BCHD White Paper: State of Health in Baltimore (Winter 2016)

Summary of Key Issues, Services, and Policies

The State of Health in Baltimore: It is impossible to discuss the health and well-being of Baltimore City’s residents without applying the lens of health equity and systemic disparities. While the overall mortality rate in Baltimore City has declined over the past decade, the City still has a mortality rate 30% higher than the rest of the state and ranks last on key health outcomes compared to other jurisdictions in Maryland.

This reality is compounded by a series of complicated systemic social, political, economic, and environmental obstacles. With more than 1 in 3 of Baltimore’s children living below the federal poverty line and more than 30% of Baltimore households earning less than $25,000/year, income, poverty, and race have an enormous impact on health outcomes.

This state of health is especially urgent when we consider that Baltimore houses some of the best healthcare institutions in the country. We know that healthcare alone cannot drive health: while 97% of healthcare costs are spent on medical care delivered in hospitals, only 10% of what determines life expectancy takes place within the four walls of a clinic. Where we live, work, and play each day drives our health and well-being. 

As the local health authority, the Baltimore City Health Department (BCHD)’s mission is to serve Baltimore by promoting health and advocating for every individual’s well-being, in order to achieve health equity for all residents. We work every day to improve the health of our community and address the disparities we face.

A current snapshot of health in the City includes:

  • The leading causes of death are heart disease, cancer, stroke, HIV/AIDS, and chronic lower respiratory disease;
  • Across the City, there exists as much as a 20-year difference in life expectancy between neighborhoods;
  • Although HIV rates in the City have declined over the past decade, Baltimore consistently ranks in the top five cities worldwide for infections. About 13,400 residents are estimated to be living with HIV; and while African Americans constitute 62% of the population, they account for more than 85% of those living with HIV;
  • One in three youths is either obese or overweight. One in four children drinks a regular soda every day, and less than one in five eats recommended servings of fruits and vegetables;
  • 19% of adult residents in Baltimore City have been diagnosed with asthma, compared to a statewide average of 14%;
  • 12.3% of babies born in the City are low birth weight, compared to a national average of 6%;
  • 30% of children in Baltimore have Adverse Childhood Experience (ACE) scores of 2 or more, meaning that they have experienced more than two incidences of events such as domestic violence, living with someone with an alcohol/drug problem, the death of a parent, or being a victim/witness of neighborhood violence.
  • 25% of adults living in Baltimore are regular smokers, compared to a national average of 17%.
  • Baltimore has one of the highest rates of heroin use and overdose in the country – in 2014, 192 deaths were heroin-related. Over 60,000 people in the City are estimated to have a drug or alcohol addiction. 

Principles

BCHD’s work is driven by three principle tenets:

  1. We go to where people are. We believe that services and public health information should be delivered directly to community members. BCHD delivers health services in schools to ensure children don’t miss class, deploys home-visiting services to ensure people receive critical maternal and child health care and sends Safe Streets outreach workers into the neighborhoods where conflicts occur in our community.
  2. We engage the community in setting goals. Our long-term goals are based on scientific best practices, but our short-term metrics are developed and shaped by the community. We adopt a robust community engagement approach to all of our work, partnering with neighborhood associations, faith-based organizations, and issue-specific stakeholders to ensure that the work we do is informed by –and responsive to-- the needs of Baltimore’s citizens. 
  3. We go “upstream” and tackle the root causes of poor health. Public health is a powerful tool to fight injustice, and we embrace every opportunity to level the playing field of inequality. We know that health impacts every issue, from education to crime to unemployment – if our youth and adults are not healthy, they cannot learn or work productively. By investing in public health, we can ensure that Baltimore reaches its maximum potential.

BALTIMORE’S PUBLIC HEALTH PRIORITIES

Issue 1: Addressing the Opioid Epidemic

Background: With approximately 19,000 active heroin users in Baltimore and far more who misuse and abuse prescription opioid medications, our city cannot be healthy without addressing opioid addiction and overdose.  In 2014, 303 people died from drug and alcohol overdose, which is more than the number of people who died from homicide. Drug addiction impacts our entire community and ties into nearly every issue facing our city including crime, unemployment, poverty, and poor health. 

Victories: BCHD has developed a comprehensive, 3-pillar strategy to combat opioid addiction that led the way in Maryland and that serves as a national model of innovation:

  • Prevent deaths from overdose and save lives. In 2015, Commissioner Wen declared opioid overdose a public health emergency and the most critical part of BCHD’s opioid overdose prevention campaign has been expanding access to naloxone – the lifesaving drug that reverses the effect of an opioid drug overdose. In October 2015, a new law went into effect that allowed Dr. Wen to issue a “standing order” and prescribe naloxone to the City’s 620,000 residents. Baltimore City became the first jurisdiction in Maryland to expand access to naloxone using a standing order.

