Nursing Shortage Initiatives: Philanthropic & Gov't Sectors
January 29, 2008 - The supply of nurses graduating from local schools is not keeping pace with both the demand for new nurses in hospitals and with the number of school applicants. Therefore, there is an increasing shortage of nurses in Illinois. The state is launching the Regional Nursing Workforce Initiative, a public-private approach to addressing the major causes of the shortage at both the regional and state level. The Health Program Affinity Group hosted this meeting with Initiative leader Steven Frenkel, Deputy Chief of Staff with the Office of Governor Blagojevich, to discuss the plan and how to best address the shortage from a philanthropic base. Organizations with interest in job training, higher education, or economic development were encouraged to attend.

The Health Program Affinity Group hosted a session on Nursing Shortage Initiatives: The Philanthropic and Government Sector. The discussion was introduced by Anna Laubach, Illinois Children's Healthcare Foundation, and Mark Ishaug, AIDS Foundation of Chicago, and featured contributions from Judy Erwin, Illinois Board of Higher Education; Steven Frenkel, Office of Governor Blagojevich; and Bob Sheets, Illinois Department of Commerce and Economic Opportunity; concluding remarks were offered by Ada Mary Gugenheim, The Chicago Community Trust.

The Chicago region is facing a nursing shortage that will increase annually unless improvements are made to the pipeline that brings nurses into the health care system and encourages them to stay there. The State is working to organize resources from many governmental areas, including health care, workforce development, and economic opportunity, and align these resources to improve the training, recruitment, and retention of nurses. Partnerships between the public and private sectors are an important step toward realizing this goal.

According to estimates from the State, the northeast Illinois region will need 5,000 registered nurses a year due to new positions being created and turnover in existing positions; the annual supply of new nurses to the region is 1,500, leaving an annual gap of 3,500 (this estimate does not yet account for nurses who move into the region, meaning that this figure is likely to be revised somewhat downward).

The State is looking at a multi-pronged strategy to address this shortage, and the knowledge and the experience of the philanthropic sector can play an important role in helping them form specific strategies. Current plans to fix blockages and flaws in the pipeline include:

• Recruiting faculty for nursing programs, including encouraging nurses to take teaching sabbaticals and finding ways to offer financial incentives to nursing faculty;
• Increasing the diversity of the people entering nursing programs;
• Finding ways to increase the access of nursing programs to clinical practices so that more students can fulfill clinical requirements;
• Improving supervision of nurses to reduce problems that may eventually lead to nurses leaving their jobs; and
• Improving the general skills of public schools students so that they are more prepared to enter nursing programs after high school.

Planning for these and other efforts is ongoing, and participants were encouraged to join committees to help plan specific actions and shape public-private partnerships.

Participants shared some of their previous experiences in building the health care workforce. These experiences included:

• Offering an award to nurses who work in underserved communities, providing recognition, publicity, and esteem to winners and helping enhance nursing's reputation;
• Offering grants to help high-performing nursing education programs expand their capacity and spur improvement in lower-performing programs;
• Helping schools purchase needed equipment to enhance the capacity of their programs and keep them up-to-date;
• Offering financial assistance and case management to lower-income hospital employees to help them gain the education and training they need to move to higher-paying careers in health care; and
• Exploring technology options such as telemedicine that could allow nurses to extend their services to more locations, or electronic learning that can help candidates gain training while reducing their travel.

Follow-Up Roundtable II: Cook County Healthcare Solutions
January 14, 2008 - In September, the Health Program Affinity Group hosted a panel discussion that focused on the Cook County health care crisis and its impact on the health care safety net system. A follow-up grantmakers' roundtable was then held in November. Both sessions were well-attended and generated many ideas, clarifications, and most importantly, potential proactive funding opportunities. A third roundtable was held to continue the momentum of these discussions. Experts in health care safety net delivery, including Dr. Lee Francis of Erie Family Health Center, Heidi Nelson of Heartland Health Outreach, Judith Haasis of CommunityHealth, and Linda Shapiro of Access Community Health Network, joined grantmakers in an informal conversation focusing on ideas and plans for the future of the health care safety net.
The Health Program Affinity Group hosted a Follow-Up Roundtable II: Cook County Healthcare Solutions-Potential Proactive Opportunities for Grantmakers. The discussion was introduced by Anna Laubach, Illinois Children's Healthcare Foundation, and Nanette Silva, Community Memorial Foundation, and featured contributions from Dr. Lee Francis, Erie Family Health Center; Heidi Nelson, Heartland Health Outreach; Judith Haasis, CommunityHealth; and Linda Diamond Shapiro, Access Community Health Network.

In previous sessions, the Health Program Affinity Group discussed ongoing problems with the regional healthcare safety net and Cook County's role in mending existing holes and improving regional healthcare. Due to ongoing issues in County government, the group decided to look at strategies that do not necessarily involve the County but can address the healthcare needs of lower-income, uninsured, and underinsured in the region through other avenues.

During the discussion, participants identified the following possible strategies:

