Poisoning Prevention Program Standard for
   Home/Childcare Site-based Intervention to Address Lead Hazards. These essential components must
   be included: 1) a visit to the home to provide lead poisoning prevention education and identify
   potential lead hazards, 2) sampling via dust wipe samples or lead check swabs that is conducted to
   document the presence of lead, and 3) the property owner is notified of the results of the assessment,
   including laboratory sample results or result of lead check swabs (positive or negative), and non-
   abatement measures that can be taken to correct lead hazards.

D. The “Standards for Home Visitation to Address Lead Hazards Documentation” form contains all the
   required deliverables. Completed forms are sufficient as the data source for measurement or an agency
   could generate a report that includes all five components listed in the Deliverables.

E. This objective applies the Wisconsin Childhood Lead Poisoning Prevention Program Standard for
   Home/Childcare Site-based Intervention to Address Lead Hazards to one target audience or a
   combination of audiences. Target audiences will be those whose primary residence or childcare site
   was built before 1950. For pregnant women residing in pre-1950 housing, the Standard can be
   incorporated into a perinatal care coordination or newborn visitation program, or into Medicaid
   Prenatal Care Coordination services. The Standard resource kit is available by calling (608) 266-5817.
   Supporting materials available from the Wisconsin Childhood Lead Poisoning Prevention Program
   (WCLPPP) include infant bibs, lead check swabs, HEPA vacuums, and lead sampling technician
   training. Dust samples can be analyzed at the State Laboratory of Hygiene and billed to the Basic
   Agreement (fee exempt). WCLPPP staff is available to conduct training and orientation on the
   home/childcare site-based intervention standard.




                                                     26
                       Childhood Lead Program - Blood Lead Testing Objective
    A. Objective, B. Deliverable, C. Context, Data Source for Measurement, E. For Your Information

A. By December 31, 2008, xx children at risk for lead poisoning who reside in (insert name of
   jurisdiction) will receive an age-appropriate blood lead test.
B. A report to document the number (by age) of unduplicated children at risk for lead poisoning residing
   in (insert name of jurisdiction) who received an age-appropriate blood lead test.
C. Acceptable value for this objective is up to $18 per blood lead test. Children at highest risk for lead
   poisoning are those eligible or enrolled in Medicaid or the WIC Program, those living or spending
   time in pre-1950 housing or pre-1978 housing that is undergoing renovation, or those with a sibling
   with lead poisoning. Age appropriate blood lead screening tests are done at around 12 months and
   around 24 months, or at least once between the ages of 3 to 5 years if the child has no previous test
   documented. References include “A Wisconsin Physician's Guide to Blood Lead Screening &
   Treatment of Lead Poisoning in Children (10/00)” and “Wisconsin Childhood Lead Poisoning
   Prevention & Control Handbook for Public Health Departments (2002).”
D. SPHERE Individual/Household Report to include data from the following screen: Lead Testing,
   including test date, result, and provider; or an agency-generated report.
E. The Inputs/Activities field in GAC for this objective must include a discussion of where testing will be
   conducted, a description of the target population, and whether this objective reflects tests done by
   public providers (e.g., WIC, Health Department), private providers or both. A baseline number of
   tests done in 2006 or year-to-date 2007 for the targeted population must be provided.




                                                     27
            Childhood Lead Program - Environmental Lead Hazard Investigation
                  at a Blood Lead Level of 10mcg/dL or greater Objective
A. Objective, B. Deliverable, C. Context, Data Source for Measurement, E. For Your Information

A. By December 31, 2008, xx environmental lead hazard investigations will be completed on the
   primary residences and pertinent secondary properties of children with venous blood lead levels
   >= 10 mcg/dL who reside in (insert name of jurisdiction) according to the Elevated Blood Lead
   Investigation protocol.

B. A report to document: 1) the number of environmental lead hazard investigations associated with
   children with venous blood lead levels >=10 mcg/dL who reside in (insert name of jurisdiction),
   2) the children’s blood lead levels, 3) components of the environmental lead hazard investigation
   to include the risk assessment of property, issuance of lead hazard reduction work orders and
   property clearance.

C. Acceptable value for this objective is up to $800 per environmental lead hazard investigation. The
   most important factor in managing childhood lead poisoning is reducing the child’s exposure to
   lead. CDC recommends that public health investigate the child’s primary residence and secondary
   properties, e.g., day care, to identify and reduce the lead hazards to prevent further exposure and
   reduce the blood lead level (Managing Elevated Blood Lead levels Among Young Children, CDC,
   March 2002). An environmental lead hazard investigation should be conducted according to
   Chapter 9 of the “Wisconsin Childhood Lead Poisoning Prevention & Control Handbook (2002).”

D. SPHERE Individual/Household Report to include data from the following screens: (1) Lead
   Testing, including test date, result, and provider, and (2) Case Management for Wisconsin
   Childhood Lead Program; or an agency-generated report.

E. None.




                                                28
               Childhood Lead Program - Non-negotiation Assurance Objective
A. Objective, B. Deliverable, C. Context, Data Source for Measurement, E. For Your Information

A. Throughout the contract period, residents from the jurisdiction of the (insert name of
   jurisdiction) Health Department will receive lead poisoning prevention and intervention services
   that are provided according to federal and state guidelines.

B. A report to document the extent to which the five components listed in Context were achieved;
   specifically that is, counts of the actual number of residents with the characteristics described, and
   the number of those residents who received the recommended interventions in each of the five
   categories listed in Context. For evaluation purposes, those children whose families are non-
   responsive to outreach or moved from the jurisdiction before appropriate follow-up services could
   be provided can be removed from this cohort.

C. There is no designated value range for this objective; it is automatically accepted if the entire
   Childhood Lead program allocation is $6000 or less. Assurance means the local health department
   should be achieving 100% of the following (or working towards this goal): 1) Age appropriate
   blood lead testing of all children enrolled in WIC; 2) Venous confirmation testing of all children
   with capillary blood lead levels of 10mcg/dL or greater; 3) home visits to provide information
   about lead poisoning prevention and treatment for all children with venous blood lead levels of
   10mcg/dL or greater; 4) environmental lead hazard investigations of the primary residences and
   pertinent secondary properties of all children with venous blood lead levels of 15mcg/dL or greater
   according to the Elevated Blood Lead Investigation protocol (Chapter 9 of the Wisconsin
   Childhood Lead Poisoning Prevention Program handbook, 2002), 5) referring all children with
   venous blood lead levels of 10mcg/dL or greater or their family to programs or agencies that can
   support their needs.

D. SPHERE Individual/Household Report to include data from the following screens: (1) Client
   Information, including WIC ID, (2) Lead Testing, including test date, type, result, and provider;
   and (3) Referral and Follow-Up Results, if need is identified; or an agency-generated report. Total
   enrollment in WIC can be retrieved from ROSIE.

E. If an agency receives less than $6,000 in consolidated contract funds from the Wisconsin
   Childhood Lead Poisoning Prevention Program, it can choose to do this assurance objective
   without negotiation. The intent is to reflect basic provision of services. The rates from 2006 must
   be provided as a baseline of past assurance efforts




                                                 29
              Childhood Lead Program - CDBG Capacity Building Objective
A. Objective, B. Deliverable, C. Context, Data Source for Measurement, E. For Your Information

 A. By December 31, 2008, xx contractors, rental property owners or maintenance staff from
    (insert name of jurisdiction) will demonstrate knowledge of lead-safe work practices
    through completion of a course conducted by a certified training provider.

 B. A report to document: 1) the lead-safe work practices course sessions conducted by a
    certified training provider, 2) the number of contractor, rental property owner or maintenance
    staff attendees from (insert name of jurisdiction) identified through successful completion
    post-test results who gained knowledge of lead-safe work practices.

 C. Acceptable value for this objective is up to $250 per anticipated course attendee. This
    standardized 8-hour, lead-safe work practices training course must be conducted by a
    certified training provider. The training components include: 1) health effects of lead, 2)
    regulations regarding lead-based paint, 3) preparing the worksite, 4) non-abatement lead-
    based paint activities, 5) clean-up and disposal. Successful completion of the course requires
    a score of at least 70% on a test given by the certified training provider.

 D. SPHERE System Report to include data from the following screens: (1) System Activity-all
    required fields, including audience focus and documentation of additional information in the
    Results/Outcome field, and (2) Health Teaching Topic Environmental Lead Exposure; or an
    agency-generated report.

 E. The lack of contractors, property owners or maintenance staff who are trained in lead-safe
    work practices can be a significant barrier to increasing the availability of lead-safe housing.
    This objective seeks to increase local capacity to correct lead hazards in old housing and
    prevent routine renovation, remodeling and lead hazard control activities from inadvertently
    poisoning children.




                                               30
             Childhood Lead Program - CDBG Lead-Safe Housing Units Objective
 A. Objective, B. Deliverable, C. Context, Data Source for Measurement, E. For Your Information

A. By December 31, 2008, xx pre-1950 housing units located in (insert name of jurisdiction) will
   be made lead-safe.

B. A report to document the housing units located in (insert name of jurisdiction) that were
   assessed, year the structure was built, and results of clearance testing.

C. Acceptable value for this objective is between $40 and $350 per housing unit. Prior to 1950,
   paint companies produced paint with a high content of lead. Children living in pre-1950 housing
   are at a high risk for lead poisoning due to deteriorated lead-based paint. The most important
   method to prevent lead poisoning is to correct lead hazards in older housing. This objective may
   involve partnering with local housing or weatherization agencies, contractors or builders to
   assure older housing meets lead safe standards. A lead-safe standard requires that, at a
   minimum: 1) all paint will be intact, and 2) the property passes clearance standards (visual
   inspection of work completion and dust wipe testing) as specified in HFS 163.

D. SPHERE System Activity Report to include data from the following screens: (1) System
   Activity-all required fields including documentation of collaborating partners, number of
   housing units assessed, year housing unit was built, and results of clearance testing, and (2)
   Intervention: Collaboration (no detail screen); or an agency-generated report.

E. The Input/Activities field should be completed to describe how your agency intends to partner
   with local housing or weatherization agencies, contractors or builders to assure older housing
   meets lead safe standards. An interpretation by Department of Health and Family Services legal
   staff indicates that "(GPR) grant money could be used to purchase and install materials to make
   high-risk properties safe . . . if the grant specifies this" (communication from Eric Wendorf,
   04/02/03). This objective allows for the purchase of windows, window well liners, doors, or
   other components that have a high or medium impact on reducing the lead hazards in a property.
   A local health department that is working with the local agency that distributes the Community
   Development Block Grant (CDBG), Small Cities or HOME funding can select this objective to
   reflect an outcome of the partnership, i.e., the number of lead-safe housing units that will result
   from the collaboration. For example, a local health department may be able to provide lead
   hazard investigation services and/or property clearance.




                                                  31
FAMILY PLANNING – REPRODUCTIVE HEALTH PROGRAM – 2008
[Followed by the EIDP-LHD Program for 2008]
    Program Boundary Statement

    Program Quality Criteria

    Program Objectives




                                 32
                       Family Planning and Reproductive Health Services
                             2008 Program Boundary Statement
For each performance-based contract program, the Division of Public Health has identified a
boundary statement. The boundary statement sets the parameters of the program within which
the Local Health Department (LHD), Tribe or agency will need to set its objectives. The
boundaries are intentionally as broad as federal and state law permits to provide maximum
flexibility. However, if there are objectives or program directions that the program is not willing
to consider, those are included in the boundary statement.

Program Boundary Statement:
The purpose of the Reproductive Health/Family Planning Program is to reduce the number of
unintended pregnancies, and provide statewide access to quality and affordable contraceptive and
related reproductive health services, consistent with the scope of family planning services
defined in Title X Program Guidelines and Title XIX (Medicaid) administrative codes (HFS
107.21)
    • Title X Program Guidelines define the mandatory and recommended client and clinic
        services in Part II, Sections 7-11. See
        http://opa.osophs.dhhs.gov/titlex/2001guidelines/ofp_guidelines_2001.html.
    • Wisconsin Family Planning Medicaid Administrative Code defines the scope of
        contraceptive and related reproductive health services. See
        http://www.legis.state.wi.us/rsb/code/hfs/hfs107.pdf.

The goals of family planning and related reproductive patient care are to:
   • promote preconceptional health (including planned and prepared for pregnancy, and
      pregnancy spacing),
   • facilitate safe, effective, timely, and successful contraception to prevent unintended
      pregnancy,
   • maintain reproductive health,
   • protect fertility (including STD prevention, and testing and treatment),
   • reduce risks to future pregnancy,
   • promote early pregnancy confirmation and early identification of pregnancy-related risks,
   • encourage early pregnancy-related care.

Services supporting the above goals are provided in the context of contraceptive care. This is
defined as an office visit having an ICD-9 code of v.25 (contraceptive management) as the
primary or secondary diagnosis code within the previous or current calendar year.

Services are to be provided in coordination with EIDP Capacity/Infrastructure Services in Local
Health Departments.

Long-term Program Goals:
   • Reduce STD rates (Chlamydia and gonorrhea) among all ages, including adolescents.
   • Reduce unintended pregnancies among women of all reproductive ages.
   • Reduce adolescent pregnancy.
   • Decrease inter-conception intervals less than 2 years.


                                                33
Annual Program Goals:
   • Increase access to emergency (back-up) contraception: particularly in advance of actual
      urgent need.
   • Increase adoption of “dual protection” methods: simultaneous decisions about a method
      to reduce the risk of STD/STI as well as to protect from unintended pregnancy.
   • Increase Medicaid Family Planning Waiver outreach and enrollment.
   • Increase access (client convenience) to contraceptive supplies.

Priority Populations:
    • Low-income, under- or uninsured women at risk of unintended pregnancy.
    • Sexually-active adolescents.

References:
Federal Regulations/Guidelines:
   Title X Program Guidelines
   (http://opa.osophs.dhhs.gov/titlex/2001guidelines/ofp_guidelines_2001.html)

State of Wisconsin Statutes:
     Medicaid Family Planning Administrative Rules: HFS 105.36
     http://www.legis.state.wi.us/rsb/code/hfs/hfs105.pdf

   Wisconsin Family Planning Statutes: s. 253.07
   http://folio.legis.state.wi.us/cgi-
   bin/om_isapi.dll?clientID=34156287&infobase=stats.nfo&j1=253.07&jump=253.07&softpa
   ge=Browse_Frame_Pg

   Wisconsin Family Planning Administrative Rules (HFS 151.04)
   http://www.legis.state.wi.us/rsb/code/hfs/hfs151.pdf

Program Policies:
    Region V Infertility Prevention Guidelines (http://www.hcet.org/wfpp/sandr/clap.html)
    DHFS Adolescent Pregnancy Prevention Plan

Optimal or Best Practice Guidance:
Two objectives are required:
  • Reproductive Health/Family Planning Objective: Must include an objective for the
      number of women receiving contraceptive services.

   •   EIDP Objective: Must include an objective for the number of women receiving early
       intervention and detection of pregnancy services.

   •   Multi-county Agencies: Multi-county agencies must write an objective for each county
       for both EIDP and Reproductive Health/Family Planning services.




                                              34
Unacceptable Proposals:
The following activities are not-allowable for Reproductive Health/Family Planning:
   • promotion of services valued at more than 10% of the county RH/FP allocation,
   • enrollment into Medicaid or BadgerCare valued at more than 10% of the county RH/FP
       allocation,
   • provision of and paying for services for people who are eligible for Medicaid when
       services are covered by Medicaid: (Title V/GPR is the payer of last resort)

The following activities are not-allowable for EIDP Services:
   • promotion of services valued at more than 10% of the county RH/FP allocation,
   • enrollment into Medicaid or BadgerCare valued at more than 20% of the county RH/FP
       allocation,
   • provision of and paying for services for people who are eligible for Medicaid when
       services are covered by Medicaid: (Title V/GPR is the payer of last resort).

Relationship to State Health Plan: Healthiest Wisconsin 2010
High-Risk Sexual Behavior: defined as “sexual behaviors, including unprotected sex, that make
someone more susceptible to infections or diseases, or that result in unintended pregnancy.”




                                              35
                    Family Planning and Reproductive Health Services
                            2008 Program Quality Criteria

Generally high program quality criteria for the delivery of quality and cost-effective administration
of health care programs have been, and will continue to be required in each public health program to
be operated under the terms of this contract. Contractees should indicate the manner in which they
will assure each criteria is met for this program. Those criteria include:

Assessment and surveillance of public health to identify community needs and to support
systematic, competent program planning and sound policy development with activities focused at
both the individual and community levels.

   Reproductive Health/Family Planning programs must be part of a community plan or strategy,
   based on a community needs assessment, to ensure:
       •   reasonable accessibility and availability of EIDP and Reproductive Health/Family
           Planning services for the community,
       •   effective outreach to patients eligible for services under the Wisconsin Medicaid Family
           Planning Waiver, and efficient and convenient enrollment,
       •   effective community pathways and referrals for essential services, as required by s.
           253.07, for timely and appropriate comprehensiveness and continuity of care,
       •   measurement of effectiveness, using indicators accepted within the field of family
           planning, to evaluate the community system of services,
       •   on-going surveillance to evaluate progress in the community.

Delivery of public health services to citizens by qualified health professionals in a manner that is
family centered, culturally competent, and consistent with the best practices; and delivery of public
health programs for communities for the improvement of health status.
   a. Reproductive Health and Family Planning
        (1) Reproductive Health/Family Planning programs must provide:
            • Contraceptive services (emergency and ongoing methods), and
            • “Related reproductive health services,” which include the following components:
                   reproductive health screening and assessment services (including cervical cancer
                   screening),
                   sexually transmitted disease screening and assessment, diagnosis and treatment,
                   and disease intervention services,
                   pregnancy testing, risk assessment, and early pregnancy care services, timely
                   appropriate care and follow-up,
                   patient education and anticipatory guidance,
                   enrollment into Medicaid Healthy Start and the Family Planning Waiver,
                   short-term care coordination services including follow-up testing, assessment, and
                   referral and follow-up on any abnormal findings for which further diagnosis and
                   treatment is recommended.




                                                 36
   (2) The scope of “related reproductive health services” must be consistent with federal
       Title X and Wisconsin Medicaid family planning rules, which define the health services
       that are allowable as part of family planning services, and must be provided within the
       context of contraceptive services.

   (3) The “context of contraceptive care” is defined as an office visit having an ICD-9 code of
       v.25 (contraceptive management) as the primary or secondary diagnosis code within the
       previous or current calendar year.

   (4) The scope of family planning and reproductive health services has been expanded to
       include increased provision and education about emergency contraception and “dual
       protection” services. These changes reflect practices that have emerged in the field of
       family planning and reproductive health.

          “Dual protection” means choosing a family planning method and making
          decisions about one's sexual behavior at the same time, as recommended by the
          World Health Organization: “Anyone with a risk factor for sexually transmitted
          infections (STIs) should use dual protection…” Patients must receive
          information necessary to make an informed decision about appropriate dual
          protection.

          Emergency contraception (EC), particularly in advance of actual need, must be
          provided consistent with evidence on EC’s timing and effectiveness following
          exposure to an unintended pregnancy. Patients must receive information on the
          role of EC as a back-up method of contraception, and recommended use for
          maximum effectiveness in preventing unintended pregnancy.


b. Early Intervention and Detection of Pregnancy

   (1) Reproductive Health/Family Planning programs must provide EIDP services that include
       intervention to prevent unintended pregnancy as well as intervention to promote early
       pregnancy-related care. The scope of EIDP services is expanded to include “Early
       Intervention and Detection of Pregnancy” services.

   (2) EIDP goals include:
          early detection of pregnancy and pregnancy-related risks,
          timely intervention and continuity of care appropriate for patient pregnancy status and
          pregnancy plans (including pregnancy and contraceptive services),
          access to Medicaid programs (including Healthy Start and the Family Planning
          Waiver).

   (3) EIDP services must support the above goals and must include activities that:
       • increase awareness about family planning and pregnancy-related health care needs
          and services,



                                             37
      •   promote (outreach) the Family Planning Waiver, regular Medicaid services,
          BadgerCare, and Healthy Start services,
      •   enroll eligible women into the Family Planning Waiver as well as Healthy Start,
      •   directly provide pregnancy testing services,
      •   ensure timely and appropriate access to emergency and on-going contraception.

   (4) EIDP services must be available to women at risk of an unintended pregnancy or who
       suspect they could become (or could have become) pregnant. Among women who
       suspect they are at risk of an unintended pregnancy (within the past 72 hours), emergency
       contraception must be available, i.e., present and ready for use, as an early intervention.
       Information about EC, as an alternative to waiting until a pregnancy test can be
       performed, and the risk of unintended pregnancy, must be provided.

   (5) EIDP Pregnancy Testing Services

             Pregnancy Testing Services are defined as a pregnancy test performed under
      circumstances in which pregnancy is suspected. CPT/ICD-9 Coding: an office visit
      including a pregnancy test (CPT Code 81025) with a v72.4 ICD-9 Code (pregnancy
      examination or test).

      EIDP services do not include patients receiving pregnancy tests that are routinely
      performed (defined by practice or protocol) for the purposes of “ruling-out” a possible
      pregnancy – prior to a medical intervention, such as medication or hormonal
      contraception. CPT/ICD-9 Coding: a pregnancy test (procedure code 81025) with a
      v82.8 ICD-9 Code (special screening for other specified conditions).

   (6) Pregnancy testing services must be provided in conjunction with:
       • risk assessment, timely and appropriate referral for pregnancy or contraceptive care,
          and timely follow-up,
       • patient education and anticipatory guidance sufficient for clients to make informed
          choices and decisions,
       • presumptive eligibility enrollment in the Medicaid Family Planning Waiver and
          Healthy Start Programs (as needed),
       • short-term care coordination services to manage identified needs.

c. Reproductive Health and Family Planning programs must:

   (1) Provide clinic services under the supervision of a registered nurse.

   (2) Have the capacity to directly provide the following services on-site: pregnancy testing
       services, emergency contraception, immediate prescription contraception with the option
       to defer medical/laboratory services; prescription supplies; non-prescription supplies,
       sexually transmitted disease testing and treatment including but not limited to gonorrhea
       and Chlamydia, using the established selective screening guidelines developed by
       DHFS/DPH (http://www.hcet.org/wfpp/sandr/clap.html).



                                             38
       (3) Ensure reasonable access and waiting period for provision of (on-site or off-site) physical
           examinations and laboratory tests.

   d. Reproductive Health/Family Planning programs must assure that the content of patient care
      and the provision of services within family planning programs comply with current
      established policies, and are consistent with professional standards and guidelines within the
      field of family planning including:

       (1) Ch. 105, 107, Wis. Admin. Code, (Medicaid),
           (http://www.legis.state.wi.us/rsb/code/hfs/hfs107.pdf),

       (2) Title X Program Guidelines,
           (http://opa.osophs.dhhs.gov/titlex/2001guidelines/ofp_guidelines_2001.html),

       (3) DHFS Guidelines for Perinatal Care: Preconceptional Health Services,
           (http://www.hcet.org/wfpp/sandr/sandg.html#hbg)

       (4) “Patient Rights and Provider Responsibilities: Privacy and Confidentiality Issues for
           Family Planning and Reproductive Health Services - A Resource Guide for the
           Wisconsin Family Planning Program” (http://www.hcet.org/wfpp/sandr/conf.html) to
           assure patient privacy rights and consumer confidence in confidentiality safeguards for
           all patient information;

       (5) Region V Infertility Prevention Guidelines, http://www.hcet.org/wfpp/sandr/clap.html);

       (6) American Academy of Obstetricians and Gynecologists (ACOG) Women's Health
           Guidelines, (http://sales.acog.com/acb23/category.cfm?&DID=6&CATID=16);
           Contraceptive Technology (http://www.contraceptiveupdate.com/).

   e. Reproductive Health/Family Planning programs must submit pap smears, and Chlamydia and
      Gonorrhea tests for all patients receiving clinical services to the Wisconsin State Laboratory
      of Hygiene or request approval in writing to use other laboratories that assure equivalent
      quality standards.

Record keeping for individual focused services that assures documentation and tracking of client
health care needs, response to known health care problems on a timely basis, and confidentiality of
client information.

   Reproductive Health/Family Planning programs must establish policies and procedures to:
      • protect and safeguard family planning patient privacy and confidentiality rights in
         compliance with HIPAA privacy requirements,
         (http://www.hcfa.gov/medicaid/hipaa/adminsim/privacy.htm), and
      • comply with regulations and guidelines defining chart requirements for the content of
         patient records including Wisconsin Family Planning Medicaid Program requirements,
         (http://www.legis.state.wi.us/rsb/code/hfs/hfs105.pdf), and Title X requirements,
         (http://opa.osophs.dhhs.gov/titlex/2001guidelines/ofp_guidelines_2001.html).


                                                 39
Information, education, and outreach programs intended to address known health risks in the
general and certain target populations to encourage appropriate decision making by those at risk and
to affect policy and environmental changes at the community level.

   a. Reproductive Health/Family Planning programs must provide public information and
      education, and outreach services designed to increase awareness and understanding among
      all women of childbearing age of family planning and related reproductive health care issues,
      key reproductive health knowledge areas, and where to obtain services; and coordinate with
      other public information within the community to ensure the reproductive-age population
      access to appropriate, evidence-based information involving sexual decisions, the
      consequences and risks of sexual activity, and the choices to reduce the likelihood of
      unintended consequences.

   b. Reproductive Health/Family Planning programs must place particular emphasis on reaching
      population segments who lack access, are at higher relative risk of unintended pregnancy and
      reproductive health morbidity, and other population segments appropriate to the county.

Coordination with related programs to assure that identified public health needs are addressed in a
comprehensive, cost-effective manner across programs and throughout the community.

   Reproductive Health/Family Planning programs must coordinate and integrate with other state
   and local programs and initiatives, including the Medicaid Family Planning Waiver, Adolescent
   Pregnancy Prevention Program; Healthy Start; Prenatal Care Coordination, WIC, etc.

A referral network sufficient to assure the accessibility and timely provision of services to address
identified public health care needs.

   Reproductive Health/Family Planning programs must be integrated into community referral
   networks that provide effective access for essential services and facilitate timely continuity of
   patient care. For example, networks established through memoranda of understanding with other
   providers for appropriate referral of clients.

Provision of guidance to staff through program and policy manuals and other means sufficient to
assure quality health care and cost-effective program administration.

   a. Reproductive Health/Family Planning programs must establish and maintain written policy
      and program information to staff in manuals that contain:

       • policies and protocols that reflect current standards and guidelines recognized in the field
         of family planning.
       • medical and administrative policy and procedures that are periodically reviewed and
         updated.




                                                 40
  b.   Reproductive Health/Family Planning programs must establish and maintain quality
       assurance mechanisms (including chart audits) that are consistent with the Title X and Title
       XIX requirements, and periodically measure compliance with established policies.


Financial management practices sufficient to assure accurate eligibility determination, appropriate
use of state and federal funds, prompt and accurate billing and payment for services provided and
purchased, accurate expenditure reporting, and, when required, pursuit of third-party insurance and
Medicaid coverage of services provided.

   Reproductive Health/Family Planning programs must:

   a. Maintain a budget for reproductive health and family planning program expenses and
      revenue, including program-generated revenue. A minimum of 20% program generated
      income is required to be earned by programs.

   b. Screen all patients for third party health coverage (private and coverage under the Medicaid
      Program including BadgerCare, Healthy Start and the Family Planning Medicaid Waiver).

   c. Submit claims for third party reimbursement.

   d. Establish reasonable requirements for patient charges based on a sliding fee (discount)
      schedule using the most current Poverty Income Guidelines and assure no eligible patient is
      charged for “no-charge” and “fee-exempt” tests provided through the Wisconsin State
      Laboratory of Hygiene (WSLH).

   e. Fully utilize “no-charge” and “fee-exempt” tests available through the WSLH.

   f. Submit laboratory specimens and laboratory request forms following WSLH instructions,
      and follow WSLH instructions for 3rd party billing coordination.

   g. Maintain a current agreement (if the family planning program is separate from the local
      health department) or plan (if the family planning program is located within the local health
      department) for the use of WSLH fee exempt testing within the family planning program.
      Agreements or plans must be based on guidelines from the DPH-Family Planning and STD
      Programs. Agreements or plans must be reviewed annually and updated as needed.


Data collection, analysis, and reporting to assure program outcome goals are met or to identify
program management problems that need to be address.

   a. Reproductive Health/Family Planning programs must collect patient information (patient
   demographic, need/problem-related information, and visit/service information), necessary to
   meet the DHFS Reproductive Health/Family Planning Program contract reporting requirements.




                                                 41
b. Agencies must submit data in the format required by DPH, using either the DPH SPHERE
   data system or another data system, to meet the reporting requirements.

c. Programs must prepare and submit an annual narrative report. The following must be
   included in the narrative reports: 1) a summary of progress within each of the performance
   indicators (identified in the family planning/reproductive health contract); and 2) a
   description and summary of the agency’s quality assurance audit, addressing plans for any
   corrective action.




                                            42
                       Family Planning/Reproductive Health Program
                                     2008 Objectives
   (Required)
A. By December 31, 2008, yy unduplicated women of reproductive age will receive contraceptive
   services including emergency contraception and dual protection from [choose: (the zzzzzz
   County Health Department Reproductive Health Program) - or - (name of provider)] in
   zzzzzz County.

B. A report to document the number of unduplicated women of reproductive age who received
   contraceptive services from [choose: (the zzzzzz County Health Department Reproductive
   Health Program) - or - (name of provider)] in zzzzzz County, including number of emergency
   contraception doses provided and number of unduplicated clients to whom dual protection
   supplies were provided one or more times during the year.

C. Comprehensive contraceptive and related-reproductive health care provided to the reproductive-
   age population. Reproductive-age women shall also receive early intervention and detection of
   pregnancy intervention services as appropriate to their circumstances and decisions. Early
   intervention and detection of pregnancy intervention services provided shall include Medicaid
   Family Planning Waiver and Healthy Start presumptive eligibility enrollment, emergency and
   on-going contraceptive services, and pregnancy testing. Coordination shall occur with services
   under the EIDP-Local Health Department allocation to ensure timely and convenient access to
   contraceptive supplies and services. Dual protection services are defined as receiving a surgical
   or prescription contraceptive method to prevent unintended pregnancy and a female or male
   condom to reduce the risk of sexually transmitted disease.

D. SPHERE Individual/Household Report to include the MCH Required Demographic Data and
   data from the following screen: Contraceptive Services (CPT office visit code dependent on
   service provided and any V25 Diagnosis code) or agency generated report.

E. Proper documentation of CPT office visit codes and ICD-9 codes related to contraceptive
   services, as defined in the Family Planning/Reproductive Health Program Quality Criteria, is
   essential for accurate and valid measurement of the objective (i.e., the number of patients who
   received services). Only information entered into the Division of Public Health GAC-Web
   application will be used to evaluate the extent to which this objective is met. Timely access to
   contraceptive supplies, including emergency backup contraception, dual protection, and
   Medicaid Family Planning Waiver enrollment are three priorities under this service.




                                                 43
Family Planning/Reproductive Health
(Optional)
A. By December 31, 2008, yy unduplicated (insert description of population segment) will
   receive contraceptive services from [choose: (the zzzzzz County Health Department
   Reproductive Health Program) - or - (name of provider)] in zzzzzz County.

B. A report to document the number of unduplicated (insert description of population segment)
   who received contraceptive services from [choose: (the zzzzzz County Health Department
   Reproductive Health Program) - or - (name of provider)] in zzzzzz County.

C. Comprehensive contraceptive and related reproductive health care provided to specific segments
   of the reproductive-age population.

D. SPHERE Individual/Household Report to include the MCH Required Demographic Data and
   data from the following screen: Contraceptive Services (CPT office visit code dependent on
   service provided and any V25 Diagnosis code) or agency generated report.

E. Examples of population segments include, but not limited to, teens, women ages 35-44, non-
   English speaking women, specific ethnic groups. Proper documentation of CPT office visit codes
   and ICD-9 codes related to contraceptive services, as defined in the Family
   Planning/Reproductive Health Program Quality Criteria, is essential for accurate and valid
   measurement of the objective (i.e., the number of patients who received services). Only
   information entered into the Division of Public Health GAC-Web application will be used to
   evaluate the extent to which this objective is met.




                                               44
EIDP – Family Planning/Reproductive Health
(Required)
A. By December 31, 2008, yy unduplicated women of reproductive age will receive early
   intervention and detection of pregnancy services from [choose: (the zzzzzz County Health
   Department Reproductive Health Program) - or - (name of provider)] in zzzzzz County.

B. A report to document the number of unduplicated women of reproductive age who received early
   intervention and detection of pregnancy services from [choose: (the zzzzzz County Health
   Department Reproductive Health Program) - or - (name of provider)] in zzzzzz County
   including total number of pregnancy tests, number of unduplicated clients with a positive test
   result, number of unduplicated clients with a negative test result, and the number of unduplicated
   clients with negative results that received same day prescription contraceptive services.

C. Pregnancy testing, and timely intervention, services, and referrals, appropriate for the health
   needs and circumstances of individual clients and their pregnancy status and plans.

D. SPHERE Individual/Household Report to include MCH required demographic data and data
   from the following screens: Pregnancy Test (CPT office visit code dependent on service
   provided and V72.4 Diagnosis Code) and Contraceptive Services (CPT office visit code
   dependent on service provided and any V25 Diagnosis code) or agency generated report.

E. Proper documentation of CPT office visit codes and ICD-9 codes related to EIDP services, as
   defined in the Family Planning/Reproductive Health Program Quality Criteria, is essential for
   accurate and valid measurement of the objective (i.e., the number of patients who received).
   Only information entered into the Division of Public Health GAC-Web application will be used
   to evaluate the extent to which this objective is met.




                                                  45
EIDP-LHD PROGRAM - 2008
   Program Boundary Statement

   Program Quality Criteria

   Program Objectives




                                46
                  Early Intervention and Detection of Pregnancy Services
                   Capacity/Infrastructure in Local Health Departments
                              2008 Program Boundary Statement
For each performance-based contract program, the Division of Public Health has identified a
boundary statement. The boundary statement sets the parameters of the program within which the
Local Health Department (LHD) will need to set its objectives. The boundaries are intentionally as
broad as federal and state law permits to provide maximum flexibility. However, if there are
objectives or program directions that the program is not willing to consider, those are included in the
boundary statement.

Program Boundary Statement:

The purpose of the early intervention and detection (EIDP) program is to provide intervention for
early detection of pregnancy and early prevention of unintended pregnancy, appropriate for the
individual circumstances and pregnancy plans of reproductive-age women.

The goals of the EIDP program are:
   • Early pregnancy detection
   • Early identification of pregnancy-related risks
   • Timely and appropriate pregnancy-related care
   • Prevention of unintended pregnancy
   • Preconceptional health (planning and preparation for healthy pregnancy, and pregnancy
      spacing)
   • Safe, effective, timely, and successful contraception to prevent unintended pregnancy
   • Expanded access to Medicaid programs (including Healthy Start and the Family Planning
      Waiver)

Services supporting the above goals are to be provided in coordination with reproductive health and
family planning services.

Long-term Program Goals:
   • Reduce unintended pregnancies among women of all reproductive ages
   • Reduce adolescent pregnancy
   • Decrease inter-conception intervals less than 2 years

Annual Program Goals:
   • Increase Medicaid Family Planning Waiver outreach and enrollment
   • Increase access to emergency contraception
   • Increase access to contraceptive services and supplies.