In 2015, BCHD and partner organizations trained over 8,000 people at street markets, metro stops, jails, and neighborhood meetings on how to administer naloxone. BCHD assisted the Baltimore Police Department to incorporate naloxone training into the police academy and within the first month of carrying this remedy, officers used naloxone to save the lives of four of our citizens. Baltimore City was also one of the first jurisdictions to require naloxone training as part of the court-mandated time in Drug Treatment Court. We have trained federal, state and city legislators so that they can not only save lives but also serve as ambassadors and champions to their constituents.

We use up-to-date epidemiological data to target our training to “hotspots”, taking naloxone directly into the most at-risk communities and putting it in the hands of those most in need. This was put into effect in 2015 when we saw that 39 people died from an overdose of the opioid Fentanyl between January and March of 2015. Fentanyl is many times stronger than heroin, and individuals using heroin were not aware that the heroin had been laced with Fentanyl. Unfortunately, Fentanyl continues to be an issue and an additional spike in Fentanyl deaths occurred in October 2015, when there were 14 deaths related to fentanyl—a 133 percent increase over last year. To address this spike in Fentanyl related deaths, BCHD launched aggressive outreach efforts in “hotspot” areas and announced a new platform that will allow Baltimore City residents to be trained online in how to use naloxone and receive the “standing order” prescription.

  • Increasing access to on-demand treatment and long-term recovery support. Stopping overdose is only the first step in addressing addiction. To adequately treat people with substance use disorders, we must ensure there is adequate access to on-demand treatment. Nationwide, only 11% of patients with addiction get the treatment they need. In collaboration with Behavioral Health System Baltimore, the local behavioral health authority, BCHD has already taken several actions to ensure access to treatment, including:
  • Created a 24/7 Crisis, Information, and Referral phone line for anyone with addiction and mental health concerns  that receives nearly 1,000 calls every week for crisis services and referral to appointments;
  • Secured $3.6M in capital funds to build a stabilization center which will be the first step towards creating a 24/7 “Urgent Care” for behavioral health
  • Hired community-based peer recovery specialists and piloted universal addiction screening in our hospitals;
  • Implementing the Law Enforcement Assisted Diversion Program (LEAD) with City partners, to establish criteria for police officers to identify and connect individuals to services such as drug treatment and housing, rather than to central booking for arrest.
  • Provide education to reduce stigma and prevent addiction. In addition to treating patients, the dialogue around substance use disorder must also change and BCHD has been at the forefront of changing public perception of addiction so those in need are not ashamed to seek treatment. BCHD is leading a city-wide effort to educate the public and providers on the nature of addiction: that it is a disease, recovery is possible, and we all must play a role in preventing addiction and saving lives.

Key activities include:

  • A public education campaign, “DontDie.org”, educates citizens that addiction is a chronic disease and encourages individuals to seek treatment;
  • Conversations with emergency doctors across the City to create awareness about the best approaches to prescribing opioid medication;
  • Educational programs for doctors and providers of all specialties around careful prescribing of opioid medications and the need for training in anti-overdose medication naloxone.

Baltimore City was the first jurisdiction in Maryland to take this proactive approach to address addiction and has one of the most ambitious overdose response and addiction treatment programs in the country. The United States Senate and the Centers for Disease Control and Prevention (CDC) have both highlighted BCHD’s innovative approaches to addressing the opioid epidemic, as a best practice for other cities to learn from. 

Challenges and Aspirations: While we have made important strides in responding to substance abuse and overdose within the city, there is still an urgent imperative to respond to this crisis by:

  • Ensuring naloxone accessibility by ensuring that the cost of this life-saving antidote, which has quadrupled over the past two years in Baltimore, remains affordable.
  • Increasing access to on-demand treatment – we must ensure sufficient high-quality treatment options are available to those suffering from opioid addiction. BCHD ultimately intends to establish a 24/7 emergency room dedicated to behavioral health and on-demand access to addiction support, as well as proven intervention models such as LEAD and expanded case management for individuals being released from jail.
  • Additional funding for prevention and stigma reduction – to stop the cycle of addiction, we must continue to invest in prevention services and anti-stigma education.

 

Issue 2: Youth Violence Prevention

Background: Addressing violence and public safety are key priorities for Baltimore City, and BCHD strongly believes that preventing violence is an essential function of public health. The hallmark model for violence prevention at BCHD is the Safe Streets program, a program designed to combat shootings and homicides in targeted communities in Baltimore.

Victories: Safe Streets takes a public health approach to violence and maintains that violence is a learned behavior that can be prevented using disease control methods; as violent events often “cluster” similar to an infectious disease outbreak. The program has proven successful in significantly reducing incidences of shootings and homicides. In 2014 alone, the program had 15,000 client interactions and 800 mediated conflicts, more than 80% of which were deemed likely or very likely to have resulted in gun violence. In addition to neighborhood-level impact, the program also prevents the intensive trauma and often costly city-wide ripple effects associated with a major event of violence.