• Expand the use of IRIS (Internet Referral Information System) and possibly move administrative control of IRIS from County government to an independent body. Some of the ongoing problems in the healthcare system involve finding ways to connect patients to available services and discovering what hospitals have capacity for needed services, particularly specialized services. Expanding the use of IRIS would increase the options of clinics and other health organizations attempting to find needed services.
• Help Cook County move to a better governance model for its healthcare system. County government has all the information it needs to adopt an improved governance system; what seems to be missing is the political will to make the changes. Advocacy and education efforts could help mobilize citizens and the media to put pressure on the County to make the needed improvements.
• Encourage the creation of federally qualified health centers (FQHCs) inside hospitals to reduce the emergency room burden. Increasing numbers of people are turning to emergency rooms as their primary medical service provider, meaning that finding strategies to direct some of these people into a more suitable medical environment can both help them receive more comprehensive care while allowing ERs to focus on emergency cases. Establishing an FQHC inside a hospital and then directing personnel to assign incoming patients to either the ER or the FQHC as appropriate has been shown to be a useful strategy.
• Develop a sustainable business model for hospitals, clinics, and other healthcare providers. Organizations in the healthcare system depend on having a mix of payers to survive; treating a high number of uninsured patients can generate a tremendous financial strain. Funders and providers can work together to find ways for these organizations to obtain the payer mix and funding they need.
• Build a regional healthcare response. DuPage and Lake Counties have both developed approaches to healthcare that cut across all involved sectors and combine each sector's efforts. A similar effort in Cook County would be on a much larger scale but could deliver benefits from coordinated efforts.
• Promote workforce development. A Health Program Affinity Group session in late January will examine some of the efforts to increase the number of nurses receiving necessary training. Funders may also want to consider methods that will help individuals prepare for that training, as many individuals do not have the background they need to successfully complete an education in nursing.
• Advance the use of telemedicine, telepharmacies, and telepsychiatry. These practices can help connect people to services that otherwise might be too remote. There have been recent advances in telepharmacies in particular; Illinois recently passed a law allowing the practice, and regulations covering telepharmacies are expected to be completed this summer. Pharmaceutical vending machines, which enable a pharmacist to write prescriptions while dispensing the drugs at a remote location, could be very helpful in allowing clinics to help their patients acquire necessary prescriptions quickly and easily. Funders could make grants to help clinics acquire these machines.

In order to look into these concepts in more detail and discuss the best methods for advancing them, a smaller sub-group of the Health Program Affinity Group will meet. Donors Forum staff will also explore what role they can play in bringing funders and providers together to talk about next steps in fixing the Cook County healthcare system.

Follow-Up Roundtable: Cook County Healthcare Solutions
November 12, 2007 - In September, the Health Program Affinity Group hosted a panel discussion on the topic of the Cook County health care situation. The session was well-attended and generated many ideas, clarifications, and, most importantly, potential proactive opportunities. To continue the momentum of the discussion, this follow-up session was held to provide grantmakers an opportunity to share their thoughts about the current state of the County health care system and exchange ideas about ways to proceed from this point.
The Health Program Affinity Group hosted a program to follow up on the September panel discussion concerning the current state of the health care system in Cook County. The conversation focused primarily on discussing the major issues uncovered by the panel and on brainstorming ways in which funders may help remedy the situation. The group agreed that while funders can help develop programs through collaboration and advocacy, it is not the responsibility of the funders to rescue Cook County from its own mistakes. Rising medical, energy, and pharmaceutical costs, paired with increasing amounts of uninsured/underinsured patients, increased demand for specialty care, and declining revenues, are only a few of the challenges facing the Bureau of Heath Services. Good programs are developed only to fail due to lack of long-term financial planning by the County board. Physicians who support the Bureau are losing morale and are leaving or preparing to do so in increasing numbers. Funders are also growing frustrated that little action has been taken to respond to these issues at a productive pace.

There is a consensus among funders, the County Board of Commissioners, and the medical community that the Cook County health care system is in a state of crisis. Problems remain because there is not action being taken to fix the situation, nor is there a long-term strategy to build revenue and support programs. Funders are disinclined to contribute dollars to programs without a plan for long-term sustainability. Therefore, instead of struggling to work through the problems with Cook County, the group discussed several options to work around the issues.

Telemedicine was discussed at length as a topic for collaborative funding. Telemedicine is a developing form of clinical medicine in which doctors can transfer information to one another for the purposes of faster diagnoses, consulting, and treatment. Funders decided it might be beneficial to bring in several key stakeholders and safety-net providers who may benefit from upgrading their practice to utilize telemedicine. Speakers from the September 20th program, including Dr. Lee Francis of the Erie Family Health Center, Heidi Nelson of Heartland Alliance for Human Rights and Human Needs, and Donna Thompson of Access Community Health Network, will be invited to participate. The Donors Forum will host a meeting with these stakeholders and interested funders to discuss the need for telemedicine, how it might benefit their facility, what problems it might directly solve for them, and most importantly, what other measures would help. Current users of telemedicine might also be invited to the program so they could further explain the benefits. Funders may also hold separate program on "Telemedicine 101" to educate health care funders on types of telemedicine, such as telepsychiatry and interpretation technology, and the benefits of each. The purpose of this program would be more of a brainstorming or creative session to design ways to work around the problems in the Bureau of Health Services.

HPAG may also talk about developing an advocacy effort. Advocacy is the best way to help the Bureau of Health Services understand that the community will not tolerate insufficient reform efforts, nor will the nonprofit community be a crutch for the Cook County budget cuts in health care. Funders will work together to attend public meetings with County commissioners and take the stance that they will only contribute money to health care reform when the County makes comprehensive improvements to its health care system. The safety net can only be amended by internal policy reform, and funders should work together to ensure this message is clear.

Another program suggestion was based on the recent public health issue of MRSA. MRSA, a strain of community-acquired, drug-resistant staph bacteria, is on the rise among children and teens in the United States. Dr. Robert Daum, head of infectious disease and pediatrics at the University of Chicago, is calling this strain an "unappreciated epidemic." The disease is most commonly spread in areas where people have close contact, such as jails, daycare centers, and athletic teams. Healthcare funders are interested in exploring ways to increase public awareness of this issue and reach out to the underserved. HPAG plans to hold a program centered around awareness of MRSA, inviting a speaker from Communicable Disease and Public Health (CDPH) to discuss how funders may aid research on this disease, along with a bacteriologist to speak on preventative measures. The group may also invite a representative from the National High School Coaches Association or the Illinois Association of School Nurses to participate in the panel.

