Model Practice Title
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Please provide the name or title of your practice
Mobile Amish Immunization Clinics in St. Mary's County, Maryland
Practice Categories
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Model and Promising Practices are stored in an online searchable database. Applications may align with more than one practice category. Please select all the practice areas that apply.
- Access to Care
- Advocacy and Policy Making
- Animal Control
- Coalitions and Partnerships
- Communications/Public Relations
- Community Involvement
- Cultural Competence
- Emergency Preparedness
- Environmental Health
- Food Safety
- Global Climate Change
- Health Equity
- HIV/STI
- Immunization
- Infectious Disease
- Informatics
- Information Technology
- Injury and Violence Prevention
- Marketing and Promotion
- Maternal-Child and Adolescent Health
- Organizational Practices
- Other Infrastructure and Systems
- Organizational Practices
- Primary Care
- Quality Improvement
- Research and Evaluation
- Tobacco
- Vector Control
- Water Quality
- Workforce
- Conference Theme: Bridging Clinical Medicine and Population Health
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Other:
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Is this practice evidence based, if so please explain.
The implementation of the current practice is based upon evidence-based practice; MMWR Weekly January 8, 2010 / 58(51&52); 1-4 cited updates to the recommended Immunization schedules for persons aged zero through eighteen years and the Amish Mobile Clinic has utilized the most current recommended schedule of vaccines, to promote immunizations within the community . Recently MMWR Weekly November 18, 2016 / 65(45); 1270-1273 highlighted the importance of equitability of access needed to be addressed in order to achieve higher vaccination rates, therefore decreasing mortality rates in children. Additionally, the World Health Organization targeted diphtheria, Pertussis, tetanus, measles, poliomyelitis and tuberculosis. “Global policies for immunization and establishment of the goal of providing universal immunization for all children by 1990 were established in 1977, this goal was considered an essential element of the WHO strategy to achieve health for all by 2000” (WHO, 2013).
Winnable Battles
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To keep pace with emerging public health challenges and to address the leading causes of death and disability, CDC initiated an effort called Winnable Battles to achieve measurable impact quickly.Winnable Battles are public health priorities with large-scale impact on health and known effective strategies to address them. Does this practice address any CDC's seven Winnable Battles? If so, please choose from the following:
- Food Safety
- HIV in the U.S.
- Nutrition, Physical Activity, and Obesity
- Tobacco
- Healthcare-associated Infections
- Motor Vehicle Injuries
- Teen Pregnancy
- None
Overview: Provide a brief summary of the practice in this section (750 Word Maximum)
Your summary must address all the questions below:
- Brief description of LHD- location, demographics of population served in your community
- Describe public health issue
- Goals and objectives of the proposed practice
- How was the practice implemented/activities
- Results/Outcomes (list process milestones and intended/actual outcomes and impacts.
- Were all of the objectives met?
- What specific factors led to the success of this practice?
- Public Health impact of practice
- Website for your program, or LHD.
750 Word Maximum
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Please use this portion to respond to the questions in the overview section.
St. Mary’s County is situated on a peninsula in Southern Maryland with over 500 miles of shoreline on the Patuxent River, Potomac River and Chesapeake Bay. The Naval Air Station, Patuxent River, employing 22,400 military, civilians and defense contractors, is home to the U.S. Naval Air Systems Command (NAVAIR), including the Naval Air Warfare Center Aircraft Division (NAWCAD).
St. Mary’s County Pertussis rate was 3.0 and continued to raise to an alarming rate of 6.4 in 2013. After further investigation, it was determined that the majority of the pertussis cases resided within the Amish community.
St. Mary’s County, Maryland is home to a large Amish community, with an estimated population of over 1,400. The Amish are active members of the community and provide many goods and services to the residents of Southern Maryland.
To the Amish, someone is healthy if they “look well, maintain a good appetite, and can function physically”. An unhealthy person is “unable to perform daily work and contribute to their family and community”. The Amish believe that childhood diseases, such as chicken pox and pertussis, provide natural herd- and lifelong- immunity. The community traditionally uses holistic and alternative medicine, and as devout Christians, believe in the power of prayer for healing.