In light of these results, BCHD has developed a strategic framework for youth violence prevention across the City, including:

  • Scaling what works. Given Safe Streets’ success to date, BCHD believes it is essential to continue supporting and developing the program’s current operations as well as investing in expansion to additional sites. We are currently pursuing multiple sources of funding to sustain and potentially expand this program and ensure that we can continue to prevent incidents of violence across the City.

  Leveraging additional entry points. To reach people where they are and prevent additional violence, we must identify additional entry points by working with partners throughout the City, including the:

  • Healthcare System– building off of the Safe Streets model, we seek to deploy “hospital interrupters” when youth come into the emergency room as a result of a violent incident. Additionally, we will pilot the implementation of Maryland Shock Trauma’s Violence Intervention Program, a youth violence prevention model that uses the hospital as an entry point for intervention conversations and services.
  • Justice System – the B’MORE FOR YOUTH Collaborative, drives the City of Baltimore’s comprehensive plan to prevent violence affecting youth and reduce the number of people going into the criminal justice system. It is the product of collaboration among local, state, and federal partners, identifies root causes, and recommends a coordinated, multi-sector, multi-tiered approach.
  • Violence as a public health issue. We know violence is a generational challenge impacted by the social determinants that shape people’s lives. BCHD’s approach to violence prevention starts as far “upstream” as possible. One such example is ensuring that Baltimore’s youth have access to appropriate eye care and equipment – if a child cannot see, then they are unlikely to be motivated to come to school and may turn to other activities within their neighborhood that increase their likelihood of becoming involved in a violent incident later in life. Similarly, other studies have shown that home visiting programs for pregnant women and lead poisoning prevention will improve educational outcomes and reduce violence in the child. We have also developed a robust youth health and wellness campaign within BCHD that will ensure that all youth are healthy and engaged.

Challenges and Aspirations:

  • Sustaining the Safe Streets Program – Safe Streets has historically been funded by grants, including those from the US Department of Justice and Centers for Disease Control and Prevention (CDC), all of which come to a close this year.
  • Support to pilot and scale new violence prevention initiatives – Safe Streets, while a best-in-class model, is one innovative way to tackle youth violence. We must also invest in programs similar to MD Shock Trauma’s Violence Intervention Program, Hospital Interrupters, and other public health initiatives that lead to reductions in violence—including home visiting programs for pregnant women and lead poisoning prevention programs.  

 

Issue 3: Youth Health and Wellness

Background: A decade ago, Baltimore City’s infant health outcomes ranked as one of the poorest in the country, with an infant mortality rate nearly twice the national average and huge disparities between black and white birth outcomes. In response, BCHD in partnership with the Family League of Baltimore City and Health Care Access Maryland developed a city-wide public-private partnership called B’More for Healthy Babies. The goal of the initiative is to ensure that all of Baltimore’s babies are born at a healthy weight, full-term, and ready to thrive in healthy families. It is a comprehensive, evidence-based solution that builds cross-sector partnerships for strategic planning and implementation; strengthens systems and streamlines interventions to assure maximum effectiveness, ensures community and client participation in planning, and emphasizes proactive monitoring and data-driven decision-making.

Victories:

  • B’More for Healthy Babies Since its inception, B’More for Healthy Babies has experienced extraordinary success in:
    • Reducing the infant mortality by an astonishing 28%, bringing it to its lowest point in Baltimore’s history;
    • Closing the disparity between black and white infant deaths by almost 40% between 2009 and 2012;
    • Decreasing the teen birth rate in the City by an unprecedented 36%.
    • Reducing sleep-related infant deaths by 50%

The program’s success has been widely recognized and was recently awarded the Academy

Building upon the success of B’More for Healthy Babies, BCHD seeks to take a comprehensive approach to youth health and wellness through:

  • Youth Health and Wellness Plan BCHD have developed a comprehensive youth health and wellness plan that applies the same principles that have made the B’More for Healthy Babies program so successful, to the full youth life course of 0-19 years old. This plan will focus on three categories of long-term outcomes:
  • Healthy Minds- including improved social and emotional development as well as improved behavioral health;
  • Healthy Bodies-including continuation of reduced teen births and improved physical health outcomes including immunizations and oral health;
  • Healthy Connections-including improved peer relationships, community connectedness, and connections with trusted adults.
  • School Health The Bureau of School Health at BCHD provides health services in all Baltimore City Public Schools. We have helped children better achieve their potential by supporting mental health services in 119 schools and providing students with access to health suite services, with nearly 300,000 annual visits in 180 schools. However, capacity is severely limited: several school-based health centers must share one nurse practitioner or provide care via the school health suites, which do not have nurse practitioners or physicians readily available to provide diagnosis, treatment, and preventative services.