Solutions for a Broken System: The Cook County Health Care
September 20, 2007 - The Health Program Affinity Group hosted a group discussion on Solutions for a Broken System: The Cook County Health Care Crisis. The discussion was introduced by Mark Ishaug, AIDS Foundation of Chicago, moderated by Dick Endress, Access DuPage, and featured contributions from Dr. Robert Simon, Cook County Health Services; Dr. Lee Francis, Erie Family Health Center; Heidi Nelson, Heartland Health Outreach; Donna Thompson, Access Community Health Network; Kevin Scanlan, Metropolitan Chicago Healthcare Council; John Bouman, Sargent Shriver National Center on Poverty Law.

Faced with stagnant or declining revenues, Cook County Health Services has had to make cuts while working to maintain a high quality of service. Budget difficulties are likely to continue, if not increase. Medical costs and energy costs have been rising faster than the overall rate of inflation, pharmaceutical costs also continue to grow, and increased numbers of uninsured and underinsured patients, combined with an increased demand for specialty care, will put a strain on the system.

Improved integration with the region's federally qualified health centers (FQHCs) could help relieve some of the burden on the County system. If the FQHCs can take increasing responsibility for preventive and ambulatory care, the County system can focus on the things it does particularly well such as specialty and emergency care. However, if referrals from the FQHCs to the County do not contain an adequate mix of insured and uninsured patients-that is, if the County receives more work from the FQHCs but not more revenue-the strain on the County system will only increase.

The County's IRIS (Internet Referral Information System) was supposed to help promote integration of clinics and County services, but there have been disputes between the clinics and the County over the number of non-paying patients referred to County services. However, IRIS has established a framework for increased interaction between FQHCs and the County, and further work on the system could help bring about an improved level of interaction.

Funders looking for ways to relieve the strain on the County system could focus on the following areas, which offer the opportunity to implement lasting changes that will continue into the foreseeable future:

• The supply of nurses graduating from local schools is not keeping pace with either the demand for new nurses in hospitals or with the number of applicants. Re-starting the County's nursing school could help put more nurses into the system, which could help reduce waiting times.
• New technology makes certain diagnoses possible without the need for a face-to-face visits with a specialist. If clinics are able to practice telemedicine, they can access the expertise of Cook County specialists without having to find ways to transport their patients to distant offices. This also reduces the burden on the doctors, who can quickly review information they receive electronically instead of having to schedule appointments with each individual patient.
• As health providers struggle with the growing number of uninsured patients, proposals that would provide coverage to more individuals could help provide hospital systems with more revenue. Health care systems and funders could work together to play an active role supporting proposals for broadened health coverage.
• The governance and administration of the County health system could be significantly improved. Funders could help the County access the services of consultants who can improve the administration and oversight of the County system.
  

Threats to Medicaid Eligibility & Benefits
May 1, 2007 - The Health Program Affinity Group hosted a session on Threats to Medicaid Eligibility and Benefits Resulting From the 2006 Deficit Reduction Act and the Power of Funding Legal Advocacy. The discussion was introduced by Nancy Zweibel, Retirement Research Foundation, and featured contributions from Gene Coffey, National Senior Citizens Law Center, and John Bouman, Shriver Center/Sargent Shriver National Center on Poverty Law.

The 2006 Deficit Reduction Act (DRA) made changes to Medicaid legislation that could affect people covered by Medicaid long-term care benefits and the quality of services they receive. Some potentially harmful effects have been mitigated through legal advocacy, but potential problems still loom as states implement the new rules and guidelines. When addressing this legislation, it is important to remember that the primary goal is to cut costs, not to improve the quality or quantity of available services.

The DRA made three major changes to Medicaid coverage of long-term care:

1) Changes in the penalties for gifts given by applicants for Medicaid benefits. In order to prevent people from getting rid of assets by giving them to family members rather than using those assets to pay for long-term care, Medicaid rules carry penalties that can delay benefits based on the size of such gifts.
Under the old rule, gifts were reported for a period of three years prior to the application for Medicaid benefits. The penalty for these gifts was applied from the moment a gift was given, meaning that penalties might have already expired for gifts given in the past. Under the new rule, the three-year window is increased to five years, and all gifts are treated the same, regardless of when they were given. This means that a gift given four years before application would delay the receipt of benefits by exactly the same amount as a gift of the same size given the day before the application.
This change could cause significant difficulties in the lives of potential Medicaid beneficiaries, particularly those who experience a catastrophic illness that reduces their savings shortly before their application for long-term care benefits. Though their assets may be wiped out, they may still have to wait for coverage due to penalties levied on gifts that may have been given before the onset of illness. State rules and guidelines on this penalty could soften the blow. There are provisions for coverage if denial of benefits would cause "undue hardship." In individual states, the definition of this term could offset the new penalty structure.
2) Incentives for applicants who purchase long-term care insurance. The DRA allows Medicaid applicants to retain assets equal to the amount of long-term care insurance they purchase, thereby allowing them to hold on to more of their money while still being covered. While this incentive might encourage more individuals to purchase long-term care insurance, one potential problem is that, according to recent news stories, there are high rejection rates for people currently attempting to make claims on their long-term care insurance.
3) Provisions to encourage the use of home and community-based services. The DRA provides states the option of providing home and community-based services (HCBS) to some of the people eligible for Medicaid long-term care coverage. While HCBS are often preferred by individuals and may cost less than institutionally based services, the design of the option is cause for some concern.

When choosing this option, states may do one of two things: They may either retain existing physical eligibility guidelines while adding a broader level of eligibility to cover people who may receive HCBS, or they may use their existing guidelines to determine eligibility for HCBS and then narrow their criteria for nursing facility eligibility. If the latter option is chosen, this could affect the status of people who had been eligible for nursing facility care, and if HCBS are not fully funded, the end result could be a loss of needed services. There have also been concerns about individuals choosing relatives and friends to deliver HCBS, as some of these people may not have the training or knowledge they need to deliver proper care.

