According to the 2004 National Immunization Survey (NIS) conducted by the Centers for Disease Control, Houston’s coverage rate for children 19-35 months was 65.5 % (4-3-1-3-3), Texas’ coverage rate was 70.3% and the national coverage rate was 78.8%. Participants in the Women Infant and Children (WIC) program proved to have one of the lowest immunization coverage rates in Houston with 63.6%. In order to reverse this trend, the Houston Department of Health and Human Services (HDHHS) implemented Project Milestone beginning in 2006. This program involves placing human service navigators in various City of Houston Women Infant and Children (WIC) program sites. Project Milestone is open to all WIC participants between 0-5 years of age and their families potentially reaching 21,000 infants (<1 year of age) or 46% of the 45,525 children born in the City of Houston in 2003 and over 43,000 children (1-5 years of age). The program enrolled 1,544 or 14% of children and infants at the four pilot sites.
Project Milestone started in four WIC sites in the City of Houston. The program utilizes navigators to serve as parent coaches. At the initial WIC visit, the navigator provides information to the parent/guardian of WIC client about Project Milestone and the importance of bringing their child’s immunization record to each WIC visit. Then the parent/guardian is given a needs assessment to complete, which addresses medical, emotional and social deficits prevalent in the child’s household. Next, the immunization data is entered into the Houston-Harris County Immunization Registry to secure data for future use by any immunization provider enrolled in the registry and to ultimately reduce record fragmentation issues prevalent throughout the Houston Community. In addition, Project Milestone participants are given incentives at immunization milestones such as free birth certificates and sipee cups to encourage continued participation.
Recognizing that immunization is only one part of the child’s well-being, the primary goal of Project Milestone is to offer intense follow up to families to increase the overall health and well being of the family focusing on the child as the nucleus. This will be accomplished by performing these objectives consisting of increasing immunization compliance and increasing access to external agencies.
The public health issue addressed by Project Milestone is that of improving early childhood immunization rates, removing barriers, and improving the overall health of Houston’s families with the child as the nucleus. Data obtained from Geographic Information System (GIS) analysis were used to determine the initial areas in which to allocate resources for the original four pilot sites. In addition, staff researched and identified evidenced based best practices that would be cost effective and easy to implement.
Project Milestone is innovative because it expands and enhances the navigator’s role. Although the initial focus is on childhood immunizations, the entire family is also serviced with increased access to human services. Immunization outreach procedures were based on various studies and public health programs that highlighted the success of tracking and outreach activities in regards to vaccination. One study reported that families who receive telephone and/or postcard reminders were 2.3 times more likely to keep their appointment.
Traditionally, navigators perform duties such as health promotion, referral, advocacy, eligibility determination, outreach and facilitation of service coordination. In Project Milestone, navigators also function as a parent coach with extensive outreach, tracking, and follow-up. First by functioning as a parent coach, the navigator builds a relationship of trust in order to ascertain an understanding of the barriers the families may be experiencing when trying to access health care, she then assists families in addressing the barriers. The navigator performs all of the traditional functions of the navigators as mentioned above.
The outreach and tracking component of project milestone is quite extensive consisting of:
Monthly queries of WIC’s computer system to identify newborns, querying immunization registries for updates, and entering new immunizations into the local registry.
Contacting last immunization provider listed in registry for child’s immunization history if necessary.
Sending reminders on upcoming and overdue immunizations.
Encouraging parents/guardians to obtain children’s vaccinations at their medical homes.
Agency Community RolesHDHHS initiated Project Milestone with collaboration between four internal partnerships: the Bureau of Vital Statistics, Immunizations, Nutrition Services, and Neighborhood Services. The Bureau of Vital Statistics offered birth certificates at a reduced rate to the Immunization Program as an incentive to parents for having their child’s immunizations current. The Immunization Bureau provided immunization training to teach navigators on how to screen records in order to determine which immunizations are due when. The Bureau of Nutrition Services offered space for the navigators to be housed. Neighborhood Services offered staff to serve as navigators.In order for Project Milestone to succeed, HDHHS also formed alliances with external agencies. The agencies included but were not limited to:
Local Vaccines for Children Providers
Local food pantries
Social Security Administration
Local Department of Human Services
Mental Health Association (MHA)
Council on Alcohol and Drugs – Houston
An integral piece of Project Milestone’s success was contingent on the fact that the navigators were able to go into the community and develop local partnerships for referral. HDHHS has many multi-service centers in which to offer space to external partners to ensure that clients have access to as many relevant agencies under one roof as possible. The mission of HDHHS is to provide leadership in the promotion and protection of the health and social well being of the Houston community through advocacy, education and community-based health services. This project is one that promotes that mission.