Telemedicine is an innovative and effective way to address this gap in capacity and expand the level of care offered across schools without having to staff each with a full-time primary care provider. BCHD seeks to launch a telemedicine pilot to improve care coordination by virtually connecting community physician providers to over 1,500 school children, allowing them to stay in class and keep their parents at work. This will enable regular evaluation and treatment of both acute and chronic illnesses, as well as enhance the availability of key behavioral and mental health services.

  • Reproductive Health BCHD and a broad coalition of partners in the City, including Baltimore City Public Schools, were awarded an $8.5 million grant from the U.S. Department of Health and Human Services that will be used to ensure comprehensive sex education in middle schools and high schools, with the aim of reducing the teen birth rates as well as provide accurate, evidence-based reproductive health education. 

Challenges and Aspirations:

  • B’More for Healthy Babies Sustainability - With state and federal budgets steadily decreasing, this critical program faces a $1.5 million deficit in the upcoming fiscal year. To ensure that all of Baltimore’s babies are born healthy, we must fill this gap by pursuing multiple funding streams, including philanthropic, government, and billable services. 
  • School Health Telemedicine Pilot – Deploying telemedicine will significantly expand the capacity of the school health program and ensure the improved health of hundreds of schoolchildren. We are pursuing grants and other funding opportunities to support this initiative. 

Issue 4: Behavioral Health

Background: Baltimore City faces significant behavioral health challenges and disparities.  Baltimore City residents, despite making up only 11% of Maryland’s total population, have consistently represented 30% of all statewide inpatient hospital discharges for individuals with mental illness. In 2013, 28% of Baltimore City students reported symptoms of mental illness, compared to 23% of Maryland students. Over 60,000 residents are estimated to have a drug or alcohol addiction.

Victories:

  • Establishment of a stabilization center BCHD has secured $3.6 million in capital funds to build a “stabilization center” – also known as a sobering center – for those in need of temporary service related to intoxication. This is the first step in our efforts to start a 24/7 "Urgent Care" for addiction and mental health disorders – a comprehensive, community-based “ER” dedicated to patients presenting with substance abuse and mental health complaints. Just as a patient with a physical complaint can go into an ER any time of the day for treatment, a person suffering from addiction must be able to seek treatment on-demand.  This center will enable patients to self-refer or be brought by families, police, or EMS – a “no wrong door” policy ensures that nobody would be turned away. The center would provide full capacity treatment in both intensive inpatient and low-intensity outpatient settings, and connect patients to case management and other necessary services such as housing and job training. 
  • Increased focus on treatment and case management Three hospitals in Baltimore City participate in the Screening, Brief Intervention, and Referral to Treatment (SBIRT) project, an evidence-based public health approach to providing early intervention and treatment services to at-risk substance use and mental health disorders. BCHD is leading a city-wide effort to expand the use of SBIRT to all healthcare institutions in the city to deliver early intervention and treatment services for those with or at risk for behavioral health and substance use disorders.

BCHD seeks to increase case management capability for every individual leaving jails and prisons. These individuals are in a highly vulnerable state and must be connected to medical treatment, psychiatric and substance abuse treatments if appropriate, housing and employment support, and more. We know that deploying community health workers in order to reach people where they are in the community as well as provide a credible messenger works: in deploying this tactic, BCHD also aspires to bring jobs and opportunities to vulnerable individuals and neighborhoods that otherwise have limited employment opportunities.

  • Trauma-Informed Care There is growing recognition in Baltimore City that generations of exposure to poverty, racism, violent crime, and domestic violence have resulted in extremely high levels of traumatic stress for individuals, families, and communities across the City.  Recognizing that trauma is a major underlying factor of behavioral health issues and violence, BCHD has launched a trauma-informed care training initiative across the city government, which has already reached more than 1,200 city employees including police officers and other front-line city workers.  The goal of this initiative is to educate all front-line city workers educated in trauma-informed approaches, including:
  • Understanding trauma
  • Understanding the impact of traumatic stress on brain development
  • Integrating trauma-informed practices into work with City residents

Challenges and Aspirations:

  • Operational budget for the stabilization center – While we have secured capital funding, the stabilization center requires $2.5M in operating dollars to successfully launch and begin providing services to potential attendees.
  • Increased investment in trauma-informed care – Trauma is prevalent in Baltimore and a driving factor of many other obstacles and systemic issues in the City. To ensure city-wide resilience, it is imperative that we invest further in this approach and provide trauma and resilience training for all city employees and partners.
  • 24/7 Substance Abuse and Mental Health Center – Building upon the idea of the stabilization center, this facility would be one step closer to on-demand treatment for addiction and mental health services, which are significant unmet needs in Baltimore.  The center will also alleviate pressure from emergency rooms and jails, which are ill-equipped to address these patients’ needs.