As most states are still working on their implementation of the DRA requirements and options, there are many chances for advocacy and education of government officials. Previous efforts to combat burdensome requirements for Medicaid beneficiaries to prove their U.S. citizenship helped change potentially harmful guidelines and ensure that some people (including some elderly nursing facility residents and foster children receiving Medicaid benefits) did not lose their coverage.

Pharmaceuticals-Medicare Part D: The Solution or In Need Rep
April 16, 2007 - The Health Program Affinity Group hosted a group discussion on Medicare Part D. The discussion was introduced by Howard Nochumson, Washington Square Health Foundation, and featured contributions from James Tarrant, Chicago Medical Society, and Sara L. Lieber, consultant for the Chicago Medical Society and project manager for the study.

According to a recent survey, Chicago-area participants in the Medicare Part D program have required a significant number of health interventions, including doctor visits, emergency room visits, and hospitalization, due to symptoms they experienced when they did not have their recommended dosage of medication. Early studies showing a high level of approval for the Medicare Part D program may have painted a false picture of the program's accomplishments by not asking enough specific questions to discover details about participants' experiences.

There are many barriers that prevent participants from realizing the full benefits of the medication that has been prescribed to them. These include:

• Concerns about current or future costs of the medication that prevent individuals from filling prescriptions or from taking full doses;
• Language barriers that limit communication between individuals and their doctors and pharmacists;
• Lack of communication between different doctors and pharmacists treating the same patient; and
• Lack of knowledge about traditional herbal remedies patients might be using and how they might react with patients' prescriptions.

Individuals surveyed have developed a variety of approaches to deal with occasions when they do not have enough medication. These include sharing medication with people who are close to them (frequently a spouse), visiting doctors other than their normal physician, and taking less than the recommended dose in order to stretch their medication. All of these can cause potential difficulties in maintaining people's health and avoiding future medical interventions which, in the long run, can be more expensive that the cost of providing the medication in the first place.

Community organizations and local pharmacists can often be very helpful to individuals trying to negotiate the health care system. Community organizations can help bridge language gaps and can take time explaining how the system works to individuals who otherwise might become lost or overlooked in complicated bureaucracies. Local pharmacists often form a stronger bond with their patients and are more in touch with their culture, allowing them to ask specific questions about their patients' health. Encouraging these functions can improve people's experience with the health care system.

The health care system could also be improved by finding ways for the different parts of the system to work together and by providing help to physicians for different parts of their workload. Having someone in a doctor's office that can negotiate the public side of the medical system can free up more time for the physician to spend with patients, allowing the doctor to see a larger number of patients and spend more time with each one. Other assistants can help by asking specific questions to patients to get past the general responses and find out the realities of the individual's day-to-day health, allowing the physician to get to the heart of existing health issues.

The State Health Improvement Plan (SHIP)
March 12, 2007 - The Health Program Affinity Group hosted a discussion on The State Health Improvement Plan (SHIP): A Multi-Sector Public Health Framework for Illinois. The discussion was introduced by Ernest Vasseur, Lloyd A. Fry Foundation, facilitated by Nanette Silva, Community Memorial Foundation, and featured contributions from Elissa Bassler, Illinois Public Health Institute; Dr. Eric Whitaker, Illinois Department of Public Health; Joe Antolin, Heartland Alliance for Health and Human Services; Larry Boress, Midwest Business Group on Health; Dennis Richling, Matria Health Care; and Richard Sewell, UIC School of Public Health.

Illinois' State Health Improvement Plan (SHIP) was developed by a committee that included representatives from health care providers, community-based organizations, educational institutions, employers, government, and other sectors. By drawing on a broad base, the plan is able to address health through a multi-sector, system-level approach. The SHIP provides a broad view on what the public health system should accomplish and what strategic issues should be addressed first. Efforts within these strategic areas can begin immediately-in fact, some legislation taking action in these areas has already been introduced.

The SHIP defines health in broad terms, including physical, mental, and social health, and it conceives of a system that includes public and private elements. As a result of the SHIP planning process, six strategic issues were selected:

• Access to health care services, including preventative services (the SHIP did not develop a specific mechanism for improving access so as not to duplicate the work of a different, concurrently operating task force);
• Data information and technology, including how data is gathered and how it can be disseminated to communities;
• Disparities, including those caused by ethnic, racial, and socio-economic differences;
• Measuring, managing and improving the public health system, including building partnerships and monitoring health conditions and risk factors;
• Workforce, including improving both the competencies and diversity of personnel in the system;
• Priority health conditions, focusing on four conditions in particular: Decreasing the use of alcohol, tobacco, and illegal drugs and the misuse of legal drugs; addressing obesity; improving physical activity of Illinois residents; and reducing exposure to violence.

These strategic issues provide starting points for action. Legislation has been introduced to improve data collection in the health care system, to require health facilities to develop a plan for providing language assistance to patients who need it, and to develop a culturally competent health care demonstration program.

Public/private partnerships are a significant component of the SHIP, and partnerships with employers can be useful in balancing the costs of a quality health system between sectors. Research has become available showing that employers are better off in the long run providing a complete spectrum of health services to their employees; by focusing on prevention, these efforts can eventually have a positive effect on a company's bottom line.

One of the challenges in addressing the SHIP's strategic goals includes finding ways to keep the different sectors and participants in the planning process communicating and developing solutions. Philanthropy can play a convening role while also using funds as leverage to spread the SHIP message and support system-wide changes. Developing the strategic issues and objectives involved a degree of give and take among the participants in the planning process, and this type of relationship will need to continue if objectives are to be met. As the process continues, there will likely be differences that arise between various parties and sectors, and having a way to work through these differences and develop solutions will be an important part of helping the process move forward.