Populations:
   • Low-income, under-insured or uninsured women at risk of unintended pregnancy
   • Sexually-active adolescents



                                                  47
References:

Federal Regulations/Guidelines:
   Title X Program Guidelines
   (http://opa.osophs.dhhs.gov/titlex/2001guidelines/ofp_guidelines_2001.html)

State of Wisconsin Statutes:
    Medicaid Family Planning Administrative Rules: HFS 105.36
    http://www.legis.state.wi.us/rsb/code/hfs/hfs105.pdf

Wisconsin Family Planning Statutes: s. 253.07
   http://folio.legis.state.wi.us/cgi-
   bin/om_isapi.dll?clientID=34156287&infobase=stats.nfo&j1=253.07&jump=253.07&softpage=
   Browse_Frame_Pg

Program Policies:
   Division of Public Health, Reproductive Health and Family Planning Program Quality Criteria
   Department of Health and Family Services, Adolescent Pregnancy Prevention Plan

Optimal or Best Practice Guidance:

EIDP Objectives:
Organizations should select objectives appropriate to organization capacity, organization priorities,
population needs, and the size of the grant allocation.

Regardless of template objective selected (or other objective developed), the organization must
establish and maintain the capacity to provide appropriate activities that support the purpose and
goals of EIDP, including:

   •   Directly provide pregnancy tests, education and counseling, referral, and appropriate short-
       term care coordination
   •   Provide information, and timely and appropriate access to emergency contraception for
       women who suspect recent exposure to possible unintended pregnancy
   •   Provide timely and appropriate access to contraceptive services
   •   Directly provide presumptive enrollment into Medicaid Healthy Start and Family Planning
       Waiver

EIDP services are to be provided in coordination with reproductive health and family planning
services available within the community.

Unacceptable Proposals:

The following activities are not allowable when providing EIDP services:




                                                  48
   •   Sub-contracting for services under this grant award rather than developing internal capacity
       and infrastructure.
   •   Providing and paying for services for people who are eligible for Medicaid when services are
       covered by Medicaid: (that is, Title V and GPR is the payer of last resort).

Relationship to State Health Plan: Healthiest Wisconsin 2010

Access to Primary and Preventive Health Services: Increase the percent of the population with health
insurance for all of the year.




                                                49
                  Early Intervention and Detection of Pregnancy Services
                   Capacity/Infrastructure in Local Health Departments
                             2008 Program Quality Criteria
Generally high program quality criteria for the delivery of quality and cost-effective administration
of health care programs have been, and will continue to be, required in each public health program to
be operated under the terms of this contract. Contractees should indicate the manner in which they
will assure each criterion is met for this program. Those criteria include:

Assessment and surveillance of public health to identify community needs and to support
systematic, competent program planning and sound policy development with activities focused at
both the individual and community levels.

   Early intervention and Detection of Pregnancy (EIDP) services must be part of a community plan
   or strategy to ensure reasonable accessibility and availability of EIDP and family planning and
   reproductive health services for the community, and to ensure effective outreach to patients
   eligible for services under the Wisconsin Medicaid Family Planning Waiver and Healthy Start.

Delivery of public health services to citizens by qualified health professionals in a manner that is
family centered, culturally competent, and consistent with the best practices; and delivery of public
health programs for communities for the improvement of health status.

   a. Overview

       (1)    EIDP Program goals include:
              • early detection of pregnancy and pregnancy-related risks;
              • timely intervention and continuity of care appropriate for patient pregnancy status
                 pregnancy plans, including pregnancy and contraceptive services;
              • access to Medicaid programs, including Healthy Start and the Family Planning
                 Waiver.

       (2)   The purpose of this EIDP grant allocation is to support capacity and infrastructure in
             local health departments (LHD) to promote and protect reproductive health in the
             reproductive-age population. This capacity establishes the LHD as a credible source of
             accurate and reliable information, and as an access point (entry point) into community
             services.

       (3)   EIDP Capacity and Infrastructure means that an agency is organized and prepared to
             engage in an active assurance role to:
             • increase awareness and understanding about family planning and reproductive
                health and pregnancy-related health care needs and services;
             • promote (outreach) the Medicaid Family Planning Waiver, regular Medicaid
                services, Badger Care, and Healthy Start services;
             • enroll eligible women into the Family Planning Waiver as well as Healthy Start;
             • directly provide pregnancy testing services;


                                                  50
         •   ensure timely and appropriate access to emergency and on-going contraception.

b. To engage in an active EIDP assurance role, the agency must develop and maintain the
   following capability:

   (1)   Agency will maintain complete and accurate, evidence-based information about family
         planning (including emergency and on-going contraception), reproductive health,
         preconception, and pregnancy-related health needs that is available for distribution and
         dissemination to agency clients and other women of reproductive age in the
         community.
         • Agency staff will have access to current evidence-based information.
         • Information will be incorporated into ongoing client education, community
             education and public information activities.

   (2)   Agency will maintain complete and accurate information about the Family Planning
         Waiver, Healthy Start, BadgerCare and regular Medicaid services and enrollment that is
         available for distribution and dissemination to agency clients and other women of
         reproductive age in the community.
         • Agency staff will have access to current information.
         • Information about these programs and benefits will be incorporated into ongoing
             client education, community education and public information activities.

   (3) Agency will maintain Medicaid certification for Presumptive Eligibility to enroll
       eligible women in Healthy Start and the Family Planning Waiver, providing a
       community entry point for access to services and care.
       • Agency staff will have the knowledge and skills to screen and properly enroll eligible
           women, and to inform enrolled women about how and where to obtain covered
           services and supplies.
       • Agency will establish and maintain linkages with the economic support office to
           facilitate efficient enrollment and re-enrollment.

   (4) Agency will be a source for pregnancy tests in the community, providing an entry into
       either Healthy Start and pregnancy-related care, or contraceptive services through
       Family Planning Waiver enrollment and referral.

   (5) Agency will maintain linkages with community healthcare providers to enable clients to
       obtain services and supplies in a timely manner and appropriate to client circumstances.
       Agency will not be required to directly provide contraceptive supplies.
       • Agency will maintain information about community pharmacy policies and
          practices, including emergency contraception availability and services under the
          Medicaid Family Planning Waiver.
       • Agency will maintain arrangements with community family planning program(s)
          and other providers for timely and appropriate access to services and supplies.

c. Pregnancy testing services must be provided in conjunction with:



                                             51
   (1) Risk assessment, timely and appropriate referral for pregnancy or contraceptive care, and
       timely follow-up;
   (2) Patient education and anticipatory guidance sufficient for clients to make informed
       choices and decisions;
   (3) Presumptive eligibility enrollment in the Medicaid Family Planning Waiver and Healthy
       Start Programs (as needed);
   (4) Short-term care coordination services to manage identified needs.

d. EIDP services must include intervention to prevent unintended pregnancy as well as
   intervention to promote early pregnancy-related care. Therefore, EIDP services must also be
   available to women at risk of an unintended pregnancy or who suspect they could become (or
   could have recently become) pregnant.

   (1) EIDP services must ensure timely and appropriate access to emergency hormonal
       contraception and on-going contraceptive services and supplies. Among women who
       suspect they are at risk of an unintended pregnancy (within the past 72 hours), emergency
       contraception must be accessible as an early intervention. Information about emergency
       contraception as an alternative to waiting until a pregnancy test can be performed and the
       risk of unintended pregnancy must be provided.

   (2) Emergency contraception (EC) must be accessible to patients, consistent with evidence
       on EC’s timing and effectiveness following exposure to an unintended pregnancy.
       Patients must receive information on the role of EC as a back-up method of
       contraception, and recommended use for maximum effectiveness in preventing
       unintended pregnancy.

e. EIDP services must:

   (1) Be delivered under the supervision of a Registered Nurse;

   (2) Ensure access to reproductive health services that is appropriate for individual client
       health needs and circumstances, including:
       • Reproductive health screening and assessment services, including cervical cancer
          screening;
       • Sexually transmitted disease screening and assessment, diagnosis and treatment, and
          disease intervention services.

f. EIDP services must assure that the content of patient care and the provision of services
   comply with current established policies, and are consistent with professional standards and
   guidelines within the field of family planning involving pregnancy testing, and patient
   education and counseling.

g. Relevant standards and guidelines include:
   (1) Title X Program Guidelines
   (2) (http://opa.osophs.dhhs.gov/titlex/2001guidelines/ofp_guidelines_2001.html),
   (3) DHFS’s Guidelines for Perinatal Care: Preconceptional Health Services


                                             52
       (4) (http://www.hcet.org/wfpp/sandr/sandg.html#hbg)
       (5) “Patient Rights and Provider Responsibilities: Privacy and Confidentiality Issues for
           Family Planning and Reproductive Health Services - A Resource Guide for the
           Wisconsin Family Planning Program” (http://www.hcet.org/wfpp/sandr/conf.htm) to
           assure patient privacy rights and consumer confidence in confidentiality safeguards for
           all patient information;
       (6) American Academy of Obstetricians and Gynecologists (ACOG) Women's Health
           Guidelines (http://sales.acog.com/acb/stores/1/product1.cfm?SID=1&Product_ID=246)
           and
       (7) Contraceptive Technology (http://www.contraceptiveupdate.com/).

Record keeping for individual focused services that assures documentation and tracking of client
health care needs, response to known health care problems on a timely basis, and confidentiality of
client information.

   EIDP services must:
      (1) protect and safeguard reproductive health patient privacy and confidentiality rights in
          compliance with HIPAA privacy requirements
          (http://www.cms.hhs.gov/hipaa/hipaa2/regulations/privacy/default.asp), and

       (2) comply with regulations and guidelines defining chart requirements for the content of
           patient records including Wisconsin Family Planning Medicaid Program requirements
           (http://www.legis.state.wi.us/rsb/code/hfs/hfs105.pdf), and Title X requirements
           (http://opa.osophs.dhhs.gov/titlex/2001guidelines/ofp_guidelines_2001.html).

Information, education, and outreach programs intended to address known health risks in the
general and certain target populations to encourage appropriate decision making by those at risk and
to affect policy and environmental changes at the community level.

   a. EIDP services must be part of public information and education, and outreach activities to
      increase awareness and understanding among all reproductive-age women of family planning
      and related reproductive health care issues, key knowledge areas, and where to obtain
      services.

   b. EIDP services must place particular emphasis on reaching population segments that lack
      access, are at higher relative risk of unintended pregnancy and reproductive health morbidity,
      and other population segments appropriate to the county.

Coordination with related programs to assure that identified public health needs are addressed in a
comprehensive, cost-effective manner across programs and throughout the community.

   EIDP services must be coordinated and integrated with other state and local programs and
   initiatives, including the Medicaid Family Planning waiver, Adolescent Pregnancy Prevention
   Program; Healthy Start; Prenatal Care Coordination, WIC, etc., to facilitate timely and
   appropriate continuity of care.




                                                 53
A referral network sufficient to assure the accessibility and timely provision of services to address
identified public health care needs.

    EIDP services must be integrated into community referral networks that provide effective access
    for essential services and that facilitate timely continuity of patient care. For example, networks
    established through memoranda of understanding with other providers for appropriate referral of
    clients.

Provision of guidance to staff through program and policy manuals and other means sufficient to
assure quality health care and cost-effective program administration.

    EIDP service policies and practices must reflect current standards and guidelines recognized in
    the field of family planning and reproductive health, be periodically reviewed and updated, and
    have quality assurance safeguards to ensure compliance with contract requirements and
    standards.

Financial management practices sufficient to assure accurate eligibility determination, appropriate
use of state and federal funds, prompt and accurate billing and payment for services provided and
purchased, accurate expenditure reporting, and, when required, pursuit of third-party insurance and
Medicaid coverage of services provided.

    a. EIDP services must screen all patients for third party health coverage (private and Medicaid
       including BadgerCare, Healthy Start and the Family Planning Medicaid Waiver), and submit
       claims for third party reimbursement, if reimbursable services are directly provided.

    b. EIDP services must establish reasonable requirements for patient charges based on a sliding
       fee (discount) schedule using the most current Poverty Income Guidelines, if clients are
       charged for services.


Data collection, analysis, and reporting to assure program outcome goals are met or to identify
program management problems that need to be address.

    a. Agencies providing EIDP-LHD services must collect client information for the required
    deliverables that correspond to the activities listed under Delivery of public health services
    sections b.(1) – b.(5), and other client information necessary to meet the DHFS EIDP-LHD
    contract reporting requirements.
    b. Agencies must submit data in the format required by DPH, using either the DPH SPHERE
       data system or another data system, to meet the reporting requirements.




                                                  54
                           2008 EIDP-LHD Template Objective
                      EIDP-Local Health Department Capacity/Infrastructure

A. During the contract period, all women of reproductive age who receive services through the
   zzzzzz County Health Department will be provided with appropriate information about family
   planning and reproductive health, pregnancy related health, and Medicaid services including the
   Family Planning Waiver and Healthy Start.

B. An agency generated report to document the number of women of reproductive age served by the
   zzzzzz County Health Department, and the number of those women who received specific
   early intervention and detection of pregnancy services capacity (infrastructure) services;
   including the number who received: 1) information about family planning and reproductive
   health and pregnancy related health and services, 2) information about Medicaid services
   including the Family Planning Waiver and Healthy Start, 3) enrollment into Healthy Start or
   enrollment in the Family Planning Waiver through the agency, 4) pregnancy tests, and 5)
   contraceptive services (directly or through referral), including emergency contraception (directly
   or through referral).

C. All women of reproductive age shall receive information about: family planning and
   reproductive health and pregnancy related health; the availability of family planning supplies and
   services, and how and where to obtain these services; and information about Medicaid services
   including the Family Planning Waiver and Healthy Start. All women of reproductive age shall
   receive other early intervention and detection of pregnancy intervention services as appropriate
   to their circumstances and decisions. Early intervention and detection of pregnancy intervention
   services provided shall include Medicaid Family Planning Waiver and Healthy Start presumptive
   eligibility enrollment, emergency and on-going contraceptive services, and pregnancy testing.
   Coordination shall occur with the county's family planning agency(ies) to ensure timely and
   convenient access to contraceptive supplies and services. There is no designated value range for
   this objective.

D. Data Source for Measurement for each of the five points specified in the Contract Deliverable: 1)
   SPHERE Community Report to include the data from the following screens: Community
   Activity (all appropriate fields including Audience Focus, Methods to Support Intervention,
   Intervention: Outreach and Sub-intervention: (check appropriate box - Family Planning and
   Reproductive Health and/or Pregnancy-related Health and Services - no detail screens for the
   subinterventions); or an agency generated report summarizing the total number (i.e., individual
   client detail is not required). 2) SPHERE Community Report to include the data from the
   following screens: Community Activity (all appropriate fields including Audience Focus,
   Methods to Support Intervention, Intervention: Outreach and Subintervention: (check appropriate
   box - Family Planning Medicaid Waiver or Healthy Start - no detail screens for the
   subinterventions); or an agency generated report summarizing the total number (i.e., individual
   client detail is not required). 3) SPHERE Individual/Household Report to include the MCH
   Required Demographic Data and data from the following screen: Intervention: Case Finding and
   Subintervention: Presumptive Eligibility for Family Planning Medicaid Waiver or Presumptive
   Eligibility for Healthy Start (no detail screens for subinterventions); or agency generated report.


                                                 55
   4) SPHERE Individual/Household Report to include the MCH Required Demographic Data and
   data from the following screen: Pregnancy Test (CPT office visit code dependent on service
   provided and V72.4 Diagnosis Code); or agency generated report. 5) SPHERE
   Individual/Household Report to include the MCH Required Demographic Data and data from the
   following screen: Contraceptive Service (if providing directly) (CPT office visit code dependent
   on service provided and any V25 Diagnosis Code) or Referral and Follow-up/Results (through
   referral); or agency generated report.

Goals of this EIDP allocation for capacity and infrastructure in local health departments are to: 1)
increase awareness about family planning and pregnancy-related health care needs and services, 2)
promote (outreach) the Medicaid Family Planning Waiver, regular Medicaid services, BadgerCare,
and Healthy Start services, 3) enroll eligible women into the Medicaid Family Planning Waiver and
Healthy Start, 4) directly provide pregnancy testing services, and 5) ensure timely and appropriate
access to on-going and emergency contraception.




                                                 56
IMMUNIZATION PROGRAM – 2008

    Program Boundary Statement

    Program Quality Criteria

    Program Objectives




                                 57
                                  2008 Program Boundary Statement
                                    Wisconsin Immunization Program
For each performance-based contract program, the Division of Public Health has identified a
boundary statement. The boundary statement sets the parameters of the program within which the
local health department (LHD), Tribe or agency will need to set its objectives. The boundaries are
intentionally as broad as federal and state law permit to provide maximum flexibility. However, if
there are objectives or program directions that the program is not willing to consider or specific
programmatic parameters, those are included in the boundary statement.

LHDs, Tribes and agencies are encouraged to leverage resources across categorical funding to
achieve common program goals. The Wisconsin Immunization Program aligns well with the
boundaries of the WIC and MCH Programs.

Program Boundary Statement:

The LHD’s Immunization Program is expected to administer vaccines primarily to children from
birth through 18 years of age. The LHD will assure the development and maintenance of a
jurisdiction-wide immunization infrastructure necessary to raise immunization levels for universally
recommended vaccines. In addition, the LHD will assure adequate surveillance, prompt reporting
and epidemiologic follow-up of vaccine preventable diseases. The LHD will follow the Policies and
Procedures Manual developed and distributed by the Wisconsin Immunization Program unless
otherwise agreed upon. LHDs will also assure that community wide systems are in place to prevent
vaccine preventable diseases such as diphtheria, tetanus, pertussis, polio, measles, mumps, rubella,
Haemophilus influenzae B, varicella, pneumococcal disease, meningococcal disease, influenza,
rotavirus, human papillomavirus (HPV), and hepatitis A and B. To ensure that funds provided for
this program through the consolidated contract are used effectively, contractees will be required to
measure the outcome of their efforts to achieve goals. LHD will maintain partnerships with all
Immunization Providers in their jurisdiction.

Long-term Program Goals:
As part of a continuous quality improvement (CQI) initiative, the Wisconsin Immunization Program
has reviewed and analyzed Healthiest Wisconsin 2010 and Healthy People 2010 objectives utilizing
*multiple data sources to guide programmatic priorities. Sixty-one immunization objectives are
identified in the state and federal health plans. Of the total objectives where data is available, 65.3%
(32/49) of Healthiest Wisconsin 2010 and Healthy People 2010 goals have been met. The Wisconsin
Immunization Program will continue to evaluate 2010 goals on a bi-annual basis.



*Data sources include and used in the analysis include the National Immunization Survey (NIS), the Behavioral Risk
 Factor Surveillance System (BRFSS) multiple DHFS databases, and the Wisconsin Immunization Registry (WIR).
The Annual Consolidated Contract Process is an important component of the Wisconsin
Immunization Program’s CQI initiative and will be utilized to drive programmatic outcomes using
evidence-based practices and data driven activities. To that end, state, regional and local




                                                               58
public health entities have a leadership role in educating for implementing, assessing and assuring
population-based immunization activities to meet local, state and federal immunization goals and
objectives. Due to limited resources, high leverage activities need to be prioritized thus having the
greatest impact on programmatic functions and stated goals within the defined public health
functions of assessment, policy development, and assurance.

Currently, Wisconsin’s rate for the 4:3:1:3:3:1 series is 77.7%. To achieve the Healthy People 2010
goals stated in Healthiest Wisconsin 2010 and Healthy People 2010, 90% percent of Wisconsin
children aged 19-35 months will receive all universally recommended vaccines (4 DTaP, 3 Polio, 1
MMR, 3 Hib, 3 Hep B, and 1 Varicella [4:3:1:3:3:1]). Through performance-based contracts, we can
execute population-based immunization activities to achieve local, state and federal immunization
goals.

Annual Program Goals:
For 2008, increase the percent of Wisconsin children ages 12-35 months who receive all the
universally recommended vaccines of 4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 HepB and 1 Varicella
(4:3:1:3:3:1) to 84%. Coverage levels for 2005 from the National Immunization Survey (NIS) were
77.7%. Further, to increase the effective use of the Wisconsin Immunization Registry or an
Immunization Registry capable of interfacing with the Wisconsin Immunization Registry as
evidenced by an increase in the overall jurisdictional rise in immunization levels. LHD must explore
jurisdiction specific practices to increase the number and effective use of Registries as described
above.


Target Populations:

The Immunization Program primarily serves Wisconsin children ages 0-18 years.

References:

Federal Regulations/Guidelines:
   CDC “Federal Grant Guidance Document”
   CDC Current ACIP Recommendations
   CDC VFC Operation Guide
   CDC "Pink Book"
   CDC "Immunization Program Operations Manual"
   CDC Healthy People 2010

State of Wisconsin Statutes/Guidelines:
    WI Statute 252
    WI Administrative Rule HFS144
    WI State Health Plan "Healthiest Wisconsin 2010", including the Implementation Plan




                                                 59
Program Policies:

   Wisconsin Immunization Protocols "General Polices and Procedures for Immunization
   Programs"
   Core Competencies for Public Health Professionals
   (http://www.trainingfinder.org/competencies/background.htm)



Optimal or Best Practice Guidance:

   •    Contractees must use the Wisconsin Immunization Registry (WIR) or an electronic
        immunization population-based data system that links with the WIR.
    • Contractees should make every effort to identify and link immunization outreach and
        promotion activities with existing local health department efforts targeted at high risk
        families. These may include but are not limited to: PNCC, WIC Programming and
        Education, New Baby Mailings and Home Visits, Baby-Fast Support Systems, LPHD Health
        Check Programming, Birth to Three Programming, Developmental Screening Programs,
        Safe and Healthy Home Inspections, LPHD Car Seat Safety Programs, CSHCN Case
        Management, Preparedness Education for Families, POCAN Case Management, Lead
        Screening Programs, Day Care efforts, WWWP and Reproductive Health Programming,
        etc.
    • Contractees must engage in community partnerships to identify and address the needs of
        high-risk populations in a culturally competent and linguistically appropriate manner and to
        educate families and the community on the importance of on schedule immunization of
        children.
Contractees should make every effort to share information on vaccine preventable diseases,
immunizations and local assessment data with local private health care providers and key
community stakeholders in an effort to increase immunization coverage rates within their
jurisdictions.

Unacceptable Proposals:

The Wisconsin Immunization Program will not accept objectives that focus efforts on school,
daycare, adolescent or adult populations unless the current population-based assessment for
children 12-35 months of age shows immunization rates for 4:3:1:3:3:1 are at or above 90% as
measured by 24 months of age. The Immunization Program does caution contractees that experience
has shown that great effort is needed to sustain an immunization rate at or above 90%; therefore,
once the coverage rate is at or above 90%, objectives that focus efforts on schools, daycare,
adolescent, or adult populations should be undertaken with a great deal of forethought.

Past programmatic template objectives may not fit into the new framework in which we are trying to
achieve these goals. Use of past objectives will require negotiation and does not guarantee
acceptance.




                                                 60
Relationship to State Health Plan: Healthiest Wisconsin 2010:

Health Priorities:
   • Access to primary and preventive health services
   • Social and economic factors that influence health
   • Existing, emerging and re-emerging communicable diseases

Infrastructure Priorities:
    • Integrated electronic data and information systems
    • Community health improvement processes and plans
    • Coordination of state and local public health system partnerships


Essential Services:
   • Evaluate effectiveness, accessibility and quality of personal and population-based health
       services
   • Link people to needed health services
   • Monitor health status to identify community health problems
   • Identify, investigate, control and prevent health problems
   • Educate the public about current and emerging health issues
   • Promote community partnerships to identify and solve health problems
   • Create policies and plans that support individual and community health efforts
   • Enforce laws and regulations that protect health and ensure safety


                              Addendum - WI Immunization Program


Possible interventions/activities where an Immunization Intervention might be used to reach high
risk persons for increasing immunization rates:

   •   Check Immunization Records at sites for Lead Screening
   •   PNCC clients – have an immunization education module and follow birth with appointment
       for 1:1:1:1
   •   Check records of children of women being followed for inter-conception counseling
   •   Follow breast feeding mothers at 1-2 months and check on first imms appointment
   •   Immunization teaching at PHN new baby home visits
   •   Use Baby-Fast Support System to educate mentors and have imm teaching module (Moms
       under 25 years of age mentoring and support)
   •   Check Immunization records and refer if not U-T-D for all developmental screenings done
       for children 6 mos – 5 years
   •   Check Immunization records at Car Seat Checks done by LHD staff or PHN's
   •   Check Immunization records at all visits that assess for hazards in the home
   •   CSHCN seen and referred have records checked for Imms and referral if not U-T-D
   •   Have an immunization module in CSHCN case management


                                                61
   •   Include Immunization teaching in all Health Education Activities targeted to MCH
       populations
   •   Insert checking for U-T-D immunizations in self-reporting behavior changes in targeted
       MCH programs targeting changes in specific health related behaviors
   •   Use Immunization strategies to tie in with efforts of other MCH local partnerships and
       coalitions to address MCH issues in community or jurisdiction
   •   Educate dental professionals to also check for U-T-D Immunization Rates
   •   Community prevention and preparedness strategies also include emphasis on U-T-D
       immunizations
   •   Work with WIC
   •   Use EIDP education to assure that young women are fully immunized and/or referred for
       immunizations.
   •   Work with private medical doctors to utilize registries.

LHD along with the Wisconsin Immunization Program will contact private providers not currently
using a registry to help facilitate in any way possible the use of WIR or a registry capable of
interfacing with WIR.

LHD along with the Wisconsin Immunization Program will monitor the use of the registry by private
providers and when necessary assure that immunization data will be entered accurately and in a
timely manner.




                                               62
                              2008 Program Quality Criteria
                             Wisconsin Immunization Program
Generally high program quality criteria for the delivery of quality and cost-effective administration
of health care programs have been, and will continue to be, required in each public health program to
be operated under the terms of this contract. Contractees should indicate the manner in which they
will assure each criterion is met for this program. Those criteria include:

Assessment and surveillance of public health to identify community needs and to support
systematic, competent program planning and sound policy development with activities focused at
both the individual and community levels.

   a. Contractees must assure reported vaccine preventable diseases (VPD) are investigated and
      controlled as detailed in the most current edition Wisconsin Disease Surveillance Manual
      (EPINET). Immunization programs should maintain regular contact with local required
      reporters of VPDs to encourage and assure prompt reporting. Contractees should solicit the
      help of the Immunization Program when needed to help assure that an adequate system is in
      place to report and investigate vaccine preventable disease (VPD).

   b. Contractees must annually formally evaluate immunization delivery and vaccine preventable
      disease surveillance systems and improve those systems in their jurisdictions where needed.

   c. Contractees must work in collaboration with the Immunization Program to increase the use
      existing electronic data collection systems for vaccine record keeping and vaccine
      preventable disease data systems.

Delivery of public health services to Wisconsin residents by qualified health professionals in a
manner that is family centered, culturally competent, linguistically appropriate and consistent with
the best practices; and delivery of public health programs for communities for the improvement of
health status.

       Contractees must assure the delivery of immunization services in a safe, effective and
       efficient manner as detailed in the Wisconsin Immunization Program Policies and Procedures
       and in section 252, HFS 145, Wis. Admin. Code. Contractees must assure the immunization
       of children is consistent with Healthy People 2010 goals.

Record keeping for individual focused services that assures documentation and tracking of client
health care needs, response to known health care problems on a timely basis, and confidentiality of
client information.

   a. Contractees must use the Wisconsin Immunization Registry (WIR) or an electronic
      immunization population-based data system that links with the WIR. The data system must
      have a tracking and recall function to identify children whose immunization records are
      behind schedule. Tracking and recall shall be conducted at least bi-monthly as required by
      the Wisconsin "Policies and Procedures Manual for Immunization Programs".



                                                  63
   b. Contractees' immunization practice must assure the immunization of children, and share
      children’s immunization records with parents or guardians, schools and day care centers and
      other healthcare providers as provided by the Wisconsin School Immunization Law.

Information, education, and outreach programs intended to address known health risks in the
general and certain target populations to encourage appropriate decision making by those at risk and
to affect policy and environmental changes at the community level.

       Contractees must engage in community partnerships to identify and address the needs of
       high-risk populations, reduce racial and ethnic health disparities and to educate families and
       the community on the importance of immunizations.

Coordination with related programs to ensure that identified public health needs are addressed in a
comprehensive, cost-effective manner across programs and throughout the community.

       Contractees must coordinate immunization services with local child healthcare (service)
       providers; e.g., WIC projects, Medical Assistance programs, and other local public health
       programs to assess the immunization status of, refer, and provide immunization services to
       under-immunized children.

A referral network sufficient to assure the accessibility and timely provision of services to address
identified public health care needs.

       Contractees must develop relationships among public and private healthcare providers to
       facilitate access by children and families to immunization services. Contractees should work
       with these providers to assure that current immunization guidelines are followed. These
       relationships should also be used to promote the prompt reporting of suspect vaccine
       preventable diseases, and the use of the WIR or a registry capable of interfacing with the
       WIR.

       (1)   The local health department (LHD) should promote the medical home concept by
             referring vaccine recipients to their medical home provider for subsequent
             immunizations and coordinate with this medical provider to assure adherence to the
             recommended immunization schedule. If no medical home exists, the LHD must
             continue to provide immunization services.

       (2)   Promote the exchange and sharing of immunization data through the use of
             immunization registries.

       (3)   The LHD will assure adequate surveillance, prompt reporting and epidemiologic
             follow-up of vaccine preventable diseases. When prompt reporting of a vaccine
             preventable disease does not occur, the LHD will formally address the issue with the
             reporting agency to assure that reports are made according to the latest EPINet Manual.

Provision of guidance to staff through program and policy manuals and other means sufficient to
ensure quality health care and cost-effective program administration.



                                                 64
   a. Contractees will ensure program staff is competent in current immunization program policy
      and procedures, including that provided through the Centers for Disease Control and
      Prevention (CDC) distance learning course and CDC updates.

   b. The LHD will follow the Wisconsin "Policies and Procedures Manual for Immunization
      Programs" developed and distributed by the Wisconsin Immunization Program unless
      otherwise agreed upon; as well as Immunization Policy Memos issued periodically from the
      Immunization Program and posted on the Health Alert Network (HAN). The LHD must
      have written policies on the proper handling and storage of state supplied vaccine. These
      policies must be reviewed with all immunization program related staff on at least an annual
      basis.

Financial management practices sufficient to ensure accurate eligibility determination, appropriate
use of state and federal funds, prompt and accurate billing and payment for services provided and
purchased, accurate expenditure reporting, and, when required, pursuit of third-party insurance and
Medical Assistance coverage of services provided.

   a. Billing for payment of childhood immunization services is not required under this section.

   b. LHDs must assure that parents of children who are on Medical Assistance will not be
      charged a vaccine administration fee or be requested to make a donation for vaccine or
      vaccine related services. Administration fees can not be mandatory and clients must be
      informed that failure to pay the administration fee or make a donation does not preclude them
      from receiving state supplied vaccine. This information must be added to immunization
      advertising materials used by the LHD. The message must be given to the client in a way
      and in a language the client understands.

Data collection, analysis, and reporting to ensure program outcome goals are met or to identify
program management problems that need to be addressed.

   a. Contractees must collect and analyze agency and available private provider immunization
      data for children 12-35 months of age, school immunization law reports and other available
      population based information needed to identify strengths and weaknesses in local delivery
      systems and plan improvements. Only children who have moved out of the agencies
      jurisdiction may be removed from the cohort for analysis.

   b. LHDs will utilize the WIR for immunization level data analysis.

   c.   LHDs and Tribes will assure staff competence with the WIR system. LHD and Tribal staff
        must attend at least one of the 2 or more annual Regional WIR User Group Meetings.
        Attendance at these meetings is necessary for staff to maintain a thorough working
        knowledge of the functionality of the WIR.




                                                65
                                     IMMUNIZATION PROGRAM
                                           OBJECTIVE

        Pockets of Need – Immunization

A. By December 31, 2008 Agencies must attain or be making progress towards the goal of 90%
   (accomplishment will be based on % increase according to the table in the context section) of children
   residing in (insert name of Health Department) jurisdiction who will turn 19 months of age during the
   contract year 2008 will have received their 4th dose of DTaP.

B. A Wisconsin Immunization Registry (WIR) population based report to include the total number of
   children who turned 19 months of age during contract year 2008 and who had received their 4th dose of
   DTaP. Reports should be run with a 45 day buffer to ensure that all updated data has been received by the
   WIR.

C. Children will be assessed for receipt of the 4th dose of DTaP by 19 months of age. Progress towards
   reaching 90% will be measured using a WIR Benchmark report as that baseline and the Immunization
   Programs prescribed % increase based on the agencies baseline data. Only children who have moved out
   of the agency's jurisdiction may be removed from the selected cohort for analysis. Benchmark reports are
   available to show those clients who have reported refusals for recommended vaccines. These reports
   should be run to show agency effort toward achieving the objective goal.

                   Guidelines for determining increase needed for progress towards 2010 goals
                           If Current baseline is:             % Increase in baseline required
                                   <50%                                     10%
                                 50 - 59%                                    5%
                                 60 - 69%                                    4%
                                 70 - 79%                                    3%
                                 80 - 85%                                    2%
                                 86 - 89%                                    1%
                                   > 90%                                  maintain
                   Agencies should consult with their Regional Immunization Program Advisor
                   for assistance in determining activities and interventions that will help them
                   achieve the required increase for their population assessment.



D. Wisconsin Immunization Registry Records.

E. 2005 NIS Survey data indicates that for WI 89.1% of 19 month olds had received their 4th dose of DTaP.
   Baseline data using DTaP vaccine as an indicator will assist the department in identifying children who at
   greatest need of access to primary health care for the need for further interventions.

    Agencies are expected to follow children through completion of on-time primary immunizations. Agency
    activities shall include monitoring for receipt all recommended childhood vaccines.




                                                      66
In addition, through this objective LHD's will work to address the Healthy People 2010: 14-26 goal to
“Increase the proportion of children who participate in fully operational population-based immunization
registries” by identifying local gaps in WIR coverage.

The Wisconsin Immunization Program recommends the following activities to help ensure success of this
objective:
    • contacting parents of infants without immunization histories
    • reminder/recall
           o three letters (1 certified)
           o if no response to letters 1 phone call from health department
           o home visit (optional)
    • follow-up interventions to complete series
    • tracking
    • sharing information with area physicians
    • requesting that information is entered into the WIR.
    • Coordination of immunization services with other LHD programs

Additional interventions/activities are in an addendum to the Immunization Program Boundary Statement.
These are suggested interventions/activities that LHD's may want to consider in order to achieve this
objective.

Agency activities related to this objective may include: contacting parents of infants without
immunization histories, reminder/recall, follow-up interventions to complete series, tracking, sharing
information with area physicians and requesting that information be entered into the WIR.




                                                  67
                                        IMMUNIZATION PROGRAM
                                             OBJECTIVE

                                              2008 Contract Year

         4:3:1:3:3:1 Template Objective

F. By December 31, 2008, Agencies must attain or be making progress towards the goal of 90%
   (accomplishment will be based on % increase according to the table in the context section) of infants born
   to families residing in (insert name of Health Department) jurisdiction who turn 24 months of age during
   the contract year will have received 4 DTaP, 3 Polio, 1 MMR, 3 Hib 3 Hepatitis B and 1 varicella
   vaccination.

G. A Wisconsin Immunization Registry (WIR) generated population based report documenting the number
   of children in (insert name of Health Department) jurisdiction who turned 24 months of age in 2008.
   Reports should be run with a 45 day buffer to ensure that all updated data has been received by the WIR.

