Chicago Department of Public Health Opening Community Sedentary is a small, rural town in northern Illinois of approximately 14,000 residents
Community Sedentary: Fit4Life
A Case Study in Policy Development Mid-America Regional Public Health Leadership Institute Year Twelve Fellows:
Karen Austin, BA, Administrator, Illinois Department of Public Health
Fee F. Habtes, MA-HAS, MPH, Administrator, Illinois Department of Public Health
Gina Massuda, MPH, Director of Health Promotions, Cook County Department of Public Health Janet L. Nuss, MPH, RN, Direct Services Administrator, Illinois Department of Public Health
Lee Washington, MD, Medical Director, Aunt Martha’s Youth Services, Chicago, Illinois
Victoria Wright-Durham, MA, Distance Learning Coordinator, Chicago Department of Public Health
Opening:
Chicago Department of Public Health Opening Community Sedentary is a small, rural town in northern Illinois of approximately 14,000 residents. Consistent with national statistics, the prevalence of obesity in the general population progressively increased in Community Sedentary between 1960 and 2000. This trend was partially fueled by a change from employment requiring physical activity to an emphasis on more sedentary work. The prevalence of obesity among children and adolescents in Community Sedentary has doubled and tripled, respectively, consistent with national averages, and seems to be worsening. In 1990, due to a revenue shortfall, Community Sedentary School District requested and was granted a waiver to make P.E. an optional part of the student curriculum. Concurrently, with the increase in obesity, preventable health problems have proliferated in Community Sedentary. The nearest hospital is thirty miles away and is threatening to close due to the cost pressures of providing managed care to a community plagued with health burdens. If the hospital closes, patients will be forced to travel 150 miles to the nearest hospital and the economic life of the community will be devastated. In June 2003, the local health department convened meetings with concerned community residents, the school superintendent, and representatives of the business and health care communities, to discuss policy and program development needed to address the issue of obesity and its related implications for Community Sedentary. A work group was developed and given the task of developing and implementing a Fit4Life exercise program inclusive of all children and adults in the community.
Case Body:
Community Sedentary is a small, rural town in northern Illinois of approximately 14,000 residents. Consistent with national statistics, the prevalence of obesity in Community Sedentary has progressively increased between 1960 and 2000. This trend has been partially fueled by decreases in physical activity seen in the work force and in the school system of Community Sedentary. In the ’60s and ’70s, major sources of employment in Community Sedentary were postal work, landscaping, and manufacturing, all requiring walking, lifting, and physical labor except for relatively few supervisory positions in each industry. Employment has now shifted to more sedentary work including retail, insurance business mainly related to the nearby hospital, and some remaining work with the local post office primarily involving sorting and filing as opposed to physical delivery of mail. In Community Sedentary, grades K through 8 are completed at Sedentary Hills while grades 9 through 12 are completed at Sedentary High. In 1990, due to a revenue shortfall, Community Sedentary School District requested and was granted a waiver to make P.E. an optional part of the student curriculum. While sports were the primary source of activity for school aged children during the ’60s and ’70s, only a small proportion of the children in Community Sedentary now consistently engage in sports; those children are the select few with high levels of athletic ability while other children are content to watch TV or engage in other sedentary forms of recreation. Since physical education courses are an option in the school system, most students who are not athletically inclined or involved in competitive sports decline participation. Because of decreased enrollment in P.E. courses, only part-time P.E. instructors are currently employed in each school. This sedentary population of children, therefore, experiences almost no physical activity during winter months when the weather in northern Illinois prevents most outdoor activities. The prevalence of obesity among children and adolescents in Community Sedentary has doubled and tripled, respectively, consistent with national averages. Among adults, obesity has become increasingly prevalent, even among those who were physically active in sports when they were young. With the increase in obesity, preventable health problems have proliferated in Community Sedentary. Community residents have become increasingly concerned with these associated health burdens and their economic impact on the nearest hospital, Hospital Standalone. Fifteen years ago, Community Sedentary, represented by its business and health care professionals, made the decision to ensure community residents access to health care while helping local businesses control health care costs through promotion of managed care insurance through NowIgotcha. Representatives of NowIgotcha demonstrated to community leaders that a capitated system of payment for local physicians and Hospital Standalone would add value to the community by creating an incentive for the health care professionals to keep patients well and would decrease health care costs of businesses in the community. Physicians, hospital representatives, and community leaders all supported this concept and believed it would ultimately serve the community’s interest. The capitation managed care system was thereby approved and implemented 15 years ago. Despite their voiced support and commitment, NowIgotcha, Hospital Standalone, and local physicians have never disseminated mass preventable disease educational materials to clients in Community Sedentary. At the time the managed care system was implemented, Community Sedentary wasn’t plagued by obesity to the extent it is now. The incidence of diabetes was comparable to national averages, as was the case for other major diseases associated with sedentary lifestyles, such as cardiovascular disease and hypertension. In the 15 years since Community Sedentary implemented the managed care agreement, the inflated cost of medical care as well as the problem of obesity and the associated health burdens in the community have resulted in skyrocketing costs. Upward adjustments made to the capitation rates by NowIgotcha have only kept pace with increases in the consumer price index. The discrepancy between increased service utilization and decreased reimbursement has jeopardized the operations of Hospital Standalone, which may force it to close its doors. If the hospital closes its doors, not only