Costs and ExpendituresFunding sources included: City of Houston, CDC Immunization Grant, and Texas Dept of State Health Services Immunization Grant. Costs during the three-month pilot (January - March 2006) included:
Birth Certificates (144 x $23): $3,312.00
Office Supplies and Copies: $1,000.00
United Way CD (6 x $ 35 for referral listings): $210.00
Navigators (full-time 11.63 x 480 hrs x 4): $22,329.60
Supervisor (20% time, 23 x 96 hrs): $ 2,208.00
Computers (4 x $1, 250): $5,000.00
ImplementationThe primary goal is to offer intense tracking and follow up to families to increase the overall health and well-being of the family focusing on the child as the nucleus. This was achieved by preparing navigators on their “parent coach” role through the Gateway to Care navigator training program, educating on screening immunization records, CHIP application training, and registry training. Training took approximately 12 weeks. Also, WIC staff received a one day in-service on Project Milestone. Management developed procedures designed to incorporate the navigator into the WIC flow, which took two weeks. Finally, addressing logistical issues including allocating staff; space at the WIC sites; and technological resources consisting of computers, printers, and network access towards the pilot phase of this program took another two weeks. These activities took approximately four months to complete.
Steps used daily by navigators in order to achieve program objectives include the following:
Increase immunization compliance
Collect demographic information from the parent that enables them to do telephone and mail follow-up when necessary.
Refer clients to providers that are accepting new patients and who are a part of the Houston Vaccines for Children Program, non-traditional sites where parents can receive free immunizations, or to HDHHS health centers.
Navigators are well versed in the immunization schedule and when clients are due for immunizations either a reminder card or phone call is sent to the parent or guardian indicating that the child is at an age when shot are due.
Upon receiving new information, navigators will query the immunization registry and if needed, input missing vaccine history into the system.
Increase family access to external human services agencies
Give each parent a self assessment form.
Refer parent/guardian to resource organizations preferably located in the client’s neighborhood.
Follow-up with client to ensure that services were obtained.
Objective 1: Increase immunization compliance.
Performance Measures: Decrease in Missing Immunization histories from 19% to 10.9% thus increasing number of immunization records available in state and local registries.
Feedback: Results were shared with program management and navigators. Results showed improvements in obtaining histories. Navigators are now instructed to enter information directly into registries so that information can be shared with various providers in the community and reduce record fragmentation.
Objective 2: Increase access to external agencies.
Performance Measures: 67.9% of clients who were referred to a an outside agency.
Feedback: Results were shared with program managers and navigators. Results showed community need for various services such as family planning, child care, and help receiving food stamps and other welfare programs. Navigators are now charged with intense follow-up contacts with families to ensure successful linkage with outside agencies.
SustainabilityProject Milestone is an integral part of HDHHS’ overall strategy towards the holistic approach of a child’s health by serving as liaison between the public, community-based organizations, and medical providers. One of the primary objectives of this approach is to reduce the tendency for families to fragment medical care. For instance, HDHHS has provided convenient immunization service delivery for Houston’s children. Program managers soon realized that the children seen at these safety net sites often had other potential sources of care.
The shift in strategy has allowed for sustainability in Project Milestone and resulted in diverse expertise in accomplishing program objectives. HDHHS has reallocated immunization screeners working at service delivery sites and assigned them to navigator roles instead. Another source of personnel came from HDHHS’ case management program. These staff members were trained in outreach activities including tracking and follow-up of internal and external referrals. In addition, project coordination has been moved from the Immunizations Bureau to Family Support Services in which includes programs such as Targeted Case Management for high risk pregnancies and Healthy Families Healthy Futures.
Since the implementation of Project Milestone, HDHHS has committed funds to not only continue the program, but to expand it as well. Navigators are now stationed at eleven out of sixteen City of Houston operated WIC programs. Eight of the navigators were reallocated personnel and three are new to the City of Houston. HDHHS utilizes the City’s general funds and has incorporated grant funds from CDC and Texas Department of State Health Services in order to sustain the program.