H. Children will be assessed for having at 4 DTaP, 3 Polio, 1 MMR, 3 Hib 3 Hepatitis B and 1 varicella
   vaccination by 24 months of age. Progress towards reaching 90% will be measured using a WIR
   Benchmark report as that baseline and the Immunization Programs prescribed % increase based on the
   agencies baseline data. Only children who have moved out of the agency's jurisdiction may be removed
   from the cohort for analysis. Benchmark reports are available to show those clients who have reported
   refusals for recommended vaccines. These reports should be run to show agency effort toward achieving
   the objective goal.

                    Guidelines for determining increase needed for progress towards 2010 goals
                             If Current baseline is:            % Increase in baseline required
                                     <50%                                     10%
                                   50 - 59%                                    5%
                                   60 - 69%                                    4%
                                   70 - 79%                                    3%
                                   80 - 85%                                    2%
                                   86 - 89%                                    1%
                                     > 90%                                  maintain
                    Agencies should consult with their Regional Immunization Program Advisor
                    for assistance in determining activities and interventions that will help them
                    achieve the required increase for their population assessment.



I.   Wisconsin Immunization Registry Records.

J.   Access to primary and preventive health services is one of the priorities identified in Wisconsin’s State
     Health Plan, Healthiest People 2010: A Partnership Plan to Improve the Health of the Public.

     Agencies are expected to follow children through completion of on-time primary immunizations. Agency
     activities shall include monitoring for receipt all recommended childhood vaccines.


                                                       68
In addition, through this objective LHD's will work to address the Healthy People 2010: 14-26 goal to
“Increase the proportion of children who participate in fully operational population-based immunization
registries” by identifying local gaps in WIR coverage.

The Wisconsin Immunization Program recommends the following activities to help ensure success of this
objective:
    • contacting parents of infants without immunization histories
    • reminder/recall
           o three letters (1 certified)
           o if no response to letters 1 phone call from health department
           o home visit (optional)
    • follow-up interventions to complete series
    • tracking
    • sharing information with area physicians
    • requesting that information is entered into the WIR.
    • Coordination of immunization services with other LHD programs

Additional interventions/activities are in an addendum to the Immunization Program Boundary Statement.
These are suggested interventions/activities that LHD's may want to consider in order to achieve this
objective.

These activities are addressed in the boundary statement: “……The local health department will assure
the development and maintenance of a community-wide immunization infrastructure necessary to raise
immunization levels and prevent vaccine preventable diseases such as diphtheria, tetanus, …and hepatitis
B."




                                                 69
MCH PROGRAM – 2008

    Program Boundary Statement

    Program Quality Criteria

    Program Objectives




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                             2008 Program Boundary Statement
                                 Maternal and Child Health
                (Including Children and Youth with Special Health Care Needs)

For each performance-based contract program, the Division of Public Health has identified a
boundary statement. The boundary statement sets the parameters of the program within which the
Local Public Health Department (LPHD), Tribe or agency will need to set its objectives. The
boundaries are intentionally as broad as federal and state law permit to provide maximum flexibility.
However, if there are objectives or program directions that the program is not willing to consider or
specific programmatic parameters, those are included in the boundary statement.

LPHDs, Tribes and agencies are encouraged to leverage resources across categorical funding to
achieve common program goals. The Maternal and Child Health (MCH) Program aligns well with
the boundaries of the Childhood Lead Poisoning Prevention, Immunization, Preparedness,
Prevention, Reproductive Health, and Tobacco Prevention and Control programs.

Program Boundary Statement:

Long-term Program Goals:
The Title V MCH/CYSHCN Services Block Grant has, as its general purpose, the improvement of
the health of all mothers and children in the Nation consistent with the applicable health status goals
and national health objectives established by the Secretary under the Public Health Service Act for
the Year 2010.

The MCH Formula Grants to States are to enable each State: (per Federal language)
   • To provide and assure mothers and children (especially those with low income or limited
     availability to services) access to quality MCH services;
   • To reduce infant mortality and incidence of preventable diseases and handicapping
     conditions among children; to reduce the need for inpatient and long-term health services; to
     increase the number of children appropriately immunized against disease and the number of
     low income children receiving health assessments and follow-up diagnostic and treatment
     services; and otherwise to promote the health of mothers and infants by providing prenatal,
     delivery, and postpartum care for low income, at-risk pregnant women, and to promote the
     health of children by providing preventive and primary care services for low income
     children;
   • To provide and promote family-centered, community-based, coordinated care (including care
     coordination services) for children with special health care needs and to facilitate the
     development of community-based, systems of service for such children and their families.

States are required to use their Federal MCH Block Grant funds in the following way:
    • At least 30% of funds received for preventive and primary care services for children; and
    • At least 30% of funds received for services for children with special health care needs.




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Annual Program Goals:

National Performance Measures
1. The percent of screen positive newborns who received timely follow up to definitive diagnosis
    and clinical management for condition(s) mandated by their State-sponsored newborn screening
    programs.
2. The percent of children with special health care needs age 0 to 18 years whose families partner in
    decision making at all levels and are satisfied with the services they receive.
3. The percent of children with special health care needs age 0 to 18 who receive coordinated,
    ongoing, comprehensive care within a medical home.
4. The percent of children with special health care needs age 0 to 18 whose families have adequate
    private and/or public insurance to pay for the services they need.
5. Percent of children with special health care needs age 0 to 18 whose families report the
    community-based service systems are organized so they can use them easily.
6. The percentage of youth with special health care needs who received the services necessary to
    make transitions to all aspects of adult life, including adult health care, work, and independence.
7. Percent of 19 to 35 month olds who have received full schedule of age appropriate
    immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis,
    Haemophilus Influenza, and Hepatitis B.
8. The rate of birth (per 1,000) for teenagers aged 15 through 17 years.
9. Percent of third grade children who have received protective sealants on at least one permanent
    molar tooth.
10. The rate of deaths to children aged 14 years and younger caused by motor vehicle crashes per
    100,000 children.
11. The percent of mothers who breastfeed their infants at 6 months of age.
12. Percentage of newborns who have been screened for hearing before hospital discharge.
13. Percent of children without health insurance.
14. Percentage of children, ages 2 to 5 years, receiving WIC services with a Body Mass Index (BMI)
    at or above the 85th percentile.
15. Percentage of women who smoke in the last three months of pregnancy.
16. The rate (per 100,000) of suicide deaths among youths aged 15 through 19.
17. Percent of very low birth weight infants delivered at facilities for high-risk deliveries and
    neonates.
18. Percent of infants born to pregnant women receiving prenatal care beginning in the first
    trimester.

State Performance Measures
1. Percent of eligible women enrolled in the Wisconsin Medicaid Family Planning Waiver during
    the year.
2. Percent of Medicaid and BadgerCare recipients, ages 3-20, who received any dental service
    during the reporting year.
3. Percent of children, ages 6 months-5 years, who have age-appropriate social and emotional
    developmental levels.
4. Rate per 1,000 of substantiated reports of child maltreatment to Wisconsin children, ages 0 - 17,
    during the year.




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5. Percent of children who receive coordinated, ongoing comprehensive care within a medical
    home.
6. Percent of children less than 12 years of age who receive one physical exam a year.
7. Percent of women who use tobacco during pregnancy.
8. Percent of children, ages 2-4, who are obese or overweight at or above the 95th percentile.
9. Ratio of the black infant mortality rate to the white infant mortality rate.
10. Death rate per 100,000 among youth, ages 15-19, due to motor vehicle crashes.

Target Populations:

The MCH/CYSHCN program is intended to increase healthy birth outcomes, and promote optimal
growth and development for children and their families. Agencies are encouraged to focus on racial
and ethnic disparities and healthy birth outcomes as appropriate.

The populations served under this Title V federal funding include women of childbearing age,
pregnant women, and children birth to 21 years old, including children and youth with special health
care needs, and their families.

References:

Federal Regulations/Guidelines:
Title V of the Social Security Act Maternal and Child Health Services Block Grant - Section 501-
510.

State of Wisconsin Statutes:
The Wisconsin Legislature has given broad statutory and administrative rule authority to its state and
local government to promote and protect the health of Wisconsin’s citizens.

   Chapter 253 mandates a state maternal and child health program in the Division of Public
   Health to promote the reproductive health of individuals and the growth, development, health
   and safety of infants, children and adolescents. It addresses:

       s.253.06       State supplemental food program for women, infants, and children
       s.253.07       Family planning (Wisconsin Administrative Code Chapter HFS 151 describes
                      family planning fund allocations).
       s.253.08       Pregnancy counseling services
       s.253.085      Outreach to low-income pregnant women
       s.253.09       Abortion refused; no liability; no discrimination
       s.253.10       Voluntary and informed consent for abortions
       s.253.11       Infant blindness
       s.253.115      Newborn hearing screening
       s.253.12       Birth and developmental outcome monitoring program
       s.253.13       Tests for congenital disorders
       s.253.14       Sudden infant death syndrome

Program Policies:



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Optimal or Best Practice Guidance:
The Contractee must assure quality by utilizing one or more of the following documents for
guidance in the organization and delivery of services:
   • Wisconsin Medicaid Prenatal Care Coordination Services Handbook and related Medicaid
       Updates
   • Family Planning Reproductive Health Standards of Practice
   • Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents,
       Second Edition
   • Caring for Our Children: National Health and Safety Performance Standards Guidelines for
       Out-of-Home Child Care Programs: Second Edition, 2002
   • Bright Futures in Practice: Oral Health
   • Bright Futures in Practice: Physical Activity
   • Bright Futures in Practice: Nutrition, Second Edition
   • Bright Futures in Practice: Mental Health

The intent of the Title V MCH/CYSCHN Services Block Grant is to address the health needs of
mothers, infants, children, adolescents, including children and youth with special health care needs,
and families in Wisconsin. We are required by federal legislation to conduct a five year needs
assessment to determine Wisconsin's program priorities for maternal and child health. Based on
results of the needs assessment, the Wisconsin MCH/CYSHCN Program has established template
objectives reflecting these priorities as well as promoting measurable outcome achievements as
documented in the identified fields in the data source for measurement and in SPHERE. It is
important to also note that the objective statement, deliverable, context, input activities, and data
source for measurement are required fields.

Unacceptable Proposals:

When using Title V MCH/CYSCHN Service Block Grant funds, the following activities are non-
allowable:
    • Conducting Medicaid outreach.
    • Providing and paying for services for people who are eligible for Medicaid (MA) and the
       service is covered by MA or the Birth to 3 Program. Title V is the payer of last resort.
    • Conducting health fairs with no demonstrated knowledge or behavior change for the family
       or client.
    • Providing dental treatment services. Primary prevention dental services such as sealant
       application are acceptable.
    • Objectives relating solely to the payment of FTEs to conduct MCH activities with no product
       stated.
    • Reimbursement solely for data entry (e.g., SPHERE or Wisconsin Immunization Registry).
    • Objectives only for the referral of patients to dental providers.
    • Providing perinatal care coordination services to a designated number of women without
       reporting key perinatal outcomes. (see perinatal care coordination template objective)
    • Educational objectives that focus only on increasing knowledge (a skill demonstration or
       behavior change component must be included).




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Relationship to State Health Plan:
The following table shows a direct linkage between the Healthiest Wisconsin 2010 priorities,
Wisconsin’s MCH Priorities, National and State Performance Measures, and the MCH Program’s
template objectives.




                                              75
                                                 MCH Program – Connecting the Dots
                                 < aligns 2008 MCH template objectives with State and National priorities >

WI’s Priority Needs (2005           National                          State                          2008 MCH Program Template Objective             Healthiest WI
     needs assessment)        Performance Measures            Performance Measures                    (by number on template report & subject)       2010 Priorities

                                                                                             1. perinatal care coordination
Disparities in Birth                                        Ratio of the black infant                                                            Access to primary &
                            Percent VLBW delivered at                                        2. PNCC data and evaluation NEW
Outcomes                                                    mortality rate to white infant                                                       preventative health
                            facilities for high risk
  • Infant mortality                                        mortality rate                   3. interconception services                         services
  • LBW                     First trimester prenatal care                                    4. healthy birth outcomes
  • Preterm                 Percent of women who
                                                            Percent of women who use         5. breastfeeding NEW                                Social & economic
  • Early prenatal care     smoke in last 3 months of
                                                            tobacco during pregnancy
                                                                                             20. MCH program evaluation (SPHERE) NEW
                                                                                                                                                 factors that influence
                                                                                                                                                 health
                            pregnancy                                                        21. MCH community health improvement plan NEW
                                                                                             22. MCH-related health teaching                     Tobacco use and
                                                                                             23. MCH-related systems strategies                  exposure


                                                                                             1. perinatal care coordination
Contraceptive Services      Rate of births among            Percent of eligible women                                                            High risk sexual
                                                                                             2. PNCC data and evaluation NEW
 • Unintended               teenagers 15-17                 enrolled in the Wisconsin                                                            behavior
    pregnancy                                               Medicaid Family Planning         3. interconception services
 • Teen births                                              Waiver during the year           20. MCH program evaluation (SPHERE) NEW
 • Abstinence from                                                                           21. MCH community health improvement plan NEW
    adolescent sexual                                                                        22. MCH-related health teaching
    activity
                                                                                             23. MCH-related systems strategies

                                                                                             1. perinatal care coordination
Mental Health for all       Rate of deaths from suicide     Percent of children, ages 6                                                          Mental health and
                                                                                             10. social-emotional developmental assessments
populations groups          among 15-19                     months - 5 years, who have                                                           mental disorders
                                                            age-appropriate social and       15 & 16. suicide prevention NEW
                                                            emotional developmental          20. MCH program evaluation (SPHERE) NEW
                                                            levels                           21. MCH community health improvement plan NEW
                                                                                             22. MCH-related health teaching
                                                                                             23. MCH-related systems strategies
                                                                                             24. comprehensive school health



                                                                                       76
                                                  MCH Program – Connecting the Dots
                                  < aligns 2008 MCH template objectives with State and National priorities >

WI’s Priority Needs (2005           National                          State                          2008 MCH Program Template Objective            Healthiest WI
     needs assessment)        Performance Measures            Performance Measures                    (by number on template report & subject)      2010 Priorities

                                                                                            6. infant health care coordination
Medical Home for all         CSHCN receive care within      Percent of children who         7. one-time home visit                               Access to primary &
children                     a medical home                 receive coordinated,                                                                 preventive health
                                                                                            9. developmental assessments NEW
                                                            ongoing comprehensive care                                                           services
                                                            within a medical home           10. social-emotional developmental assessments
                                                                                            11. comprehensive primary health exam
                                                                                            20. MCH program evaluation (SPHERE) NEW
                                                                                            21. MCH community health improvement plan NEW
                                                                                            22. MCH-related health teaching
                                                                                            23. MCH-related systems strategies
                                                                                            25. CYSHCN referral & follow-up
                                                                                            26. CYSHCN care coordination
                                                                                            27. Medical Home
                                                                                            20. MCH program evaluation (SPHERE) NEW
Dental Health (including     Percent of third graders who   Percent of Medicaid and         21. MCH community health improvement plan NEW        Access to primary &
CSHCN, racial/ethnic,        have protective sealants       BadgerCare recipients, ages                                                          preventive health
                                                                                            22. MCH-related health teaching
linguistic, and geography,                                  3-20, who received any                                                               services
income)                                                     dental services during the      23. MCH-related systems strategies
                                                            year                            28. early childhood caries prevention
                                                                                            29. oral health survey
                                                                                            30. oral health assessments
                                                                                            31. fluoride mouthrinse
                                                                                            32. fluoride supplement

                                                                                            6. infant health care coordination
Health Insurance and         Percent of children without    Percent of children less than                                                        Access to primary &
                                                                                            11. comprehensive primary health exam
Access to Health Care        health insurance               12 years of age who receive                                                          preventive health
                                                            one physical exam a year        20. MCH program evaluation (SPHERE) NEW              services
                             Percent of CSHCN age 0-18                                      21. MCH community health improvement plan NEW
                             whose families have
                             adequate insurance.                                            22. MCH-related health teaching
                                                                                            23. MCH-related systems strategies
                                                                                            24. comprehensive school health
                                                                                      77
                                                 MCH Program – Connecting the Dots
                                 < aligns 2008 MCH template objectives with State and National priorities >

WI’s Priority Needs (2005           National                       State                           2008 MCH Program Template Objective             Healthiest WI
    needs assessment)         Performance Measures         Performance Measures                     (by number on template report & subject)       2010 Priorities

                                                                                           25. CYSHCN referral & follow-up
                                                                                           26. CYSHCN care coordination
                                                                                           1. perinatal care coordination
Smoking and Tobacco         Percent of women who          Percent of women who use                                                             Tobacco use and
                                                                                           2. PNCC data and evaluation NEW
  Use                       smoke during the last three   tobacco during pregnancy                                                             exposure
 • Youth                    months of pregnancy                                            3. interconception services
 • Pregnant Women                                                                          4. healthy birth outcomes
                                                                                           5. breastfeeding NEW
                                                                                           20. MCH program evaluation (SPHERE) NEW
                                                                                           21. MCH community health improvement plan NEW
                                                                                           22. MCH-related health teaching
                                                                                           23. MCH-related systems strategies



                                                                                           8. comprehensive home visitation NEW
Intentional Childhood       Rate of deaths from suicide   Rate per 1,000 of                                                                    Intentional &
Injuries                    among 15-19                   substantiated reports of         15 & 16. suicide prevention NEW                     unintentional injury and
• Child Abuse and                                         child maltreatment to WI         17. child death review NEW                          violence
    Neglect                                               children ages 0-17 during        20. MCH program evaluation (SPHERE) NEW
                                                          the year
                                                                                           21. MCH community health improvement plan NEW
                                                                                           22. MCH-related health teaching
                                                                                           23. MCH-related systems strategies
                                                                                           24. comprehensive school health




                                                                                      78
                                                  MCH Program – Connecting the Dots
                                  < aligns 2008 MCH template objectives with State and National priorities >

WI’s Priority Needs (2005           National                          State                        2008 MCH Program Template Objective             Healthiest WI
    needs assessment)         Performance Measures            Performance Measures                  (by number on template report & subject)       2010 Priorities

                                                                                           7. one-time home visit
Unintentional Childhood     Rate of deaths to children 14   Death rate per 100,000                                                             Intentional &
                                                                                           9. developmental assessments NEW
Injuries                    years and younger from          among youth, ages 15-19,                                                           unintentional injury and
                            motor vehicle crashes           due to motor vehicle crashes   12. safe infant sleep practices NEW                 violence
                                                                                           13. home safety assessments
                                                                                           14. child passenger seats
                                                                                           17. child death review NEW
                                                                                           20. MCH program evaluation (SPHERE) NEW
                                                                                           21. MCH community health improvement plan NEW
                                                                                           22. MCH-related health teaching
                                                                                           23. MCH-related systems strategies



                                                                                           1. perinatal care coordination
Overweight and At Risk      Percent of mothers who          Percent of children, ages 2-                                                       Overweight, obesity &
for Overweight              breastfeed their infants at 6   4, who are obese or            5. breastfeeding NEW                                lack of physical activity
                            months of age.                  overweight at or above the     18. strategies for healthy environments
                                                            95th percentile.               19. worksite wellness NEW
                            Percent children, ages 2-5,
                            receiving WIC with a BMI                                       20. MCH program evaluation (SPHERE) NEW
                            at/above 85th percentile.                                      21. MCH community health improvement plan NEW
                                                                                           22. MCH-related health teaching
                                                                                           23. MCH-related systems strategies




                                                                                      79
                               2008 Program Quality Criteria
                                 Maternal and Child Health
                (Including Children and Youth with Special Health Care Needs)

Generally high program quality criteria for the delivery of quality and cost-effective administration
of health care programs have been, and will continue to be, required in each public health program to
be operated under the terms of this contract. Contractees should indicate the manner in which they
will assure each criterion is met for this program. Those criteria include:

Assessment and surveillance of public health to identify community needs and to support
systematic, competent program planning and sound policy development with activities focused at
both the individual and community levels.

   Contractees must include a maternal and child health needs assessment, at least every five years
   as required by Title V of the Social Security Act, in their community needs assessment process.

Delivery of public health services to citizens by qualified health professionals in a manner that is
family centered, culturally competent, and consistent with the best practices; and delivery of public
health programs for communities for the improvement of health status.

   a. Contractees must assure that maternal and child health services are delivered and supervised
      by qualified staff as required by the activity or service being delivered.

   b. Contractees must designate a staff person as the maternal and child health contact to receive,
      disseminate, and respond to policy and program information provided by the State.

   c. Contractees must designate a staff person as the children and youth with special health care
      needs contact to receive and disseminate policy and program information provided by the
      State and Regional CYSHCN Centers.

   d. The Contractee must assure quality by utilizing one or more of the following documents as
      guidance in the organization and delivery of services.
      (1) Wisconsin Medicaid Prenatal Care Coordination Services Handbook and related
            Medicaid Updates
      (2) Family Planning Reproductive Health Standards of Practice
      (3) Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents
            (most recent edition)
      (4) Caring for Our Children: National Health and Safety Performance Standards Guidelines
            for Out-of-Home Child Care Programs: Second Edition, 2002
      (5) Bright Futures in Practice: Oral Health
      (6) Bright Futures in Practice: Physical Activity
      (7) Bright Futures in Practice: Nutrition, Second Edition
      (8) Bright Futures in Practice: Mental Health
      All programs will be evaluated based on these best practice guidelines. If a LPHD wants to
      use an alternate, but comparable document, the State of Wisconsin Maternal and Child
      Health Program must approve it.


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   e. Contractees must integrate the MCH Five Guiding Principles in MCH programs, services and
      systems.
      • Family-Centered Care
      • Cultural Competence
      • Community-Wide Leadership
      • Health Promotion and Resiliency
      • Outreach and Needs Assessment

Record keeping for individual focused services that assures documentation and tracking of client
health care needs, response to known health care problems on a timely basis, and confidentiality of
client information.

   a. Contractees must assure that all general health care records are kept confidential as required
      by s. 146.82, Wis. Stats.

Information, education, and outreach programs intended to address known health risks in the
general and certain target populations to encourage appropriate decision making by those at risk and
to affect policy and environmental changes at the community level.

   a. Contractees must assure effective outreach strategies to high-risk women of childbearing age,
      pregnant women, and children birth to 21 years old, including children and youth with
      special health care needs, and their families in the maternal and child health population.

   b. All materials for public distribution developed by a Contractee with Title V MCH Block
      Grant funds must identify the funding source on the publication as follows: “Funded in part
      by the MCH Title V Services Block Grant, Maternal and Child Health Bureau, Health
      Resources and Services Administration, U.S. Department of Health and Human Services.”

Coordination with related programs to assure that identified public health needs are addressed in a
comprehensive, cost-effective manner across programs and throughout the community.

   a. Contractees must have a mechanism in place to assure coordination with the Regional
      CYSHCN Centers.

   b. Contractees must coordinate maternal and child health programs with other community
      health programs.

A referral network sufficient to assure the timely provision of services to address identified client
health care needs.

   a. LPHDs that provide maternal and child health prevention and intervention services must
      have a referral network. Referral networks may include: healthcare providers including
      mental health and oral health, Regional CYSHCN Centers, child care centers, WIC, human
      or social services, schools, Birth to 3 programs, and other relevant services.




                                                  81
Provision of guidance to staff through program and policy manuals and other means sufficient to
assure quality client care and cost-effective program administration.

Financial management practices sufficient to assure accurate eligibility determination, pursuit of
third-party insurance and Medicaid coverage of services provided, prompt and accurate billing and
payment for services provided and purchased, accurate expenditure reporting, and appropriate use of
state and federal funds.

   a. Contractees must seek other available funding sources, as Title V MCH Block Grant is payer
      of last resort.

   b. Contractees must bill the Wisconsin Medicaid Program for all covered services provided to
      eligible recipients.

   c. Contractees must provide 75% match ($0.75 local contribution for every $1.00 federal) for
      all Title V MCH Block grant funds and report through GAC and CARS system as described
      in the contract.

Data collection, analysis, and reporting to assure program outcome goals are met or to identify
program management problems that need to be addressed.

   a. Contractees must collect and analyze data on all public health activities and interventions
      provided.

   b. Contractees must report using SPHERE (Secure Public Health Electronic Record
      Environment).

   c. Contractees will comply with year-end program reporting requirements set by the State of
      Wisconsin MCH Program including documentation of 75% match ($0.75 local contribution
      for every $1.00 federal) and report through GAC and CARS system as described in the
      contract.

   d. An agency narrative as defined by Maternal and Child Health (MCH) end-of-year reporting
      requirements (Enclosure 3) must be submitted by each agency receiving MCH/Title V
      funding including MCH, CYSHCN, EIDP-LHD, and FP/RH. This agency report will assist
      in demonstrating the comprehensiveness of the MCH work (both funded and unfunded by
      these dollars) being done by agencies across the state




                                                 82
                                             MCH Program
                                              Objectives
1. By December 31,2008, (insert number) women will receive perinatal care coordination services from the
   (insert name) Health Department that are comprehensive and include a focus on tobacco use and
   exposure, alcohol use, depression, breastfeeding, safe infant sleep practices, postpartum contraception,
   and medical home.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: the
number of women who received perinatal care coordination services from the (insert name) Health
Department that are comprehensive; the number of those women who 1) smoked during pregnancy , 2)
decreased or stopped smoking during pregnancy, 3) was exposed to environmental tobacco smoke during
pregnancy and postpartum, 4) used alcohol during pregnancy, 5) received education, referral and follow-up
services for alcohol use, 6) received screening, referral and follow-up services for perinatal depression, 7)
initiated and continued to breastfeed for 1 month, 8) demonstrated knowledge of safe infant sleep practices, 9)
received contraception services prior to delivery, and 10) identified a medical home; and other assessment,
teaching and referral data to document comprehensive services.

Context: Acceptable value range for this objective is $850-$1,000 per woman and is based on a similar
maximum reimbursement for Medicaid Prenatal Care Coordination services. This value supports the
provision of services from enrollment through 60 days postpartum. If this time period is in 2 different
calendar years/contract periods, it is expected that services and data collection will continue. Only those
women newly enrolled in Perinatal Care Coordination services during the contract period should be counted
for this objective. All MCH Quality Criteria apply to this objective.

Perinatal Care Coordination services include outreach, assessment, care plan development, ongoing care
coordination, health education and nutrition counseling and are available during pregnancy through 60 days
following delivery for women who are not eligible for the Medicaid Prenatal Care Coordination (PNCC)
benefit. Perinatal Care Coordination services are comprehensive, following the Guidelines and Performance
Measurements for PNCC. (See Appendix 7 of the Medicaid PNCC Handbook at
www.dhfs.state.wi.us/Medicaid2/handbooks/pncc/index.htm.)

Individualized services provided in a comprehensive perinatal care coordination program are guided as
follows:
    • Smoking cessation services will be provided for pregnant women based on the First Breath Program
        of the Wisconsin Women’s Health Foundation focusing on the 5A’s: Ask, Advise, Assess, Assist, and
        Arrange. Smoking by household members will also be addressed.
    • An in-depth assessment of alcohol use will be provided for those women who report alcohol use
        during pregnancy or during the 3 months prior to pregnancy at the time of the initial screening with
        the Pregnancy Questionnaire. See the PNCC Pregnancy Questionnaire Completion Instructions at
        http://dhfs.wisconsin.gov/medicaid/updates/2006/2006-09.htm for follow-up assessment questions.
        Education, referral and follow-up services will be provided as needed.
    • Perinatal Depression Screening will be provided at the first prenatal visit, during the 3rd trimester, and
        in the postpartum period using basic screening questions (included on the PNCC Pregnancy
        Questionnaire) and a standardized screening tool for follow-up assessments (Edinburough, CES-D, or
        other standardized tool). See the WAPC position statement on Perinatal Depression available at
        www.perinatalweb.org.
    • Breastfeeding promotion and support will be provided during pregnancy and in the early postpartum
        period.




                                                      83
    •   Education on safe infant sleep practices will include the American Academy of Pediatric Guidelines.
        See recommendations at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/5/1245.
    •   PNCC clients will have postpartum contraception on hand prior to delivery and have plans in place
        for continuing supplies and services following delivery through their medical provider, local family
        planning clinic or the Emergency Contraception/Family Planning Waiver Response Line.
    •   A Medical Home will be identified for the obstetric and reproductive health care of the women. Care
        coordination services will be provided in collaboration with medical and family planning services.

Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and data from the following screens: Intervention: Case Management, Sub-Interventions:
Prenatal Assessment(all fields), Prenatal Care Plan, Prenatal Ongoing Monitoring, Postpartum
Assessment(all fields), Postpartum Care Plan, Postpartum Ongoing Monitoring, Interventions: Referral and
Follow-up/Results, and Health Teaching Topics and Results.

Input Activities: All women receiving comprehensive perinatal care coordination services obtain
individualized assessment, care plan development, care coordination, health education, and nutrition
counseling as guided by the information noted in the context.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                      84
2. By December 31, 2008, outcome measures on all pregnant and post partum women served by the
   Medicaid Prenatal Care Coordination program will be evaluated by the (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document outcomes of
Medicaid PNCC services provided by the (insert name) Health Department; the number of women who
received a prenatal assessment; the number of women who received a prenatal and postpartum assessment;
the number of women who: 1) Have a Medical Home/Primary Care Provider, 2) By Trimester, started
medical care and PNCC Services, 3) Smoked during pregnancy, 4) Decreased or stopped smoking during
pregnancy, 5) Used alcohol during pregnancy, 6) Received education, referral and follow-up services for
alcohol use, 7) received depression screening with a standardized depression screening tool, 8) Initiated and
continued to breastfeed for one month, 9) Demonstrated knowledge of safe infant sleep practices, and 10)
Received contraception services prior to delivery; other assessment, teaching and referral data to document
comprehensive services; and an agency report comparing actual outcomes with key outcome measures
identified in the Context.

Context: Acceptable value range for this objective is up to $3,000 plus $25 - $40 per PNCC participant.
Agencies must identify the number of PNCC clients served in a previous year in the Baseline for
Measurement. All MCH Quality Criteria apply to this objective.

PNCC services are available to high risk, Medicaid-eligible pregnant women during pregnancy through 60
days following delivery. Women served by the PNCC program receive comprehensive services including
outreach, assessment, care plan development, ongoing care coordination, health education and nutrition
counseling as described in the Medicaid PNCC Handbook
(www.dhfs.state.wi.us/Medicaid2/handbooks/pncc/index.htm).

The purpose for this template objective is to improve local Maternal and Child Health programs’ capacity to
collect and analyze data for the evaluation of the Medicaid Prenatal Care Coordination (PNCC) benefit. A
comprehensive analysis of the PNCC program will improve evidence-based decision making, help reduce
disparities in perinatal outcomes, and may influence future planning for PNCC services. For further
evaluation, the Division of Public Health reserves the right to conduct a confidential file match of aggregate
SPHERE data files with Medicaid billing files. The following key outcome measures, to be used in the
evaluation, identify select goals or desired outcomes for PNCC programs and participants:
    • 100% of PNCC participants will have a medical home/primary care provider
    • 87% of PNCC participants will begin medical prenatal care in the first trimester.
    • 50% of participants will be enrolled in PNCC during the first trimester.
    • 14% of PNCC participants use tobacco during pregnancy.
    • 36% of PNCC participants who use tobacco during pregnancy will decrease or stop smoking.
    • 90% of PNCC participants who report using alcohol during pregnancy will receive education, referral
         and follow-up services.
    • 90% of PNCC participants will be screened for depression with a standardized depression screening
         tool (CES-D, Edinburgh).
    • 65% of PNCC participants will initiate and continue to breastfeed for 1 month.
    • 90% of PNCC participants will demonstrate safe infant sleep practices.
    • 90% of PNCC participants will have contraceptive supplies prior to delivery.

Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and complete data from the following screens: Intervention: Case Management, Sub-
Interventions: Prenatal Assessment(all fields), Prenatal Care Plan, Prenatal Ongoing Monitoring, Postpartum
Assessment(all fields), Postpartum Care Plan, Postpartum Ongoing Monitoring, Interventions: Referral and




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Follow-up/Results, and Health Teaching, Sub-Interveniton: Topics and Results. Intervention: Delegated
Functions, Sub-Intervention: Contraceptive Services/Results (if provided directly.

Input Activities: Utilize SPHERE to document PNCC services and evaluate data by comparing the actual
outcomes with key outcome measures as identified in the Context.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




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3. By December 31, 2008, (insert number) women with a previous adverse pregnancy outcome will receive
   interconception education, counseling, and referral and follow-up services from (insert name) Health
   Department that includes an emphasis on reproductive health/spacing of pregnancies, nutrition, physical
   activity, maternal infections, chronic health problems, substance abuse, smoking, environmental tobacco
   smoke, depression, and medical home.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: the number
of women with a previous adverse pregnancy outcome who received interconception education, counseling,
referral and follow-up services from (insert name) Health Department; and the number of women who: 1)
have contraceptive supplies, 2) are taking a multivitamin with folic acid, 3) have a plan to increase physical
activity, 4) receive referral and follow-up services for maternal infections, 5) receive referral and follow-up
services for chronic health problems, 6) use tobacco, alcohol and other drugs, 7) received education referral
and follow-up services for substance use, 8) decreased or stopped smoking, 9) decreased exposure to
environmental tobacco smoke, 10) received depression screening with a standardized depression screening
tool, and 11) identified a medical home.

Context: Acceptable value range for this objective is $850 - $1,000 per woman based on monthly contacts up
to the child’s first birthday. All MCH Quality Criteria apply to this objective.

Preconception care intends to promote the health of women of reproductive age before conception and
thereby improve pregnancy-related outcomes. In 2006 the Centers for Disease Control and Prevention (CDC)
released revised preconception care guidelines that include recommendations to: 1) use the interconception
period to provide additional intensive interventions to women who have had a previous pregnancy with an
adverse outcome, and 2) integrate component of preconception health into existing local public health and
related programs, including emphasis on interconception interventions for women with previous adverse
outcomes. The guidelines are located at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm

Women are eligible for interconception services if they have had a previous adverse pregnancy outcome.
Birth certificates are a primary source of data to identify women who delivered infants with low birth weight,
prematurity, medical concerns, or infant death. Interconception services can be initiated upon completion of
Medicaid Prenatal Care Coordination or MCH-funded perinatal care coordination services (60 days
postpartum) or immediately following the occurrence of an adverse pregnancy outcome for women who did
not receive care coordination services during the prenatal period.

Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and data from the following screens: Intervention: Health Teaching, Sub-Intervention:
Topics and Results, Intervention: Counseling, Sub-Intervention: Topics and Results, and Intervention:
Referral and Follow-Up/Results.

Input Activities: Individualized interconception education, counseling, and referral and follow-up services
will address the following areas when needs are identified: reproductive health/spacing of pregnancies;
nutrition; physical activity; maternal infections; chronic health problems; substance abuse; smoking;
environmental; tobacco smoke; depression; and medical home.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




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4. By December 31, 2008, (insert number) strategies to support and promote healthy birth outcomes in
   (insert name of jurisdiction) will be implemented by the (insert name of coalition, collaborative or
   partnership).

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: 1) the
strategies implemented to support and promote healthy birth outcomes; 2) the results of the strategies
implemented, and 3) an agency report to describe the make up of the (insert name of coalition,
collaboration or partnership).

Context: Acceptable value range for this objective is up to $3,000 per strategy. All MCH Quality Criteria
apply to this objective.