While limited, community members may use the larger healthcare system after consultation and approval by Amish Elders. Similar to the general population, Amish who pursue healthcare services face many barriers, including:
• Culture and beliefs
• Language and communication
• Health literacy
• Lack of insurance
• High costs
• Access
The Amish in St. Mary’s County currently operate 10 schools, which serve approximately 250 students in grades 1–8. These schools are typically one-room, and children of all ages study together. Historically, the Amish do not vaccinate their children, but some members of the community have begun to do so. Recent events, including a measles outbreak in 2014, have resulted in members of the community approaching St. Mary’s County Health Department (SMCHD) for preventive services.
• While cases typically go unreported, a recent case of pertussis within the community resulted in complications;
• Measles outbreaks in 2014 included many cases within the Amish communities in Pennsylvania and Ohio;
• Annual school immunization surveys submitted to SMCHD by Amish Elders indicate high percentages of non- or under- vaccinated children
In an effort to reduce access barriers and expand outreach to underserved populations within the county, SMCHD developed a mobile, home-based clinic model for implementation in the Amish community. The primary objective of the clinic was to provide community-wide immunizations for infants, children and adults in a manner that was sensitive to the cultural identity of the Amish community and at no cost. To achieve this goal, SMCHD:
• Worked collaboratively with the Amish holistic health worker and Amish Elders;
• Contracted with a local pediatrician, known to the Amish community, to staff the mobile clinic;
• Provided health department staff to operate the clinic, maintain records and complete immunization record books;
• Provided all supplies, including vaccines;
• Provided on-going follow-up and health promotion services
While pertussis and measles were a community focus, all childhood immunizations were offered and administered.
• Adult Amish parents inquired about, and were educated on vaccinations
• Education was provided to adults on communicable and infectious diseases
• Follow-up clinics have been scheduled and held on a semi-annual basis.
Because of this collaborative effort to increase the immunizations within the Amish community, St. Mary’s County will stay healthier and have lower incidence of having cases of illness and outbreaks. All of the objectives were met. Success of this program is due to the collaboration and the buy-in of all involved from the Amish community, local pediatrician, and St. Mary’s County Health Department. In turn, this collaboration addressed the needs of an identified population within our community, as well as assist the Health Department with the framework needed to be able to develop other programs with the potential of more successful outcomes. Finally, for more information, please see St. Mary’s County website at www.smchd.org/.
Responsiveness and Innovation
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be (1) new to the field of public health (and not just new to your health department) OR (2) a creative use of an existing tool or practice, including but not limited to use of an Advanced Practice Centers (APC) development tool, The Guide to Community Preventive Services, Healthy People 2020 (HP 2020), Mobilizing for Action through Planning and Partnerships (MAPP), Protocol for Assessing Community Excellence in Environmental Health (PACE EH). Examples of an inventive use of an existing tool or practice are: tailoring to meet the needs of a specific population, adapting from a different discipline, or improving the content.
- Statement of the problem/public health issue
- What target population is affected by problem (please include relevant demographics)
- What is the target population size?
- What percentage did you reach?
- What has been done in the past to address the problem?
- Why is the current/proposed practice better?
- Is current practice innovative? How so/explain?
- Is it new to the field of public health
OR
- Is it a creative use of existing tool or practice:
What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO’s Toolbox etc.)
- Is the current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)
2000 Word Maximum
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Please state the Responsiveness and Innovation of your practice (2000 Word Maximum)
St. Mary’s County, Maryland is home to a large Amish community with an estimated population of over 1,400. The Amish are active members of the community and provide many goods and services to the residents of Southern Maryland. In 2013, data reflected the Pertussis rate was 3.0 and continued to rise to an alarming rate of 6.4 in St. Mary’s County, Maryland. After further investigation, it was determined that the majority of the pertussis cases resided within the Amish community.
In the past, the St. Mary’s County Health Department would visit the Amish community when there were reportable illnesses. The Infectious Disease department would assist with the awareness and education regarding the illnesses, as well as what preventable measures could be utilized to prevent the spread of disease in the future. The Amish community began to recognize an increase of Pertussis and allowed the Infectious Disease nurses to speak to several of their community elder leaders. The Infectious Disease nurses were able to educate them and gain their trust; through the newly acquired trust, the elders have allowed immunizations to be administered via an Amish Mobile Clinic, at one of the Amish community homes twice yearly. An appointed Amish elder coordinates the Amish Mobile Clinic event date with the health department, and is responsible for advertising and promoting the immunization event within the Amish community.
