MCN EPA Final Report

8/7/2019 MCN EPA Final Report

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Migrant Clinicians Network| Saving Lives By Changing Practices 2

Executive SummarySaving Lives by Changing Practice:Pesticide-Related Health Conditions Prevention

Change Conceptis an environmental and occupational health (EOH) programsupported through a five-year cooperative agreement between the Migrant CliniciansNetwork (MCN) and the US Environmental Protection Agency (EPA), Office of PesticideProgram as part of the EPA National Strategies for Healthcare Providers: PesticideInitiative. The program set out to systemically address the limited clinical focus andunderstanding in the practice setting regarding pesticides and other environmental andoccupational health concerns. The primary aim of this program was to develop and testa clinical model to integrate EOH into primary care in order to assist clinicians in betterrecognizing and managing pesticide exposures. From 2005-2010, the programachieved the following:

Replicable EOH model for primary care implemented in eight Migrant/CommunityHealth Centers (M/CHC) that resulted in:

1. changes in clinical systems including intake, screening, outreach andeducation;

2. demonstration of primary care providers willingness to acknowledge andaddress environmental and occupational injury and exposure which leads toimproved patient care;

3. new linkages between clinics and clinicians and the agricultural work place;and

4. connections between primary care providers and pesticide experts and

Occupational and Environmental Medicine (OEM) Specialists.

2,512 clinicians trained

63,070 clinical resources distributed

35,822 pesticide patient educational materials distributed

537,766 unique visits to MCNs environmental and occupational health web pages

Active partnerships with over 13 organizations with expertise in pesticides,

occupational and environmental medicine and agricultural medicine


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Table of Contents

Executive Summary ......................................................................................................2Table of Contents .......................................................................................................... 3

List of Figures ............................................................................................................... 4List of Tables .................................................................................................................4Introduction ...................................................................................................................5Expert Advisory Committee ......................................................................................... 6EOH Model for Primary Care ........................................................................................ 8Clinician Training ........................................................................................................ 11

Training Modules....................................................................................................................................................12Technical Assistance and Resource Development.................................................. 14

EOH Screening Questions for Primary Care Providers.........................................................................................14MCN Pesticide Clinical Guidelines ........................................................................................................................15 A Migrant Farmworker Occupational Health Reference Manual ........... ........... .......... ........... ........... ........... .........15Video: Pesticide Poisoning in a Community Health Center .......... .......... ........... ........... .......... ........... .......... ..........15National Pesticide Practice Skills Guidelines for Medical and Nursing Practice..................................................16Migrant Measures...................................................................................................................................................16 Clinical Publications ..............................................................................................................................................17

Partnerships ................................................................................................................ 17Resources Distributed................................................................................................19

Clinical Resources ..................................................................................................................................................19Patient Education Materials ...................................................................................................................................20EOH Web Pages and Resources.............................................................................................................................21

LESSONS LEARNED...................................................................................................22


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List of FiguresFigure 1: Expert EOH Advisory Committee Members .................................................... 7Figure 2: Geographic Distribution of MCN Trainings..................................................... 11Figure 3: Continuing Education ..................................................................................... 12Figure 4: Patient Education Materials............................................................................ 21Figure 5: Pesticide Resources Downloaded from MCNs Website................................ 22

List of TablesTable 1: Expert Advisory Committee Evaluation ............................................................ 8Table 2: Clinical Resources Distributed, 2006-2010 ..................................................... 19Table 3: Patient Educational Material Distributed.......................................................... 20

Mike Rowland, MD, MPH, cares for a

patient in his capacity as Medical Directorof the Maine Migrant Health Program

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IntroductionSaving Lives by Changing Practice: Pesticide-Related Health Conditions PreventionChange Conceptis an environmental and occupational health (EOH) programsupported through a five-year cooperative agreement between the Migrant Clinicians

Network (MCN) and the US Environmental Protection Agency (EPA), Office of PesticideProgram as part of the EPA National Strategies for Healthcare Providers: PesticideInitiative. The program set out to systemically address the limited clinical focus andunderstanding in the practice setting regarding pesticides and other environmental andoccupational health concerns. The objectives of the program were to:

1. Organize strategic meetings with primary healthcare providers, healthcare clinics,and other healthcare delivery systems to communicate the need to incorporatepesticide education and awareness into the practice settings.

2. Design and implement methods of integration of the key practice skills requiredfor healthcare providers to deal effectively with pesticide-related health conditions

in the practice settings.3. Develop and provide access (through training, continuing education, website) to

relevant resources and tools that healthcare providers need to deal effectivelywith pesticide-related health conditions.