Collaboration with multiple and diverse partners is a key component of perinatal system-building activities.
This objective supports evidence-based strategies or promising practices to support and promote healthy birth
outcomes. Acceptable strategies to be implemented include the following:
    • Establish or form a partnership with a local perinatal coalition.
    • Identify needs and develop a community plan to build systems to support:
            o Maternal Health (prematurity, preconception care, health behaviors, perinatal care),
            o Maternal Care (prenatal care, referral systems), or
            o Infant Health (safe sleep practices, breastfeeding, injury prevention).
    • Implement strategies identified in the community plan.
    • Evaluate interventions.

Data Source for Measurement: SPHERE System Report to include data from the following screens:
System Activity (all appropriate fields including the strategies and results documented in the
Results/Outcomes field) and Intervention: Coalition Building (Healthy Birth Outcomes), Community
Organizing (Healthy Birth Outcomes), or Collaboration (Healthy Birth Outcomes).

Input Activities: [Insert a brief description of the population to be served and proposed strategies to
promote healthy birth outcomes.]

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




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5. By December 31, 2008, (insert number) new steps in becoming a Breastfeeding Friendly Health
   Department will be completed by the (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: 1)
Completion of the Self-Appraisal Tool* and 2) a description of the strategies and activities implemented by
the health department that are required in the Ten Steps to Successful Breastfeeding for Health Departments.*

Context: Acceptable value range for this objective is up to $3,000 per step. All MCH Quality Criteria apply
to this objective.

The Breastfeeding Friendly Health Department Initiative is a new process for Wisconsin and assists Health
Departments in their efforts to protect, promote, and support breastfeeding. Upon completion of all ten steps
of this template objective, the Health Department achieves "Breastfeeding Friendly" status and is recognized
in Wisconsin as a Breastfeeding Friendly Health Department. The Ten Steps to Successful Breastfeeding are
as follows (with Steps 1-3 requiring chronological completion): 1) Establish a designated individual/group
that is responsible for initiating and assessing progress in completing the steps to become “Breastfeeding
Friendly.” 2) Have a written breastfeeding policy that is routinely communicated to all health department
staff. 3) Train all staff to support breastfeeding. 4) Inform pregnant women and their families about the
benefits and management of breastfeeding by offering monthly breastfeeding classes. 5) Support mothers in
establishing and maintaining exclusive breastfeeding to six months. 6) Encourage sustained breastfeeding
beyond six months with appropriate introduction of complementary foods. 7) Provide a breastfeeding
friendly environment for families. 8) Select a different business each year and provide worksite lactation
support training. 9) Train two local childcare centers each year on how to support a breastfeeding mother.
10) Coordinate breastfeeding support and promotion with other programs in the health department, private
and public health care systems, and community organizations.

*Contact Kate Pederson at pederka@dhfs.state.wi.us for a description of the Ten Steps to Successful
Breastfeeding for Health Departments and accompanying Self-Appraisal Tool.

Data Source for Measurement: SPHERE System Report to include data from the following screens: System
Activity (all appropriate fields including audience focus, the results of the Self-Appraisal Tool and a
description of the steps and activities implemented in becoming a Breastfeeding Friendly Health Department
documented in the Results/Outcome field) and Intervention: Policy Development and Sub-intervention:
Breastfeeding.

Inputs/Activities: [List the steps that will be the focus of the objective in becoming a breast feeding
friendly health department. If appropriate, indicate the steps that have already been accomplished.]

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




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6. By December 31, 2008, (insert number) at-risk infants will receive health care coordination services
   from (insert name) Health Department that focus on primary health exams, immunizations, and
   developmental screening according to American Academy of Pediatrics recommendations.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document the number
of at-risk infants who received health care coordination services from (insert name of local health
department) including 1) the number of visits, 2) the number or percent of primary health examinations and
immunizations received according to the American Academy of Pediatrics recommended schedule, and 3) the
number and results of ASQ and ASQ: SE screenings.

Context: Acceptable value range for this objective is $200-$350 for expected care coordination services per
child. All MCH Quality Criteria apply to this objective.

This program is targeted to infants and families not enrolled in the Wisconsin Medicaid Program. This
objective is intended to provide services to infants and families using birth certificate records transmitted
daily from State Vital Records. Services are considered to be comprehensive and frequent with multiple visits
occurring throughout the child's first year of life.

To provide essential services to infants referred from the Wisconsin Birth Defects Registry and their families,
it is expected that there be a cooperative relationship developed between the CYSHCN Regional Center and
local health department. Care coordination will be provided as defined and described in the "Minnesota
Model of Public Health Interventions Manual, Case Management intervention, Individual/Family Practice
level," page 93. Well child exams are according to the periodicity recommended by the American Academy
of Pediatrics and include necessary primary health care services, education and anticipatory guidance to
maintain optimal health status, as reflected in "Bright Futures Guidelines for Health Supervision of Infants,
Children and Adolescents." The ASQ and ASQ: SE tools are recommended for use in programs periodically
screening beginning at 4 months of age for infant developmental achievements and 6 months of age for
social-emotional behavioral competence.

Data Source for Measurement: SPHERE Individual/Household report to include the MCH required
demographic data and data from the following screens: Intervention: Case Management, Sub-Interventions:
Infant Assessment (all fields), Targeted Case Management Care Plan (no detail screen), Targeted Case
Management Ongoing Monitoring (no detail screen), Intervention: Screening, Sub-Interventions:
Developmental Assessment: ASQ (with Details) and Developmental Assessment ASQ: SE (with details).

Input Activities: (Insert name) health department periodically screens the birth certificate records for case
finding of at-risk infants and their families according to one or more of the following criteria: (select one or
more from the following: teenage mother, late prenatal care, less than 7 prenatal visits, prenatal care
commenced after 28 weeks gestation, less than 13 months since last delivery, congenital anomalies, low
birth weight, admitted to neonatal intensive care unit, small for gestational age, infant referred from
the Wisconsin Birth Defect Registry, and/or other factors based on local needs assessment.)

The program expects to provide (insert number) of visits to each enrolled infant and their family until the
infants first birthday.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




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7. By December 31, 2008, (insert number) infants 0-2 months and their parent(s) who are not enrolled in
   Medicaid Prenatal Care Coordination or MCH-funded perinatal care coordination will receive one home
   visit by a Public Health Nurse with necessary referral and follow-up services from (insert name) Health
   Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document 1) the
number of unduplicated infants 0-2 months and their parent(s) not enrolled in Medicaid Prenatal Care
Coordination or MCH-funded perinatal care coordination who received at least one Public Health Nurse home
visit, and 2) necessary referral and follow-up services from (insert name) Health Department.

Context: Acceptable value range for this objective is $75-$125 per child served. All MCH Quality Criteria
apply to this objective.

Not covered by this objective are those infants and parents provided a postpartum home visit related to
Medicaid Prenatal Care Coordination or MCH-funded perinatal care coordination services. The home visit
will be made within 60 days after the birth of the infant.
This service, which might include health education, anticipatory guidance to maintain optimal health status,
referral and follow-up services, as reflected in "Bright Futures Guidelines for Health Supervision of Infants,
Children and Adolescents."

Data Source for Measurement: SPHERE Individual/Household Report to include the data from the
following screens: Intervention: Screening, sub-interventions: Postpartum Assessment (all fields), Infant
Assessment (birth to 12 months, all fields). Intervention: Health Teaching, sub-intervention: topic(s), and
Results. Intervention: Referral and Follow-up with results.

Input Activities: [Specify if these home visits will target a specific high-risk group. Briefly describe the
services generally provided during the visit.]

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




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8. By December 31, 2008, (insert number) at-risk families with children ages birth to 7 years will receive
   comprehensive home visitation services from the (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for measurement to document: 1) an
unduplicated count of children served by the (insert name) Health Department during the contract period, 2)
the number of children and their families who received services and have a plan of care in place, 3) the
number of children served who scored at or above the established cut-off caution value in all of the subscales
(including the Total) on their most recent HOME Inventory, 4) the number of children served with up-to-date
immunizations, 5) the number of children served with up-to-date health exams, 5) the number of children
served with a primary care provider, 6) the number of families served who accessed referral sources and the
status of all referrals made for services, 7) the number of children served who scored age appropriately on the
most recent Ages and Stages: Social & Emotional tool, including the number of children who did not score
age appropriately on developmental levels who are receiving intervention services, 8) the number of children
served who scored age appropriately in all developmental domains of the most recent Ages and Stages
Questionnaire including the number of children who did not score age appropriately on developmental levels
who are receiving intervention services, 9) the number of residences of families that were assessed and found
deficient for home safety including the number and types of corrections made for hazards identified through
the home safety assessments, and 10) the number families served who received health teaching, the types of
health teaching topics covered, and results.

Context: Acceptable value range for this objective is $1,200 to $1,500 per family per year for an average of 2
to 3 home visits each month if funds provide enhanced services to at-risk families eligible for Medicaid
targeted case management. Acceptable value range for this objective is $2,200 to $2,800 per family per year
for an average of 2 to 3 home visits each month if family is not Medicaid eligible. All MCH Quality Criteria
apply.

Comprehensive home visitation programs are a family-centered, strength-based service delivered in the home
for a sustained period of time and with enough intensity to produce positive behavior changes in the areas of
parent leadership, parent-child relationship and adequate social support. Parent leadership means maintaining
a stable home, keeping appointments, handling routine child-related, household and family responsibilities.
Parent-child relationship means providing nurturing care, engaging in positive parent-child interactions, using
positive guidance and discipline, and creating a developmentally appropriate learning environment for the
child. Adequate social support means making use of positive support systems other than the home visitor,
making use of available community resources and public support systems. Research has shown that home
visitation programs using a family development model promote positive impacts on prenatal, postnatal, and in
long-term life outcomes. Interventions address parents’ lack of knowledge and skills, help create extended
networks of formal support, and help alter normative and societal standards for child rearing and education.
ASQ, ASQ: SE, HOME and Home Safety Assessment tools are used to support ongoing assessment of
impacts of services. Following parent’s use of key preventive health services for their child helps assure that
enrolled children receive health exams and immunizations as recommended. In addition families receive
necessary referral and follow-up services to assure adequate community agency services and supports.
Successful comprehensive home visitation programs have implemented the 12 elements of best practice that
guide program development in key areas of outreach, services, and staffing. For additional information about
the 12 critical elements for comprehensive home visitation, contact Ann Stueck at stuecac@dhfs.state.wi.us .

Data Source for Measurement: SPHERE Individual/Household Report to include MCH Required
Demographic Data and data from the following screens: Intervention: Case Management, Sub-Interventions:
Infant Assessment (birth to 12months, all fields), Targeted Case Management Care Plan (no detail screen),
Targeted Case Management Ongoing Monitoring(no detail screen), Intervention: Screening, Sub-
Interventions: Health Care Utilization (for children > 12mons of age, all fields), Home Safety Assessment (all



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fields), Home Inventory (all fields), Developmental Assessment ASQ, Developmental Assessment ASQ:SE,
Interventions: Health Teaching, Sub-Intervention: topic(s) and results, Referral and Follow-Up/ Results.

Input Activities: The (insert name) Health Department plans to outreach to families of infants and children
ages (insert target ages) for services in the comprehensive home visitation program.

All families receiving comprehensive home visitation services obtain individualized assessment, care plan
development, ongoing monitoring of the care plan, health education, and child health, development and safety
screening as guided by the information noted in the context. Referral and follow-up services are provided to
enrolled families as necessary to address identified needs and follow up is provided to assure referrals resulted
in an expected outcomes.

For each infant/child screened that did not score age appropriately on developmental levels, a plan of action is
created to address areas of concern. Referral and follow-up are made to early intervention as needed.

For each infant/child screened with social-emotional concerns a plan of action is created. Referral and
follow-up are made to appropriate services.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                       93
9. By December 31, 2008, (insert number) infants and children ages 4 months to 5 years will receive age-
   appropriate developmental assessments and referral to intervention services if needed from the (insert
   name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: 1) an
unduplicated number of infants and children assessed during the contract period from (insert name) Health
Department, 2) the number of those children who scored age appropriately in all developmental domains of
the most recent Ages and Stages Questionnaire, and 3) the number of children who did not score age
appropriately on developmental levels who are receiving intervention services.

Context: Acceptable value range for this objective is $50-$75 per screen, per child. All MCH Quality Criteria
apply to this objective.

"Ages & Stages Questionnaire” (ASQ) is the required screening tool to be used for the developmental
assessment. The ASQ is administered initially at infant’s age of 4 months, and then subsequently at 6, 8, 10,
12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, and 60 months of age. It is a low-cost, reliable way to
screen infants and young children for developmental delays during the crucial first 5 years of life. Available
from Brookes Publishing, information and ordering is found at:
www.brookespublishing.com/store/books/bricker-asq/index.htm. Training from University of Wisconsin-
Extension is available to assure use of ASQ tool as intended. For more information about scheduled trainings
in 2008, check the Web site: http://www.uwex.edu/ces/flp/homevisit/training/index.cfm .

Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and data from the following screens: intervention- Screening, Sub-Intervention:
Developmental Assessment ASQ and Plan of Action, Intervention: Referral and Follow-Up/Results.

Input Activities: The (insert name) Health Department plans to outreach to infants and children ages
(insert target ages) for the program to screen child development.

For each infant/child screened that did not score age appropriately on developmental levels, a plan of action is
created to address areas of concern.. Referral and follow-up are made to early intervention as needed.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                      94
10. By December 31, 2008, (insert number) infants and children ages 6 months to 5 years will receive age-
    appropriate social-emotional developmental assessments and referrals to interventions services if needed
    from (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document 1)
unduplicated number of infants and children ages 6 months to 5 years who received social-emotional
developmental assessments from (insert name) Health Department and 2) the number of children who did
not score age appropriately who are receiving intervention services.

Context: Acceptable value range for this objective is $75-$125 per screen per child. All MCH Quality
Criteria apply to this objective.

“Ages and Stages Questionnaire: Social Emotional (ASQ: SE) is the required screening tool to be used for the
assessment. The ASQ: SE questionnaire is used to assess infant's social-emotional development beginning
initially at 6 months of age, and there after at child’s age of 12, 18, 24, 30, 36, 48, and 60 months. Available
from Brookes Publishing, information and ordering is found at:
www.brookespublishing.com/store/books/squires-asqse/index.htm . Training from University of Wisconsin-
Extension is available to assure use of ASQ: SE tool as intended. For more information about scheduled
trainings in 2008, check the Web site: http://www.uwex.edu/ces/flp/homevisit/training/index.cfm .

Data Source for Measurement: SPHERE Individual/Household Report to include MCH Required
Demographic Data and data from the following screen: Intervention: Screening, Sub-Intervention:
Developmental Assessment ASQ: SE and Plan of Action, and Intervention: Referral and Follow-up/Results.

Input Activities: The (insert name) Health Department plans to outreach to infants and children ages (insert
target ages) for the social-emotional screening program.

For each infant/child screened with social-emotional concerns a plan of action is created. Referral and follow-
up are made to appropriate services.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                      95
11. By December 31, 2008, (insert number) infants and children ages birth through (insert number) years
    who are not Medicaid eligible will receive a comprehensive primary health exam with referral and
    follow-up services when indicated from (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document 1) the
number of unduplicated children ages birth through (insert number) years who were not Medicaid eligible
and received a comprehensive primary health exam, and 2) necessary referral and follow-up services from
(insert name) Health Department.

Context: Acceptable value range for this objective is $75-$175 per exam. All MCH Quality Criteria apply to
this objective.

Comprehensive primary care for children includes a well-child examination and the necessary primary health
care services, education and anticipatory guidance to maintain optimal health status, and is reflected in
"Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents."

Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and data from the following screens: Interventions: Screening with sub-interventions:
Physical Exam/Office visit (General), Infant Assessment (birth to 12 months all fields), Developmental
Assessment, (Select by the screening tool used), Health Care Utilization (all fields), Height/Weight, Head
Circumference (0-2years of age). Intervention: Delegated Function, Sub-Interventions:
Hemoglobin/Hematocrit, Lead Testing. Intervention: Health Teaching, sub-intervention: identify topic, and
Results, and Intervention: Referral and Follow-Up/Results if need is identified.

Input Activities: The total number of expected exams (insert name) Health Department intends to provide
according to the American Academy of Pediatrics is (insert approximate number of exams per age range
on the periodicity schedule).

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                      96
12. By December 31, 2008, a crib education program to support safe infant sleep practices will be
    implemented by the (insert name) Health Department in collaboration with community partners.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document
implementation of a crib education program in (insert name) County to include identification of the
community partners and the total number of families served.

Context: Acceptable value range for this objective is up to $5,000 to implement a crib education program
plus $65 per crib if purchased by the health department. All MCH Quality Criteria apply to this objective.

National crib education programs provide educational materials and access to low cost portable cribs to help
reduce the risk of injury and death of infants due to unsafe sleep environments. The Cribs for Kids program
(www.cribforkids.org) is one resource that provides standardized educational materials, Graco Pack N Play
cribs and other resources. The Evenflo company also has a crib program. The Infant Death Center of
Wisconsin (414-266-2743) can provide additional information and technical assistance to support
implementation of crib education programs. Health Departments are encouraged to collaborate with
community partners such as hospitals, businesses and service organizations to identity funding sources to
purchase cribs. MCH funds may also be used to purchase new, portable cribs.

Data Source for Measurement: SPHERE System Report to include data from the following screens:
System Activity (all appropriate fields including the community partners and total number of families served
documented in the Results/Outcomes field) and Intervention: Collaboration, Sub-Intervention: Infant Safe
Sleep Practices, Intervention: Community Organizing, Sub-Intervention: Infant Safe Sleep Practices,
Intervention: Health Teaching, Sub-intervention: topic: Infant Safe Sleep Practices, with Results.

Input Activities:
Identify community partners.
Identify a funding source to purchase new, portable cribs (MCH dollars, donations, grants).
Implement a crib education program to include education, crib distribution and follow-up services to assure
safe infant sleep practices.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




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13. By December 31, 2008, (insert number) residences located within (insert name of jurisdiction) with
    children ages (insert number) to (insert number) years will have a documented decrease in hazards
    previously identified through home safety assessments.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document, 1) the
number of residence (household) assessed using the home safety assessment tool and 2) the number and types
of corrections made for hazards identified through home safety assessments per residence (household).

Context: Acceptable value range for this objective is $125-$250 for one annual assessment per household.
All questions in the Home Safety Assessment must be answered to count toward the total number of
households completed. All MCH Quality Criteria apply to this objective.

The SPHERE Home Safety Assessment screen is provided as a PDF form and used as a tool for assessing
hazards in homes until it can be printed from SPHERE. The SPHERE Home Safety Assessment screen was
developed by representatives from local health departments and staff within the state MCH program and is
based on national as well as international research.

Data Source for Measurement: SPHERE Individual/Household Report to include MCH Required
Demographic Data and data from the following screens: Intervention: Screening, Sub-Intervention: Home
Safety Assessment (all appropriate fields), Intervention: Health Teaching, Sub-Intervention: Topics and
Results, and Intervention: Referral and Follow-Up/Results if appropriate.

Input Activities: (Specify the staff who will provide the home safety assessment; for example, Public
Health Nurse, Public Health Educator, or trained volunteer.)

(Describe the health department’s plan to assure family has information to correct areas of concern,
what support or products may be available from health department staff to assist the family, and the
follow up provided for each household assessed to determine what hazards are corrected.)

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                      98
14. By December 31, 2008, (insert number) children ages birth through seven years from (insert name of
    jurisdiction) will be properly positioned in a child safety seat as demonstrated by their parent or
    caregiver.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document the number
of children ages birth through seven years from (insert name of jurisdiction) who were properly positioned
in a child car passenger seat system by their parents or other caregivers.

Context: Acceptable value range for this objective is $40-$125 per child. All MCH Quality Criteria apply to
this objective.

This objective is for local health department programs that provide designated individual assessment,
installation and instruction services on child passenger safety to families with one or more children in the
selected age group. To count toward this objective a pregnant woman instructed on child passenger safety seat
installation must return with the baby after the baby is born to document proper positioning. (However, there
is in SPHERE a Child Passenger Safety Seat screen (pregnant woman) where you can document the
instruction provided.).The new child safety seat law requires that children must be in a car seat until they
reach the age of four years and in a booster seat until they reach the age of eight years.

Data Source for Measurement: SPHERE Individual/Household Report to include MCH Required
Demographic Data and data from the following screen: Intervention: Screening, Sub-Intervention: Child
Passenger Safety Seat (child). If using the SafeKids form, the agency must also collect and report additional
MCH Program required data; that is, the birth date and race of the child and health care coverage information.

Input activities: Child safety seat programs are expected to follow the National Highway Traffic Safety
Administration recommendations (www.nhtsa.dot.gov) and activities to meet this objective must be
completed by NHTSA-certified staff.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                      99
15. By December 31, 2008, a pedestrian safety program to prevent pedestrian-related injury to children will
    be implemented by the (insert name) Health Department in collaboration with community partners.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document
implementation of a pedestrian safety program in (insert name) County to include identification of the
community partners and the total number of children served.

Context: Acceptable value range for this objective is up to $2,500 to implement a pedestrian safety program.
All MCH Quality Criteria apply to this objective.

Pedestrian safety programs provide education and issue awareness concerning pedestrian safety by hosting
high-visibility school-based events, documenting risks to pedestrians around schools and high-risk
intersections, and the improvement of pedestrian environments for children. The Safe Kids Walk this Way
program (www.safekids.org), partnering with FedEx Express, is one resource that hosts national walk to
school days and leads year-round school- and community-based safety committees to improve pedestrian
environments for children. Health Departments are encouraged to collaborate with community partners such
as hospitals, businesses and service organizations to identity funding sources to support educational and
awareness programs.


Data Source for Measurement: SPHERE Community Report to include data from the following screens:
Community Activity (all appropriate fields including audience focus and community partners documented in
the Results/Outcomes field) and Intervention: Health Teaching, Sub-intervention/Topic: Pedestrian Related
and Results (Demonstration/self report of behavior, practice or skill).

Input Activities:
Identify community partners.
Identify a funding source to host educational programs, events, and pedestrian environment improvements
(MCH dollars, donations, grants).
Implement a pedestrian safety program to include education, awareness events, and pedestrian environment
improvements.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     100
16. By December 31, 2008, a community-based wheel safety program for children will be implemented by
    the (insert name) Health Department in collaboration with community partners.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document
implementation of a wheel safety program in (insert name) County to include identification of the
community partners and the total number of children served.

Context: Acceptable value range for this objective is up to $2,500 to implement a wheel safety education
program plus $20 per helmet if purchased by the health department. All MCH Quality Criteria apply to this
objective.

Wheel safety programs provide reduced bicycle and other wheel-related injuries by increasing helmet use,
promoting safe wheel-riding behaviors, and creating safer wheel-riding environments. The Safe Kids Ready
to Roll program (www.safekids.org), along with Bell Sports, is one resource that provides program guides
and bike rodeo kits to help community coalitions conduct interactive educational events. Health Departments
are encouraged to collaborate with community partners such as hospitals, businesses and service
organizations to identity funding sources to purchase helmets and other safety devices. MCH funds may also
be used.


Data Source for Measurement: SPHERE Community Report to include data from the following screens:
Community Activity (all appropriate fields including audience focus and community partners documented in
the Results/Outcomes field) and Intervention: Health Teaching, Sub-intervention/Topic: Bicycle Related and
Results (Demonstration/self report of behavior, practice or skill).

Input Activities:
Identify community partners.
Identify a funding source to purchase new helmets (MCH dollars, donations, grants).
Implement a wheel education program to include education, interactive events, helmets, and follow-up
services to assure safe bicycle and wheel behaviors.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     101
17. By December 31, 2008, a community coalition will be established to develop a plan for a local needs
    assessment to include the level of community awareness of sexual assault, sexual assault services and
    service needs for sexual assault victims by the (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document
establishment of a coalition/partnership in (insert name) County and a plan for a needs assessment of sexual
violence awareness and services.

Context: Acceptable value range for this objective is up to $5,000 to establish and support Coalition
meetings, and to plan and initiate a needs assessment. All MCH Quality Criteria apply to this objective.

Sexual violence is a statewide problem. The victims of sexual violence are most often young, but cross the
life span. Perpetrators of sexual violence are most often older then their victim, and in most instances the
victims know the person who has assaulted them. There are victims in every Wisconsin county and
community. Victims of sexual violence identify themselves as all races/ethnic groups, cross socio-economic
levels, and live in both rural and urban areas. There is substantial evidence that demonstrates a relationship
between the experience of sexual violence and significant immediate and life-long implications on physical,
mental and behavioral health. Sexual violence is recognized as a public health issue with a continuum of
related actions from primary prevention to assuring services to victims. For technical assistance contact the
Wisconsin Coalition Against Sexual Assault (WCASA) at (608) 257-1516 wcasa@wcasa.org or Sue LaFlash,
DPH Sexual Assault Prevention Program Coordinator at (608) 266-7457 laflasi@dhfs.state.wi.us.


Data Source for Measurement: SPHERE System Report to include data from the following screens:
System Activity (all appropriate fields including the community partners and outcomes of coalition
documented in the Results/Outcome field, Intervention Coalition Building, Subintervention Sexual Assault.

Input Activities
Identify community partners.
Agendas and minutes from a minimum of 3 meetings.
The completed needs assessment or outline and timeline for completion of the needs assessment.
Contact with the Wisconsin Coalition Against Sexual Assault or the DPH Sexual Assault Program
Coordinator for technical assistance.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     102
18. By December 31, 2008, a strategic plan focused on suicide prevention for youth and young adults will be
    developed under the leadership of (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: 1) list of
participating individuals and agencies, 2) description of the coalition, collaborative or partnership, and 3) a
narrative report with a summary of activities and a copy of the preliminary draft of a strategic plan.

Context: Acceptable value range for this objective is up to $5,000. All MCH Quality Criteria apply.
Formation of the coalition, collaborative, or partnership must include members from various organizations in
the jurisdiction; including, but not limited to: public health, education, law enforcement, health professionals
(including mental health), and substance abuse prevention. Guidance for coalition building can be found at
http://wch.uhs.wisc.edu/01-Prevention/01-Prev-Coalition.html Chosen strategies must support the
implementation of The Wisconsin Suicide Prevention Strategy, available at:
http://dhfs.wisconsin.gov/health/injuryprevention/SuicidePrevention.

Data Source for Measurement: SPHERE Community Report to include data from the following screens:
Community Activity (all appropriate fields), and Intervention: Coalition Building, SubIntervention: Suicide
Prevention, Intervention: Collaboration, Sub-Intervention: Suicide Prevention, and Intervention: Community
Organizing, Sub-Intervention: Suicide Prevention.

Input Activities: The agency must include members from various organizations in the jurisdiction;
including, but not limited to: public health, education, law enforcement, health professionals (including
mental health), and substance abuse prevention and any community partners already engaged in suicide
prevention activities. The strategic plan is a collaborative effort with the LHD in a leadership role. The
preliminary draft of a strategic plan is the expected outcome at the end of the contract year.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                       103
19. By December 31, 2008, (insert number) strategies to promote suicide prevention for youth and young
    adults in (name of jurisdiction) will be implemented by the (insert name of coalition, collaborative, or
    partnership).

Deliverable: A SPHERE Report as defined within the Data Source for Measurement to document: 1) the
strategies implemented by the (insert name of coalition, collaborative, or partnership), and 2) a description
of any environmental and/or policy changes that occurred as a result of each strategy implemented to promote
suicide prevention for youth and young adults by the (insert name of coalition, collaborative, or
partnership).

Context: Acceptable value range for this objective is up to $3,000 per strategy. All MCH Quality Criteria
apply.

Chosen strategies must support the implementation of The Wisconsin Suicide Prevention Strategy, available
at: http://dhfs.wisconsin.gov/health/injuryprevention/SuicidePrevention.

Data Source for Measurement: SPHERE Community Report to include data from the following screens:
Community Activity (all appropriate fields including audience focus and the strategies/outcomes documented
in the Results/Outcome field), and interventions: Community Organizing, Sub-Intervention: Suicide
Prevention, Intervention: Collaboration, Sub-Intervention: Suicide Prevention, and any other intervention
related to individual strategies implemented

Input Activities: [Include a brief description of the strategies chosen and how they will be
implemented.]

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     104
20. By December 31, 2008, key community partners will be convened to explore the formation of a local
    Child Death Review (CDR) team by (name of jurisdiction).

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: 1) key local
individuals and agencies contacted and invited to participate in the exploration and possible formation of a
local CDR team, 2) a summary of activities taken to explore and possibly form a local Child Death Review
Team, and define next steps.

Context: Acceptable value range for this objective is up to $5,000. All MCH Quality Criteria apply.

Guidance for coalition building can be found at http://wch.uhs.wisc.edu/01-Prevention/01-Prev-
Coalition.html The process should follow the Wisconsin Child Death Review Team Guidelines – 2007, which
is available at Children’s Health Alliance website: www.chawisconsin.org/preventinjury.htm and by
contacting Karen Ordinans at CHAW (414) 390-2194. The goals of a Child Death Review Team are “to
improve understanding of how and why children die, to identify the need for and to influence policies and
programs to improve child health, safety, and protection, and to prevent other child deaths (Wisconsin Child
Death Review Team Guidelines – 2007).” Key community partners to contact must include: the county
medical examiner or coroner; local law enforcement; local child protective services; county prosecuting
attorney or designee; local public health; a pediatrician or health care provider with special expertise in
pediatrics and child development. Additional team members are dependent on community needs and
resources.

Data Source for Measurement: SPHERE System Report to include data from the following screens: System
Activity (all appropriate fields including a listing of community partners and the results/next steps in the
Results/Outcomes field), and Intervention: Collaboration, Sub-Intervention: Child Death Review Team,
Intervention: Coalition Building, Sub-Intervention: Child Death Review Team, Community Organizing, Sub-
Intervention: Child Death Review Team.

Input Activities: Core community partners to contact include: public health, law enforcement, child
protective services, prosecutor/district attorney, medical examiner/coroner, pediatrician, family health
provider or pediatric nurse practitioner, emergency medical services. Additional and ad hoc representatives
from other agencies, providers and professions involved in protecting children’s safety and health should be
considered and explored as well.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     105
21. By December 31, 2008, (insert number) strategies to create environments that support and promote
    healthy eating, daily physical activity and a healthy weight for (insert population focus or name of
    jurisdiction) will be implemented by the (insert name of coalition, collaborative, or partnership).

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: 1) a
description of the focus area chosen and the strategies implemented by the (insert name of coalition,
collaborative, or partnership), and 2) a description of the population focus or jurisdiction, a description of
the environmental and/or policy changes that occurred as a result of each strategy implemented and other
outcomes measured.

Context: Acceptable value range for this objective is up to $3,000 per strategy. All MCH Quality Criteria
apply to this objective.

Chosen strategies must support the implementation of the Wisconsin Nutrition and Physical Activity State
Plan, which provides a framework to address obesity, improve nutrition and increase physical activity. The
Plan serves as a guide for all partners who are planning and implementing initiatives for the prevention and
management of obesity. The strategies are primarily evidence-based or promising strategies and will impact
the related health priority areas of Healthiest Wisconsin 2010: Adequate and Appropriate Nutrition;
Overweight, Obesity and Lack of Physical Activity. Additionally, at-risk of overweight and overweight is a
state and national MCH performance measure. For more information and the Nutrition and Physical Activity
State Plan and evidence-based strategies go to: http://dhfs.wisconsin.gov/health/physicalactivity/index.htm.

Allowable focus areas include:
• Implementation of goal(s) detailed in the local nutrition and physical activity coalition’s strategic/action
    plan.
• Increase opportunities for physical activity through the implementation of environmental and/or policy
    change strategies based on the results of community audits/assessments.
• Increase access to fruits and vegetables through the implementation of environmental and/or policy
    change strategies based on community audits/assessments.
• Establishment of childcare, school or community gardens through the Got Dirt? Garden Initiative.
• Assist schools in meeting the criteria for the Governor's School Health Award.
• Assist pre-school and/or childcare centers in implementing the “Color Me Healthy” program on physical
    activity and healthy eating.

The Nutrition and Physical Activity Program is available to provide technical assistance for choosing and
implementing evidence-based obesity prevention strategies. The Program also has various assessment tools,
resource kits, evidence-based strategy summaries and curriculum available.

Data Source for Measurement: SPHERE System Report to include data from the following screens: System
Activity (all appropriate fields including the population focus or jurisdiction and strategies/outcomes
documented in the Results/Outcome field) and Intervention: Coalition Building, Sub_intervention: Healthy
eating, weight and physical activity, Intervention: Community Organizing, Sub_intervention: Healthy eating,
weight and physical activity, and Intervention: Collaboration, Sub-Intervention: Healthy eating, weight and
physical activity, and Intervention: Policy Development, Sub-Intervention: Healthy eating, weight and
physical activity.
Inputs Activities: [Include a brief description of the focus area chosen and the strategies that will be
implemented.]

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.



                                                      106
22. By December 31, 2008, (insert number) worksites in (insert population focus or name of jurisdiction)
    will implement worksite wellness programs that include environmental and policy changes targeting the
    prevention of obesity, healthy eating and active lifestyles in partnership with the (insert name of
    coalition, collaborative, or partnership).

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: 1) a
description of the worksite wellness programs implemented, 2) the name of the worksites, 3) total number of
employees and number of employees participating in the wellness program for each worksite, environmental
and/or policy changes that occurred and 4) a summary of the worksite program outcomes.

Context: Acceptable value range for this objective is up to $4,000 per worksite. All MCH Quality Criteria
apply.

This objective supports the implementation of the Wisconsin Nutrition and Physical Activity State Plan,
which provides a framework to address obesity, improve nutrition, and increase physical activity. The Plan's
strategies, objectives and action steps serve as a guide for all partners who are planning and implementing
interventions and initiatives for the prevention and management of obesity. The Wisconsin Worksite Wellness
Resource Kit and What Works in Worksites (http://dhfs.wisconsin.gov/health/physicalactivity/index.htm)
provide evidence-based or promising strategies. The objective will also impact the related health priority
areas of Healthiest Wisconsin 2010: Adequate and Appropriate Nutrition; Overweight, Obesity and Lack of
Physical Activity. Worksites are an important setting for changing adult behavior and that women/moms are
the primary gatekeepers to the family. Nutrition and physical activity is the primary focus of activities
through this template.

Data Source for Measurement: SPHERE System Report to include data from the following screens: System
Activity (all appropriate fields including the population focus or jurisdiction and a description of the worksite
wellness programs implemented, Name(s) of the worksites, the total number of employees and the total
number of employees participating in the program and a summary of the outcomes documented in the
Results/Outcome field) and Intervention: Community Organizing, Sub-Intervention: Healthy eating, weight
and physical activity, Intervention: Collaboration, Sub-intervention: Healthy eating, weight and physical
activity and Intervention: Policy Development, Sub-Intervention: Healthy eating, weight and physical
activity.

Inputs Activities:
• Utilize the Wisconsin Worksite Wellness Resource Kit,
• Complete a pre/post environmental assessment using the Worksite Wellness Assessment Checklist or a
   similar tool,
• Complete the Nutrition and Physical Activity Program Worksite survey at the end of the contract year,
• Target worksite(s) with a high percentage of women or minority populations,
• Focus on improving the nutrition and physical activity environment and behaviors through a worksite
   wellness program.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




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23. By December 31, 2008, (insert name) Health Department will develop a plan that utilizes Secure Public
    Health Electronic Record Environment (SPHERE) reports to evaluate key outcomes for maternal and
    child health programs within their jurisdiction.