Issue 5: Chronic Disease Prevention

Background: BCHD is committed to fighting one of the most pervasive challenges and the leading cause of death and poor health in Baltimore City: chronic disease. We take a multi-pronged approach to addressing chronic disease that encompasses direct services, education, and policy actions. Our chronic disease efforts encompass the following:

  • Cardiovascular Disease/Tobacco Cessation Smoking is the number one preventable contributor to early death from heart disease, stroke, and cancer. BCHD provides smoking cessation services, community education, school-based projects, and enforcement of retailer compliance with tobacco control ordinances. Programs are community-based and deploy health educators and youth educators to engage community members in cessation campaigns, in recognition that 90% of adult smokers started smoking before age 18.
  • Related to this tobacco work is ongoing education and awareness for chronic disease including projects such as a cancer awareness education and a cross-city hypertension initiative to provide screening for high blood pressure in vulnerable communities.
  • Food Access Baltimarket is a suite of community-based food access and food justice programs through BCHD. The program envisions a Baltimore with communities that have equitable access to healthy, affordable, and culturally-specific foods every day. The mission of the program is to improve the health and wellness of Baltimore City residents by using food access and food justice as strategies for community transformation. The three programs that makeup Baltimarket include:
    • Virtual Supermarket – a grocery delivery service that serves over 600 customers at 6 sites and manages over $200,000 in orders, which are handled by 21 trained community-based advocates.
  • Healthy Corner Stores – 10 stores located in Upton/Druid Heights, Harlem Park, and Franklin Square communities that engage in the promotion of healthy eating via community nutrition education, PSAs about healthy snacking, and more.
  • Neighborhood Health Advocates and Food Justice Forum – This summer, the Food Justice Community Conversation Guide will launch with the goal of 25 community-run conversations about food justice in the next year. These conversations are facilitated by BCHD-trained Neighborhood Health Advocates—members of the community who work to help others to get access to healthy, affordable, and fresh food through BCHD.
  • Lead Prevention BCHD seeks to reduce lead poisoning in the City through primary prevention and aggressive enforcement of the city's lead laws. More than 56,000 children under age 6 are at risk for lead poisoning in Baltimore. Lead poisoning can cause permanent brain damage and no amount of lead in children is safe. BCHD educates and encourages families and providers to test children ages 1 and 2 for lead levels, outreach to pregnant women to evaluate potential lead hazards, and with other partners, including Baltimore Housing, conducts home visits and develops strategies to reduce lead paint hazards in homes.
  • Asthma 12.4 % of Baltimore City adults currently have asthma, compared to 8.4% statewide and 8.6 % nationally. The hospitalization rate for adult asthmatics in the City was 3.3 times higher than the state rate (42.9 vs. 13.2 per 10,000 people). BCHD’s asthma programs focus on disease management and access to key resources for patients struggling with asthma. BCHD conducts home visits for children with asthma to educate caregivers about preventing asthma triggers and reducing ER visits for children.

Victories: We have made significant progress in tackling chronic disease through public health campaigns and advocating for policy changes at all levels of government:

  • Lead prevention reforms: Childhood lead poisoning has decreased significantly and is currently at the lowest levels since Maryland’s lead law was implemented in 1994 and enhanced enforcement began at the City level in 2000. Since then, the number of lead poisoning cases has decreased by 98%. Additionally, a BCHD-led pilot to test children’s jewelry revealed extreme levels of lead in many readily available products at local stores. Based on the results of this testing, BCHD implemented regulatory action against lead in children’s jewelry which prohibits the sale of such jewelry if measuring over 600ppm of lead. 
     
  • Sugar-sweetened beverages: one in three children in Baltimore are overweight or obese, and a major contributor is sugar-sweetened beverages (SSBs). With the support of BCHD, legislation has been introduced to the City Council that would require retailers to post warning labels stating the fact that sugar-sweetened beverages lead to tooth decay, obesity, and diabetes. The legislation is based on scientific evidence that warning labels influence consumer behavior and ensures that consumers can make informed choices about their purchase. This is particularly important in Baltimore City with rising rates of obesity among children and with beverage companies’ practices of disproportionate marketing in communities of color and low-income communities.
  • Alcohol and tobacco regulation: BCHD has advocated for several policy initiatives to address the harmful effects of tobacco and alcohol. These include regulation of hookah establishments, a state-wide tobacco tax to be used for medical care, a ban on indoor smoking, including e-cigarettes, buffer zones around schools, and increased enforcement funding and capacity. In the last year, BCHD’s advocacy has resulted in a statewide ban on powdered alcohol and a citywide ban on the sales of the dangerous compounds known as synthetic drugs.