By addressing Amish barriers to immunizations, including limited transportation, language, and lack of health insurance and high healthcare costs, St. Mary’s County has seen an increase in the amount of immunized individuals since 2014. This has been facilitated largely through collaboration and trust built between the Amish community, the St. Mary’s County Health Department Health Officer and Infectious Disease nurses, and a local pediatrician. Effective cross-cultural, empathetic communication has been at the crux of building immunization acceptance. Recognizing and centering care to the Amish culture has allowed for current practice to become the new standard for vaccination awareness and immunization promotion in St. Mary’s County. As immunization is a proven tool for controlling and even eradicating infectious disease, this new practice aids in preventing health disparities, and promoting good health for the entirety of the Southern Maryland community.
Healthy People 2020 objectives were utilized to create the foundation of the above outlined practice in St. Mary’s County, Maryland. The Healthy People 2020 objectives focused on:
• Attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death;
• Achieving health equity, eliminating disparities, and improving the health of all groups;
• Creating social and physical environments that promote good health for all;
• Promoting quality of life, healthy development, and healthy behaviors across all life stages.
As a result of the collaborative efforts in increasing immunizations to the Amish community, The Amish Mobile Clinic has allowed the health department to assist the community members in meeting these Healthy People 2020 objectives. Because of the Amish Mobile clinic, a total of 282 Amish children were immunized since 2013; CY 2014- 87; CY 2015- 94; CY 2016- 101; this represents a 14% increase since CY 2014, just within the Amish community.
The implementation of the current practice is based upon evidence-based practice; MMWR Weekly January 8, 2010 / 58(51&52); 1-4 cited updates to the recommended Immunization schedules for persons aged zero through eighteen years and the Amish Mobile Clinic has utilized the most current recommended schedule of vaccines, to promote immunizations within the community . Recently MMWR Weekly November 18, 2016 / 65(45); 1270-1273 highlighted the importance of equitability of access needed to be addressed in order to achieve higher vaccination rates, therefore decreasing mortality rates in children. Additionally, the World Health Organization targeted diphtheria, Pertussis, tetanus, measles, poliomyelitis and tuberculosis. “Global policies for immunization and establishment of the goal of providing universal immunization for all children by 1990 were established in 1977, this goal was considered an essential element of the WHO strategy to achieve health for all by 2000” (WHO, 2013).
The community response to the Amish Mobile Clinics has been positive. As the number of individuals vaccinated increases, so does the requirement for staff at the Amish Mobile Clinics. The health department has seen an increase in the amount of volunteers willing to participate in this innovative event, and the majority of volunteers have continued to volunteer in subsequent years, proving their support for the practice.
LHD and Community Collaboration
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broad-based involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
- Goal(s) and objectives of practice
- What did you do to achieve the goals and objectives?
- Steps taken to implement the program
- Any criteria for who was selected to receive the practice (if applicable)?
- What was the timeframe for the practice
- Were other stakeholders involved? What was their role in the planning and implementation process?
- What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s)
- Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise, provide an estimate of start-up costs/ budget breakdown.
5000 words maximum
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Enter the LHD and Community Collaboration related to your practice (5000 words maximum)
St. Mary’s County, Maryland is home to a large Amish community with an estimated population of over 1,400. The Amish are active members of the community and provide many goods and services to the residents of Southern Maryland. In 2013, data reflected the Pertussis rate was 3.0 and continued to rise to an alarming rate of 6.4 in St. Mary’s County, Maryland. After further investigation, it was determined that the majority of the pertussis cases resided within the Amish community. Because of the frightening rate increase of Pertussis cases, the St. Mary’s County Health Department identified that a collaborative effort needed to be formed, as well as new practice interventions put into practice.
To the Amish, someone is healthy if they “look well, maintain a good appetite, and can function physically”. An Amish community member states, an unhealthy person is “unable to perform daily work and contribute to their family and community”. The Amish believe that childhood diseases, such as chicken pox and pertussis, provide natural herd- and lifelong- immunity. The community traditionally uses holistic and alternative medicine, and as devout Christians, believe in the power of prayer for healing.