Sex In Our Schools: What Are Kids Learning Part Two
February 12, 2007 - The Youth Task Force, the Health Program Affinity Group, Funders for Lesbian and Gay Issues, and the Education Funders Group hosted a discussion on Sex in Schools: What Are Kids Learning, Part 2. The discussion was introduced by Julie Walther, Girl's Best Friend Foundation, and featured contributions from Dorinda Welle, The Ford Foundation; Kenneth Papineau, Chicago Public Schools; Vicki Pittman, Chicago Public Schools; Soo Ji Min, Illinois Caucus for Adolescent Health; Jonathan Stacks, Illinois Caucus for Adolescent Health (ICAH); Marcela Howard, Advocates for Youth; James Wagoner, Advocates for Youth; and students Mya Patitucci, Kevin Brown, and Adaku Utah, who are part of Furthering Responsible Education Everywhere, a program of ICAH.

In April 2006, the Board of Education for the Chicago Public Schools adopted a new Family Life and Comprehensive Sexual Health Education Policy. The policy was the result of organizing and advocacy on multiple levels, and it created a new mandate in the CPS system for comprehensive sexuality education within specific guidelines. While establishing such a policy is a significant step, there is more work to be done-the policy needs to be implemented in all Chicago schools, and efforts are underway to implement a similar mandate on the state level.

The CPS policy guidelines emphasize information that is comprehensive, age appropriate, medically accurate, abstinence-based, and includes information on emotional, social, and psychological aspects of sexuality along with physical and health aspects. The comprehensive approach can produce benefits in a wide range of areas, including student health, emotional well-being, and even job training and preparedness.

As part of the policy, CPS has provided every school with curriculum in both print and online forms. The online version allows teachers to search for lesson plans by subject area or by skills they are teaching, allowing them to present material that specifically addresses their students. CPS is working to monitor how many schools are using the curriculum and how often they employ it, and CPS staff will work with schools that are under-employing the curriculum to find ways to help these schools meet the new mandate. While CPS has occasionally encountered resistance from teachers and principals, most who go through the training for the curriculum speak positively of the experience.

The creation of the new policy happened with significant input from CPS students, and students also plan to be involved in promoting the policy. By spreading word about the policy to students throughout the system and telling them what kind of education they have a right to receive, student organizers hope to build participation in the new policy from the ground up.

Along with working on implementation of the new Chicago policy, organizers will focus on attempting to expand comprehensive sexuality education resources to suburban and downstate locations. Building momentum for a statewide mandate could help marshal resources for underserved areas while clarifying occasional confusion about what can and cannot be taught. Some of these areas do not have the organizational resources that the Chicago region has, and partnerships with community colleges and other groups are being explored as a way to offer the needed health and education services.

This organizing effort comes at a time when federal funding for abstinence-only education has constructed an infrastructure of programs that aggressively market themselves to schools. Since they do not need additional funding from the schools, these programs can present themselves as a fully funded sexuality education resource. While well funded, such programs often contain inaccurate, incomplete, or non-factual information, and there is not yet any peer-reviewed research showing the effectiveness of abstinence-only education. By emphasizing curricula that are medically accurate and fact-based, comprehensive sexuality education programs present an alternative to abstinence-only programs-an alternative that not only provides students with a broader range of knowledge but that has, in some cases, been shown to promote higher rates of abstinence from sexual activity than do abstinence-only programs.

HPAG Peer Exchange
October 23, 2006
The Health Program Affinity Group hosted a peer exchange where members could discuss their recent activities and exchange information. Ernest Vasseur, Lloyd A Fry Foundation, facilitated the discussion.

The peer exchange covered the following issues:

• Helping people receive the pharmaceuticals they need is a major concern that cuts across many communities. There are different avenues for obtaining pharmaceuticals at low prices-such as through programs sponsored by pharmaceutical companies, or by purchasing medications that may be near the end of their shelf life at a low cost-but to date, many of these efforts have been somewhat scattered, and the practitioners of the various programs have not coordinated their efforts. However, there are efforts underway in both Chicago and Lake County to develop comprehensive programs to obtain and distribute low-cost pharmaceuticals (the possibility of having the two area programs work together as a single regional program will be explored). These programs would follow the model of the Chicago Food Depository to a degree, though issues such as making sure pharmacists are present to help distribute the drugs properly need to be addressed. Other pharmaceutical options include running a pharmaceutical program directly out of a federally qualified health center, or having a community organization staff member enroll and re-enroll community members in programs provided by pharmaceutical companies for indigent patients that require re-enrollment every three months. Another possibility that has not been fully explored is to use buying power of the Veterans Administration, which is the single largest purchaser of pharmaceuticals in the nation, to negotiate purchases of pharmaceuticals for community distribution. These programs and other ideas will be discussed at a March meeting of the Health Program Affinity Group.
• Examination of the practices of community health-care organizations shows that having a connection to four linked elements is an indicator of the likely success of the program. These elements are: 1) Providing health education about a prevalent condition; 2) Screening people for the condition; 3) Referring people who have the condition or are at risk of developing it for treatment; 4) Following up with the people who have been referred to make sure services are delivered. If programs have a screening component, it is important to make sure the organization operating the program understands the screening equipment and knows what to do with the results of any tests. A screening program that does not help participants follow up on potential problems can be worse than no screening program at all.
• A plan to treat diabetes using transplants of encapsulated islet cells could result in a functional cure for diabetes in as soon as five years. Currently, treatment using islet cells (which help produce insulin) requires patients to take immunosuppressant drugs to prevent their immune system from destroying the transplanted cells. Eventually, the transplanted cells are destroyed. However, by enclosing the cells in capsules that keep T cells out while letting other nutrients in and out, the transplant could be permanent and could take place without the need for immunosuppressant drugs. The research for this plan is expected to cost $100 million over five years, which is a very small sum of money compared to the amount spent on health care for people with diabetes.
• While difficult, positive changes in health behavior can be realized through long-term, multi-pronged approaches. The reduction of smoking in the United States and the decline in the rate of traffic fatalities are two examples of long-term efforts that showed positive results. However, while some change is possible, there will also be resistance to efforts for change-smoking in the United States may have been reduced, but there are still a large number of smokers, and many of them are young.
• The community health care system could be improved by implementing a common curriculum for training professionals in the field. This would allow them better advancement opportunities as well as the chance to move to different jobs within the field if they so choose. San Francisco is one example of a city that has such a curriculum.
• The Chicago Department of Public Health has a new initiative on chronic diseases, and the group will explore inviting Erica
  
  Salem from the Department to discuss the initiative.
  