Challenges and Aspirations:

  • Lead prevention – Despite significant progress, our work is far from done: over 5% of children test positive for lead. Building upon current lead prevention efforts, additional funding is necessary at the local, state, and federal levels in order to implement universal screening and provide primary prevention services. Most importantly, additional efforts are needed to support lead abatement in homes, as lead paint hazard is the leading cause of childhood lead poisoning.
  • Sugar-sweetened beverages labels – As mentioned above, legislation has been introduced to the City Council that would require retailers to post warning labels noting the connection between sugar-sweetened beverages and health conditions such as obesity. We have experienced pushback from the American Beverage Association and similar special interests, despite the scientific foundation on which this legislation was developed. We are continuing to work with community partners on this and other efforts to reduce the scourge of childhood obesity and reduce disparities in Baltimore.
  • Local tobacco authority – Due to a previous ruling, Baltimore City is unable to successfully enforce tobacco violations locally. We are currently pursuing legislation in the Maryland General Assembly that would permit local jurisdictions to enact and enforce measures regulating the sale and distribution of tobacco products, with measures at least as stringent as those enacted in state law.

Issue 6: Senior Health and Wellness

Background: As with youth health and wellness, BCHD is committed to providing health education and services for our city’s older adults. The Division of Aging and Care Services serves as the local Area Agency on Aging and coordinates funds from the federal Older Americans Act to ensure an adequate service delivery system. Additionally, the Division ensures essential services for seniors, including health evaluation, personal care, transportation, and volunteer opportunities.

Victories: BCHD has piloted several innovative approaches to ensure improved health outcomes amongst the elderly, including:

  • Falls The Robert Wood Johnson Foundation recently awarded a $200,000  grant to a BCHD-led partnership with local hospitals and community partners such as the American Association of Retired Persons (AARP) that will use predictive data to track patients and reduce falls by one-third over three years. This project involves interventions in senior housing buildings and through hospitals and ERs to educate about fall prevention and provide services to reduce the risk of falls.
     
  • Community Resources A growing concern among many Baby Boomers is taking on the role of caregiver for their parents. BCHD has teamed up with the city's libraries to offer a "Caregiver Corner" for anyone looking to find information on aging. This project was designed to provide caregivers with information and resources through several different initiatives by BCHD. The goal is to broaden outreach and support to family caregivers. Caregiver Corner is one initiative under the “Project Taking Care of Mom and Dad” designed to provide caregivers and older adults who visit the library with relevant resources and information.
     
  • Advocacy and Planning BCHD has led advocacy efforts to oppose cuts to State funding for Baltimore City; including funding for senior centers. We will develop a strategic plan for care for older adults in Baltimore, in a similar vein as the Youth Health and Wellness Plan, that will tie together efforts across the city and present a blueprint for ensuring that our most vulnerable seniors have access to the comprehensive care and community they need.

Challenges and Aspirations:

  • Senior Center Funding – currently, the state distribution model for senior center funding is based on total unemployment and income rates rather than the total population. We have pursued legislation in the Maryland General Assembly to change the formula so that it is based on a population’s total elderly population, as well as the elderly population living 150% below the federal poverty line. We are also proposing that a state task force be created to examine the state funding distribution for seniors. 
  • Older Americans Act - The Older Americans Act was created to ensure that preference is given to providing services to older persons with the greatest economic and social need, particularly low-income minority persons. Funding has not kept up with the aging impoverished population, and it is essential that those dollars are aligned with those who have the greatest economic need and that the right balance is struck among needs and costs. The current intrastate funding formula does not adequately target this vulnerable population and we have proposed revisions so that it is more responsive to the need of Baltimore City seniors.

Issue 7: Acute Communicable Disease and Public Health Preparedness

Background: BCHD provides several essential functions for the City, including communicable disease tracking, education and prevention, emergency preparedness and response, restaurant inspections, and animal control. Our field staff, from animal control officers; to sanitarians; to outbreak investigators, have tackled emergencies ranging from Legionnaire’s, measles, and Ebola investigations to transporting patients to life-saving treatment during severe weather. These activities are core to Baltimore City’s safety and preparedness response.

Victories:

  • HIV Prevention and Education. In the fall of 2015, BCHD secured two grants totaling  $22 million to bring HIV prevention, prophylaxis, and treatment to underserved populations while creating 70 new jobs in the City. The White House has acknowledged Baltimore's leadership in this area, and Baltimore was one of a handful of cities to join the Fast Track Cities coalition to end AIDS by 2030. Our HIV team will continue to partner directly with community and provider groups and provide education and treatment, in one of the largest collaborations to combat HIV.

BCHD has a long history of providing innovative services to prevent and treat HIV/AIDS.  As one of the first jurisdictions in the country to implement a Needle Exchange Program (NEP), the program has exchanged over one million syringes annually with a 75% return rate.  The NEP program is credited with significantly moving the needle on HIV transmission with injecting drug users in Baltimore since its inception.  The NEP is also the testbed for the Staying Alive Program, naloxone training, and directly observed therapy for non-compliant patients on HIV medications. In 2015, almost 3,000 individuals received naloxone training by NEP staff.