While limited, community members may use the larger healthcare system after consultation and approval by Amish elders. Similar to the general population, Amish who pursue healthcare services face many barriers, including:
• Culture and beliefs
• Language and communication
• Health literacy
• Lack of insurance
• High costs
• Access
The St. Mary’s County Health Department, a local pediatrician, Dr. Amarpeet Dhillon, and the Amish Community have joined together and work in a collaborative effort to increase the immunization rates among the Amish. By increasing immunization rates among the Amish, St. Mary’s County therefore decreases mortality rates within the community. Immunization rate increases are achieved mainly by means of an Amish Mobile Immunization Clinic in which clinic workers administer vaccinations at the home of an Amish community member twice yearly. The primary objective of the Amish Mobile Immunization Clinic was to provide community-wide immunizations for infants, children and adults in a manner that was sensitive to the cultural identity of the Amish community and at no cost. To achieve this goal, SMCHD:
• Worked collaboratively with the Amish holistic health worker and Amish elders;
• Contracted with a local pediatrician, known to the Amish community, to staff the mobile clinic;
• Provided health department staff to operate the clinic, maintain records and complete immunization record books;
• Provided all supplies, including vaccines;
• Provided on-going follow-up and health promotion services
The Amish Mobile Immunization Clinic practice took St. Mary’s County Health Department approximately four months to put into active practice. This involved writing and obtaining approval on the new Amish Mobile Immunization Clinics protocol, a signed contract with local pediatrician trusted by the Amish community, Dr. Dhillon, obtaining extra immunization supplies, ensuring enough funds would be available to support the clinic, date and times to set up the first clinic day and advertisement. The stakeholders, Amish elders and Dr. Dhillon, were heavily involved in writing the goals, outcomes, feedback for the protocol, and writing contracts between involved parties.
Finally, there is cost of initiating and maintaining the Amish Mobile Clinic. The St. Mary’s County Health Department is able to utilize VFC immunizations from the State of Maryland for this program due to the fact that the Amish families do not have health insurance. Dr. Dhillon has agreed to $575.00 per every four hours; supplies cost is $450.00. St. Mary’s County Health Department has been able to keep the cost to $500.00 for staffing. This is due to being able to utilize Nursing Interns volunteers that are working on obtaining their Bachelor’s Degree in Nursing.
Evaluation
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
- What did you find out? To what extent were your objectives achieved? Please re-state your objectives.
- Did you evaluate your practice?
- List any primary data sources, who collected the data, and how (if applicable)
- List any secondary data sources used (if applicable)
- List performance measures used. Include process and outcome measures as appropriate.
- Describe how results were analyzed
- Were any modifications made to the practice as a result of the data findings?
2000 Words Maximum
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Please enter the evaluation results of your practice (2000 Words Maximum)
In an effort to reduce access barriers and expand outreach to underserved populations within the county, St. Mary’s County Health Department developed a mobile, home-based clinic model for implementation in the Amish community. The primary objective of the clinic was to provide community-wide immunizations for infants, children and adults in a manner that was sensitive to the cultural identity of the Amish community and at no cost. While conducting the clinics, St. Mary’s County Health Department Infectious Disease program has continuously evaluated the process and overall outcomes.
In regards to the ongoing process evaluation, the Infectious Disease Program completes a summary at the end of each mobile clinic that addresses what went well and want can be improved. Evaluation of numerous items such as communication, supplies, storage of the vaccine, man power hours devoted to the clinic, check in and out process, and time management. It is imperative to evaluate all of these factors.
In comparison, the ongoing overall outcome evaluation the program has been extremely successful in increasing the number of vaccines administered to the Amish; therefore decreasing mortality. Another outcome has been the increased communication, increased by-in and collaboration between the St. Mary’s County Health Department and Amish community in general.
There were several performances measures utilized when evaluating the program; Patient experience feedback, cost of healthcare services, and disparities on performance. For example, the Infectious Disease Program nurse will talk directly to the elder Amish woman in charge to get direct feedback on any questions and/or concerns that she observed or was made aware of.