4. Develop and test a training model for primary healthcare providers thatincorporate key practice skills for the recognition and treatment of pesticidepoisonings.

5. Evaluate and promote the use of a training model for healthcare providers acrossa wide-range of practice settings.

From 2005-2010, MCN established a comprehensive EOH program that involved

numerous activities.

1. MCN fostered partnerships with Migrant/Community Health Centers (M/CHCs) todevelop and pilot a replicable EOH model for primary care.

2. MCN designed clinical resources and clinician training modules targeting primarycare clinicians.

3. MCN trained clinicians and promoted the importance of addressing EOH andpesticides in primary care through on-site continuing education sessions athealth centers, at regional and national conferences, and via webcasts.

4. Through an environmental and occupational webpage with a specific pesticidefocus and via email, direct mailings and on-site distribution, MCN disseminated

thousands of resources each quarter.5. Through this program MCN offered technical assistance and support to clinics

and healthcare providers to help them address EOH concerns in primary care.6. MCN forged numerous partnerships to broaden the reach of this effort.


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The program achieved the following results:

1. Established a replicable EOH model for primary care implemented in eightM/CHCs

2. Trained 2,512 clinicians

3. Distributed 63,070 clinical resources

4. Distributed 35,822 pesticide patient educational materials

5. Documented 537,766 unique visits to MCNs EOH web pages

6. Fostered active partnerships with over 13 organizations with expertise inpesticides, occupational and environmental medicine and agricultural medicine

Amy K. Liebman, MPA, MA, MCNs Director of Environmental and Occupational Health,directed and managed this program. She worked closely with MCN clinical staff, EdZuroweste, MD, Chief Medical Officer and Candace Kugel, CNM, FNP, Director ofPerformance Improvement and Womens Health Specialist. Jillian Hopewell, MPA, MA,MCN Director of Education and Professional Development, Karen Mountain, MBA,MSN, RN, MCN Chief Executive Officer and Elaine Penn, MCN Chief Financial Officeralso contributed time, effort and expertise to this program. The program was alsoguided by an expert advisory committee, and several members including MichaelRowland, MD, MPH, Matthew Keifer, MD, MPH and Dennis Penzell, DO, MS, served asfaculty for trainings and were deeply involved in various program initiatives.

Expert Advisory CommitteeSaving Lives by Changing Practiceswas guided by the expertise of a committee ofOccupational and Environmental Medicine (OEM) Specialists, Primary Care Providers,Migrant Clinicians and Farmworker Advocates. The names and affiliations of eachmember are listed in Figure 1. The committee met on an annual basis, receivedbimonthly email communications regarding program progress and planning and servedas expert reviewers of resources developed. Select members of the committeeprovided the program extensive support and expertise on an individual basis. Severalmembers, Dennis Penzell, DO, MS, Matthew Keifer, MD, MPH, and Michael Rowland,MD, MPH, served as expert faculty and worked closely with program staff to developspecific pesticide resources to further program efforts. Dr. Keifer, Dr. Rowland, Dr.

Penzell and Dr. Sudakin also provided consults to clinicians with pesticide-relatedquestions. Kathy Kirkland, through the Association of Occupational and EnvironmentalClinics (AOEC), provided numerous introductions and linkages to other OEMspecialists, Pediatric Environmental Health Specialty Units and other organizations. JoeFortuna, MD, through the American College of Occupational and EnvironmentalMedicine (ACOEM), linked MCN to relevant ACOEM section activities. Ed Zuroweste,MD and Wilton Kennedy, DHSc, PA-C as well as Dr. Rowland offered importantcontributions from the perspective of a frontline migrant clinician. Shelley Davis ensured


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that relevant farmworker policy was integrated into the clinical components of theprogram.

Figure 1: Expert EOH Advisory Committee Members

The advisory committee was critical to the programs success. Their involvement andactive participation brought a high level of clinical excellence to the program, which wasneeded to recruit partner clinics and obtain their continued commitment to implementthe EOH model. Table 1 summarizes an evaluation by advisory committee membersregarding their involvement and satisfaction with the program.

