At a glance
CDC supports Nebraska and other state and local health departments, or their bona fide agents, through cooperative agreements to support childhood lead poisoning prevention activities. Read about the program's successes.
About the program
The State of Nebraska received $515,000 through cooperative agreement EH21-2102 from the Centers for Disease Control and Prevention (CDC) in the third funding year. The funds address childhood lead poisoning prevention and surveillance programmatic activities being conducted from September 30, 2023, to September 29, 2024.
Nebraska Department of Health and Human Services
P.O. Box 95026
Lincoln, Nebraska 68509-5026
Phone: 888-242-1100, ext. 3
Highlights
Success story: funding year 3
Improving blood lead case investigation data quality in Nebraska
Challenge
Childhood blood lead surveillance provides a vital source of evidence for guiding action. Blood lead surveillance identifies and tracks key health indicators in addition to critical demographic metrics including race, ethnicity, county, and ZIP Code. Surveillance data are instrumental in providing essential services like case management, identifying high risk ZIP Codes for enhanced testing activities, and for analyzing and evaluating trends that guide funding for key interventions. However, persistent data quality issues in Nebraska hinder public health efforts. These issues include inaccurate and incomplete patient records, duplicate entries, and inconsistent data from various institutional systems.
Intervention
During 2021 through 2023, the Nebraska Lead Poisoning Prevention Program (NeCLPPP) initiated a multi-step process to improve the quality of data collected for cases of children with blood lead levels (BLLs) at or above the blood lead reference value (BLRV). The initial step involved training lead poisoning investigators on the required fields to complete during blood lead case investigations in the Nebraska Electronic Disease Surveillance System (NEDSS). To achieve this, the program delivered annual and onboarding training sessions for new local health department staff. Additionally, the program implemented weekly reviews of new blood lead case investigations to identify missing data fields. Investigators received reminders if any required fields were incomplete.
Furthermore, NeCLPPP created a quarterly data quality analysis program to assess the completeness of ZIP Code, county, race, and ethnicity data for cases; produced a quarterly list of investigations with missing data; and cross-checked records with missing data with other data sources, such as the state's immunization registry and a statewide health information exchange, to find and complete missing information.
Impact
These interventions resulted in improvements in data completeness across critical fields in blood lead case investigations from 2021 to 2023. Specifically, data completeness increased for county of residence from 65% to 99%, race from 65% to 98%, ethnicity from 38% to 96%, and ZIP Code from 99% to 100%. More complete data facilitate enhance accuracy and provide a better understanding of demographic and geographic trends. NeCLPPP continues to evaluate and enhance its efforts to improve surveillance data quality.
Funding for this work was made possible in part by NUE2EH001419 from the Centers for Disease Control and Prevention (CDC). The views expressed in this material do not necessarily reflect the official policies of CDC; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
Success story: funding year 2
Increasing electronic blood lead reporting in Nebraska
Challenge
While most blood lead laboratory results are reported electronically in Nebraska, approximately 20% are reported by fax or mail. Laboratory reports submitted via automated electronic reporting are more quickly entered into the surveillance system and allow local public health departments to start case management in an efficient timeframe. Annually, thousands of blood lead laboratory reports must be entered manually, which slows response time for follow-up testing and case management.
Intervention
To increase electronic reporting among clinics and providers that use point-of-care devices, the Nebraska Department of Health and Human Services (NDHHS) Nebraska Childhood Lead Poisoning Prevention Program (NECLPPP) started a three-phase intervention. Phase I adapted the Nebraska COVID-19 Laboratory Results Upload Portal to facilitate the use of alternate reporting methods for blood lead results using file formats such as CSV, XLS, and XLSX. Phase II involves enhancing the portal's user interface and data quality flagging. Phase III involves expanding the use of the application portal across the state of Nebraska.
Phase I was completed in the summer of 2022. NECLPPP partnered with Douglas County, a large county health department, to pilot the Laboratory Results Upload Portal in May 2022. The initial goal focused on five facilities, which include Women Infants and Children (WIC) clinics, Federally Qualified Health Centers (FQHCs), and family medicine clinics.
Impact
At the end of Phase I, 14 facilities were engaged in electronically uploading data, which included four WIC clinics, two FQHCs, and eight family medicine clinics that predominately serve Black, Hispanic, and low-income individuals in communities that are served by these clinics.
In 2022, there was an 8% increase in electronic blood lead laboratory reporting due to the upload project. During January–September 2022, the Laboratory Results Upload Portal uploaded 2,649 blood lead laboratory results (2,578 capillary and 71 venous laboratory results) into Nebraska's surveillance system. Of those 2,649 laboratory results, 189 were at or above the blood lead reference value of 3.5 μg/dL, which resulted in prompt case management and confirmatory/follow-up testing recommendations. Due to the success of Phase I, NECLPPP plans to onboard additional clinics for electronic reporting with the goal of eliminating fax and paper reporting. NECLPPP will begin Phases II and III by October 2023.
Funding for this work was made possible in part by NUE2EH001419 from the Centers for Disease Control and Prevention (CDC). The views expressed in this material do not necessarily reflect the official policies of the CDC; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
Success story: funding year 1
Establishing case management protocol with existing resources in Nebraska
Challenge
It's estimated that one-third of Nebraska's housing stock was built before 1978 and contains lead-based paint. Low-income and minority children are particularly at risk for lead exposure and lead poisoning, as they are more likely to live in older housing. Early identification of lead-exposed children and prompt linkages to supportive services are critical to reducing lead poisoning's detrimental effects. Case management for lead-exposed children is key to monitoring compliance with blood lead testing, medical follow-up, medical treatment, and referral to early intervention services. While the Nebraska Department of Health and Human Services has collaborative arrangements with local health departments across the state to provide follow-up for lead-exposed children, some children need more intensive clinical case management above the local health department's capacity.
Intervention
Nebraska has a robust Medicaid-managed care system encompassing a statewide network of case management teams among three managed care organizations (MCOs). Upon confirmation that all parties adhere to HIPAA regulations, the Nebraska Childhood Lead Poisoning Prevention Program (NeCLPPP) collaborated with the Division of Medicaid and Long-Term Care (MLTC) to access the N-Focus application, which houses Medicaid enrollment data for the state. With access to this information, NeCLPPP and MLTC developed the following protocol for medical case management referral for children enrolled in an MCO plan:
Step 1: Using Nebraska's Blood Lead Surveillance System, NeCLPPP identifies children eligible for case management based on a confirmed venous blood lead level (BLL) of ≥5 μg/dL or several elevated capillary blood lead tests of ≥5 μg/dL with no confirmatory venous testing. NeCLPPP checks in N-Focus to see if that child is enrolled in Medicaid.
Step 2: If the child is enrolled in Medicaid, NeCLPPP notifies MLTC staff members, who forward a referral to the case management team of the MCO serving that child.
Step 3: The MCO reports the status of the referrals back to MLTC and NeCLPPP every month.
Impact
Within the first five months of initiating this protocol, 21 children received intensive clinical case management services who otherwise would not have had access. Because NeCLPPP's collaborative and resourceful protocol builds upon existing services of the MCOs, the impact gained from these services came at no additional cost. As the work of NeCLPPP continues to promote BLL testing in vulnerable low-income and minority populations, this protocol will be invaluable for linking children with identified elevated BLLs to these needed services.
Funding for this work was made possible in part by the Cooperative Agreement Number [NUE2EH001364] from the Centers for Disease Control and Prevention (CDC). The views expressed in this material do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.