Update on the Cook County Health Safety Net
September 29, 2006 - The Health Program Affinity Group hosted an Update on the Cook County Health Safety Net. Introduced by James N. Alexander, The Otho S.A. Sprague Memorial Institute, the discussion featured presentations from Dr. Kevin Weiss, Institute for Healthcare Studies; Dr. Terrence Conway, Health Management Associates; Patricia R. Terrell, Health Management Associates; and Matt Powers, Health Management Associates.

A report on the state of the Cook County health care system was released at the beginning of August, and it received considerable media attention. Both the Tribune and the Sun-Times endorsed its findings, and response from other quarters has been similarly positive. The major work ahead is translating this initial acceptance into a long-term reform effort that can help avert a future crisis in the health care system while allowing the system to realize its potential as one of the best public health systems in the nation.

The Cook County health system is not only a vital part of the public health safety net, but it is also important to the entire regional health care system. A strong, well-functioning County system would help other hospitals and area employers as well as the public it serves, while a weakened system would allow patients to fall through the cracks while placing a strain on other area hospitals as well as businesses.

The Cook County system is facing a looming crisis due to a confluence of factors including: a decrease of revenue from the State Medicaid program; the growing number of uninsured and underinsured people in the County; increasing costs that far outpace inflation; new regulations addressing quality of care and patient safety; the difficulty not-for-profit hospitals and clinics are having in meeting increased demand; national policy issues that put more strain on the system instead of addressing problems; and State changes to models for delivering care.

The report focused on six major areas that need to be addressed for the future health and sustainability of the system:

1) Transparency: There should be a report card that clearly explains how well the system is doing in its mission.
2) Governance: Members of the County Board do not generally have the time or expertise needed to efficiently manage a $1 billion health care system. A new governance structure staffed by health-care experts would make the system more effective and efficient.
3) Human resources: Many people interviewed for the study raised the concern of patronage hiring in the health-care system, meaning that too often people are in place who may not have the skills or expertise their position demands.
4) Systems efficiency: Some effort has been made to increase efficiency in the County system, and these efforts have shown results. These efforts need to be replicated and expanded.
5) Finances: Cook County is heading for a budget gap, and Medicaid resources have decreased. The system needs to work hard to become more efficient, rather than simply eliminating essential services to save money. In the end, these efficiencies may not be enough to close the budget gap, and an increase in the County's tax subsidy may need to be explored.
6) Community engagement: The County health care system needs to recognize the role it plays in the overall health care system and do a better job of reaching out to and interacting with other elements. Additionally, demographic shifts have led to increasing numbers of low-income people moving out of Cook County, so the County system should engage the systems in other counties.

These reforms will not be easy and will likely take place over considerable periods of time. The first step in the process-a step that could be supported by foundations-would be the creation of a blue-ribbon commission that will take a detailed look at ways to implement the suggested reforms. Obtaining County approval of this commission and moving it forward will not be easy, and finding ways to negotiate the politics of the situation and engage different segments of the community, including institutional leadership, to support this work could be crucial to helping the work move forward.

Health and Nutrition in Chicago Public Schools
June 6, 2006 - The Health Program Affinity Group hosted a session on Health and Nutrition in Chicago Public Schools. The discussion was introduced and facilitated by James N. Alexander, The Otho S.A. Sprague Memorial Institute, and featured presentations from Terry Mason, Commissioner of the City of Chicago Department of Public Health; Renee Grant-Mitchell, Chicago Public Schools, Office of Specialized Services; Kenneth G. Paipneau, Chicago Public Schools, Office of Specialized Services; Maged Hanafi, Chicago Public Schools, Food Services; Joel J. Africk, American Lung Association of Metropolitan Chicago; and Rachel E. Duncan, Stakeholders Collaborative.

From dealing with high rates of asthma, an increase in chlamydia cases, and other health concerns to serving nearly 70,000,000 meals a year, the Chicago Public Schools are involved in many aspects of their students' health. Recent efforts to improve nutrition, health education, and the provision of health services have focused on coordinating existing services and making sure all schools have access to community resources that could help their students. Additionally, new initiatives have improved the quality of health and nutrition services available to students.

Many schools in the CPS system have entered into partnerships with community organizations to deliver health services to their students, but these services have often been poorly coordinated. As a result, there has occasionally been duplication of services or a concentration of services in one area while another goes underserved. The Stakeholders Collaborative and the CPS have worked together to coordinate what programs and partnerships are available and to employ those programs more efficiently.

Along with the improved coordination, new services and programs have recently been introduced. CPS has purchased a new health curriculum that is designed to be inserted into classrooms for everyday use in practically any subject. The curriculum allows CPS to monitor how often various schools are using the materials so that they may ensure the program is being taught. Also, CPS Food Services has introduced salad bars into selected schools and is monitoring how often it is used and what impact it may be having on students' eating habits. There are plans to increase the number of schools with salad bars.

Another recent program has been the partnership between the CPS and eye care service providers, which has given nearly 30,000 students a free eye examination and/or prescription glasses. This program will continue in the next school year, with possible adjustments to ensure that children who receive glasses through the program continue to wear them as needed.

While coordination has improved recently, there is still more that needs to be done to create better communication and stronger partnerships. Working with City departments, like the Department of Public Health, could help improve available services. Also, CPS is developing a Wellness Policy for the entire system that will help all schools have effective health policies.