While the Affordable Care Act has improved access to health insurance and Medicaid, many of our residents with HIV/AIDS need additional support.  BCHD provides clinical and support services for people living with HIV/AIDS and their contacts through programs like Linkage to Care and the Ryan White Program. Linkage to Care staff members identifies patients who test HIV positive and patients are then taken directly to a participating physician to educate the patient and initiate the appropriate therapy.  This program has linked over 1200 patients to primary care, an important step in stopping the transmission of HIV.  In 2015, the Maryland Department of Health and Mental Hygiene recognized this program by awarding with two state-wide awards, “Most Encounters with HIV Positive Clients” and “Most Referrals to HIV Primary Care”.  The Ryan White Program receives approximately $17 million annually to provide HIV-related medical and support services to over 10,000 individuals living in Baltimore City and the five surrounding counties.

The Baltimore City Health Department has hosted the "Get Yourself Tested" Ball, annually for the last 6 years. This event is aimed at the “House and Ball community”, which is made up of gay and transgender individuals.  Each year, approximately 600 individuals attend the event, with hundreds of people volunteering for HIV testing. These events have yielded between 4%-6% of new HIV diagnoses. At all other venues where testing occurs in Baltimore – emergency departments, CBOs, clinics, our outreach testing, and STD clinics – the new diagnosis rate is 1% or less. Because of this extremely high rate of infection found at this event, we have identified the Ball as a key event that reaches both a viable high-risk population group of undiagnosed individuals and a useful arm into the community to address HIV. All individuals with new diagnoses are able to be linked to care through our Linkage to Care Program.

  • Vaccines In the aftermath of the Disneyland measles outbreak last spring, BCHD took the lead in coordinating the Baltimore Statement on Childhood Vaccinations through a coalition of pediatric chiefs and chairs in the City, as well as the Maryland Chapter of the American Academy of Pediatrics. The statement highlighted BCHD's unequivocal message regarding the safety and effectiveness of childhood vaccines.
     
  • Public Health Preparedness BCHD’s Office of Public Health Preparedness and Response (OPHPR) is equipped to steward the City through any major public health emergency. This program trains staff and during times of emergency convenes and communicates with the City’s healthcare infrastructure. In the aftermath of the unrest following Freddie Gray’s death, BCHD lead the public health response; setting up a prescription access line to assist seniors whose pharmacies were closed and arranged shuttles to and from senior buildings for food and banking needs.

Recently, in response to the record-breaking blizzard that hit Baltimore City, BCHD led a city-wide response to ensure that patients were able to access life-saving medical treatments, including dialysis and chemotherapy. Working in tandem with the Baltimore City Fire Department, the Office of Emergency Management, and the National Guard, BCHD was able to deploy resources to safely and successfully transport 300+ patients in the midst of snow-covered roads and hazardous driving conditions. Baltimore City was recognized as the only jurisdiction state-wide that provided medical transport immediately post-blizzard.

Other ongoing efforts include BCHD’s response to emerging diseases like the Zika virus; and the essential core public health activities that include investigation and surveillance of foodborne illness, animal bites/rabies, and other infectious diseases such as Legionnaire’s disease; and tracking of HIV, syphilis, gonorrhea, chlamydia and other sexually-transmitted diseases. In 2015, Acute Communicable Disease Program investigated over 50 outbreaks and hundreds of potential rabies exposures.  Outbreaks occur in many settings, including restaurants, hospitals, schools, and daycares, and often the health impact of a reportable disease is significant. Large outbreaks, like a foodborne outbreak that occurred at the City’s Convention Center a few years ago, required the Department to reassign staff to interview as many as 5,000 conference attendees and collect samples from all of those with symptoms. 

Challenges and Aspirations:

  • Funding for emergency preparedness – We can and should be prepared for all severe emergencies, particularly unanticipated ones. We advocate for continued funding to prepare for emergencies and outbreaks, particularly in anticipation of an upcoming Zika virus outbreak. After 9/11 and the Anthrax Attack, the federal government made available significant grant funding to build public health capacity to train staff, plan for emergencies and respond. In 2012, the BCHD OPHPR had a staff of 12.  In 2016, OPHPR is staffed by 4, severely impacting the department’s capacity to respond to any sustained emergency. As the federal funding decreases, the program’s capacity decreases leaving the City vulnerable. 
  • Funding for a clinic safety net - The decrease in State and Federal funding is not limited to just the emergency preparedness program, but also many of the safety net programs our vulnerable citizens depend on.  As mentioned previously, the Affordable Care Act was intended to provide all citizens access to health insurance and healthcare. While there have been some successes, many of our very low income, vulnerable citizens rely on our grant-funded safety net programs, such as tuberculosis control, syphilis and gonorrhea testing, and family planning clinics. Failure to support essential public health services will dramatically impact very visible public health measures and the lives of all of our citizens.   