The data is collected from the paperwork that is filled out at each Amish Mobile clinic. The information from the immunization records are uploaded into Immunet and then an Excel spreadsheet is created regarding the number of patients and number of vaccines administered on the day of the clinic. When reviewing the time of the nursing staff, it was discovered that it took the same amount of time for one nurse as compared to two nurses when the correct flow of patients was utilized.
Modifications were made to assist in obtaining better processes and outcomes as highlighted by the performances measurements. St. Mary’s County Health Department has found that the department needed to make adjustment towards staff. It was found that there only a need for one Infectious Disease nurse to assist in the clinic and that it is imperative to have a good traffic flow process of where patients can complete their paperwork, where to have the physician placed, vaccinator placed, and nurse placed to check out each patient who comes into the clinic. Also, the first two clinics the second nurse would hand out the clipboards with the needed paperwork for the clinics. It was discovered that the Amish were getting upset because they felt that people were being taken out of turn. The process is that one of the elder Amish women hand out the clipboards and she gives each of them a number. This intervention was a win-win for all involved because it increased the Amish involvement and decreased the man-hours spent on that task. This review assists in St. Mary’s County’s Health Department in reflecting how successful the intervention was in addressing the need of an identified population within our community, as well as ensuring the effective use of resources. Finally, a framework has been made to assist with future interventions with potential even more successful outcomes.
Sustainability
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)
- Lessons learned in relation to practice
- Lessons learned in relation to partner collaboration (if applicable)
- Did you do a cost/benefit analysis? If so, describe.
- Is there sufficient stakeholder commitment to sustain the practice?
- Describe sustainability plans
1500 Words Maximum
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Please enter the sustainability of your practice (2000 Words Maximum)
The Amish are active members of St. Mary’s County and are known for farming and providing vegetable markets as well as furniture stores, plant nurseries, and other valued businesses in St. Mary’s County. The Amish have a strong history, settling in the United States in the 1700's fleeing religious persecution from Germany. The Amish are also known as plain people, because they separate themselves from society, socializing within their community. Amish education ends at the eighth grade, generally at fourteen years of age. After completing school the children enter the workforce, in the Amish community.
The Amish generally use folk art and alternative or holistic medicine. When the Amish need medical intervention they use prayer consult with Amish Elders and Bishops before seeking modern medicine or healthcare. The Amish culture does not prohibit modern medicine. Barriers include transportation, language, lack of health insurance, and high health care costs. It is important for health care providers to recognize these beliefs and center care around them. St. Mary’s County Health Department has worked diligently on making and continuing communication and trust within the Amish community as well as understanding and respecting their culture in order to be able to continue to having the Amish Mobile Clinic.
The lessons learned from conducting the Amish Mobile Clinic are:
• Scheduling should accommodate large scale community activities such as “Market Days”
• Clinic must be prepared to handle vaccination of adults in addition to children
• Processes that reduce paperwork should be implemented to facilitate clinic efficiency and communication
• SMCHD needs to adapt EHR to maximize effectiveness of prevention and wellness services in mobile-clinic setting
• Send out letters to the Amish community every March and October to plan for the date that the clinic can be held.
There is a local pediatrician in St. Mary’s County, Dr. Amarpreet Dhillon that has gained the Amish community’s trust. Dr. Dhillon and his staff are committed in collaborating with St. Mary’s County Health Department in conducting with Amish Mobile Clinic. St. Mary’s County Health Department and Dr. Dhillon have a written contract that is renewed every two years regarding the Amish Mobile Clinic.
All community partners worked diligently on assisting with the Amish with cultural acceptance; collaboration; communication; and trust. Barriers have been broken down; therefore the clinic remains thriving and successful. The Mobile Amish Immunization program has assisted in addressing the needs of an identified population, promoted and fostered collaboration, ensured effectiveness of use of resources, as well as provided a strong framework to build other programs to be just as successful and able to sustainability.
Additional Information
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How did you hear about the Model Practices Program:
- I am a previous Model Practices applicant
- At a Conference
- NACCHO Website
- Public Health Dispatch
- Colleague in my LHD
- Model Practices brochure
- NACCHO Exhibit Booth
- NACCHO Connect
- Colleague from another public health agency
- E-Mail from NACCHO
- NACCHO Exchange