Addressing Patient Safety: Chicago Solutions
May 22, 2006 - The Health Program Affinity Group hosted a session on Addressing Patient Safety: Chicago Solutions. The discussion was introduced and facilitated by Elizabeth Lee, Michael Reese Health Trust, and featured presentations by Leonard Lamkin, Chicago Patient Safety Forum; Larry Boress, Midwest Business Group on Health; Jane Holl, Northwestern University; Donna Woods, Northwestern University; Bruce Lambert, University of Illinois at Chicago; and Gordon Schiff, John H. Stroger Jr. Hospital of Cook County.

According to recent studies, there are more deaths from preventable patient safety errors each year in the United States than there are from diabetes. The Chicago Patient Safety Forum (CPSF) was created to provide a place where all levels and sectors of the health care establishment-including hospitals, community doctors, pharmacies, insurance companies, and more-could get together and share ideas about improving patient safety. It is currently the only patient safety organization in the country that is not directly affiliated with some other organization.

CPSF is action oriented-its goal is not just to study patient safety, but to make sure best practices in patient safety are implemented in as many places as possible. Their efforts include working on the Illinois Adverse Events Law and serving as the Illinois node of the Institute for Healthcare Improvement's 100K Lives Campaign. The goal of this campaign is to save 100,000 lives that otherwise would have been lost through patient safety errors by implementing six proven patient safety initiatives. Eighty hospitals in the area are currently participating in the campaign; some have implemented all of the initiatives, while others are struggling with just one.

Particular focus in patient safety has been given to pediatrics and pharmaceutical practices. In both areas, problems are caused by fragmentation in the medical field and a lack of communication between various parties. In pediatrics, a survey and focus groups helped locate some of the places where communication breaks down, including when a patient is transferred from one hospital to another or during shift changes. The existing medical culture often hinders the communication process-people may be hesitant to speak up about problems because they believe (often correctly) that they could be reprimanded or even fired if they do.

The problem in the pharmaceutical arena is similar. There may be more than twenty different places where a patient's pharmaceutical records are kept, and often there are significant discrepancies between the various records. Moving to electronic records may help, but only if the procedures for creating and updating these records are designed well and if physicians, hospitals, and pharmacies actually adopt this form of record keeping and work together to build a system that is well integrated.

Some of the problems of communication and culture could be addressed through better training and education. There are pilot programs being developed to include some of these aspects as the core competencies that medical practitioners must learn.

The topics discussed during the peer exchange included the following:

• Participants nominated people who could serve as a new nonprofit representative for HPAG meetings. Several candidates were named, and the co-chairs will follow up to see if any of the candidates are willing to participate.
• The group has meetings scheduled for both May and June. The May meeting will be on the 22nd and will be about patient safety; the June meeting will be on the 6th and will discuss health and nutrition in Chicago schools. Participants agreed to invite the Education Funders Group and Youth Task Force to the June meeting.
• Participants discussed what health care services are available on Chicago's northwest side, which has some communities that have experienced an increased need for health services without receiving a corresponding increase in their capacity to deliver services. Some organizations have noticed the increased demand, though, and are developing plans to move into the underserved neighborhoods.
• Diabetes research using islet cells is proceeding rapidly enough that there may be a functional cure for diabetes within five years. Trials are proceeding both in the United States and Italy, and the results so far appear promising. However, there currently are not enough islet cells to go around, and the funding demands for the continued trials are high.
• The Health and Medicine Policy Research Group is planning a summit for June 7th that will examine the holes in the Chicago region's health care safety net. The goals of this summit are similar to those of a summit held in 1990, which brought together public and private sector representatives to generate a road map for improving the health care delivery system. As with the previous summit, the meeting in June will bring together representatives of non-profit and for-profit health care organizations, public officials, the local business community, and funders. Participants agreed that this summit is something in which they should be involved. Material on the 1990 summit will be circulated to the group through the Donors Forum to help group members prepare for the June summit.
• A report on the Cook County health care system, with particular focus on Stroger Hospital, is currently in the draft and review process and should be released in late May. Among other issues, it will examine how County leadership works with the hospital and the financial status of the County, which could reach a crisis as soon as the summer of 2006.
• The Sargent Shriver National Center on Poverty Law worked with the Illinois Department of Human Services (IDHS) to develop nine goals for improving language and cultural competency in the health care system. While IDHS may not be able to implement all of the goals immediately, the goals are designed to be somewhat discrete, so individual pieces could be implemented right away even if other pieces have to wait.
  

The rising number of uninsured individuals, their growing need for medical services, and the increasing costs of those services are all combining to put significant pressures on public health care delivery systems. There are three ways to meet the health-care needs of the uninsured and under-insured; create a national plan of universal health coverage, increase coverage of entitlement programs on the state level, or work with local-level systems to increase collaborations and efficiencies. Until more progress is made on broader state and national reforms, local funders may need to concentrate their efforts on improving community-based systems.

The local health care picture varies significantly from place to place. For example, Dallas currently has a consortium of public and private civic leaders working to improve health care in communities, while the health care picture in Los Angeles seems to be in chaos with many private providers pulling out of the city entirely to avoid dealing with the high number of uninsured, undocumented patients that live there. San Francisco has very high funding levels for public clinics, yet these clinics, like other clinics across the nation, often claim they are underfunded.

A concept paper analyzing Cook County's safety net for the uninsured and under-insured will be released at the end of March. The analysis began by asking about the target population the system intends to serve-who are they? Where do they live? What services do they need, and what services are offered? By looking at these questions and by finding what public and private partners are available in communities where the target population lives, health systems can create an accurate picture of what services they need to offer and how those services will be provided. Only when a plan for services is in place can the system start to address the questions that many administrators mistakenly ask before any others-how much will the services cost? How will the system by administered?

The concept paper is expected to provide a concrete work plan for improving the health care safety net. The goal is to start a discussion about the system and to engage local leaders in the issue of health care. As the leaders become more involved and push some of the concepts advanced in the paper, the safety net should grow stronger.