will patients who need care be forced to travel 150 miles to the nearest hospital, but the economic foundation of the community will be devastated. Currently, Hospital Standalone not only employs 20 percent of Community Sedentary’s work force, but provides a major source of income for the community’s small businesses with whom the hospital contracts for various supplies and services. Given concerns regarding the escalating crisis, community leaders held a town hall meeting to mobilize the community for action. Represented at the meeting were the Director of the local health department, Dr. Prevention, the town’s two general practice physicians, the hospital’s community relations director and chief financial officer, the Superintendent of the Community Sedentary School System, John Cheapskate, PhD, the town’s mayor, a local pastor, and several concerned community residents and business leaders. Several issues, including the problem with obesity and the impact it has had on the town, were discussed at the meeting. Standalone’s Director of Community Services stated that the hospital has seen a dramatic increase in the number of admissions and Emergency Department visits due to problems related to obesity, such as diabetes, myocardial infarction, and hypertension. The average age of patients admitted for diabetes has steadily decreased from 70 years of age in 1970 to 40 years of age in 2000. In addition, several teenagers have been admitted for type II diabetes, an occurrence unheard of in previous years. Under the capitated payment arrangement, neither the hospital nor the physicians are being compensated for the technologically intensive care that is being provided to the population of Community Sedentary. Consequently, survival has been a struggle. Without marked intervention, the hospital announced it will have to close its doors within the next two years. Community residents expressed concern about the multiple ill effects Standalone’s closing could have on the health and economic life of the community. As a major employer of Community Sedentary’s residents and a contractor with a significant portion of the town’s businesses, the hospital’s closing would substantially threatened employment. With rising unemployment, people would spend less in local shops, thereby threatening other businesses within the community. Moreover, with rates of cardiovascular disease and diabetes on the rise, community members would be forced to travel prohibitively long distances for health care. This would undoubtedly contribute to excess morbidity and mortality. Community Sedentary residents realized that these consequences were dire and resolved to work collaboratively to address the problem. Changing insurance companies and/or payment methods was not an option because NowIgotcha had successfully taken command of the area’s market and consequently, had no competitors. The stakeholders would have to make the situation workable by promoting public health measures to reduce the health care and economic burden caused by preventable disease. This effort would require behavior change and system change at multiple levels, including school and business settings, to ensure the development and implementation of effective policies.
Closing:
In response to the increased prevalence of obesity and related preventable diseases in Community Sedentary and the associated economic impact on Hospital Standalone and the community as a whole, a town meeting was held in June 2003. As a result of this meeting, a work group, led by Dr. Prevention, the director of the local health department, was formed to make decisions about the problems, define goals and the proper means to reach them, settle conflicting points of view, and decide how resources should be handled. After conducting meetings with concerned residents, the local school superintendent, and representatives of the business and health care communities, the task force agreed to develop a state of the art, evidence-based fitness program for schools and the workplace. In preparation for development of the fitness program, grant funding through the Illinois Department of Public Health Division of Chronic Diseases was made available to examine factors that may have affected the prevalence of obesity in Community Sedentary (e.g. lack of mandated school physical education programs, vending machines in the schools, excessive television viewing time, lack of physical activity opportunities in the community (facilities, parks, etc.), inadequate knowledge of proper nutrition and adequate physical activity, and parental attitudes toward overweight children and causes. The work group also agreed to assist the Community Sedentary School System and business leaders in developing appropriate policy for the implementation of the programs into school and business settings. Referencing the success experienced by the PE4Life program in a neighboring school district, Dr. Prevention demonstrated how emphasizing noncompetitive health benefits of physical education could improve grades, productivity, and most important to the crisis at hand, decreased costs associated with preventable illness. The work group then decided to work with Superintendent Cheapskate, PhD to place a referendum on the next ballot for additional tax dollars to support mandatory P.E. classes in the schools and to support legislation currently proposed in the Illinois General Assembly by Representative Skip Obesity to ban junk food vending machines from all public elementary, middle, and high schools in the state. The work group set up a second meeting to develop an action plan for implementing the program(s) in the schools and work place. Each community representative was asked to return to their constituencies and brainstorm on strategies for implementing a safe, effective fitness program that would be inclusive of all children and adults in the community.
Case Questions :
1. What barriers to effective public health leadership can be identified in this case on the part of the school system, the business and health care communities?
2. Does political or corporate pressure create a barrier?
3. Does financial and personnel limitations present a barrier?
4. What strategies could be developed to overcome these barriers?
5. If the geographical location of the case was altered (e.g. large, urban community versus small, rural community), what effect would that have on the potential for exhibiting leadership qualities?
6. Explain how the task force, led by the director of the local health department, facilitated the complex process of policy development, one of the core functions of public health.
7. Why was it necessary to mobilize the community to identify and resolve the problems presented in this case study?
8. What impact do you think the lack of information and education of Community Sedentary about preventable diseases had on the development of the health problems in the community?
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