Deliverable: A SPHERE Report as defined within the Data Source for Measurement and a narrative plan
describing how the maternal and child health Secure Public Health Electronic Record Environment
(SPHERE) reports will be utilized by (insert name) Health Department to evaluate key outcomes for
maternal and child health programs within their jurisdiction.

Context: Acceptable value range for this objective is up to $3,000. All MCH Quality Criteria apply to this
objective.

This objective cannot be the only MCH objective selected. It must be selected in addition to one or more
other MCH objective(s).

The MCH Program’s general purpose is to better support the improvement of the health of all mothers and
children through family-centered, community-based, coordinated care (including care coordination services)
and facilitation of the development of community-based, systems of service for children and their families.
The purpose for this template objective is to improve the local health department’s capacity to perform local
assessments, capacity to collect and analyze data of MCH related programs to identify community needs and
to support systematic and competent program planning and sound policy development with activities focused
at both the individual and community levels. Benchmarks for key outcomes will be based on best practices or
evidence based interventions and/or strategies and may include the Maternal and Child Health (MCH)
National and State Performance Measures, Health System Capacity Indicators, Health Status Indicators, the
State’s MCH priorities, and the Healthiest Wisconsin 2010 related objectives.

Data Source for Measurement: SPHERE System Report to include data from the following screens:
System Activity (all appropriate fields including documentation in the Results/Outcome field) and
Intervention: Surveillance, Sub-intervention: Maternal and Child Health Programs. Additional details to be
worked out in consultation with SPHERE staff. For all MCH objectives selected by (insert name) Health
Department data will be entered into SPHERE as defined within the Data Source for Measurement for each
objective.

Input Activities:
• Identify maternal child health components within the health department.
• Participate in SPHERE related trainings and request technical assistance to become more experienced
   users of SPHERE
• In consultation with SPHERE staff, develop tracking of planning process within SPHERE.
• For maternal and child health activities and/or maternal and child health related objectives chosen, enter
   data into SPHERE as identified by the Data Source for Measurement and Deliverable.
• Determine how SPHERE can support the agency’s data collection to evaluate key outcomes of their
   maternal child health programs.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     108
24. By December 31, 2008, (insert number) strategies will be implemented to address one or more maternal
    and child health priority area(s) as identified in the (insert name of jurisdiction) Community Health
    Improvement Plan.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: 1) the
strategies implemented and the outcomes, and a narrative report to describe how the strategies relate to
advancing the MCH priority areas selected.

Context: Acceptable value range for this objective is up to $3,000 per strategy. All MCH Quality Criteria
apply.

A Community Health Improvement Plan is a written document accepted by the community’s governing
authority that presents a comprehensive approach to maintaining and improving health, including assessing
the community’s health needs, determining its resources and assets for promoting health, developing and
implementing a strategy for action, and establishing where responsibilities should lie.

The strategies to be implemented through this objective must be aligned with at least one of the following
MCH priority areas: disparities in birth outcomes, contraceptive services, mental health (for all population
groups), medical home (for all children), dental health, health insurance and access to health care, smoking
and tobacco use, intentional childhood injuries, unintentional childhood injuries, and overweight and at risk
for overweight.

Data Source for Measurement: SPHERE System Report to include data from the following screens: System
Activity (all appropriate fields including audience focus and the strategies implemented with outcomes in the
Results/Outcomes field) and Intervention: Policy Development and Sub-intervention: MCH Priority area
chosen.


Inputs/Activities: [Include a brief description of the MCH priority area(s) chosen and the strategies
that will be implemented and include names of community partners.]

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     109
25. By December 31, 2008, (insert number) (insert population focus) from (insert jurisdiction or agency)
    will demonstrate or self-report a behavior or skill change resulting from the (insert name of health
    activity) sponsored by the (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document the number
of (insert population focus) from (insert name) County enrolled in (insert name of health activity) who
demonstrated or self-reported (choose: an increase - or - a decrease) in (insert specific health-related
behavior, practice or skill).

Context: Acceptable value range for this objective is $15-$25 per person enrolled. All MCH Quality
Criteria apply.
This objective is intended for health education/health teaching related group activities. The topics must be
aligned with at least one of the following MCH priority areas: disparities in birth outcomes, contraceptive
services, mental health (for all population groups), medical home (for all children), dental health, health
insurance and access to health care, smoking and tobacco use, intentional childhood injuries, unintentional
childhood injuries, and overweight and at risk for overweight.

Data Source for Measurement: SPHERE Community Report to include the data from the following
screens: Community Activity (all appropriate fields including audience focus, method, and any additional
outcomes documented in the Results/Outcomes field) and Intervention: Health Teaching, Sub_intervention:
Topics and Results.

Inputs Activities: [Include a brief description of the topic area(s) chosen and the population groups that
will be impacted by this objective. Describe the role of the health department in accomplishing this
objective.]

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     110
26. By December 31, 2008, (insert number) strategies for (insert focus of activities) for (insert population
    focus or name of jurisdiction) will be implemented by the (insert name of coalition, collaborative, or
    partnership).

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: 1) the
(insert name of coalition, collaborative, or partnership) and 2) the number of strategies it implemented for
(insert focus of activities) for (insert population focus or name of jurisdiction), and the outcomes of these
strategies...

Context: Acceptable value range for this objective is up to $3,000 per strategy. All MCH Quality Criteria
apply.

This objective is for systems activities with a focus on the community. Implementing strategies is based upon
the completion of an identified needs assessment and development of a community plan. Working with others
in groups, such as in coalitions, collaboratives, or partnerships is a powerful and effective way to address
challenging issues and bring about community change. Infrastructure should include expertise in the focus
area, as appropriate.
The focus of the strategies must be aligned with at least one of the following MCH priority areas: disparities
in birth outcomes, contraceptive services, mental health (for all population groups), medical home (for all
children), dental health, health insurance and access to health care, smoking and tobacco use, intentional
childhood injuries, unintentional childhood injuries, and overweight and at risk for overweight.

Data Source for Measurement: SPHERE System Report to include data from the following screens: System
Activity (all appropriate fields including the audience focus and the strategies/outcomes documented in the
Results/Outcome field) and Intervention: Coalition Building (no detail screen), Community Organizing (no
detail screen), or Collaboration (no detail screen).

Inputs Activities: [Include a brief description of the MCH priority area(s) chosen and the strategies
that will be implemented and include names of community partners.]

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                      111
27. By December 31, 2008, a coordinated plan will be developed by the (insert name) Health Department in
    partnership with (insert name or number) school district(s) that addressees at least one of the
    components found in the Wisconsin Framework for Coordinated School Health Programs.

Deliverable: A SPHERE report as defined within the Data Source for Measurement and narrative report to
document::1) a description of a developed comprehensive written plan, 2) a description of the goals and
objectives, 3) a clear delineation of agreements and contributions of the partners, and 4) a timeline that details
when objectives will be achieved.

Context: Acceptable value range for this objective is up to $3,000 for one component. All MCH Quality
Criteria apply to this objective.

The intent of this objective is to encourage a direct partnership between the local health department and their
respective local school district. Schools by themselves cannot, and should not be expected to, address the
nation's most serious health and social problems. Families, public health, health care workers, the media,
religious organizations, community organizations that serve youth, and young people themselves also must be
systematically involved. However, schools can provide a critical facility in which many agencies might work
together to maintain the well-being of young people. The Wisconsin Coordinated School Health Program
(CSHP) Framework http://dpi.wi.gov/sspw/cshp.html is composed of six components that are designed to
organize and implement an effective school health program. Please visit the above link, scroll down to the
Wisconsin Comprehensive School Health Framework, and select one of the six components. To further assist
the local partnerships planning efforts, the Coordinated School Health Program Model includes the following
helpful strategies:
     1. Assist with gathering and interpreting health and education status and outcomes;
     2. Develop a coordinated community plan to address chronic disease and other important health issues
     according to CDC school health guidelines;
     3. Develop the capacity to provide education, training, and services to students, staff, and families;
     4. Use technical assistance and funding to support school efforts to address education and healthy
     outcomes, and
     5. Schedule regular meetings with local education and public health leadership

For technical assistance contact Claude Gilmore at (608) 266-9354 or gilmoca@dhfs.state.wi.us or Brian
Weaver at (608) 266-7921 or brian.weaver@dpi.state.wi.us.

Data Source for Measurement: SPHERE System Report to include data from the following screens: System
Activity (all appropriate fields including the goals and objectives and partners documented in the
Results/Outcome field) and Intervention: Community Organizing, Sub-intervention: School Health, and
Intervention: Policy Development, Sub-intervention: School Health

Input Activities : The activities necessary to assist the local partnership to accomplish this objective include
the following; establishing a partnership or identify an existing partnership with a local school or school
district; selecting one of the six components of the Coordinated School Health Program Framework; and
including one or more of the strategies of the Coordinated School Health Program Model.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




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28. By December 31, 2008, (insert number) children and youth with special health care needs (CYSHCN)
    and their families will receive referral and follow-up from (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: the number
of children and youth with special health care needs and their families who received referral and follow-up
from (insert name) Health Department.

Context: Acceptable value range for this objective is $175-$225 per CYSHCN. The referral and follow-up
intervention will have a baseline value of $175 and a higher value up to $225 will need to be justified with an
explanation of the challenges involved in reaching hard-to-reach populations (e.g. non-English speaking
families, no phone, homeless, etc). All MCH quality criteria apply to this objective.

The CYSHCN National Performance Measure #5 states that Community-based service systems will be
organized so families can use them easily, and this objective enables families to receive a referral to the
service which they seek and follow-up to assure that the service is obtained. The health and human service
system is complex with variation on the local, regional and state levels. Families of CYSHCN often need
assistance in navigating the system, identifying their priorities, learning of programs which may be helpful
and having a resource person to follow-up. The follow-up component is especially important given that
families may encounter challenges to completing program applications, asking for help and/or articulating
their needs to others. The required data elements for the Children and Youth with Special Health Care Needs
(CYSHCN) Program are contained in the CYSHCN Intake Form, which has the required data elements
highlighted. For a copy of the CYSHCN Intake Form, send your request to Amy Whitehead by e-mail at
whitead@dhfs.state.wi.us or call (608) 267-3861.

Data Source for Measurement: Individual/Household Report to include MCH Required Demographic Data,
required CYSHCN data elements from the CYSHCN Intake Form and data from the following screens:
Intervention: Screening, Sub-Intervention: Health Care Utilization (all fields), the to be developed CYSHCN
Transition (required for ages 14 to 21 years), and Intervention: Referral and Follow-up/Results.


Input Activities: [Include a brief description of the strategies that will be implemented to provide
CYSHCN and their families referral and follow-up.]

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     113
29. By December 31, 2008, (insert number) children and youth with special health care needs (CYSHCN)
    and their families will receive care coordination from (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: the number
of children and youth with special health care needs and their families who received care coordination from
(insert name) Health Department.

Context: Acceptable value range for this objective is $300-$400 per CYSHCN. The care coordination
intervention will have a baseline value of $300 and a higher value up to $400 will need to be justified with an
explanation of the challenges involved in reaching hard-to-reach populations (e.g. non-English speaking
families, no phone, homeless, etc). All MCH quality criteria apply to this objective.

The CSHCN National Performance Measure #5 states that Community-based service systems will be
organized so families can use them easily, and this objective enables families with CYSHCN to receive care
coordination which in turn will help them to secure needed supports. The health and human service system is
complex with variation on the local, regional and state levels. Some families of CYSHCN may be over-
extended and need a higher level of assistance in navigating the system, identifying their priorities, applying
for programs and assuring that the CYSHCN has a primary care provider. Additionally, new needs are
continuously emerging for families with CYSHCN and a care coordinator is able to help a family over the
course of time to address the challenges with the family. Care coordination/case management will be provided
as defined and described in the Minnesota Model of Public Health Interventions Manual, including the “Basic
Steps for Case Management, Individual/Family Practice level,” page 95. CYSHCN care coordination/case
management is targeted to those CYSHCN and their families that need/request this comprehensive service.
The required data elements for the Children and Youth with Special Health Care Needs (CYSHCN) Program
are contained in the CYSHCN Intake Form, which has the required data elements highlighted. For a copy of
the CYSHCN Intake Form, send your request to Amy Whitehead by e-mail at whitead@dhfs.state.wi.us or
call (608) 267-3861.


Data Source for Measurement: SPHERE Individual/Household Report to include MCH Required
Demographic Data, required CYSHCN data elements from the CYSHCN Intake Form and data from the
following screens: Intervention: Case Management, Sub-Interventions: CYSHCN Care
Coordination/Assessment (all appropriate fields), CYSHCN Care Plan, CYSHCN Ongoing Monitoring,
Intervention: Screening, Sub-Intervention: Health Care Utilization (all fields), Intervention: Health Teaching,
Sub-Intervention: Topics and results, Intervention: Referral and Follow-up/Results.

Input Activities: A care coordination assessment, care plan, ongoing monitoring and evaluation of the
activities done within this plan to ensure effectiveness in meeting the child's and family's needs. Collateral
calls and/or research to find out about resources for the family will be made if needed. Follow-up with the
family will be maintained throughout the contract period. Additional activities can be described.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                      114
30. By December 31, 2008, (insert number) strategies for local infrastructure building that support and
    promote the National and State Performance Outcome for Medical Home and will be implemented by the
    (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: 1) the
strategies to build the infrastructure that support and promote the National and State Performance Outcome
for Medical Home and 2) outcomes that occurred as a result of the implementation of the strategies.

Context: Acceptable value range for this objective is up to $3,000 per strategy. All MCH quality criteria
apply to this objective.

Many children fall through the cracks due to the lack of a Medical Home. The federal Title V Maternal Child
Health Bureau (MCHB) has identified six National Performance Outcomes (NPOs) and the second one states
that all children and youth with special health care needs will receive a coordinated ongoing comprehensive
care within a Medical Home. Wisconsin was selected as a leadership state by MCHB for its work in Medical
Home and efforts to further spread the Medical Home approach are underway. A new State Performance
Measure to address the need for a Medical Home for all children is in place as a follow-up to the Title V
needs assessment. Wisconsin has a newly developed Medical Home Toolkit which has numerous resources
for implementing this objective: http://wimedicalhometoolkit.aap.org/. Local public health departments are in
a position to facilitate local capacity building to address these outcomes. Strategies that may be implemented
through this objective include:
• Engage parents as partners in decision making through recruiting and sustaining their participation in a
     Medical Home pilot.
• Assure developmental screening through local public health links to primary care.
• Assist existing entities (e.g., WIC clinic or schools) to establish methods for securing health insurance or
     increasing coverage for the uninsured or partially insured children through work with the Medical Home.
• Increase the number of community providers who are trained to use a validated developmental screening
     tool (e.g., Ages and Stages) consistent with the American Academy of Pediatrics Developmental
     Surveillance and Screening of Infants and Young Children policy statement (PEDIATRICS Vol. 108 No.
     1 July 2001, pp. 192-195 or
     http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;108/1/192.)
• Establish an interagency council or network to increase the number of children who are linked to Medical
     Homes.
• Conduct a community needs assessment on adolescent transition from pediatrics to adult health care and
     report results and recommendations to key stakeholders and policy makers.

Data Source for Measurement: SPHERE System Report to include data from the following screens: System
Activity (all appropriate fields including the audience focus, and the strategies/outcomes documented in the
Results/Outcome field) and Intervention: Coalition Building, Sub-Intervention: Medical Home, Intervention:
Community Organizing, Sub-Intervention: Medical Home, or Intervention: Collaboration, sub_intervention:
Medical Home...

Input Activities: [Include a brief description of the strategies that will be implemented to impact
infrastructure building for medical home.]

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     115
31. By December 31, 2008, (insert number) children ages 6 months through 5 years will receive early
    childhood caries prevention services from (insert name) Health Department.

Deliverable: A SPHERE report as defined within the Data Source for Measurement and narrative report to
document: by child's age and type of service, the early childhood caries prevention services provided by
(insert name) Health Department.


Context: Acceptable value range for this objective is $35-$90 per child. All MCH Quality Criteria apply to
this objective.

The following early childhood oral health preventive services are integrated into primary health care visits: 1)
anticipatory guidance for parents and other caregivers, 2) an oral assessment for infants and children ages 6
months through 5 years, 3) fluoride varnish applications (up to 4 applications per year per child), and 4)
referral to a dentist if necessary. It is recommended that outreach be done for services to infants and young
children to sites such as health clinics, WIC Program, Head Start or Early Head Start, and child care
programs.

Staff training, technical assistance and materials are available through the DHFS Oral Health Program.
Contact Lisa Bell, State Public Health Dental Hygienist at 608-266-3201 (BellLA@dhfs.state.wi.us) or
Warren LeMay, Chief Dental Officer at 608-266-5152 (lemaywr@dhfs.state.wi.us)


Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and data from the following screens: Intervention: Screening, Sub-Interventions: Oral
Health Assessment/Results, Fluoride Assessment/Results, Intervention: Delegated Functions, Sub-
intervention: Fluoride Varnish/Results, Intervention: Health Teaching, Sub-Intervention: Oral Health/Results,
and Intervention: Referral and Follow-Up/Results.


Input Activities: The early childhood caries prevention program will provide: 1) anticipatory guidance for
parents and other caregivers, 2) an oral assessment for infants and children ages 6 months through 5 years, 3)
fluoride varnish applications (up to 4 applications per year per child), and 4) referral to a dentist if necessary.
Program to follow protocols as documented in: Integrating Preventive Oral Health Measures Into Healthcare
Practice at http://dhfs.wisconsin.gov/health/Oral_Health/trainingresources.htm and Fluoride Varnish
Application Program for Children Agency Protocol at
http://dhfs.wisconsin.gov/health/Oral_Health/pdf_files/varnishpolicyprocr42505.pdf DHFS resource Fluoride
Varnish Application for Children Sample Agency Protocol.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                       116
32. By December 31, 2008, (insert number) third grade children will participate in an oral health survey
    utilizing an open mouth assessment conducted by (insert name) Health Department to determine the oral
    health status and needs of this population.


Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: findings of
the survey conducted by (insert name) Health Department utilizing an open mouth assessment of third grade
children from a random sample of schools sorted by percentage of free and/or reduced price meal program
participation.


Context: Acceptable value range for this objective is $25-$45 per child. All MCH Quality Criteria apply to
this objective.

The oral health survey will follow the Basic Screening Survey protocol. Local health departments must
collaborate with the Department of Health and Family Services Oral Health Program for survey planning,
implementation and evaluation. Technical assistance includes but is not limited to selecting the sample,
collecting data and survey analysis. In 2001-2002, a statewide representative random sample of third grade
children ("Make Your Smile Count Survey") was conducted by the Department of Health and Family
Services (DHFS). This survey report provides a statewide and regional analysis of the oral health status of
third grade children including, untreated dental caries, caries experience, dental sealant prevalence and
treatment urgency. County surveys may be compared with state and regional data as a part of an oral health
needs assessment. Staff training, technical assistance and material are available through the DHFS Oral
Health Program. Contact Lisa Bell, State Public Health Dental Hygienist at 608-266-3201
(BellLA@dhfs.state.wi.us) or Warren LeMay, Chief Dental Officer at 608-266-5152
(lemaywr@dhfs.state.wi.us).


Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and data from the following screens: Intervention: Screening, Sub-Intervention: Oral
Health Assessment/Results, and Intervention: Referral and Follow-Up/Results.


Input Activities: The oral health survey will follow the Basic Screening Survey protocol. Details of the
Basic Screening Survey protocol are at http://www.astdd.org/docs/BSS_Manual_9-25-03.pdf. Local health
departments must collaborate with the Department of Health and Family Services Oral Health Program for
survey planning, implementation and evaluation.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     117
33. By December 31, 2008, (insert number) children who have their first and second permanent molars and
    are not Medicaid eligible will receive an oral health assessment, dental sealants and referral and follow-up
    from (insert name) Health Department for necessary restorative treatment needs.


Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: the
number of those children who have their first and second permanent molars, who are not Medicaid eligible,
that received oral health assessment, dental sealants and referral from (insert name) Health Department for
necessary restorative treatment needs


Context: Acceptable value range for this objective is $45-$65 per child. All MCH Quality Criteria apply to
this objective.

School-based dental sealant programs are evidence-based prevention strategies that prevent dental caries
(cavities) in the pits and fissures of permanent molars. The children targeted by this objective are usually
second and sixth or seventh graders. A dentist or dental hygienist must screen, determine the need for, and
place dental sealants. Dental sealant programs should follow the DHFS recommended protocol as
documented in the DHFS “Sample Dental Sealant Agency Protocol” found at:
http://dhfs.wisconsin.gov/health/Oral_Health/pdf_files/sealantprotocol42505.pdf. Technical assistance is
available through the DHFS Oral Health Program. Contact Lisa Bell, State Public Health Dental Hygienist at
608-266-3201 (BellLA@dhfs.state.wi.us) or Warren LeMay, Chief Dental Officer at 608-266-5152
(lemaywr@dhfs.state.wi.us).\



Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and data from the following screens: Intervention: Screening, Sub-Intervention: Oral
Health Assessment/Results, Intervention: Delegated Functions, Sub-Intervention: Dental Sealants/Results,
and Intervention: Referral and Follow-Up/Results.

Input Activities: The dental sealant program will include an outreach component to schools and parents;
informed consents; assessment and a determination of appropriate teeth for sealant placement; oral health
education; and partnership building. The sealant program will follow protocols as documented in: the
Wisconsin Dental Sealant Agency Protocol. A copy of these protocols can be obtained
at:http://dhfs.wisconsin.gov/health/Oral_Health/pdf_files/sealantprotocol42505.pdf and Seal America, The
Prevention Invention – Second Edition at http://www.mchoralhealth.org/Seal/index.html

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                     118
34. By December 31, 2008, (insert number) children ages 6 years or older from non-fluoridated
    communities will participate in a weekly school-based fluoride mouthrinse program administered by
    (insert name) Health Department.


Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: by age and
community, the number of children who participated in a school-based fluoride mouthrinsing program
administered by (insert name) Health Department.


Context: Acceptable value range for this objective is $3-$10 per child. All MCH Quality Criteria apply to
this objective.

School-based fluoride mouthrinsing programs are evidence-based prevention strategies that prevent dental
caries (cavities). The children targeted by this objective are usually first through sixth graders; however, it is
also appropriate for seventh and eighth graders. School-based fluoride mouthrinsing programs are not
indicated in fluoridated communities or where the natural fluoride level is at an appropriate level. Technical
assistance is available through the DHFS Oral Health Program. Contact Lisa Bell, State Public Health Dental
Hygienist at 608-266-3201 (BellLA@dhfs.state.wi.us) or Warren LeMay, Chief Dental Officer at 608-266-
5152 (lemaywr@dhfs.state.wi.us).


Data Source for Measurement: SPHERE Community Report to include the data from the following screens:
Community Activity (all appropriate fields, including audience focus) and Intervention: Delegated Functions,
Sub-Intervention: Fluoride Mouthrinse/Results.

Input Activities: The school-based fluoride mouthrinse program will consist of outreach and collaboration
with elementary schools; parental permission forms; classroom record of participation; assurance of ordering
necessary supplies; and coordination by teachers, school nurses, or volunteers of weekly fluoride rinsing.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                       119
35. By December 31, 2008, (insert number) children ages 6 months through 16 years from non-fluoridated
    communities will participate in a dietary fluoride supplement program administered by (insert name)
    Health Department.


Deliverable: A SPHERE report as defined within the Data Source for Measurement to document: by age and
community, the number of children who participated in a dietary fluoride supplement program administered
by (insert name) Health Department.


Context: Acceptable value range for this objective is $10-$28 per child. All MCH Quality Criteria apply to
this objective.

The target population for this program is children from age 6 months to 16 years. The children targeted must
not have access to fluoridated water or have natural fluoride levels at or above certain concentration levels for
specific age groups. Water sources must be tested to determine the fluoride content prior to determining the
dosage for dietary fluoride supplements. In other words, this program is targeted to children in non-
fluoridated communities or rural areas with low natural fluoride in the water. Technical assistance is available
through the DHFS Oral Health Program. Contact Lisa Bell, State Public Health Dental Hygienist at 608-266-
3201 (BellLA@dhfs.state.wi.us) or Warren LeMay, Chief Dental Officer at 608-266-5152
(lemaywr@dhfs.state.wi.us).


Data Source for Measurement: SPHERE Community Report to include the data from the following screens:
Community Activity (all appropriate fields including audience focus) and Intervention: Delegated Functions,
Sub-Intervention: Fluoride Supplement/Results.

Input Activities: The dietary fluoride supplement program will consist of the following activities: outreach
to parents; parental permission; obtaining and/or confirming fluoride content of participants drinking water;
use of the Supplemental Fluoride Dosage Schedule found at
http://dhfs.wisconsin.gov/health/Oral_Health/pdf_files/pph4290.pdf ; ordering of appropriate supplements
and supplies; comprehensive records of supplement distribution; and follow-up with parents to assure
continuance in the program. Obtain standing medical order for supplements from agency Medical Director.

These listed activities are required but are not intended to be all encompassing. Additional activities can be
described.




                                                      120
ORAL HEALTH PROGRAM - 2008

    Program Boundary Statement – will come out in separate correspondence

    Program Quality Criteria– will come out in separate correspondence

    Program Objectives




                                      121
                                                   2008 Oral Health Program
                                                          Objectives

         #1 - Childhood Caries Prevention

         Objective Statement: By December 31, 2008, (insert number) children ages 6 months to 5 years will receive
early childhood caries prevention services from (insert name) Health Department.

         Deliverable: A report to document, by child’s age and type of service, the early childhood caries prevention
services provided by (insert name) Health Department.

           Context: The following early childhood oral health preventive services are integrated into primary health care
visits: 1) anticipatory guidance for parents and other caregivers, 2) an oral assessment for infants and children ages 6
months through 5 years, 3) fluoride varnish applications (up to 4 applications per year per child), and 4) referral to a
dentist if necessary. It is recommended that outreach be done for services to infants and young children to sites such as
health clinics, WIC Program, Head Start or Early Head Start, and child care programs.

         Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and data from the following screens: Oral Health Assessment, Fluoride Assessment, Fluoride Varnish
(no detail screen), Health Teaching (Oral Health), and Referral and Follow-Up/Results.

          For Your Information: DHFS resource Fluoride Varnish Application for Children Sample Agency Protocol.
Staff training, technical assistance and materials are available through the DHFS Oral Health Program. Contact Warren
LeMay, Chief Dental Officer at (608) 266-5152 or lemaywr@dhfs.state.wi.us.




                                                           122
                                                      Oral Health Program
                                                           Objectives

         #2 - Third Grade Oral Health Open Mouth Assessment/Survey

          Objective Statement: By December 31, 2008, (insert number) third grade children will participate in an oral
health survey utilizing an open mouth assessment conducted by (insert name) Health Department to determine the oral
health status and needs of this population.

          Deliverable: A report to document findings of the survey conducted by (insert name) Health Department
utilizing an open mouth assessment of third grade children from a random sample of schools sorted by percentage of free
and/or reduced price meal program participation.

         Context: The oral health survey will follow the Basic Screening Survey protocol. Local health departments must
collaborate with the Department of Health and Family Services Oral Health Program for survey planning,
implementation and evaluation. Technical assistance includes but is not limited to selecting the sample, collecting data
and survey analysis.

       Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and data from the following screens: Oral Health Assessment and Referral and Follow-Up/Results.

         For Your Information: In 2001-2002, a statewide representative random sample of third grade children ("Make
Your Smile Count Survey") was conducted by the Department of Health and Family Services (DHFS). This survey
report provides a statewide and regional analysis of the oral health status of third grade children including, untreated
dental caries, caries experience, dental sealant prevalence and treatment urgency. County surveys may be compared with
state and regional data as a part of an oral health needs assessment. Staff training, technical assistance and material are
available through the DHFS Oral Health Program. Contact Warren LeMay, Chief Dental Officer at (608) 266-5152 or
lemaywr@dhfs.state.wi.us.




                                                           123
                                                       Oral Health Program
                                                            Objectives

         #3 - Oral Health Assessment and Sealants

          Objective Statement: By December 31, 2008, (insert number) children who have their first and second
permanent molars and are not Medicaid eligible will receive an oral health assessment, dental sealants and referral from
(insert name) Health Department for necessary restorative treatment needs.

         Deliverable: A report to document the number of those children who have their first and second permanent
molars, are not Medicaid eligible, and received oral health assessment, dental sealants and referral from (insert name)
Health Department for necessary restorative treatment needs.

          Context: School-based dental sealant programs are evidence-based prevention strategies that prevent dental
caries (cavities) in the pits and fissures of permanent molars. The children targeted by this objective are usually second
and sixth or seventh graders.

         Data Source for Measurement: SPHERE Individual/Household Report to include the MCH Required
Demographic Data and data from the following screens: Oral Health Assessment, Dental Sealants (no detail screen), and
Referral and Follow-Up/Results.

          For Your Information: A dentist or dental hygienist must screen, determine the need for, and place dental
sealants. DHFS resource Sealant Sample Agency Protocol. Technical assistance is available through the DHFS Oral
Health Program. Contact Warren LeMay, Chief Dental Officer at (608) 266-5152 or lemaywr@dhfs.state.wi.us.




                                                            124
                                                       Oral Health Program
                                                            Objectives

         #4 - School-Based Fluoride Mouthrinse Program

         Objective Statement: By December 31, 2008, (insert number) children ages 6 years or older from non-
fluoridated communities will participate in a weekly school-based fluoride mouthrinse program administered by (insert
name) Health Department.

         Deliverable: A report to document, by age and community, the number of children who participated in a school-
based fluoride mouthrinsing program administered by (insert name) Health Department.

         Context: School-based fluoride mouthrinsing programs are evidence-based prevention strategies that prevent
dental caries (cavities). The children targeted by this objective are usually first through sixth graders; however, it is also
appropriate for seventh and eighth graders. School-based fluoride mouthrinsing programs are not indicated in fluoridated
communities or where the natural fluoride level is at an appropriate level.

      Data Source for Measurement: SPHERE Community Report to include the data from the following screens:
Community Activity (all appropriate fields) and Fluoride Mouthrinse (no detail screen).

        For Your Information: Technical assistance is available through the DHFS Oral Health Program. Contact
Warren LeMay, Chief Dental Officer at (608) 266-5152 or lemaywr@dhfs.state.wi.us.




                                                            125
                                                     Oral Health Program
                                                          Objectives

         #5 - School-Based Fluoride Supplement Program

        Objective Statement: By December 31, 2008, (insert number) children ages 6 months through 16 years from
non-fluoridated communities will participate in a dietary fluoride supplement program administered by (insert name)
Health Department.

         Deliverable: A report to document, by age and community, the number of children who participated in a dietary
fluoride supplement program administered by (insert name) Health Department.

          Context: The target population for this program is children from age 6 months to 16 years. The children targeted
must not have access to fluoridated water or have natural fluoride levels at or above certain concentration levels for
specific age groups. Water sources must be tested to determine the fluoride content prior to determining the dosage for
dietary fluoride supplements. In other words, this program is targeted to children in non-fluoridated communities or
rural areas with low natural fluoride in the water.

      Data Source for Measurement: SPHERE Community Report to include the data from the following screens:
Community Activity (all appropriate fields) and Fluoride Supplement (no detail screen).

        For Your Information: Technical assistance is available through the DHFS Oral Health Program. Contact
Warren LeMay, Chief Dental Officer at (608) 266-5152 or lemaywr@dhfs.state.wi.us.




                                                          126
PREPAREDNESS PROGRAM

  Program Boundary Statements

  Program Quality Criteria

  Program Objectives




                           2008 Program Boundary Statement
            Public Health Preparedness Program, Pandemic Influenza Program
                         And Cities Readiness Initiative Program




                                         127
For each performance-based contract program, the Division of Public Health has identified a boundary statement. The
boundary statement sets the parameters of the program with which the local public health department (LPHD), Tribal
Health Center, Public Health Preparedness Consortium, or other agency will set its objectives. The boundaries are
intentionally as broad as federal and state law permits to provide maximum flexibility. However, if there are objectives
or program directions that the program is not willing to consider, those are included in the boundary statement.

Program Boundary Statement:

Public Health Preparedness funds must be utilized to develop state, regional or local emergency-ready public health
departments and Wisconsin Tribes by upgrading, integrating and evaluating state and local public health jurisdictions’
preparedness for and response to terrorism, pandemic influenza, and other public health emergencies with federal, state,
local, and tribal governments, the private sector, and non-governmental organizations. These emergency preparedness
and response efforts are intended to support the National Response Plan, and comply with the National Incident
Management System, Homeland Security Exercise and Evaluation Program (HSEEP), and utilize the Incident Command
System (ICS) structure.

    Infrastructure must be developed in the areas of emergency response and recovery, communicable disease
    surveillance, epidemiological interventions, environmental health investigations, communication and notification,
    laboratory specimen transfer and testing, training and education. Competency-based training and education will be
    provided based on the Columbia University Emergency Preparedness Core Competencies for All Public Health
    Workers.

In addition, these are full use funds intended to expand the infrastructure of the public health system. “Full-use” is
defined as services, programs, and activities that integrate to the extent possible the requirements of public health
preparedness and the needs of day-to-day public health functions – serving both functions simultaneously: (1) Respond
to a public health emergency whether it is a biological, radiological, chemical, or natural threat or disaster, and (2)
address public health issues occurring or affecting the community continually or on a frequent basis.

CDC has developed preparedness goals and associated measures designed as public health system response performance
parameters that are directly linked to the health protection of the public. CDC’s Preparedness Goals are intended to
frame urgent public health system response concepts for terrorism and non-terrorism events, including infectious disease,
environmental and occupation-related emergencies. “Response” is intended to indicate non-routine public health system
reaction to limit possible mortality, morbidity, loss of quality of life, or economic damage.
THE CDC’S PREPAREDNESS GOALS ARE - PREVENT: (1) Increase the use and development of interventions
known to prevent human illness from chemical, biological, radiological agents, and naturally occurring health threats.
DETECT AND REPORT: (2) Decrease the time needed to classify health events as terrorism or naturally occurring in
partnership with other agencies, (3) Decrease the time needed to detect and report chemical, biological, radiological
agents in tissue, food or environmental samples that cause threats to the public’s health, (4) Improve the timeliness and
accuracy of communications regarding threats to the public’s health, INVESTIGATE: (5) Decrease the time to identify
causes, risk factors, and appropriate interventions for those affected by threats to the public’s health, CONTROL: (6)
Decrease the time needed to provide countermeasures and health guidance to those affected by threats to the public’s
health. RECOVER: (7) Decrease the time needed to restore health services and environmental safety to pre-event
levels, (8) Improve the long-term follow-up provided to those affected by threats to the public’s health, and IMPROVE:
(9) Decrease the time needed to implement recommendations from after-action reports following threats to the public’s
health. (See the Centers for Disease Control and Prevention Public Health Emergency Preparedness Grant Guidance
for specific details.)

Relationship to State Health Plan: Healthiest Wisconsin 2010
Public Health Preparedness outcomes have been mapped to the following Healthiest Wisconsin 2010 Health and System
Priorities and Essential Public Health Services.