Improving the safety net means reducing the often competitive, parochial, crisis-focused nature of many parts of the health-care system and instead building collaborative relationships that can create a seamless continuum of care. One existing gap in care, maternal and child health services, was identified about a decade ago, and efforts in that area showed dramatic results (though poor birth outcomes still exist). Focusing on other existing gaps, like chronic illnesses, would hopefully show similar improvements. Along with closing service gaps, a good safety net also requires an efficient hub, one staffed by leaders who know the territory, are involved in the ongoing operations, and are accountable for their decisions.

Perhaps the biggest problem working against the improvement of Cook County's health care safety net is a lack of leaders pushing the issue. Just as recent school reform efforts did not gain traction until business leaders and parents became involved in campaigns, health care needs a broad spectrum of people to step up and move it forward as a critical issue. Cultivating and engaging civic leaders in health care issues is a role foundations can play in improving the safety net. When the concept paper is released in March, it needs to be the start of a prolonged effort on Cook County health care, and civic leaders can make sure the issue does not fade away right after it is brought up.

Health & Homelessness: Challenges & Policy Initiatives
January 23, 2006 - The Health Program Affinity Group and the Grantmakers Concerned with Ending Homelessness co-hosted a discussion on Health and Homelessness: Current Challenges and Policy Initiatives. Introduced by Ernest Vasseur, Lloyd A. Fry Foundation, the discussion featured presentations from Heidi Nelson, Heartland Health Outreach, Bechara Choucair, Heartland Health Outreach, Barbara Bolsen, The Night Ministry, Arturo Bendixen, AIDS Foundation of Chicago, and Sue Augustus, Corporation for Supportive Housing.

People experiencing homelessness deal with the same range of medical problems as the general population, though certain issues are more aggravated. Homeless individuals have a higher incidence of mental illness and substance abuse issues than the general population, and they tend to experience more chronic illnesses. Asthma, HIV infection, and TB also have high incidence in the homeless population.

Recent assessments of the health care needs of the homeless have looked at various parts of the Chicago region, including DuPage County, Lake County, and the south suburbs. The assessments show that the primary barrier keeping the homeless from receiving health care is a lack of insurance; 70 percent of the homeless people studied in one assessment had no insurance. The assessment also showed that a lack of awareness of available programs and a fear or distrust of institutions prevent some homeless individuals from benefiting from available government programs. While some clinics are available to people without insurance, the wait at these clinics can be long, and the clinics often require a co-payment that may be more than homeless individuals can afford.

Perhaps the biggest gap in existing health services for the homeless is programs that can provide pharmaceuticals for those who need them. Some programs have allowed existing programs to purchase pharmaceuticals at steep discounts, but the supply of drugs often falls short of the demand.

Health care services for the homeless include services that are provided at fixed locations as well as services that are mobile, bringing health services to neighborhoods with significant amounts of homeless individuals. One difficulty experienced by the Night Ministry, which provides medical testing and other services in a bus that visits seven neighborhoods six nights a week, is following up with people who receive tests or seek medical referrals. The recent implementation by the Night Ministry of rapid HIV testing, which can give people results shortly after they receive the test, has made it easier to give people their results and start them on a follow-up plan. The Night Ministry is continually working to improve their network of referrals, and they have seen recent improvements in the number of visitors who receive follow-up care.

Another recent initiative targeting the health needs of the homeless population is a study that is helping chronically ill homeless individuals obtain stable housing. A group of nearly 200 patients who had been homeless and then been hospitalized with a chronic illness have been enrolled in the study. When they are discharged from the hospital, they immediately receive temporary housing until permanent housing can be found. The housing status, hospital usage, and nursing home usage of this study group are then compared to the same data for another group of nearly 200 recently hospitalized, chronically ill homeless individuals who are part of a control group.

The complete results of the study will not be known for about a year and a half, but preliminary results show decreased nursing home usage and emergency room visits by the study group. The hospitalization rates for both groups are very similar, but that is expected the change as the study moves forward. If these results hold, the study will show that moving aggressively on housing both improves the health of chronically ill homeless individuals and saves money by reducing hospital and nursing home usage.

A key to getting programs like this to work is to have central coordination and constant collaboration. Organizations providing housing and supportive care can learn from each other, and a coordinating agency can use grants as incentives for the organizations to learn as quickly as they can.

While the efforts to help the chronically ill homeless can serve as a model to other cities and states, there are things Illinois could adopt from other locales to improve the services it offers. At present Illinois is one of a handful of states that has separate determinations for SSI eligibility and Medicaid eligibility; an individual may be found ineligible for Medicaid, only to later be approved for SSI. Instead of then being automatically made eligible for Medicaid, the individual is left to re-apply to the program, which many people do not do. Streamlining the determination process would provide coverage for more individuals.

Illinois could also improve its intake procedures by re-introducing the "probably eligible" standard for Medicaid applicants. Such a change could be combined with the governor's recently announced initiative to have all Illinois children insured.

Another initiative that could be copied in Chicago is the housing for the homeless in San Francisco, which currently does not include strict sobriety requirements. Instead, these units follow the reduced harm model, which encourages residents to change harmful decisions rather than holding them to a strict standard of sobriety and evicting them if they do not live up to it. Such buildings are showing positive results in keeping individuals housed while significantly reducing their hospital visits.

Mercury Contamination: Health & Environmental Effects
December 8, 2005 - The Environmental Grantmakers Group and the Health Program Affinity Group co-sponsored a discussion on Mercury Contamination: Health & Environmental Effects. Ed Miller, Illinois Clean Energy Community Foundation, introduced the program, which featured presentations by Dr. Henry Anderson, State of Wisconsin Department of Health and Family Services; Dr. Dan Hryhorczuk, University of Illinois at Chicago School of Public Health, and Faith Bugel, Environmental Law & Policy Center.

Discussions of mercury contamination have often focused on the effects on children and infants, but studies show it can be a proble