Issue 8: Population Health and Health in All Policies

Background: We know that medical care accounts for only 20% of a patient’s health outcomes: social, behavioral, and environmental factors comprise the remaining 80%. Where we live, work, and play is the major driver of health outcomes, and as the public health authority for the City, BCHD is leading the way on initiatives that address the “upstream” factors of health—the social determinants—from housing to food to transportation to education.

We view health as foundational to every issue – unhealthy children cannot learn in school, and unhealthy adults cannot be a productive part of the workforce. As we examine critical issues across the City – the economy, public safety, education— health is an essential driver that cuts across all of them. 

This is particularly significant in Maryland, where we are already leading the way in public health due to the establishment of global budgeting. Global budgeting shifts virtually all of the hospital revenue from a “fee-for-service” model to a global payment model, incentivizing hospitals to work in partnership with other providers and the community to prevent unnecessary hospitalizations and readmissions.  The goal of the model is to promote quality healthcare, better patient health, and lower cost, and as a result, creates incentives for treatment of the whole person as well as the intersection of health with other policy priorities.

Victories:

Our current initiatives include:

  • Coordination with hospitals. BCHD works closely with local healthcare providers, including hospitals and federally qualified health centers to identify shared priorities: behavioral health, for example. From creating a stabilization center to tracking patients who are the highest utilizers of care, coordination with our healthcare partners is key to ensuring that patients are receiving essential public health services. As the neutral convener, BCHD is positioned to coordinate citywide initiatives and collaborations that involve competing hospital systems and other health organizations. Department leaders participate in grant planning and visioning sessions with local hospital systems to ensure the City’s public health priorities are included. In September 2015, BCHD convened over 100 hospital and healthcare leaders to discuss behavioral health priorities and coordination of case management services for high utilizers. BCHD is engaged with hospitals, clinics, and community groups in a number of another state, federal, and private grants to provide coordinated services to our residents. 
     
  • Social determinants of health. All of BCHD’s programs, from B’More for Healthy Babies to Safe Streets, to HIV prevention and treatment programs, adopt this approach of comprehensive attention to social needs and services and as a result, have experienced significant success to date. We are in the process of implementing a city-wide initiative to ensure that every patient can get access to the services they need: just as a doctor connects a patient to a pharmacy for medication, there should be simple ways to connect a patient to food to take with that medication.
  • Health in all policies. Health touches every issue. As a result, BCHD’s health perspective must be a consideration in all policies in the City. For example, if the City is considering implementing bike paths, or placing an incinerator in the community, the health impact should be considered. Previously, a cross-agency task force for health existed within the city, with representation from every agency. BCHD proposes re-launching this task force, to be chaired by the Health Commissioner, to ensure an ongoing city-wide dialogue regarding the role of health in all policies.

Challenges and Aspirations:

  • A unified approach to addressing patients’ social needs – While efforts are underway across the City that integrates social needs into clinical care, there is still significant variation in the quality of those programs as well as their ability to sync with one another. We are currently leading a city-wide proposal to the Centers for Medicaid and Medicare Services, the federal agency responsible for overseeing services, payments, and innovations for Medicaid and Medicare patients, in partnership with all of the Baltimore City hospitals and federally qualified health centers, that will unify these efforts and ensure that all patients can benefit from services that address the realities of their daily lives.
  • Coordination and alignment – Speaking about cross-agency or cross-issue collaboration is easy; actually implementing it from a standard operating perspective is much more complicated. To facilitate this, we propose re-launching a Cross-Agency Taskforce that can systematically bring the Health in All Policies philosophy to bear in conversations taking place within the City.
  • Strategic plan for health – In addition to the initiatives above, we must also establish our forward-looking vision for health in the City. BCHD has launched Healthy Baltimore 2020, a comprehensive process that will build on the successes listed in this document to establish a five-year blueprint for health and well-being. This blueprint will pull on data that is produced by our ongoing epidemiology work --including our Neighborhood Health Profiles, which provide snapshots of key health outcomes in each city neighborhood—as well as input from key community stakeholders that we collect via numerous community conversations.

Conclusion

While Baltimore City faces a number of public health challenges, we also have invaluable assets: one of the strongest healthcare infrastructures in the country, invested community members and partners, and a willingness –borne of necessity—to test and implement new, innovative approaches to keep our citizens healthy. As the City’s health authority, BCHD is fortunate to work directly with excellent partners and leaders in every sector: government, business, community advocacy, healthcare, faith-based, and more – all of whom share a deep commitment to ensuring health of our citizens. We hope that this briefing serves as a valuable tool for you and look forward to answering any questions you may have. Thank you for your partnership in ensuring that all of Baltimore’s citizens are healthy.

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