State Plan System Priorities:
     • Community Health Improvement Processes and Plans
     • Coordination of State and Local Public Health System Partnerships
     • Sufficient, Competent Workforce
     • Equitable, Adequate, and Stable Financing


                                                          128
State Plan Health Priorities:
     • Access to Primary and Preventive Health Services
     • Adequate and Appropriate nutrition
     • Alcohol and other substance use and addiction
     • Environmental and Occupational Health Hazards
     • Existing, Emerging and Re-emerging Communicable Disease
     • Intentional and Unintentional Injuries and Violence
     • Mental Health and Mental Disorders
     • Social and Economic Factors that Influence Health
     • Integrated electronic data and information systems
Essential Public Health Services:
     • Monitor health problems to identify community health problems
     • Identify, investigate, control and prevent health problems and environmental health hazards in the community
     • Educate the public about current and emerging health issues
     • Promote community partnerships to identify and solve health problems
     • Create policies and plans that support individual and community health efforts
     • Enforce laws and regulations that protect health and insure safety
     • Link people to needed health services
     • Assure access to primary health
     • Foster the understanding and promotion of social and economic conditions that support good health

Unacceptable Proposals:
Under the Centers for Disease Control and Prevention Cooperative Agreement the following activities are not allowable
using funding for the Public Health Preparedness Program, Pandemic Influenza Program, or Cities Readiness Program:

        •    Funds may not be used for research
        •    Reimbursement of pre-award costs
        •    Purchase vehicles of any kind
        •    Purchase incentive items
        •    Supplant any current state or local expenditures
        •    Pandemic Influenza funding may not be used to purchase of anti-viral drugs, seasonal influenza vaccine, or
             pneumococcal vaccine.
        •    CRI funding may not be used to purchase Inventory tracking software, vehicles, medications and medical
             supplies for use on the general population. Prophylaxis for health department first responders and their
             families is acceptable with the approval of the Division of State and Local Response – Project Officer in
             collaboration with the Division of Strategic National Stockpile – Subject Matter Expert.

Supplantation:
Supplantation means using Federal funds to replace State or local funds. The Public Health Service Act, Title 1, Section
319(c) specifically states: “SUPPLEMENT NOT SUPPLANT. ~~ Funds appropriated under this section shall be used to
supplement and not supplant other Federal, State, and local public funds provided for activities under this section.”

Resources:

The DPH Preparedness Program has adopted and recommends use of the guidelines for preparedness activities as
contained in the Project Public Health Ready, Columbia University Emergency Preparedness Core Competencies for All
Public Health Workers, Wisconsin Preparedness Leadership Group recommendations, and the Public Health Incident
Command System (PHICS).

References:
    • Wisconsin Public Health Emergency Plan
    • Centers for Disease Control and Prevention Public Health Emergency Preparedness Grant Guidance
    • National Response Plan
    • National Incident Management System



                                                          129
                           2008 Program Quality Criteria
         Public Health Preparedness Program, Pandemic Influenza Program
                      And Cities Readiness Initiative Program
The quality criteria focus on program development and implementation that result in cost-effective
and consistent programs and policies throughout the state. They are required for an agency to be
eligible to receive a public health preparedness contract. Contractees will implement policies and
procedures that will assure each criterion is met for this program. Those criteria include:
Assessment and surveillance of public health to identify community needs and to support systematic competent
program planning and sound policy development with activities focused at both the individual and community levels.

    Contractees will periodically assess public health preparedness within their agency or consortium by completing the
    required Wisconsin Division of Public Health (DPH) identified assessments and surveys.


    Contractees will annually conduct public health preparedness exercises and drills, and revise and update Public
    Health Emergency Preparedness (PHEP) plans and other associated plans based on the results of the exercises and
    drills. An exercise report will be completed electronically in the format as specified by DPH for each real event and
    public health exercise where the contractee leads or acts in a major public health emergency response role.


        •    The exercise report will include a summary of the real event or exercise and corrective action plans to be
             implemented.

        •    Effective January 1, 2008, all public health exercises and events that are conducted will be reported and
             evaluated in accordance with the Homeland Security Exercise and Evaluation Program (HSEEP) and NIMS
             all-hazards incident response compliance guidelines, using the HSEEP After-Action Report/Improvement
             Plan (AAR-IP) form. A notice of each event or exercise is to be posted on the Health Alert Network
             (HAN) in an area to be designated by posting either: 1) a copy of the actual AARP/IP form, or 2) a message
             indicating the exercise/event was done including the date, lead agency, name and type of event, person to
             contact to review the exercise report content.

        •    Annual drills include testing and recording results of 24/7 off-hour response times at the state, regional and
             local levels.

        •    Additional drills or exercises will be conducted for the Pandemic Influenza Program as directed by CDC
             grant guidance and DPH contract requirements.

    Competency-based education of all public health workers, clinicians, and others critical to provide a public health
    emergency preparedness response should be planned and implemented based on needs identified through
    assessments and/or evaluations of performance and the Columbia University Emergency Preparedness Core
    Competencies for All Public Health Workers.

        •    Contractees are required to continue to support preparedness education and training activities needed to
             successfully achieve targeted outcomes and preparedness goals. Training related to the core public health
             competencies include and is not limited to courses in NIMS, ICS, tactical/redundant communication
             systems, and risk communication.




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Delivery of public health services to citizens by qualified health professionals in a manner that is family centered,
culturally competent and consistent with the best practices and delivery of public health programs for communities for
the improvement of health status.

    Contractees must support public health response functions in the context of National Incident Management System
    (NIMS) and Incident Command System (ICS) command structure. NIMS provides a consistent approach for
    federal, state, tribal and local governments to work effectively and efficiently together to prepare for, prevent,
    respond to, and recover from domestic incidents, regardless of cause, size, or complexity.

         •   As a condition of receiving Public Health Emergency Preparedness cooperative agreement funds,
             Contractees agree to adopt, implement and demonstrate compliance with NIMS and ICS.

         •   In accordance with the eligibility and allowable uses of the cooperative agreement, Contractees are
             encouraged to direct FY 2008 funding towards activities necessary to advance implementation of NIMS
             within their agency and with their public health partners that have designated roles and responsibilities in
             the agency’s ICS command structure and Emergency Operation Center (EOC).

Record keeping for individual focused services that assures documentation and tracking of client health care needs,
response to known health care problems on a timely basis, and confidentiality of client information.

Information educational outreach programs intended to address known health risks in the general and certain target
populations to encourage appropriate decision making by those at risk and to affect policy and environmental changes at
the community level.

    Contractees will regularly present to the media, public partners and other stakeholders information on their agency
    or consortium and the Public Health Preparedness Program in coordination with DPH program staff.

Coordination with related public health programs and partners at the state, regional and local levels to assure that
identified public health needs are addressed in a comprehensive, cost-effective manner across programs and throughout
the community and state. Public health partners may include human/social services agencies, hospitals, clinics, law and
fire departments, schools, businesses, emergency government, other neighboring health departments and Tribes, Public
Health Preparedness Consortium, Wisconsin Emergency Management, DPH and other state agencies.



    a.   Contractees will utilize the Public Health Information Network (PHIN), Analysis, Visualization and Reporting
         (AVR) system, Wisconsin Electronic Disease Surveillance System (WEDSS), Partner Communication and
         Alert (PCA) system, the Health Alert Network (HAN), and other systems as provided by DPH and as
         appropriate, to include at minimum the Health Officer/Tribal Health Director, as these systems develop.

    b.   Contractees will coordinate with other preparedness programs by participating in state, regional, tribal, and
         local public health preparedness meetings.

    c.   Contractees will contribute to the development of a statewide system for public health emergency response that
         is coordinated, consistent and efficient.

    d.   Contractees will demonstrate involvement in setting statewide goals, strategic direction, and priorities for the
         state public health preparedness program.

    e.   Contractees will assure the ability for the general public to be able to contact the local public health
         department/tribal agency 24 hours a day, 7 days a week.




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    f.   Contractees will annually demonstrate the ability to contact the state health department 24 hours a day, 7 days a
         week.

    g.   Contractees will contribute to the development and sharing of tools, work plans, products, projects, templates,
         and other resources in a collaborative effort with DP, other health departments and Tribes, Public Health
         Preparedness Consortia, and other public health partners to coordinate and improve statewide systems for a
         consistent and effective public health emergency response.

    h.   Contractees will annually demonstrate the corrective actions implemented by the agency to improve their public
         health emergency response capacity.

    i.   Contractees will demonstrate compliance with HSEEP and NIMS/ICS requirements.

    j.   Contractees will implement specific strategies and actions to improve public health emergency response as
         directed by the goals and objectives of their regional and local work plans.

    k.   Contractees will assess Personal Protective Equipment (PPE) needs for their agency, purchase PPE, and train
         staff in PPE use for contact tracing, mass clinics, and or any public health emergency.

    l. Contractees will assist state and local SNS planners and treatment center/hospital
       administrators to coordinate activities that are key to a successful response to a public health emergency in
which SNS assets are deployed.

A referral network sufficient to assure the accessibility and timely provision of services to address identified public
health care needs.

Provision of guidance to staff through program and policy manuals and other means sufficient to assure quality health
care and cost-effective program administration.

Financial management practices sufficient to assure accurate eligibility determination, appropriate use of state and
federal funds, prompt and accurate billing and payment for services provided and purchased, accurate expenditure
reporting and, when, required pursuit of third party insurance and Medical Assistance coverage of services provided.

Data collection, analysis, and reporting to assure program outcome goals are met or to identify program management
problems that need to be addressed.




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                         2008 Program Template Objectives
         Public Health Preparedness Program, Pandemic Influenza Program
                      And Cities Readiness Initiative Program

Template Objective #1
   A. REQUIRED LOCAL HEALTH DEPARTMENT (Planning): By December 31, 2008, (insert name of
         LHD) will engage in a continuous planning process with local and regional partners to respond to public
         health emergencies.

    B.    A report to include a summary of partners included in planning, and the updates and changes made in 2008 to
          the agency’s Public Health Emergency Preparedness Plan and other related plans.

    C.   This objective relates directly to the recommendation made by the Wisconsin Preparedness Leadership Group
          to develop a measurable goal and objective to create, maintain and update comprehensive plans to respond to
          public health emergencies. The local agency is responsible to meet and plan with local and regional partners
          to prepare for public health emergency event responses, and to annually update the local Public Health
          Emergency Preparedness (PHEP) Plan and other related plans. This is in addition to the ongoing agency
          responsibilities to orient their agency staff members to their roles and responsibilities during an emergency
          event response. The intent of this objective is to focus on implementing the processes and systems that assure
          planning is done in a coordinated and effective manner in accordance with the agency’s three year
          preparedness work plan. The agency’s work plan should be considered an ongoing tool and work in progress
          to be updated as appropriate to the agency’s preparedness goals and objectives. The PHEP and other related
          plans are to be compliant with the National Incident Management System (NIMS) and use the Incident
          Command System (ICS) command structure. Other related plans may include the Mass Clinic Plan, Interim
          Pharmaceutical Stockpile (IPS), and Strategic National Stockpile (SNS) Plan, and Redundant, Crisis or Risk
          Communication Plan. Local and regional partners may include human service agencies, hospitals, clinics,
          law and fire departments, schools, businesses, emergency management, other neighboring health departments,
          Tribes, Public Health Preparedness Consortia, and the Division of Public Health, Wisconsin Emergency
          Management, and other state agencies. Specific plans to be addressed will be outlined in the Local Health
          Department Workplan.

    D.




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    E.    This objective builds on prior year efforts for continued planning with local and regional partners to respond
          to public health emergencies, including the annual update of the agency’s Public Health Emergency
          Preparedness Plan and other related plans.

    F.    Agency records

Template Objective #2
   A.    REQUIRED LOCAL HEALTH DEPARTMENT (Competencies/Training): By December 31, 2008, all
         staff in the (insert name of LHD) will achieve the Emergency Preparedness Core Competencies for All Public
         Health Workers identified for their position in a public health emergency response.

    B.    A report to include: 1) a list of all agency staff and their assigned roles during a public health emergency, 2)
          the related Emergency Preparedness Core Competencies for their roles and other competencies as
          appropriate, 3) and documentation their competencies were met or exceeded.

    C.    This objective relates directly to the recommendation made by the Division of Public Health and the
          Wisconsin Preparedness Leadership Group to adopt the Columbia Competencies for Public Health Workers
          at the state, local and regional levels. Project Public Health Ready requires staff members to demonstrate
          competency in the nine "Emergency Preparedness: Core Competencies for All Public Health Workers." This
          set of nine core competencies have been identified to be met by all public health workers to respond during a
          public health emergency, as developed by the Columbia University School of Nursing Center for Health
          Policy. All members of the public health workforce must prove their mastery of these nine core
          competencies. The additional competencies identified in the Columbia tool for the following groups must
          also be met: Public Health Leaders/Administrators, Public Health Professionals, and Public Health Technical
          and Support Staff. A complete listing of the competencies is available at
          (http://cpmcnet/columbia.edu/dept/nursing/institute-centers/chphsr/COMPETENCIES.pdf) or
          http://www.nwcphp.org/resources/key-public-health-competency-sets-and-resources. Other additional
          competencies may be identified and added to the core competencies at the discretion of the agency. Specific
          competencies and training to be addressed will be outlined in the Local Health Department Workplan.

    D.

    E.    This objective builds on prior year efforts for agency staff members to receive appropriate public health
          preparedness emergency response training to advance their knowledge and skills to demonstrate the
          emergency preparedness core competencies for their identified position in a public health emergency
          response.

    F.   Agency records

Template Objective #3
   A. REQUIRED LOCAL HEALTH DEPARTMENT (Exercises): By December 31, 2008, (insert name of
         LHD) will participate in a public health emergency preparedness exercise or real event that meets the
         requirements set by the Centers for Disease Control (CDC).

    B.    Electronic copy of the After-Action Report/Improvement Plan (AARP/IP) exercise report form with
          corrective action plan for each exercise or real event, and a summary of the corrective actions implemented in
          2008.

    C.    This objective relates directly to the recommendation made by the Wisconsin Preparedness Leadership Group
          and approved by DPH for the evaluation of all real events and exercises using a consistent after action report
          format to be used to improve plans and systems accordingly. Each public health preparedness local and/or
          regional exercise is to: 1) address the CDC performance standards, 2) incorporate the NIMS/ICS all-hazards
          incident response, 3) be compliant with Homeland Security Exercise and Evaluation Program (HSEEP)
          exercise guidelines, and 4) meet the requirements set by the CDC grant guidance, including the number and
          type of exercises to be done in 2008. HSEEP compliance includes developing and submitting an After-



                                                          134
          Action Report/Improvement Plan (AARP/IP) for real events and exercises. This form may be found in the
          exercise guidelines contained in HSEEP Volume III or by accessing the HSEEP website at
          https://hseep.dhs.gov. In 2008 use of the AARP/IP form will be required for reporting the results of all public
          health events and exercises. A notice of each event or exercise is to be posted on the Health Alert Network
          (HAN) in an area to be designated by either: 1) posting a copy of the actual AARP/IP form, or 2) posting a
          message indicating the exercise was done with the date, lead agency, name and type (actual event, or table
          top, functional, full scale exercise) and person to contact to review the actual AARP/IP content. Specific
          exercises to be addressed will be outlined in the Local Health Department Workplan.

    D.

    E.    This objective builds on prior year efforts to participate in an annual public health emergency preparedness
          exercise or real event, to follow the CDC and other requirements and guidelines for evaluation and
          documentation, and to improve plans and systems based on the results of the exercise or real event.

    F.    Agency records

Template Objective #4
   A.    REQUIRED TRIBE (Planning): By December 31, 2008, (insert name of Tribe) will engage in a continuous
         planning process with local and regional partners to respond to public health emergencies.

    B.    A report to include a summary of partners included in planning, and the updates and changes made in 2008 to
          the agency’s Public Health Emergency Preparedness Plan and other related plans.

    C.    This objective relates directly to the recommendation made by the Wisconsin Preparedness Leadership Group
          to develop a measurable goal and objective to create, maintain and update comprehensive plans to respond to
          public health emergencies. The local agency is responsible to meet and plan with local and regional partners
          to prepare for public health emergency event responses, and to annually update the local Public Health
          Emergency Preparedness (PHEP) Plan and other related plans. This is in addition to the ongoing agency
          responsibilities to orient their agency staff members to their roles and responsibilities during an emergency
          event response. The intent of this objective is to focus on implementing the processes and systems that assure
          planning is done in a coordinated and effective manner in accordance with the agency’s three year
          preparedness work plan. The agency’s work plan should be considered an ongoing tool and work in progress
          to be updated as appropriate to the agency’s preparedness goals and objectives. The PHEP and other related
          plans are to be compliant with the National Incident Management System (NIMS) and use the Incident
          Command System (ICS) command structure. Other related plans may include the Mass Clinic Plan, Interim
          Pharmaceutical Stockpile (IPS), and Strategic National Stockpile (SNS) Plan, and Redundant, Crisis or Risk
          Communication Plan. Local and regional partners may include human service agencies, hospitals, clinics,
          law and fire departments, schools, businesses, emergency management, neighboring local health departments,
          Tribes, Public Health Preparedness Consortia, and the Division of Public Health, Wisconsin Emergency
          Management, and other state agencies. Specific plans to be addressed will be outlined in the Tribe Workplan.

    D.

    E.    This objective builds on prior year efforts for continued planning with local and regional partners to respond
          to public health emergencies, including the annual update of the agency’s Public Health Emergency
          Preparedness Plan and other related plans.

    F.    Agency records

Template Objective #5
   A.    REQUIRED TRIBE (Competencies/Training): By December 31, 2008, all community health staff in the
         (insert name of Tribe) will achieve the Emergency Preparedness Core Competencies for All Public Health
         Workers identified for their position in a public health emergency response.




                                                         135
    B.    A report to include: 1) a list of all agency staff and their assigned roles during a public health emergency, 2)
          the related Emergency Preparedness Core Competencies for their roles and other competencies as
          appropriate, 3) and documentation their competencies were met or exceeded.

    C.    This objective relates directly to the recommendation made by the Division of Public Health and the
          Wisconsin Preparedness Leadership Group to adopt the Columbia Competencies for Public Health Workers
          at the state, local and regional levels. Project Public Health Ready requires staff members to demonstrate
          competency in the nine "Emergency Preparedness: Core Competencies for All Public Health Workers." This
          set of nine core competencies have been identified to be met by all public health workers to respond during a
          public health emergency, as developed by the Columbia University School of Nursing Center for Health
          Policy. All members of the public health workforce must prove their mastery of these nine core
          competencies. The additional competencies identified in the Columbia tool for the following groups must
          also be met: Public Health Leaders/Administrators, Public Health Professionals, and Public Health Technical
          and Support Staff. A complete listing of the competencies is available at
          (http://cpmcnet/columbia.edu/dept/nursing/institute-centers/chphsr/COMPETENCIES.pdf) or
          http://www.nwcphp.org/resources/key-public-health-competency-sets-and-resources. Other additional
          competencies may be identified and added to the core competencies at the discretion of the agency. Specific
          competencies and training to be addressed will be outlined in the Tribe Workplan.

    D.

    E.    This objective builds on prior year efforts for agency staff members to receive appropriate public health
          preparedness emergency response training to advance their knowledge and skills to demonstrate the
          emergency preparedness core competencies for their identified position in a public health emergency
          response.

    F.    Agency records

Template Objective #6
   A. REQUIRED TRIBE (Exercises): By December 31, 2008, (insert name of Tribe) will participate in a public
         health emergency preparedness exercise or real event that meets the requirements set by the Centers for
         Disease Control (CDC).

    B.    Electronic copy of the After-Action Report/Improvement Plan (AARP/IP) exercise report form with
          corrective action plan for each exercise or real event, and a summary of the corrective actions implemented in
          2008.

    C.    This objective relates directly to the recommendation made by the Wisconsin Preparedness Leadership Group
          and approved by DPH for the evaluation of all real events and exercises using a consistent after action report
          format to be used to improve plans and systems accordingly. Each public health preparedness local and/or
          regional exercise is to: 1) address the CDC performance standards, 2) incorporate the NIMS/ICS all-hazards
          incident response, 3) be compliant with Homeland Security Exercise and Evaluation Program (HSEEP)
          exercise guidelines, and 4) meet the requirements set by the CDC grant guidance, including the number and
          type of exercises to be done in 2008. HSEEP compliance includes developing and submitting an After-
          Action Report/Improvement Plan (AARP/IP) for real events and exercises. This form may be found in the
          exercise guidelines contained in HSEEP Volume III or by accessing the HSEEP website at
          https://hseep.dhs.gov. In 2008 use of the AARP/IP form will be required for reporting the results of all
          public health events and exercises. A notice of each event or exercise is to be posted on the Health Alert
          Network (HAN) in an area to be designated by either: 1) posting a copy of the actual AARP/IP form, or 2)
          posting a message indicating the exercise was done with the date, lead agency, name and type (actual event,
          or table top, functional, full scale exercise) and person to contact to review the actual AARP/IP content.
          Specific exercises to be addressed will be outlined in the Tribe Workplan.

    D.




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    E.     This objective builds on prior year efforts to participate in an annual public health emergency preparedness
           exercise or real event, to follow the CDC and other requirements and guidelines for evaluation and
           documentation, and to improve plans and systems based on the results of the exercise or real event.

    F.     Agency records

Template Objectives 7-19 Collaborative Leadership Projects
Directions: These objectives relate directly to the recommendation made by the Wisconsin Preparedness Leadership
Group to build partnerships with other emergency and public health response partners, and to standardize goals and
objectives between agencies and consortia. To accomplish this, each Local Health Department and Tribe is to select one
of the following template objectives to develop or implement a coordinated local or multi-jurisdictional leadership
project, or to address a locally or regionally identified need or concern. Local agencies may work on the objective or
project independently with technical assistance and coordination from their Consortium, or may elect to partner with
other LHDs/Tribes/Consortia to work on common topics, issues, or concerns to improve regional public health
emergency preparedness capabilities. The “project” may be the development and/or implementation of tools, templates,
policies, or other resources and may include hosting meetings or training events for local or regional partners. The
objective or topic area will be shared with other LHDs, Tribes and Consortia to coordinate efforts. Each LHD, Tribe,
and Consortium is expected to communicate and collaborate with other agencies sharing the similar objective or topic
area. The results of each objective or project will be made available to be shared with other local, regional and statewide
agencies and partners to improve local, regional and statewide capabilities.

The goal of DPH is for all agencies to use template objectives, and all LHDs/Tribes are strongly encouraged to select one
of the following template objectives for 2008. Contractees are advised that modified template objectives or other
uniquely proposed objectives may be considered and negotiated on a case-by-case basis, and may result in delayed
completion of Preparedness contracts. Below are 13 template objectives to select.

Template Objective #7
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (1 of 13): By December
         31, 2008, a completed assessment of the epidemiological competencies of the (insert name of LHD/Tribe)
         staff will be used to determine development needed to increase organizational epidemiology capacity.

    B.     An agency report summary to include the number of staff assessed to be at each level of epidemiological
           competency.

    C.     Epidemiologic capacity is critical to local public health preparedness. Assessment of local staff competencies
           assists the agency in identifying areas of future staff developments and in working with partners to combine
           resources to address needs. Tools under review include the University of Washington School of Public Health
           and Community Medicine Northwest Center for Public Health Practice Public Health Epidemiology
           Competency Set available at http://www.nwcphp.org/resources/key-public-health-competency-sets-and-
           resources

    D.

    E.     Select one of the suggested baseline statements:
             This is a new initiative.
                   OR
             This objective builds on prior year efforts to assess the epidemiological competencies of agency staff.

    F.     Agency records


Template Objective #8
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT                                     (2 of 13): By December
         31, 2008, results of testing the local system for alerting health care providers of unusual health related events
         will determine mitigation needed to improve the epidemiology capacity of the (insert name of LHD/Tribe).




                                                           137
    B.    An agency report indicating the date of the test(s) of the local system for alerting local health care providers
          of unusual health-related events, the method(s) of testing, results, and mitigation plans and progress.

    C.    Epidemiologic capacity is critical to local public health preparedness. A surveillance system will assure
          enhanced working relationships with laboratory and healthcare providers and establish a network of
          communication and data sharing. Reference (Grant Guidance: 6A(2), p. 19)

    D.

    E.   Select one of the suggested baseline statements:
            This is a new initiative.
                 OR
            This objective expands on prior year efforts of developing systems to alert health care providers of unusual
            health related events.

    F.    Agency records

Template Objective #9
    A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (3 of
          13): By December 31, 2008, outreach education to local health care providers on the
          importance of reporting non-communicable reportable conditions will increase the
          epidemiology capacity of the (insert name of LHD/Tribe).
    B.    An agency report summarizing the methods used, dates provided, organizations and number of staff
          participating in outreach education to local health care providers to increase the reporting of non-
          communicable reportable conditions.

    C.    Epidemiologic capacity is critical to local public health preparedness. Educating local healthcare providers
          about reporting of non-communicable reportable conditions will enhance communities to respond to all health
          threats. Samples of a non-communicable reportable condition include infant methemoglobinemia, metal and
          pesticide poisonings (non-lead), and suspected outbreaks of other acute or occupationally-related diseases.
          Reference (Grant Guidance: 2A(1), p. 13)

    D.

    E.    This objective expands on prior year efforts to enhance reporting of communicable disease conditions within
          the local jurisdiction.

    F. Agency records

Template Objective #10
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (4 of 13): By December 31,
         2008, a local volunteer management plan including protocols for staging, credentialing and training of
         recruited and spontaneous volunteers to increase surge capacity will be implemented in the agency’s
         jurisdiction by the (insert name of LHD/Tribe).

    B.    A copy of the local volunteer management plan including protocols for staging, credentialing and training of
          recruited and spontaneous volunteers.

    C.    Epidemiologic capacity is critical to local public health preparedness. The development and implementation
          of a plan for volunteers to increase epidemiology surge capacity would facilitate communities to be ready to
          respond to all health threats. Reference (Grant Guidance: 7F(4), p.22)

    D.

    E.    Select one of the suggested baseline statements:



                                                           138
             This is a new initiative.
                OR
             This objective expands on prior year efforts related to recruiting and/or training volunteers to respond to a
             public health emergency event.

    F.    Agency records

Template Objective #11
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (5 of 13): By December 31,
         2008 epidemiology capacity will be increased by the establishment of a surveillance system, including early
         event detection and communication between the (insert name of LHD/Tribe) and local health care providers.

    B.    An agency report summarizing the surveillance system, including early event detection and communication
          systems developed between the agency and local health care providers, the type of events monitored, partners
          participating in surveillance, and a copy of the communication plan.

    C.    Epidemiologic capacity is critical to local public health preparedness. Establishing a surveillance system,
          early detection, and communication system between agencies and health care providers will provide an
          excellent network of communication, efficient use of epidemiological resources, and facilitate communities to
          respond to all health threats.

    D.

    E.    Select one of the suggested baseline statements:
              This is a new initiative.
                  OR
              This objective expands on prior year efforts to enhance local public health surveillance systems with
              health care providers within the agency’s jurisdiction.

    F.    Agency records

Template Objective #12
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (6 of 13): By December 31,
         2008 epidemiology capacity will be increased by the (insert name of LHD/Tribe)’s development of a local
         surveillance system which includes an implementation plan for monitoring the community’s school or
         worksite absenteeism.

    B.    An agency report summarizing the local surveillance system with an implementation plan for monitoring
          school or worksite absenteeism, and identifying partnerships made with schools or worksites, methods of
          surveillance, reported indicators, and implementation plan.

    C.    Epidemiologic capacity is critical to local public health preparedness. Establishing a surveillance system,
          early detection, and communication system between agencies and schools or worksites will provide an
          excellent network of communication, efficient use of epidemiological resources, and facilitate communities to
          respond to all health threats.

    D.

    E.    Select one of the suggested baseline statements:
            This is a new initiative.
                OR
            This objective expands on prior year efforts to enhance local public health absenteeism surveillance
            systems with schools and/or businesses.

    F.    Agency records




                                                           139
Template Objective #13
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (7 of 13): By December
         31, 2008 epidemiology capacity will be increased by (insert name of LHD/Tribe) through completion of an
         epidemiology product related to a health issue of local importance.

    B.    An agency report to include a summary of the new local epidemiological study including identification of the
          health issue of local importance, and copy of the final report including assessment of the health issue,
          communication plan, interventions and evaluation.

    C.    Improvement of epidemiologic capacity is critical to local public health preparedness. Development of a new
          local epidemiology study related to a health issue of local importance will enable efficient use of
          epidemiology resources and provide an excellent network of communication and data sharing. It is highly
          recommended agency staff consult with available epidemiologic resources, such as epidemiologists in the
          Public Health Preparedness Consortium and Division of Public Health regional office to provide technical
          assistance to identify the health issue of local importance, and to develop a plan for the new local
          epidemiologic study to be conducted by the agency. Examples of potential epidemiologic studies are:
          conducting surveillance to develop a plan for monitoring and controlling a specific chronic disease of concern
          in the community such as obesity or diabetes; to determine the primary causes of death associated with
          tobacco use in the agency’s jurisdiction; obtain BMI measures of kindergarten children in the public school
          district jurisdiction to determine interventions for children and their families to promote healthy diet and
          activity levels; tabulate results of radon tests done in the jurisdiction and provide a summary to the
          community of the study results; investigate and review case studies of blastomycosis reports within the
          jurisdiction; conduct a retrospective study of data for the clinic diabetes registry to research how community
          members with diabetes are managing the disease and effectiveness of clinic services in reducing
          complications of diabetes. Reference (Grant Guidance: 5A(1), p. 18.

    D.

    E.    Select one of the suggested baseline statements:
            This is a new initiative.
                OR
            This objective expands on the completion of a previous epidemiology project related to a health issue of
            local importance to further enhance local epidemiology capacity within the agency’s jurisdiction.

    F.    Agency records

Template Objective #14
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (8 of 13): By December
         31, 2008, (insert name of LHD/Tribe) will establish a system for regional coordination of public information
         during a public health emergency.

    B.    A report including: 1) a summary of the system for regional coordination of public information during a
          public health emergency, 2) copies of any associated protocol, plan, Memorandum of Understanding (MOU)
          developed related to the system, and 3) a list of exercises or real events testing the new system.

    C.    During a regional public health event, it is critical that all local health departments and tribes coordinate the
          information being shared with local media. A Joint Information Center allows for this coordination to
          happen. Each regional area needs to determine what configuration of coordination will best meet the needs in
          their area. Pre-planning for these contingencies will help to minimize disruption during an event. A system
          may include a plan, protocol, process and/or MOU among affected jurisdictions.

    D.

    E.    This is a new initiative to be completed with partners within the region.

    F.    Agency records



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Template Objective #15
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT                                    (9 of 13): By December
         31, 2008, epidemiology capacity will be increased by the (insert name of LHD/Tribe) by conducting a test of
         the local system for alerting local health care providers of unusual health-related events.

    B.     A report to include: 1) a summary of the local health care provider alerting system, 2) dates and results of
           test(s) conducted of the alerting system, 3) and a summary of the mitigation plans and progress.

    C.     The ability of a local health agency to alert clinicians and public health partners of an urgent public health
           issue or event is a critical component of a system for identifying and responding to health threats. Creation of
           an alerting system is challenging because local health care providers utilize a variety of communication
           methods and the focus on providing patient services limits the amount of time practitioners have to respond to
           communication messages. This objective would explore methods for reaching clinicians and public health
           partners quickly and effectively about an issue of public health importance. LHD/Tribes will work with local
           hospitals, clinics and other health care providers to design and test a system built on local needs and
           resources.

    D.

    E.     Select one of the suggested baseline statements:
             This is a new initiative.
                 OR
             This objective expands on prior year efforts of developing systems to alert health care providers of unusual
             health-related events.

    F.     Agency records

Template Objective #16
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (10 of 13): By December
         31, 2008, (insert name of LHD/Tribe) will identify specific response recommendations for local special needs
         populations in their jurisdiction.

    B.     A report to include a summary of the special populations identified in the jurisdiction, and the response
           recommendations developed for each group.

    C.     Preparedness and response require communication activities with the capacity to reach every person. To do
           this, a community must know what sub-groups make up their population, where the people in the groups live
           and work, and how they best receive information. Many jurisdictions and regions have not comprehensively
           defined or located their special populations. This objective will help LPH/Tribes and other emergency
           responders to improve their ability to reach all populations – and specifically special populations – in day-to-
           day communication and during crisis or emergency situations.

    D.

    E.     This objective expands on prior year efforts to identify special populations within the agency’s jurisdiction.

    F.     Agency records

Template Objective #17
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (11 of 13): By December
         31, 2008, (insert name of LHD/Tribe) surge capacity during public health emergencies will be increased
         through the development and implementation of a plan for managing recruited and spontaneous volunteers.

    B.     A copy of the local volunteer management plan, including protocols for staging, credentialing and training
           recruited and spontaneous volunteers.



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    C.    During a major public health event, most local health departments will lack adequate human resources to
          respond. Pre-planning for the activation, training and deployment of volunteers will aid in mounting a rapid
          and thorough response.
    D.

    E.    Select one of the suggested baseline statements:
            This is a new initiative.
                OR This objective expands on prior year efforts related to recruiting and/or training volunteers to
            respond to a public health emergency event.

    F.    Agency records

Template Objective #18
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (12 of 13): By December
         31, 2008 (insert name of LHD/Tribe) will implement an outreach education or educational campaign on
         public health preparedness to targeted groups in businesses, agencies, organizations, or other identified
         groups within the community, region, or state.

    B.    A report to include: 1) names of the businesses, agencies, organizations, or other targeted groups and number
          of individuals reached in each group, 2) dates of meetings and presentations, 3) summary and copy of the
          outreach or campaign methods used (such as presentations and handouts), and 4) evaluation of the
          results/outcome of the outreach efforts.

    C.    The purpose of this objective is to educate community members about the importance of planning and
          preparedness related to public health emergencies. Conducting outreach education of an educational
          campaign within a local, regional, or statewide jurisdiction will greatly increase the preparedness levels of the
          jurisdiction, has the potential to facilitate the development of unique partnerships, and generate volunteers for
          the jurisdiction.

    D.

    E.    Select one of the suggested baseline statements:
            This is a new initiative.
                OR
            This objective expands on prior year efforts to provide outreach education or an educational campaign on
            public health preparedness.

    F.    Agency records

Template Objective #19
   A.    OPTIONAL LHD/TRIBE COLLABORATIVE LEADERSHIP PROJECT (13 of 13): By 12/31/08,
         pandemic influenza response capacity will be enhanced in (insert name of LDH/Tribe) through education and
         outreach on containment measures to targeted key community stakeholders.

    B.    A summary report to include: 1) name of the targeted key community stakeholders and number of
          individuals reached in each group, 2) summary and copy of the education and outreach efforts including dates
          of meetings and presentations, number of persons present, and their affiliations, and 3) evaluation of the
          results/outcome of the education and outreach.

    C.    In 2007, LHD/Tribes developed local pandemic influenza community containment plans. In order for
          implementation of those plans to be most effective, it is important that local partners understand and support
          public health’s role. In addition, partners themselves, such as schools, need to plan for containment measures
          and assist with crafting a local community containment plan that addresses specific aspects and needs of the
          community. This objective supports measure #G7 in the CDC Pandemic Influenza Assessment which states
          that “the public has been informed what containment procedures may be used in the community.” It also



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          support measure #A8 which requires that public health legal authority be “transparent to all stakeholders.”
          Outreach efforts may include reporting at meetings, conducting planning meetings, making presentations,
          conducting training. For tribes, this objective may include making presentations to tribal council members,
          creating memoranda of understanding with local public health agencies, and/or creating tribal ordinances to
          support the implementation of containment measures.

    D.

    E.    Select one of the suggested baseline statements:
            This is a new initiative.
                OR
            This objective expands on prior year efforts to provide education and outreach on public health
            preparedness to targeted key community stakeholders.

    F.    Agency records

Template Objective #20
   A.    REQUIRED CONSORTIUM (Planning): By December 31, 2008, (insert name of Public Health
         Preparedness Consortium) will provide support and technical assistance to member agencies to engage in
         continuous planning process with local and regional partners to respond to public health emergencies.

    B.    A report to include a summary of templates, plans, tools, plans, procedures, protocols and other resources
          created for member agencies.

    C.    This objective relates directly to the recommendation made by the Wisconsin Preparedness Leadership Group
          to develop a measurable goal and objective to contribute toward creating, maintaining and updating state,
          regional and local response plans. The Public Health Preparedness Consortium is to assist its members to
          annually update the consortium and local Public Health Emergency Preparedness (PHEP) Plan and other
          related plans. Consortium staff may collaborate with other consortia and the Division of Public Health to
          prepare templates, tools, Power Point presentations, and other materials for use by their members and public
          health partners at the local, regional and state level to plan and coordinate public health emergency response
          systems and processes. Consortium staff may create template plans, tools, education presentations and other
          materials and provide technical assistance to members on the implementation of those tools. Specific plans to
          be addressed will be outlined in the Consortium Workplan.

    D.

    E.    This objective builds on prior year efforts to provide support and technical assistance to consortium members
          and their public health partners at the local, regional and state level to plan and coordinate public health
          emergency response systems and processes.

    F.    Agency records

Template Objective #21
   A.    REQUIRED CONSORTIUM (Competencies/Training): By December 31, 2008, (insert name of Public
         Health Preparedness Consortium) will participate in the development and delivery of local, regional and
         statewide plans and tools to assess and assure staff competence and training needs.

    B.    A report summarizing trainings provided, and collaborative efforts to assess and assure
          competencies are met.
    C.    This objective relates directly to the recommendation made by the Division of Public Health and the
          Wisconsin Preparedness Leadership Group to adopt the Columbia Competencies for Public Health Workers
          at the state, local and regional levels. Project Public Health Ready requires staff members to demonstrate
          competency in the nine "Emergency Preparedness: Core Competencies for All Public Health Workers." This



                                                         143
           set of nine core competencies have been identified to be met by all public health workers to respond during a
           public health emergency, as developed by the Columbia University School of Nursing Center for Health
           Policy. All members of the public health workforce must prove their mastery of these nine core
           competencies. The additional competencies identified in the Columbia tool for the following groups must
           also be met: Public Health Leaders/Administrators, Public Health Professionals, and Public Health Technical
           and Support Staff. Other additional competencies may be identified and added to the core competencies at
           the discretion of the agency. The Consortium may collaborate with other public health preparedness
           consortia and DPH to develop systems, processes, plans and tools for use by local agencies throughout
           Wisconsin to measure and meet the public health preparedness core competencies. The Consortium will
           assist its members to use systems and processes to measure and meet the core public health preparedness
           competencies for staff in their agencies. Training related to the core competencies includes but is not limited
           to: National Incident Command System (NIMS), Incident Command System (ICS), tactical/redundant
           communications, and risk communication. The Consortium may offer, coordinate or provide training on
           other public health topics of interest or need among their members. Specific competencies and training to be
           addressed will be outlined in the Consortium Workplan. Tribal health centers are to identify all of their staff
           and Tribal Leadership that have a role in a planning or responding to a public health emergency response.
           Tribal Leadership are those who have designated authority and responsibilities for their Tribal community
           and may include Tribal Council members, Tribal Chairpersons, Health Directors, Tribal Elders, and members
           of Tribal Health Boards. The identified Tribal Leaders and tribal health center staff should actively
           participate in training and activities to meet the public health preparedness competencies in their jurisdiction
           to be able to mitigate, prepare, respond and recover to a disaster or emergency. Training is to be provided to
           each of those persons in accordance with the competencies identified for those planning and response roles,
           including those persons identified to be in the Tribal ICS structure.

    D.

    E.    This objective builds on prior year efforts to provide local and/or regional assessment, planning, and training
          to member agencies to meet the public health preparedness emergency response core competencies for their
          identified positions in a public health emergency response.

    F.    Agency records

Template Objective #22
   A.    REQUIRED CONSORTIUM (Exercises): By December 31, 2008, in conjunction with the Division of
         Public Health, the (insert name of Public Health Preparedness Consortium) will develop a system and
         process to support the implementation of routine local public health emergency preparedness exercises that
         meet the requirements set by the Centers for Disease Control (CDC).

    B.    A report to include a plan for meeting all the requirements of the CDC performance standards through local
          and/or regional exercises or real events.

    C.    This objective relates directly to the recommendation made by the Wisconsin Preparedness Leadership Group
          and approved by DPH to evaluate all real events and exercises using After Action Reports and improve plans
          and systems accordingly. Each public health preparedness local and/or regional exercise is to address the
          CDC performance standards, incorporate the NIMS/ICS all-hazards incident response, and meet the
          requirements set by the CDC grant guidance. Exercises are to be implemented and integrated into the work
          plans for the consortia and local members. Specific exercises to be addressed will be outlined in the
          Consortium Workplan.

    D.

    E.    This objective builds on prior year efforts of developing systems and processes to support the implementation
          of routine local public health emergency preparedness exercises for member agencies to the regional and
          statewide level by working collaboratively with DPH to meet the requirements set by the CDC.

    F.    Agency records



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Template Objective #23
   A.    REQUIRED CONSORTIUM (Collaborative Leadership): By December 31, 2008, (insert name of Public
         Health Preparedness Consortium) will participate in collaborative leadership efforts and processes that result
         in the implementation of products to benefit local, regional and statewide emergency response capabilities.

    B.     A report summarizing the collaborative leadership efforts and processes, resulting products, and summary of
           how they were disseminated or implemented at the local, regional and/or statewide level.

    C.     The focus of this objective is on statewide collaborative leadership and coordination with statewide efforts.
           “Products” are systems, processes, tools, templates, plans, policies, or procedures that have demonstrated
           effectiveness and have been shown to benefit local, regional or statewide emergency response capabilities.
           Consortia staff members (Program Coordinators, Epidemiologists, and Trainers/Educators) will partner with
           the Division of Public Health (DPH) to evaluate and pick projects to be implemented at the regional and/or
           statewide level. Collaboration leadership efforts may be with the Consortium and one or more other agency,
           agencies within a consortium region/DPH region/state of Wisconsin, two or more consortia. Activities
           consortia staff engage in may include participation in on a state expert panel, and developing
           tools/templates/resources during Consortia meetings. Consortia roles may include the coordination and the
           identification of resources, research national models or tools, and development of
           systems/processes/tools/templates.

    D.

    E.     This objective builds on prior year efforts to enhance and expand collaborative leadership efforts and
           processes to result in the implementation of public health preparedness products to benefit local, regional and
           statewide emergency response capabilities.

    F.     Agency records




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PREVENTION PROGRAM – 2008

   Program Boundary Statement

   Program Quality Criteria




                                146
                  Preventive Health and Health Services Block Grant
                            Program Boundary Statement
For each performance-based contract program, the Division of Public Health has identified a
boundary statement. The boundary statement sets the parameters of the program within which the
local public health agency will need to set its objectives. The boundaries are intentionally as broad
as federal and state law permits to provide maximum flexibility, however if there are objectives or
program directions that the program is not willing to consider, those are included in the boundary
statement.

Boundary Statement
The Preventive Health and Health Services (PHHS) Block Grant is a federal program to allocate
funds to states to improve the health of the general population. The primary objectives of the is
program are to (1) improve the health of communities through the achievement of selected National
Healthy People 2010 Health Objectives; (2) control health problems related to rodents; (3) provide
for community and school-based fluoridation programs; (4) conduct feasibility studies and planning
for emergency medical services systems and the establishment, expansion, and improvement of such
systems; (5) providing services to victims of sex offenses and for prevention of sex offenses (6) the
establishment, operation, and coordination of effective and cost-efficient systems to reduce the
prevalence of illness due to asthma and asthma-related illnesses, especially among children; (7) with
respect to any of the above activities, conduct related planning, administration, and education
activities; and (8) provide monitoring and evaluation of activities carried out under any of the above
activities.
In October 2000, Public Law 102-531 was amended, this amendment became Public Law 106-386,
and authorized monies for rape prevention and education programs to be administered through the
National Center for Injury Prevention and Control.
Contractees should adhere to the following boundaries when developing a proposal:
•   If the contractee is a local public health department that has not completed a current community
    health improvement plan, then the PHHS proposal must include an objective for completing such
    a plan and funds must first be used to support this plan.

•   Contractees may chose one or more health objectives that address one or more of the prominent
    public health needs which have been identified in its community health improvement plan to
    address an emerging threat or need. These selected health objectives should also be linked to the
    Turning Point priorities.

•   If a contractee has a successful, existing PHHS funded program that is unique to its area, but
    which does not address one of the prominent identified needs and which it wishes to continue, it
    may do so. However solid justification must be provided to explain why the particular program
    must be continued and why it was not a priority in the completed community health
    improvement plan.

NOTE: Director’s for the National Center for Chronic Disease and Prevention and Health
Promotion and Division of Adult and Community Health Directors recognize that natural disasters,
disease outbreaks and other crises can strike at any time, and departments of health must respond
rapidly to these new critical and unexpected health issues. At the same time, state, jurisdictional,


                                                 147
and tribal health agencies face continuing challenges such as death from motor vehicle crashes,
elderly falls, and the increasing number of those living with chronic diseases such as heart disease,
cancer and diabetes. Health agencies must also work to reduce risk factors, such as poor nutritional
choices, smoking, and lack of physical activity and ensure that community residents maintain a high
quality of life and have a healthy future.16

Unacceptable uses of funds
According to PHHSBG guidance obtained in August 2006, non-allowable uses for these funds
include:

       1. Providing financial assistance to any entity other than a public or nonprofit private entity.
          (this may be waived by the CDC, if a State requests a waiver
          and justifies the extraordinary circumstances that a waiver will assist in
          carrying out the activities.)

       2. Inpatient services.

       3. Cash payment to recipients of health services.

       4. Purchase or improve land, purchase, construct, or permanently improve a
          building or facility or purchase major medical equipment.

       5. Use as a match requirement for Federal funds.

Wisconsin’s Annual Prevention Plan Requirement Guidance from CDC:
       1. Activities need to link with National and State Health Objectives – Healthy People 2010 and
          Healthiest Wisconsin 2010.
       2. Specify the activities to be carried out. Annual activities should contain two components, a
          “Begin” and “End” date.
       3. Specify target and disparate population.
       4. Funds to be expended for the activities.
       5. CDC is now asking States to identify the scientific basis for the intervention, not just base it
          on pubic health literature as it pertains to Evidence-based guidelines, Best Practices or other
          scientific knowledge.




16
     CDC, National Center for Chronic Disease Prevention and Health Promotion. Public Health at Work, The
     Preventive Health and Health Services Block Grant; July 2006. E-copy of publication can be found at:
     http://www.cdc.gov/nccdphp/blockgrant/pdf/PHHS_BG_Success_Story_Booklet071406.pdf



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                       Preventive Health and Health Services Block Grant
                                 2008 Program Quality Criteria

Generally high program quality criteria for the delivery of quality and cost-effective
administration of health care programs have been, and will continue to be, required in each public
health program to be operated under the terms of this contract. Contractees should indicate the
manner in which they will assure each criterion is met for this program. Those criteria include:

Public health assessment and surveillance that identify community needs and supports systematic,
competent program planning and sound policy development with activities focused at both the
individual and jurisdictional levels.
       a. Involvement of key policymakers and the general public in the development of
       comprehensive public health plans.

       b. Development and implementation of a plan to address issues related to access to high
       priority public health services for every member of the community.

Delivery of public health services to citizens by qualified health professionals in a manner that is
family centered, culturally competent, and consistent with the best practices; and delivery of public
health programs for communities for the improvement of health status.

       a. There are no separate sub-criterion to this Quality Criteria Category.

Record keeping for individual focused services that assures documentation and tracking of client
health care needs, response to known health care problems on a timely basis, and confidentiality of
client information.

       a. There are no separate sub-criterion to this Quality Criteria Category.

Information, education, and outreach programs intended to address known health risks in the
general and certain target populations to encourage appropriate decision making by those at risk and
to affect policy and environmental changes at the community level.
        a. Provision of public information and education, and/or outreach activities focused on high-
        risk populations that increase awareness of disease risks, environmental health risks, and
        appropriate preventive activities.

       b. All materials produced with PHHS Block Grant funds must include the following
       statement: "This publication was made possible by the PHHS Block Grant from the Centers
       for Disease Control."

Coordination with related programs to assure that identified public health needs are addressed in a
comprehensive, cost-effective manner across programs and throughout the community.

       a. There are no separate sub-criterion to this Quality Criteria Category.




                                                 149
A referral network sufficient to assure the accessibility and timely provision of services to address
identified public health care needs.

       a. There are no separate sub-criterion to this Quality Criteria Category.

Provision of guidance to staff through program and policy manuals and other means sufficient to
assure quality health care and cost-effective program administration.

       a. Provision of written policy and program information about the current guidelines,
       standards, and recommendations for community and/or clinical preventive care.

Financial management practices sufficient to assure accurate eligibility determination,
appropriate use of state and federal funds, prompt and accurate billing and payment for services
provided and purchased, accurate expenditure reporting, and, when required, pursuit of third party
insurance and Medical Assistance Program coverage of services provided.

       a. Program-specific data collection, analysis, and reporting to assure program outcome goals
       are met or to identify program management problems that need to be addressed.

Data collection, analysis, and reporting to assure program outcome goals are met or to identify
program management problems that need to be addressed.

       a. There are no separate sub-criterion to this Quality Criteria Category.




                                                 150
RADON PROGRAM - 2008
   Program Boundary Statement

   Program Quality Criteria

   Program Objectives – there are no ‘templates’




                               151
                                   2008 Program Boundary Statement
                                            Radon Program

For each performance-based contract program, the Division of Public Health has identified a boundary
statement. The boundary statement sets the parameters of the program within which the local public health
department (LPHD), Tribe or agency will need to set its objectives. The boundaries are intentionally as broad
as federal and state law permit to provide maximum flexibility. However, if there are objectives or program
directions that the program is not willing to consider or specific programmatic parameters, those are included
in the boundary statement.

Program Outline:

Objectives for reducing exposures to elevated indoor radon in homes are funded for two classes of agencies:

Radon Information Centers (RICs): Sixteen local health or environmental agencies which serve multiple
counties will be funded to deliver eight services of a single required objective concerning: outreach, public
consultation, proficiency certification, coordination with DPH, database, and field site visits.

Local health agencies other than RICs may be funded for $3,000 outreach projects, aimed at reducing radon
exposures in homes. Up to 24 agencies will be funded, based on responses to a request for proposals (RFP).
The RFP letters will be sent to local public health agencies by mail in August, 2007. Interested agencies will
need to respond by mail with a brief project outline and objectives. Those selected will be asked to negotiate
their objectives which we will place on the “GAC”. This funding is suitable for agencies having little or no
prior experience with radon, and for experienced agencies. Agencies not funded the year before will have
priority. A most basic project would:
    • encourage testing of homes and mitigation where appropriate, with outreach publicizing the
         prevalence of elevated indoor radon locally, the lung cancer risk, and the availability of cost-effective
         radon mitigation;
    • send staff to attend a half-day regional radon meeting in December 2007, to coordinate activities with
         the radon program in the Division of Public Health and the RICs;
    • make radon detectors available for screening and follow-up tests, with information on radon and
         testing;
    • direct the public requesting technical information to Wisconsin’s regional Radon Information Centers
         (888 LOW RADON) and to the comprehensive DPH radon website www.lowradon.org;
    • when follow-up testing confirms elevated exposures in occupied spaces of their homes, direct the
         public to qualified radon mitigation contractors, listed at the DPH radon website.
This funding is for agencies that can do the work themselves, and not ask their RIC to do it.

Long-term Program Goals: The Outcome Goal is reduction of lung cancer incidence by reducing exposures
of the public to indoor radon. An Output Goal is that every home with ground contact be tested for radon,
identifying those with exposures to residents averaging higher than 4 pCi/L in occupied spaces, and reducing
those to far below 4 pCi/L with the mitigation method recommended by US EPA. Another Output Goal is
that new homes be built with features recommended as effective in helping to keep radon out of the indoor
air.


Target Populations:

    •   Residents of all homes in Wisconsin having ground contact.




                                                       152
    •   Residents in regions of the Wisconsin zip-code radon map and data base where higher percentages
        have elevated radon.

Every home with ground contact should be tested, because: homes with elevated radon have been found in
virtually every zip code in Wisconsin; the radon in any particular home is not predictable; neighboring homes
tend to have greatly dissimilar concentrations; and radon screening tests only cost about $10. The only way
for homeowners to know if their radon is elevated is to test.

References:

Federal Regulations/Guidelines:
    • US EPA: Citizen’s Guide to Radon
    • US EPA: Home Buyers and Sellers Guide to Radon
    • US EPA: Consumers’ Guide to Radon Reduction
State of Wisconsin Statutes/Administrative Rules/Guidelines:
    • WI Statutes s. 254.34
Program Policies:
    • Policies of the US EPA regarding measurement, mitigation and communication of risk for radon in
         homes, as in the three EPA documents above, should be recommended in Wisconsin. No others have
         been specified in state legislation.

Unacceptable Proposals:

    •   Radon measurement for building types other than homes will not be funded. Advising them is done
        only by DPH in coordination with RICs. This is because measurement protocols, interpretation of
        results in terms of risk, and methods of mitigation can differ from those for homes.
    •   Funds will not be provided to pay for radon mitigation itself.


Relationship to State Health Plan: Healthiest Wisconsin 2010:

System Priorities:
    • Community health improvement processes and plans
    • Coordination of state and local public health system partnerships
State Health Plan Priorities:
    • Access to primary and preventive health services
    • Environmental and Occupational Health Hazards; Environmental Radiation
Essential Public Health Services:
    • Identify, investigate, control and prevent health problems and environmental health hazards in the
        community
    • Educate the public about current and emerging health issues
    • Promote community partnerships to identify and solve health problems
    • Create policies and plans that support individual and community health efforts
    • Link people to needed health services

Methodology Used to Determine Health Priorities (Page 90 of plan), Environmental and occupational
health hazards: “Exposure to harmful substances in the physical environment is linked to many major
adverse health outcomes. Next to tobacco smoke, environmental exposure to radon gas is the leading cause of
lung cancer. …”


                                                    153
                               2008 Program Quality Criteria
                                      Radon Program
Generally high program quality criteria for the delivery of quality and cost-effective administration
of health care programs have been, and will continue to be, required in each public health program to
be operated under the terms of this contract. Contractees should indicate the manner in which they
will assure each criterion is met for this program. Those criteria include:

Assessment and surveillance of public health to identify community needs and to support
systematic, competent program planning and sound policy development with activities focused at
both the individual and community levels.

       A. Contractee must assess surveillance data (including their own data) for prevalence of
          homes with elevated indoor radon exposures in their regions. The Division of Public
          Health (DPH) radon zip-code map and database are at www.lowradon.org.

Delivery of public health services to citizens by qualified health professionals in a manner that is
family centered, culturally competent, and consistent with the best practices; and delivery of public
health programs for communities for the improvement of health status.

       A. Cultural competence and other qualifications of persons delivering radon services
          must be the same as those of employees of local health agencies, such as
          environmental sanitarians and public health nurses.

Record keeping for individual focused services that assures documentation and tracking of client
health care needs, response to known health care problems on a timely basis, and confidentiality of
client information.

       A. Contractee must maintain a database of measurements carried out by the public with
          agency assistance and, to the extent possible, follow cases of elevated exposures to
          promote appropriate interventions and outcomes. This means providing the public
          with detectors for which the lab will do double reporting (i.e., to the person who
          obtains the detector from the Contractee and the Contractee itself). However, the
          ability to follow-up may be limited in some instances since indoor radon is not
          regulated in Wisconsin and because detectors and mitigation services are available
          from the private sector.

Information, education, and outreach programs intended to address known health risks in the
general and certain target populations to encourage appropriate decision making by those at risk and
to affect policy and environmental changes at the community level.

       A. Contractee must serve as a resource for information in their region, and provide
          referrals when requested for technical information they can’t provide. This enables
          residents to understand the lung cancer risk from radon, test their homes for radon,
          interpret test results and follow-up testing, and obtain effective radon mitigation
          services where appropriate.


                                                 154
Coordination with related programs to assure that identified public health needs are addressed in a
comprehensive, cost-effective manner across programs and throughout the community.

       A. Contractee must coordinate outreach with other public health programs in their
          agency, adjusting services so as to fit into appropriate priorities among groups with
          other health needs.

A referral network sufficient to assure the timely provision of services to address identified client
health care needs.

       A. Contractee must use the referral network consisting of Regional Radon Information
          Centers, nationally certified radon mitigation contractors, and Web sites for fast
          access to DPH and EPA radon information and literature. The DPH Web site is
          www.lowradon.org.

Provision of guidance to staff through program and policy manuals and other means sufficient to
assure quality client care and cost-effective program administration.

       A. Contractee must provide guidance on radon testing and mitigation following EPA
           policies as recommended in EPA’s booklets: Citizen’s Guide to Radon, Consumer’s
          Guide to Radon Reduction, and Home Buyers and Seller’s Guide to Radon, which are
          readable and downloadable through the DPH radon Web site.

       B. Contractee must meet criteria of cost-effective program administration in state and
          local statutes, ordinances and administrative rules.

Financial management practices sufficient to assure accurate, prompt and accurate billing and
payment for services provided and purchased, accurate expenditure reporting, and appropriate use of
state and federal funds.

       A. Considerations of eligibility determination, pursuit of third-party insurance and
          Medical Assistance coverage do not apply to radon outreach funded by DPH.

Data collection, analysis, and reporting to assure program outcome goals are met or to identify
program management problems that need to be addressed.

       A. Contractee must review results of radon measurements they have facilitated. To the
          extent practicable, Contractee must follow cases where elevated screening tests are
          reported. To ensure appropriate follow-up testing is done in occupied spaces where
          screening test results indicate elevated exposures to occupants, Contractee must track
          cases to see that every opportunity for radon mitigation by sub-slab depressurization
          as recommended by US EPA is given. However, because indoor radon is not
          regulated in Wisconsin and because detectors and mitigation services are available
          from the private sector, the ability to follow-up may be limited in some instances.
          Contractees must summarize testing results and follow-up data in their reports to DPH.



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                                              (RFP Letter)


Date:          August 1, 2007

To:            All Local Public Health Departments and Tribal Health Facilities
From:          Conrad Weiffenbach, Bureau of Environmental and Occupational Health

Subject:       Request for proposals, $3,000 radon outreach funding in consolidated contracts for 2008

Funding for up to twenty-four $3,000 basic radon outreach projects will be available for local health
agencies in 2008. Examples of eligible activities are:
• outreach promoting testing of homes by publicizing local radon results, mitigation information, and
   the lung cancer risk; making test kits available and tracking results; and coordinating with DPH for
   the Radon Action Month media blitz in January by attending a half-day regional radon meeting in
   December 2007
• sending staff to EPA radon measurement, mitigation, or new construction training in Waukesha
   next spring (announcement attached, gov’t. no fee), or Baraboo, fall 2008.
• presentations to school classes, providing test kits to students having parental permission to test
   their homes
• (if have EPA two-day radon measurement training) presentations to realtor groups
• (if so trained) outreach to builders about methods of radon control in new construction
The first bullet outlines a basic project. Agencies without recent radon funding are encouraged to apply
and given some priority. Innovative outreach is welcome.

If interested, please send a brief letter summarizing (in plain English) the activities you propose and a
budget, by September 1, 2007 to Conrad Weiffenbach at the address above. Accepted proposals will be
re-formatted as objectives to meet requirements of performance-based contracting, and placed on-line in
the “GAC” for negotiation of accountable quantities. Information on Boundaries and Quality Criteria
for projects accompanies this letter.

Comprehensive Radon Information for Wisconsin at our web site, www.lowradon.org, includes risk,
testing, mitigation, a database and map of test results by county and zip code, and a list of nationally-
certified mitigation contractors. The Wisconsin Radon Information Center (RIC) serving your county
may be able to help you plan a project: call 888 LOW-RADON. A list and map of the RICs and
counties they serve is on the home page of www.lowradon.org.




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TOBACCO PREVENTION AND CONTROL PROGRAM – 2008

    Program Boundary Statement

    Program Quality Criteria

    Program Objectives




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                      Wisconsin Tobacco Prevention and Control Program
                              2008 Program Boundary Statement

For each performance-based contract program, the Division of Public Health (DPH) has identified a
Boundary Statement. The Boundary Statement sets the parameters of the program within which the
Local Public Health Department (LPHD), Tribe or agency will need to set its objectives. The
boundaries are intentionally as broad as federal and state law permit to provide maximum flexibility.
LPHDs, Tribes or agencies are encouraged to leverage resources across categorical funding to
achieve common program goals. The Wisconsin Tobacco Prevention and Control Program aligns
with the boundaries of the Maternal and Child Health and Prevention Block Grant Programs.

Program Boundary Statement
The purpose of the Comprehensive Tobacco Prevention and Control Program is to address
aggressively the burden of tobacco use and exposure in Wisconsin. Community Intervention grants
for local communities are needed to prevent initiation of tobacco use among youth and adults,
protect youth and adults from secondhand smoke, promote tobacco dependence treatment for adults
and youth, and identify and eliminate tobacco-related disparities.

The Tobacco Prevention and Control Program focuses on all components of a comprehensive
program. Best or promising practices to achieve outcomes utilize population-based approaches
emphasizing policy and environmental strategies. Community based efforts in tobacco control are
strongly linked to the reduction of youth tobacco use and exposure to secondhand smoke. Grantees
must use best or promising practices designed to change environments and develop policies that
promote tobacco-free lifestyles.

Fully Funded Communities
Communities must maintain coalitions that include members who actively participate, are supportive
of the coalition’s primary goals and represent a diversity of individuals and organizations.

Linkage to the each coalition’s 2007-2009 Multi-Year Action Plan should be included in the context
of each objective. All objectives must be linked to the long-term and annual goals of the Tobacco
Prevention and Control State Plan which can be found at
http://www.tobwis.org/uploads/media/2007-2009StatePlan.pdf.

The following are required objectives for fully funded coalitions:
• One objective that promotes statewide policy, media and education priorities that may be outside of
the funded jurisdiction, but will affect tobacco use and exposure. (Objective #1 fulfills this
requirement.)
• At least two objectives or 33% of the total contract amount (excluding the WI Wins allocation)
must address community-wide smoke-free policy change or steps leading to local policy change.
This can be a template or unique objective. Objectives that address voluntary smoke-free air policy
changes, such as smoke-free homes and private worksites do NOT meet this requirement.
(Objectives #2 - #4 fulfill this requirement.)
  One objective addressing coalition building and/or maintenance. (Objectives #5 - #7 fulfill this
  requirement.)




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Communities that receive $10,000
Communities should attempt to develop partnerships that are supportive of the Tobacco Prevention
& Control Program’s primary goals.

There is one required objective for communities that receive $10,000. The required objective
promotes statewide policy and education priorities that may be outside of the funded jurisdiction but
will affect tobacco use and exposure. (Objective #1 fulfills this requirement.) Additional objectives
can be template or unique.

Communities that receive $3,000
There is no required objective for communities that receive $3,000; however, best and promising
practice strategies should be utilized to achieve smoke-free policy change, youth tobacco use
prevention, promotion of tobacco dependence treatment services and resources, and reduction of
tobacco-related disparities. Objectives can be template or unique including selecting the statewide
education and outreach template objective.

Wisconsin Wins Funding
The Division of Public Health will negotiate the Wisconsin Wins funding with the existing 2007
contractors. If an existing contractor declines to participate, DPH will pursue alternatives. If LPHDs,
Tribes or agencies are implementing the Wisconsin Wins program, they must use the template
objective for Wisconsin Wins that include the required five public outreach activities and five media
outreach activities. These activities are an integral part of the Wisconsin Wins program. Media and
public outreach is an efficient and effective way to communicate with and motivate community
members and policy makers to support and/or get involved in the program. (See template objective
#5.) Wisconsin Wins efforts are strengthened through increased enforcement of local and state laws.
The Program provides additional funding to conduct these activities. Communities who conduct
enforcement activities must use the template objective for Wisconsin Wins enforcement. (See
template objective #6.)

Communities of Excellence Plus Training
Fully funded communities will be required to participate in a Communities of Excellence Plus
Trainings if they are offered. Communities receiving $10,000 or $3,000 have the option of
participating.

Target Populations
All Wisconsin residents including but not limited to individuals who use tobacco, populations with
tobacco-related disparities, and healthcare providers.

Best or Promising Practice Guidance
• With all objectives, communities will emphasize best or promising practices. Policy and
environmental change strategies, particularly smoke-free workplace policies, should receive priority
consideration and resources.
• Consideration should be given to populations disparately affected by tobacco use and exposure.
Populations may include individuals exposed to secondhand smoke at work, individuals who
experience homelessness, people with substance abuse and chronic mental health problems, people




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who live in poverty or have lower levels of education, or racial, ethnic, or age-related groups that
have greater tobacco use and exposure.

Unacceptable Objectives
• While promotion of treating tobacco dependence services is acceptable, the provision of these
services or pharmacotherapies will not be accepted as objectives.
• Objectives specifying increased knowledge about the dangers of tobacco use will not be approved.
Wisconsin data indicates that the majority of individuals are knowledgeable about the dangers of
tobacco use.
  While the use of media strategies that relate to the achievement of objectives AND are used to
promote a local event are acceptable, the creation and implementation of a local tobacco control
media campaign must receive prior approval from both a regional contract administrator and Central
Office program staff . The purchase of local media to promote WI Wins activities is acceptable with
no prior approval.

Relationship to State Health Plan, Healthiest Wisconsin 2010:
Infrastructure Priorities:
• Community Health Process and Plans
• Coordination of State and Local Public Health System Partnerships
Health Priorities:
• Tobacco Use and Exposure
• Social and Economic Factors that Influence Health
• Access to Primary Health and Preventive Health Services
Essential Public Health Services:
• Monitor health status to identify community health problems.
• Diagnose and investigate health problems and health hazards in the community.
• Educate the public on current and emerging health issues.
• Promote community partnerships to identify and solve health problems.
• Create policies and plans that support community health efforts.
• Enforce laws and regulations that protect health and ensure safety.
• Link people to needed health services.
• Assure access to primary health care for all.
• Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
• Foster the understanding and promotion of social and economic conditions that support good
health.

References
Federal Regulations/Guidelines:
       2006 Surgeon General’s Report on the Health Consequences of Involuntary Exposure to
       Tobacco Smoke
       CDC Best Practices for Comprehensive Tobacco Control Programs
       Clinical Practices Guideline: Treating Tobacco Use and Dependence
       The Guide to Community Preventive Services: Tobacco Use Prevention and Control
       CDC Guidelines for School Health Programs to Prevent Tobacco Use and Addiction
       Disparities in Smoke-Free Workplace Policies Among Food Service Workers
       State of Wisconsin Statutes:



                                                  160
WI Statute s. 134.66 - Tobacco Retailer Compliance
Program Policies/Guidance:
Bringing Everyone Along: A Strategic Plan to Identify and Eliminate Tobacco-Related
2007-2009 Wisconsin Tobacco Prevention and Control Plan
Healthiest Wisconsin 2010: A Partnership Plan to Improve the Health of the Public
Are You Making A Difference? Document Outcomes in Tobacco




                                       161
                      Wisconsin Tobacco Prevention and Control Program
                                2008 Program Quality Criteria

Program quality criteria for the delivery of quality and cost-effective administration of health
care programs have been, and will continue to be, required in each public health program to be
operated under the terms of this contract. Contractees should indicate the manner in which they
will assure each criterion is met for this program. Those criteria include:

1. Assessment and surveillance of public health to identify community needs and to support
   systematic, competent program planning and sound policy development with activities focused at
   both the individual and community levels.
   A. Fully funded contractees shall use a community multi-year tobacco control action plan that:
      (1) Is based on a community assessment using available surveillance information, including
          statewide data sources and information regarding tobacco use collected by the local health
          department
      (2) Utilizes community information (local, regional and/or statewide) regarding tobacco use,
          including prevalence by youth and adults, exposure to secondhand smoke, and opinions
          about policy initiatives, populations with tobacco related disparities in the community and
          tobacco dependence treatment efforts
      (3) Incorporates policy and environmental interventions that support behavior change
      (4) Uses multiple approaches for tobacco use, prevention and control
      (5) Tracks environmental changes over time.

2. Delivery of public health services to citizens by qualified health professionals in a manner that is
   family-centered, culturally competent, and consistent with the best practices; and delivery of
   public health programs for communities for the improvement of health status.
   A. Contractees shall provide one or more of the following components:
      (1) Prevention of initiation of tobacco use
      (2) Protection against exposure to secondhand smoke
      (3) Promotion of linkages to tobacco dependence treatment resource services that work with
          health care providers and related services
      (4) Identify and reduce or eliminate disparities related to tobacco use

3. Record keeping for individual focused services that assures documentation and tracking of client
   health needs, response to known health care problems on a timely basis and confidentially of
   client information.
   A. Generally, individual records are not a part of tobacco control strategies; the focus is on
       population-based systems and environmental change. However, it is possible that individual
       records might pertain in some initiatives. If there are no individual records involved, this
       criterion is not applicable.




                                                 162
4. Information, education, and outreach programs, implementing and utilizing best or promising
       practices, forming community partnerships and developing local earned media that is intended
       to address known health risks in general and certain target populations to encourage
       appropriate decision making by those at risk and to affect policy and environmental changes
       at the community level.

5. Coordination with related tobacco control initiatives and other health programs to ensure that
   identified public health needs are addressed in a comprehensive, cost-effective manner across
   programs and throughout the community.

6. A referral network sufficient to assure the dissemination of information, accessibility and timely
   provision of services and follow-up of identified public health needs.

7. Provision of guidance to staff through training and technical assistance sufficient to ensure
   quality health and cost effective program administration.
   A. Contractees must have written program information and incorporate current guidelines and
        standards for tobacco prevention and control in program planning. Guidelines and standards
        are those described in the following documents:

       Federal Regulations/Guidelines:
         2006 Surgeon General’s Report on the Health Consequences of Involuntary Exposure to
         Tobacco Smoke
       • CDC Best Practices for Comprehensive Tobacco Control Programs
            http://www.cdc.gov/tobacco/bestprac.htm
       • Clinical Practices Guideline: Treating Tobacco Use and Dependence The Guide to
       Community Preventive Services: Tobacco Use Prevention and Control
            http://www.cdc.gov/tobacco/comguide.htm
       • CDC Guidelines for School Health Programs to Prevent Tobacco Use and Addiction
            http://www.cdc.gov/tobacco/research_data/interventions/rr4302.pdf
.      • Disparities in Smoke-Free Workplace Policies Among Food Service Workers
            http://ash.org/foodserviceworkers.html

       State of Wisconsin Statutes:
         Wisconsin’s Clean Indoor Air Act (ss.101.123)
         Tobacco Retailer Compliance with Wisconsin Law (ss.134.66)
         Tobacco Compliance Investigations Law (ss.254.916)

       Program Policies:
       • Bringing Everyone Along: A Strategic Plan to Identify and Eliminate Tobacco-Related
         Disparities in Wisconsin, WI Department of Health and Family Services
            http://www.dhfs.state.wi.us/tobacco/pdffiles/DisparitiesStrategicPlan.pdf
       • 2007-2009 Wisconsin Tobacco Prevention and Control Plan

       • Wisconsin Tobacco Prevention and Control Program, Division of Public Health
            http://dhfs.wisconsin.gov/tobacco/
         Healthiest Wisconsin 2010: A Partnership Plan to Improve the Health of the Public



                                                 163
             http://dhfs.wisconsin.gov/statehealthplan/

   B. Contractees will participate in regional and state sponsored technical assistance training
      events to meet identified specific needs.

   C. Contractees are expected to attend regional coalition coordinator training and/or networking
      sessions.

8. Financial management practices sufficient to ensure accurate eligibility determination,
   appropriate use of state and federal funds, prompt and accurate billing and payment for services
   provided and purchased, accurate expenditure reporting, and when required, pursuit of third party
   insurance and Medical Assistance coverage for services provided.
    A. Lobbying is not an appropriate use of funds.

9. Data collection, analysis, and reporting to ensure program outcome goals are met or to identify
   program management problems that need to be addressed.

   A. Contractees must report monitoring outcome information in support of identified program
      objectives at mid-year and year end.

   B. For WI Wins activities, contractees must file Palm OS real-time reports and quarterly
       reports within 15 days of the end of the calendar quarter.




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                           Tobacco Prevention and Control Program
                                         Objectives

REQUIRED Objective for Fully Funded Tobacco Control Coalitions and Coalitions that
receive $10,000:

                         (#1) Tobacco Control/Outreach and Education

   A. By December 31, 2008, (insert number) strategies in support of tobacco control
      interventions in Wisconsin will be implemented by the (insert name of Coalition).

   B. A report to include: 1) the number and description of strategies implemented by the (insert
      name of Coalition) in support of tobacco control interventions, 2) results achieved, 3)
      Coalition members involved, and 4) copies of related any educational or media advocacy
      materials.

   C. There is no designated value range for this objective. For a value under $5,000, two or more
      strategies must be implemented by a coalition. Local tobacco control coalition efforts are an
      important component of the tobacco control movement at the statewide level in Wisconsin.
      The involvement of community residents and coalition members in education and outreach
      activities are key elements to sustaining a comprehensive tobacco control program. Best
      practices for community programs include participation in the promotion and support of
      tobacco control policies, programs and services including educating and mobilizing
      individuals, engaging leadership into dialogue and communication, offering opportunities for
      community-based activities and actions and providing technical assistance and resources.

   D. Agency records.

   E. This objective is in response to local community concerns regarding the time and resources
      required to participate in the implementation of activities and strategies supportive of
      comprehensive tobacco control programs at the state level. The Tobacco Prevention and
      Control Program recommends the following activities to help ensure success of this
      objective: media advocacy efforts, such as letters to the editor, editorial board visits, press
      conferences or press releases; active participation on statewide tobacco control workgroups
      and committees; organization of local meetings or presentations supporting tobacco control
      and prevention with policy makers; educational efforts with community residents and
      leadership (personal meetings or visits); recruiting and training of individuals to promote
      and support tobacco control policies, programs and services. These activities are important
      components in an overall effort focused on the sustainability of tobacco control and
      prevention in Wisconsin. Educational efforts for this objective should be targeted on those
      that increase knowledge of community leaders regarding the impact of tobacco control
      interventions through best practice strategies which lead toward the achievement of statewide
      tobacco control program and public health goals.




                                                165
The following Template Objectives meet the Smoke-Free Air Requirement for Fully Funded
Tobacco Control Coalitions:

                    (#2) Tobacco Control/Protect against Secondhand Smoke

A. By December 31, 2008 (insert number) community leaders or residents will actively participate
   in the development or implementation of a smoke-free public policy for (insert name of
   community or county).

B. A report to document or include: 1) names of the community leader or residents and their
   affiliation and a summary of their active participation in the smoke-free public policy initiatives,
   and 2) a copy of the public policy developed and/or implemented by (insert name of
   community or county).

C. There is no designated value range for this objective. For a value under $5,000, five or more
   community leaders or residents must actively participate in the implementation of a smoke-free
   public policy. In the context, explain how this objective relates to your community’s multi-
   year action plan and shows progress toward effective policy change.

D. Agency records.

E. This objective can be used toward fulfillment of the Smoke-Free Air Requirement for Fully
   Funded Tobacco Control Coalitions. The Tobacco Prevention and Control Program recommends
   the following activities to help ensure success of this objective. Educate and involve community
   leaders and obtain participation. Support and provide opportunities for involvement (e.g.,
   financial or in-kind contributions, obtain organizational endorsements, chairperson, lead in local
   district/ward, financial or in-kind contributions, obtain organizational endorsements, petition
   signing, meetings with council members). Conduct presentations and personal meetings and
   visits to educate and obtain endorsements and participation. Target community leaders from
   public health department and board of health, hospitals/clinics including physicians, youth
   groups, schools, senior citizen groups, teachers, churches and other health-related and
   community-based organizations.




                                                  166
(#3) Tobacco Control /Protect against Secondhand Smoke

A. By December 31, 2008 (insert number) (choose any; municipality(ies), town(s), village(s)) in
   (insert name) County will newly adopt smoke free public policies for (its/their) government
   buildings, vehicles and grounds.

B. A report to include copies of public policy statements newly adopted by (insert name) County
   governmental units related to clean indoor air standards for their buildings, vehicles and grounds.

C. There is no designated value range for this objective. In context, explain how this objective
   relates to your community’s multi-year action plan and shows progress toward effective
   policy change.

D. Agency Records.

E. This objective can be used toward fulfillment of the Smoke-Free Air Requirement for Fully
   Funded Tobacco Control Coalitions.




                                                 167
(#4) Tobacco Control /Protect against Secondhand Smoke

A. By December 31, 2008 (insert number) community(ies) will implement an education campaign
   to address community-wide smoke-free air policy change.

B. A report to document the education campaign conducted including: 1)identified community(ies),
   2) number and description of activities implemented, 3) number of individuals reached, and 4)
   results achieved, including earned media.

C. There is no designated value range for this objective. In the context, explain how this
   objective relates to your community’s multi-year action plan and shows progress toward
   effective policy change.

D. Agency Records.

E. This objective can be used toward fulfillment of the Smoke-Free Air Requirement for Fully
   Funded Tobacco Control Coalitions. Activities for this objective include the following. Conduct
   community awareness and education activities. Provide training in smoke-free air policy and
   secondhand smoke. Designate media spokespersons and provide media training if needed.
   Conduct presentations and personal meetings to educate and obtain support. Target community
   leaders from public health departments and boards of health, hospitals/clinics including
   physicians, youth groups, schools, senior citizen groups, teachers, churches and other health-
   related and community-based organizations.




                                               168
The following Template Objectives meet the Coalition Building and/or Maintenance
Requirement for Fully Funded Tobacco Control Coalitions:

   (#5) Coalition Building and Maintenance Multi-Year Objective Years One through Three

A. By December 31, 2010, (X) strategies to support local tobacco prevention and control local
   coalition building or maintenance will be implemented by the (insert name of the coalition,
   health department or agency).

B. A report to document the number of strategies implemented to support tobacco prevention and
   control local coalition building or maintenance in (select from the following: year one, year two
   or year three) to include a description of the specific strategies with dates, number of individuals
   involved, activities implemented and results achieved.
C. Select the appropriate year for the context (one, two, or three)
Context Year One: There is no designated value range for this objective. For a value under
$5,000, two or more strategies must be implemented by a coalition, health department or agency.
This is year one of a multi-year objective and is defined by key strategies and activities to build and
maintain the infrastructure of local tobacco control coalitions in communities. The outcome in year
one is to build and maintain a coalition that is well-organized and defined by a structure that includes
the following suggested key components: an agreed upon mission, a system of governance (i.e., by-
laws), a description of member roles and responsibilities, regular and on-going systems of
communication, an established recruitment and orientation process, and the establishment of an
evaluation process for coalition functioning. A well-organized, broad based local tobacco control
coalition is a best practice strategy for tobacco prevention and control efforts. Coalitions broaden
support for projects, provide volunteers for activities, and maximize the power of participating
groups through joint action. Coalitions become especially important when engaging in broad
community actions to change public policy. Communities must maintain coalitions that include
members who actively participate, are supportive of the coalition’s primary goals and represent a
diversity of individuals and organizations who reflect their community.
Context Year Two: There is no designated value range for this objective. For a value under
$5,000, two or more strategies must be implemented by a coalition, health department or agency.
This is year two of a multi-year objective and is defined by key strategies and activities to continue
to build and maintain a diverse membership for local tobacco control coalitions. The outcome in
year two is to recruit and actively engage individuals and agencies who are representative of various
sectors and populations in communities, such as schools, hospitals, businesses, non-profit agencies,
community volunteers, faith-based organizations and government entities. A well-organized, broad
based local tobacco control coalition is a best practice strategy for tobacco prevention and control
efforts. Coalitions broaden support for projects, provide volunteers for activities, and maximize the
power of participating groups through joint action. Coalitions become especially important when
engaging in broad community actions to change public policy. Communities must maintain
coalitions that include members who actively participate, are supportive of the coalition’s primary
goals and represent a diversity of individuals and organizations.




                                                  169
Context Year Three: There is no designated value range for this objective. For a value under
$5,000, two or more strategies must be implemented by a coalition, health department or agency.
This is year three of a multi-year objective and is defined by key strategies and activities to maintain
a well-functioning coalition. The outcome in year three is the full engagement of individual
members and organizations in tobacco prevention and control activities supportive of coalition
objectives as well as regional and statewide efforts. A well-organized, broad based local tobacco
control coalition is a best practice strategy for tobacco prevention and control efforts. Coalitions
broaden support for projects, provide volunteers for activities, and maximize the power of
participating groups through joint action. Coalitions become especially important when engaging in
broad community actions to change public policy. Communities must maintain coalitions that
include members who actively participate, are supportive of the coalition’s primary goals and
represent a diversity of individuals and organizations.
Input Activities: Select the appropriate year for the Input Activities (one, two, or three)
Input Activities Year One: Suggested strategies include those focused on recruitment, orientation
and retention of members; regular and on-going communication methods; the development and
maintenance of a coalition structure, such as by-laws or governance, mission and vision definition,
volunteer job descriptions; the planning, implementation and conducting periodic evaluation of
training opportunities; outreach and promotion of coalition activities and successes both internal and
external; conducting periodic evaluation of coalition functioning; and member assessment.

Input Activities Year Two: Suggested strategies include recruitment, orientation and retention of
members; involvement of members in leadership positions (such as chairpersons or facilitation of
subcommittees); implementation of community mobilization events; development and use of
coalition educational and promotional materials; networking to increase membership; assignment
and acceptance of specific tasks for the completion of coalition objectives; and conducting trainings
to increase coalition members knowledge regarding best practices for tobacco prevention and
control.

Input Activities Year Three: Suggested strategies include shared or situational leadership for
coalition objectives and activities; demonstrated opportunities for decision-making and participation
in coalition functions and maintenance; outreach and securing of both in-kind and financial support
(other than DPH funding); recruitment and maintenance of relationships (both internal and external)
with other community and statewide organizations supportive of tobacco prevention and control;
recognition, celebration and promotion of coalition successes; and the conduct of an on-going
evaluation process with efforts for improvement.

D. Agency Records

E. This is a multi-year objective for local tobacco prevention and control coalitions that can be used
   over a three-year period. The overall goal is to create and sustain a coalition whose members are
   actively engaged in tobacco prevention and control efforts at the local, regional and state levels.
   Strategies are defined as major approaches which are composed of individual activities
   implemented to support the overall objective. For example, a strategy for Year 1 might be
   orientation for new members. This strategy could be supported by several activities such as
   letters and meetings of introduction to potential new agencies, announcements in local



                                                  170
newspapers and new member training. The Tobacco Prevention and Control Program can
provide training and technical assistance and resources in the area of coalition building and
maintenance.




                                             171
                                 (#6) Coalition Building Objective

A. By December 31, 2008, XX new community members or organizations will participate in XX
   initiative(s) of the (insert name of coalition).

B. A report to include the names of the new members and organizations and a description of the
   initiative(s) they participated in with documentation of the new members’ specific role(s).

C. There is no designated value range for this objective. For a value under $5,000, three or more
   new community members or organizations must participate in one or more initiative(s).
   Coalitions are at the heart of social organizing strategies that lead to environmental and policy
   change in tobacco prevention and control. Building and sustaining coalitions involves:
   recruiting new members, organizations, and constituencies; orienting new members; engaging
   those new and existing members in initiatives that are meaningful for the member and meet
   coalition goals and objectives; and evaluating coalition participation and processes.

D. Agency records

E. The Tobacco Prevention and Control Program can provide training and technical assistance and
   resources in the area of coalition building and maintenance.




                                                 172
                 (#7) Example of Coalition Building and Maintenance Objective

A. By December 31, 2008, (X) strategies to support tobacco prevention and control local coalition
building or maintenance will be implemented by the (insert name of the coalition, health department
or agency).

B. A report to document the number of strategies implemented to support tobacco prevention and
control local coalition building or maintenance to include a description of the specific strategies with
dates, number of individuals involved, activities implemented and results achieved.

C. There is no designated value range for this objective. For a value under $5,000, two or more
strategies must be implemented by a coalition, health department or agency. A well-organized,
broad based local tobacco control coalition is a best practice strategy for tobacco prevention and
control efforts. Coalitions broaden support for projects, provide volunteers for activities, and
maximize the power of participating groups through joint action. Coalitions become especially
important when engaging in broad community actions to change public policy. Communities must
maintain coalitions that include members who actively participate, are supportive of the coalition’s
primary goals and represent a diversity of individuals and organizations.

Input Activities: suggested strategies include those focused on recruitment, orientation and retention
of members; regular and on-going communication methods; the development and maintenance of a
coalition structure, such as by-laws or governance, mission definition, volunteer job descriptions; the
planning, implementation and evaluation of training opportunities; outreach and promotion of
coalition activities and successes both internal and external; and conducting periodic evaluation of
coalition functioning.

D. Agency Records.

E. The Tobacco Prevention and Control Program can provide training and technical assistance and
   resources in the area of coalition building and maintenance.




                                                  173
REQUIRED Objective for those agencies accepting the WI Wins funding:

  (#8) Tobacco Control/Retailer Compliance with Restriction on Sales to Minors (WI Wins)

A. By December 31, 2007, (insert number) compliance investigations at licensed tobacco retail
   vendors, 5 related public outreach activities, and 5 related media outreach activities will be
   completed in (choose: (insert name) County - or - the jurisdiction of (insert name) Health
   Department) according to the prescribed schedule.

B. Palm OS real-time reports, and quarterly reports filed with WI Wins within 15 days of the end of
   the calendar quarter to list the number of compliance investigations completed, the number of
   citations issued (if any), and the number and description of related public and media outreach
   activities.

C. The value that will be assigned to this objective equals $50 times the number of compliance
   investigations contracted for. The WI Wins Campaign is an intervention program designed to
   help the State of Wisconsin stay in compliance with requirements of the federal Synar
   Regulation. A compliance investigation must use the Recognition and Reminder (R&R) protocol
   which is a positive reinforcement program designed to support retailers who “do the right thing”
   and refuse sales to underage youth and remind those who would sell to minors of the legal and
   health consequences of such sales. The prescribed schedule is defined as completing half of the
   required investigations no later than July 31, 2007. There must be a total of 5 media and 5 public
   outreach activities conducted during the contract cycle.

D. Palm OS Data and quarterly reports which include a description of related public and media
   outreach activities.




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The following Template Objectives are not required:

  (#9) Tobacco Control/Retailer Compliance with Restriction on Sales to Minors (WI Wins)

A. By December 31, 2007, enforcement activities will be implemented by (name of agency issuing
   citations) in (insert name(s) of municipalities) in collaboration with WI Wins Tobacco
   compliance inspections.

B. A copy of the Memorandum of Understanding with law enforcement or a copy of the local
   ordinance granting citation authority. Palm OS real-time reports, and quarterly reports filed with
   WI Wins within 15 days of the end of the calendar quarter to list the number of compliance
   investigations completed and number of citations issued.

C. The value that will be assigned to this objective equals $4 times the number of compliance
   investigations contracted for. Enforcement activities will be integrated into the WI Wins
   protocols. WI Wins is an intervention program designed to help the State of Wisconsin stay in
   compliance with requirements of the federal Synar Regulation as well as reduce youth tobacco
   consumption. These efforts are strengthened through increased enforcement of local and state
   laws prohibiting the sale of tobacco to minors.

D. Agency records, Palm OS Data reports and quarterly reports which include a description of
   related public and media outreach activities.




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(#10) Tobacco Control /Protect against Secondhand Smoke

A. By December 31, 2007, (insert number) community organizations or programs in (insert name
   of jurisdiction) that serve women of childbearing age, children, or families with children will
   implement a smoke-free homes campaign with their clients.

B. A report to include a summary of the community organizations that implemented a smoke-free
   homes campaign, the number of client interventions conducted, and a summary of earned media.


C. There is no designated value range for this objective. For a value under $5,000, two or more
   community organizations or programs that serve women of childbearing age, children, or
   families with children must implement a smoke-free homes campaign with their clients. In the
   context, explain how this objective relates to your community’s multi-year action plan and
   shows progress toward effective policy change. The focus of this objective is for populations
   with demonstrated disparities for tobacco use including women of childbearing age, families
   with children under age 18, lower socioeconomic status and certain racial/ethnic groups. Smoke-
   free home initiatives should include education on the dangers of secondhand smoke exposure,
   earned media, commitment by families to implement smoke-free policies in their homes and
   vehicles, and referral to cessation resources including the Wisconsin Tobacco Quit Line.

D. Agency records.




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(#11) Tobacco Control/Prevent Initiation

A. By December 31, 2007, (insert number) anti-tobacco advocacy initiatives will be implemented
   by (insert name of county or municipality) youth.

B. A report to include: 1) documentation of the number of anti-tobacco advocacy initiatives
   implemented by (insert name of county or municipality) youth, 2) a description and results of
   activities conducted including the names or number of youth involved, and 3) copies of media
   advocacy efforts.

C. There is no designated value range for this objective. For a value under $5,000, a two or more
   anti-tobacco advocacy initiatives must be implemented by youth. In the context, explain how
   this objective relates to your community’s multi-year action plan and shows progress
   toward effective policy change.

D. Agency records.

E. Advocacy is the act of supporting a particular cause, issue or idea while attempting to persuade
   others to take action. Education efforts are those whose outcome is solely focused on increasing
   knowledge, such as classroom or community presentations. Individuals and organizations can
   engage in advocacy. An example of advocating for a particular issue is attempting to persuade
   others of the importance of implementing smoke-free air policies. Advocacy activities can
   include writing letters to the editor, contacting community leaders, organizing community events
   or actions, such as human billboards or other means to communicate one's views for the purpose
   of social or health changes. The FACT website (www.fightwithfact.com) can provide additional
   ideas for advocacy initiatives.




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(#12) Tobacco Control /Prevent Initiation

A. By December 31, 2007, (insert number) public or private entities in (insert name of county or
   municipality) will implement a tobacco-related policy change influenced by efforts involving
   youth-led activism.

B. A report to include: 1) a list of the public or private entities in (insert name of county or
   municipality) that implemented a tobacco-related policy change, 2) the tobacco-related policy
   change they implemented, and 3) documentation of related youth-led activities.

C. There is no designated value range for this objective. In the context, explain how this
   objective relates to your community’s multi-year action plan and shows progress toward
   effective policy change.

D. Agency records.

E. Examples of policy change can be: pharmacies no longer selling tobacco products, community
   events adopting policies that prohibit tobacco company sponsorship, tobacco retailers who place
   tobacco products behind the counter, tobacco retailers who decrease the amount of in-store
   tobacco ads and promotions, restricting tobacco industry promotion at community festivals and
   sporting events.




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(#13) Tobacco Control /Prevent Initiation
A. By December 31, 2007, (insert number) (choose: school districts - or - schools) in (insert
   name of county or municipality) will newly implement or maintain a tobacco-related peer
   education program or youth-led movement.

B. A report to include: 1) a list of the (insert name of county or municipality) (choose: school
   districts - or - schools) that implemented a tobacco-related peer education program or youth-led
   movement, and 2) a brief description of the related efforts including dates, activities, number of
   youth involved, and number of youth reached.

C. There is no designated value range for this objective. For a value under $5,000, two or more
   school districts or schools must newly implement or maintain a tobacco-related peer education
   program or youth-led movement. In the context, explain how this objective relates to your
   community’s multi-year action plan and shows progress toward effective policy change.
   Identify the tobacco-related peer education program or youth-led movement that you will
   be implementing.

D. Agency records.

E. Examples include peer education programs such as TATU (Teens Against Tobacco Use,
   American Lung Association) and youth-led movements such as FACT (Fighting Against
   Corporate Tobacco, Wisconsin’s youth-led movement).




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               (#14) Tobacco Control/Promote Tobacco Dependence Treatment
A. By December 31, 2007, (insert number) (insert name) WIC clients will be referred to the
   Wisconsin Tobacco Quit Line, Fax to Quit Program or other evidence-based tobacco dependence
   treatment services.

B. A report to include documentation of the number of (insert name) WIC clients who have bee
   referred to the Wisconsin Tobacco Quit Line, Fax to Quit Program, or who accessed other
   evidence-based services.

C. Acceptable value range for this objective is $100 per WIC client. In the context, explain how
   objective relates to community’s multi-year action plan and shows progress toward
   effective policy change. WIC staff will be educated on the Wisconsin Tobacco Quit Line, Fax
   to Quit Program or relevant evidence-based strategies. If one does not already exist, an
   implementation plan, including a protocol on how participants will be recruited and receive
   follow-up, will be developed. If one exists, it should be reviewed and revised in order to assure
   effective maintenance of the protocol. Technical assistance will be provided and sample
   policies/protocols shared for implementation if requested.

D. Agency records.




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                (#15) Tobacco Control/Promote Tobacco Dependence Treatment

A. By December 31, 2007, (insert number) (insert name of county or municipality) [choose
   either: worksite(s) or community based organization(s)] who serve populations with
   disparities in tobacco will newly implement or maintain an existing policy to identify and refer
   clients who use tobacco to the Wisconsin Tobacco Quit Line, Fax to Quit Program, or other
   evidence-based tobacco dependence treatment services.

B. A report to include the list of (insert name of county or municipality) organization(s) that
   newly implemented or maintained the policy and a copy of the protocol, or internal memo
   detailing implementation or maintenance of referrals to the Quit Line or other tobacco
   dependence treatment services. Reports from the Wisconsin Tobacco Quit Line and the Fax To
   Quit program can also be submitted to demonstrate utilization of the Quit Line resources.

C. There is no designated value range for this objective. For a value under $5,000, two or more
   worksites or community-based organizations who serve populations with disparities in tobacco
   will newly implement or maintain an existing policy to identify and refer clients who use tobacco
   to the Wisconsin Tobacco Quit Line, Fax to Quit Program, or other evidence-based tobacco
   dependence treatment services. Targeted organizations will include faith-based, private and
   public agencies, and non-profit agencies, especially those serving populations with a disparity in
   the burden of tobacco use. In the context, explain how objective relates to community’s
   multi-year action plan and shows progress toward effective policy change. Organizations
   will receive education on tobacco dependence and its treatment among populations with
   disparities in the burden of tobacco, including Medical Assistance coverage of pharmacotherapy
   and counseling.

D. Agency records.

E. Technical assistance will be provided and sample policies and protocols shared for
   implementation or maintenance of the policy appropriate for each targeted population.




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            (#16) Tobacco Control/Healthcare Providers and Systems-based Change

A. By December 31, 2007, (insert number) (insert name of county or municipality) [choose
   from the following: health care, substance abuse, or mental health facility(s),
   department(s), or system(s)] will newly implement or improve a system of addressing tobacco
   dependence following the 5 A's protocol which includes; ask, advise, assess, assist, arrange for
   follow-up.

B. A report to include a list of (insert name of county or municipality) facilities, departments or
   systems that newly implemented or improved a system of addressing tobacco dependence. The
   report will also include dates of any trainings conducted, names of those who attended,
   information regarding the implementation or maintenance of evidence-based cessation support,
   copies of internal policy, protocol, memo or minutes/notes of team meetings, internal chart
   review, tobacco dependence treatment counseling and pharmacotherapy claims, or results of
   evaluation.

C. There is no designated value range for this objective. In the context, explain how objective
   relates to community’s multi-year action plan and shows progress toward effective policy
   change. The coalition will facilitate the provision of training and technical assistance on the
   application of the 5 A’s. This may include but is not limited to trainings and technical assistance
   on sample policies, protocols and continuous program improvement plans.

D. Agency records.

E. Coalitions should support the use of new or existing multi-disciplinary teams to foster system
   development or maintenance.




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                                   (#17) Evaluation Objective:

A. By December 31, 2008, an evaluation plan for one component of local tobacco prevention and
control programming will be implemented by the (insert name of coalition).

B. A report to include: 1) a copy of the evaluation plan for one local component of tobacco
prevention and control programming for the (insert name of coalition), 2) results of the evaluation
conducted, 3) coalition partners and coalition members involved, and 4) copies of related evaluation
materials

C. There is no designated value range for this objective. Local program evaluation is an important
component of an effective local tobacco prevention and control program. Through program
evaluation, local community coalitions can track the effectiveness of activities and outcomes to
make informed decisions about future program development. Program evaluation is also an
important way to document successes and promising approaches to tobacco prevention and control.

D. Agency Records.

E. The Tobacco Prevention and Control Program can provide written or on-line resources and
training and technical assistance in the area of local program evaluation. Examples of components
that local communities might evaluate are alternative-to-suspension program, local Quit Line
outreach, new or promising practices to outreach to populations disparately affected by tobacco use
and exposure, coalition member satisfaction, smoke-free air attitudes and behaviors of community
residents and leaders.




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                                 (18) Earned Media Plan Objective

A. By December 31, 2008, an earned media advocacy plan in support of local coalition tobacco
control goals and objectives will be implemented by the (insert name of the coalition).

B. A report to include: 1) a copy of the earned media advocacy plan in support of local coalition
tobacco control goals and objectives, 2) media results achieved including the medium, date, and
projected number reached, 3) copies of any related media advocacy materials.

C. There is no designated value range for this objective. Media advocacy is an important strategy in
achieving successful policies in tobacco prevention and control. It is an important strategy for
educating and influencing the public and policymakers.

D. Agency Records

E. The WI Tobacco Prevention and Control Program recommends the following activities to ensure
the success of this objective: letters to the editor, editorial board visits, press conferences or press
releases, educate local media, the public and policy makers about local control, develop and execute
an earned media plan educating the public and policy makers about local control of public health
issues, educate the media on successful tobacco control program outcomes, provide the media with
updates on relevant and current tobacco control research reports, findings and information, host an
event for media and stakeholders hold a media question and answer activity or briefing after a
tobacco control event, send media advisories that identify local spokespersons who would be
available for comment on a particular tobacco control event, news item, or report, set up interviews
with local experts on relevant tobacco control news events or reports for radio or television news
programs, organize guest columns to provide education on tobacco control report recommendations,
work with print and television reporters to develop feature stories, and conduct outreach for
placement of relevant tobacco control articles in small news outlets, newsletters, or community list-
serves or other organizations’ newsletters or publications. The Tobacco Prevention & Control
Program can provide training and technical assistance in the media advocacy planning,
implementation and evaluation.




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WISCONSIN WELL WOMAN PROGRAM (WWWP) – 2008

    Program Boundary Statement

    Program Quality Criteria

    Program Objectives




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                      Wisconsin Well Woman Program (WWWP)
                            Program Boundary Statement

For each performance-based contract program, the Division of Public Health has identified a
boundary statement. The boundary statement sets the parameters of the program within which the
LPHD/tribe/agency will need to set its objectives. The boundaries are intentionally as broad as
federal and state law permit to provide maximum flexibility, however if there are objectives or
program directions that the program is not willing to consider or specific programmatic parameters;
those are included in the boundary statement.

LPHDs/tribes/agencies are encouraged to leverage resources across categorical funding to achieve
common program goals. (To date, the WWWP has not identified other programs that its program
funds can be combined with.)

Program Boundary Statement:
The Wisconsin Well Woman Program (WWWP) provides breast and cervical cancer screening
services, along with referral, follow-up and patient education to women meeting the following
criteria:

   •   Ages 45-64 (emphasis on ages 50-64 for mammography);
           o There are exceptions for women ages 35-44 with breast abnormalities;
           o There are also exceptions for women ages 35-44 who are enrolled in the Family
               Planning Waiver and have breast abnormalities;
   •   At or below 250% of the federal poverty guidelines;
   •   No health insurance, or insurance doesn’t cover routine check-ups and screening, or unable
       to pay high deductibles and co-payments.

The WWWP will screen clients for the following conditions:

              •   Breast Cancer
              •   Cervical Cancer

The WWWP also covers testing for Multiple Sclerosis (MS), for women enrolled in the WWWP,
who have high-risk symptoms or signs of MS or have been told they have MS.

Long-term Program Goal: To reduce mortality from breast and cervical cancers by increasing the
number of low-income underserved uninsured women who are routinely screened, and by improving
the quality of screening, referral and follow-up.

Annual Program Goal: Ensure that all WWWP clients with abnormal breast and/or cervical cancer
screening test results receive timely diagnostic examinations.




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Target Populations
   • Women between the ages of 50 and 64 years old for mammography
   • Women who have never had a Pap test or have not had one within the last five years
   • African American women
   • Hispanic/Latina women
   • Asian women (primarily Hmong and other Southeast Asian women)
   • Women living in rural areas
   • Women who partner with women

References:

Federal Regulations/Guidelines:
Public Law 101-354
Public Law 105-340
Public Law 106-354


State of Wisconsin Statutes:
Chapter 255.06(2)

Program Policies:
Please see:
   • WWWP Policy and Procedures Manual
   • August 30, 2005 program update (WWWP Funding Allocations for CY 06 Consolidated
       Contracts)
   • January 18, 2006 program update (Important Changes in WWWP Eligibility)
   • February 23, 2006 program update (Important Changes in WWWP Eligibility and Expanded
       Services – Questions and Answers)

Optimal or best practice guidance:
  1. A minimum of 75% of all mammograms should be provided to women 50-64 years old.
  2. The WWWP would like to increase cervical cancer screening for women never or rarely
     screened.
  3. At least 20% of WWWP clients receiving Pap tests meet the criteria of being never or rarely
     screened.

Unacceptable Proposals:
Enrollment and/or screening of women under the age of 35 (please see program exceptions for
women ages 35-44)

Relationship to State Health Plan: Healthiest Wisconsin 2010:
   1. Coordination of state and local public health system partnerships
   2. Access to primary and preventive health services
   3. Elimination of health disparities




                                               187
                                 Wisconsin Well Woman Program
                                  2008 Program Quality Criteria

Generally high program quality criteria for the delivery of quality and cost-effective administration
of health care programs have been, and will continue to be, required in each public health program to
be operated under the terms of this contract. Contractees should indicate the manner in which they
will assure each criterion is met for this program. Those criteria include:

Assessment and surveillance by public health to identify community needs and to support
systematic, competent program planning and sound policy development.

Delivery of public health services to citizens by qualified health professionals in a manner that is
family centered, culturally competent, and consistent with the best practices.

   a. The following information applies to breast cancer screening only:

       (1)   Each coordinating agency must ensure they focus their breast cancer screening outreach
             efforts on women ages 50-64. Seventy-five percent of women receiving mammograms
             should be between the ages of 50 and 64.

       (2)   Each coordinating agency must document attempts to contact annually 100% of the
             women enrolled in the program, where rescreening is clinically indicated, to arrange
             mammography rescreening examinations and must assure that at least 50% of these
             women are rescreened for breast cancer.

       (3)   Each coordinating agency must follow the program standards for median days between
             abnormal mammography results and final diagnosis for women enrolled in the
             program. The median days between an abnormal mammography result and final
             diagnosis shall be less than 60 days, with not more than 25% over 60 days.

       (4)   Each coordinating agency must document attempts to follow-up 100% of the women
             reported to have abnormal or suspicious breast cancer screening findings to assure they
             understand the need for further evaluation and to assist and refer them for appropriate
             diagnosis and treatment.

   b. The following information applies to cervical cancer screening only:

       (1)   Each coordinating agency must follow the program standards for median days between
             abnormal Pap smear results and final diagnosis for women enrolled in the program.
             The median days between an abnormal Pap smear result and final diagnosis shall be
             less than 60 days, with no more than 25% over 60 days.

       (2)   Each coordinating agency must document attempts to follow-up 100% of the women
             reported to have abnormal or suspicious cervical cancer screening findings to assure
             they understand the need for further evaluation and to assist and refer them for
             appropriate diagnosis and treatment.



                                                 188
Record keeping that assures documentation and tracking of client health care needs, response to
known health care problems on a timely basis, and confidentiality of client information.

   Each coordinating agency must maintain a paper system or a computerized tracking database of
   women enrolled in the county. At a minimum, the database should include annual eligibility
   determination, results of screening services provided, documentation of follow-up in situations
   of abnormal screening results, and recommended rescreening dates.

Information, education, and outreach programs intended to address known health risks in the
general and certain target populations to encourage appropriate decision making by those at risk.

   Each coordinating agency must document contacts made to recruit new WWWP clients with
   special emphasis on women 50-64 years of age. The agency must provide information and
   education about covered services and rescreening at appropriate intervals.

Coordination with related programs to ensure that identified public health needs are addressed in a
comprehensive, cost-effective manner across programs.

A referral network sufficient to assure the accessibility and timely provision of services to address
identified public health care needs.

   a. Each coordinating agency is responsible for recruiting new providers to the WWWP as
      needed.

   b. Women diagnosed with breast and/or cervical cancer will be referred to Well Woman
      Medicaid as appropriate.

   c. Each coordinating agency must document contacts with each of its WWWP providers as
      needed, but at least quarterly, to access program status, identify needs, and share information.

Provision of guidance to staff through program and policy manuals and other means sufficient to
ensure quality health care and cost-effective program administration.

Financial management practices sufficient to ensure accurate eligibility determination, appropriate
use of state and federal funds, prompt and accurate billing and payment for services provided and
purchased, accurate expenditure reporting, and, when required, pursuit of third-party insurance and
Medical Assistance coverage of services provided.

   a. Each coordinating agency must ensure accurate eligibility determination whether completed
      by the local coordinating agency or the provider.

   b. Each coordinating agency must document attempts to ensure that billing problems between
      the providers and the fiscal agent are resolved.




                                                 189
   c. Each coordinating agency is responsible for educating clients on program-covered services
      and client responsibility for non-covered services.

   d. Each coordinating agency is responsible for educating providers on the WWWP and billing
      practices.

Data collection, analysis, and reporting to ensure program outcome goals are met or to identify
program management problems that need to be addressed.




                                               190
                                   WWWP/General Screening
                                       Objectives

Objective Statement: By December 31, 2008, (insert number) (insert name) County residents
ages 35-64 years will be screened through the Wisconsin Well Woman Program.

Deliverable: An agency generated report to document an unduplicated count of (insert name)
County residents ages 35-64 years who received screening services through the Wisconsin Well
Woman Program.

Context: Screening services supported by the Wisconsin Well Woman Program include breast
cancer and cervical cancer. Refer to the program boundary statement and program updates for
exceptions for women ages 35-44.

The Wisconsin Well Woman Program also provides staged assessment for Multiple Sclerosis for
high risk women.

Data Source for Measurement: Agency records.

For Your Information: Unduplicated refers to an individual client or patient counted only once
toward the measurement of an objective.




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