Project Advisor,Expert Faculty and

OEM Specialist,Matthew Keifer, MD,

MPH, trains

clinicians in PuertoRico

Shelley Davis*, JD, Deputy Director, Farmworker Justice Joe Fortuna, MD, American College of Occupational and Environmental Medicine,

Board of Directors and Section for Occupationally Underserved Populations

Matthew C. Keifer MD, MPH, Professor, University of Washington and OEMSpecialist, Harbor View Medical Center and Yakima Valley Farmworker Clinic

Wilton Kennedy, DHSc, PA-C, Past President of MCN, Assistant Professor,College of Health Sciences

Katherine H. Kirkland, MPH, Executive Director, Association of Occupational andEnvironmental Clinics

Dennis H. Penzell, DO, MS, FACP, Clinical Associate Professor, University ofSouth Florida College of Medicine/Nova Southeastern College of OsteopathicMedicine

Michael Rowland, MD, MPH, Medical Director, Maine Migrant Health Program

Daniel L. Sudakin, MD, MPH, Director, National Pesticide Medical MonitoringProgram, Oregon State University

Edward Zuroweste, MD, MCN Chief Medical Officer

*deceased


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Table 1: Expert Advisory Committee Evaluation

Questions

Individual Ratings

1=Poor 2=Satisfactory 3=Good 4=Excellent

Average

Rating

How effectively did MCN recognize and

utilize your expertise:

4 3 3 3 4 4 3 4 3.5

To what extent do you feel you were ableto make a positive contribution to the

program:

4 3 3 3 4 3 2 4 3.25

Please rate the effectiveness and

efficiency of the group meetings and

communications:

4 4 4 3 4 3 3 4 3.6

Please rate your satisfaction with the

overall project results of MCNs

Cooperative Agreement with EPA, Saving

Lives by Changing Practices:

4 4 4 4 4 4 4 4 4

Comments/Suggestions:

Liebman was an outstanding leader. She was persistent, supportive, committed and sincere. While

moving the whole process forward with great efficiency, she was able to provide individual attention

to the people under her direction and those providing her assistance.

This program has been enormously successful and I'm delighted that it has been recognized by

EPA! I hope to be able to continue to contribute.

This has been a great project and MCN has utilized and leveraged their partners well. I'll sign on for

another five years.

EOH Model for Primary Care

One of the principal aims of this program was to develop and test a clinical model tointegrate EOH into primary care in order to assist clinicians in better recognizing andmanaging environmental and occupational injury and illness. MCN based its approachon three core components:

1. Model for Improvement: The Model for Improvement1 is an evidence-basedstrategy that was successfully applied in Migrant and Community Health Centersas part comprehensive health disparities and quality improvement initiativespearhead by the Health Resource Services Administration (HRSA). This modelidentifies four key elements of successful process improvement: specific andmeasurable aims, measures of improvement that are tracked over time, key

changes that will result in the desired improvement, and a series of testingcycles during which teams learn how to apply change ideas to their ownorganizations. Implementing this model at the health center level involves ateam that includes a clinical champion as well as other staff such as physicians,nurses, medical assistants, health educators and the centers executive director.

1Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical

Approach to Enhancing Organizational Performance. San Francisco, California, USA: Jossey-BassPublishers; 2009.


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2. EOH Peer Partnership: The EOH Peer Partnership Model is a collaborativeeffort conceptualized by MCN, AOEC and ACOEM. The Peer Partnership linksprimary care clinicians in M/CHCS with OEM specialists and clinics and involvesthe following:

Developing occupational/environmental medicine clinics in migrant health

centers. Facilitating clinical consults between the primary care clinician and the

occupational medicine clinician.

Developing referral mechanisms for complicated pesticide cases. Training primary care providers in occupational/environmental medicine.

3. Pesticide Practice Skill Guidelines: As part of the EPA National Strategies forHealthcare Providers: Pesticide Initiative, the EPA, other federal agencies,pesticide experts and primary care providers developed and endorsed theNational Pesticide Practice Skills Guidelines for Medical and Nursing Practice.2These key practice skills include:

Taking an Environmental History Awareness of Community and Individual Pesticide Risk Factors

Knowledge of Key Environmental/Occupational Health Principles Clinical Management of Pesticide Exposure Reporting Pesticide Exposure and Supporting Surveillance Efforts Providing Prevention Guidance and Education to Patients

After an initial year of program planning and design, resource development and centerrecruitment, MCN designed a flexible model that incorporated the three corecomponents described above, met the unique needs of individual health centers, andimproved as well as changed clinical practices and systems. MCN partnered with two

federally-funded M/CHCs each year to pilot this clinic-based model. These M/CHCsinclude: Maine Migrant Health Program, Golden Valley Health Centers in California,Hospital General Castaer in Puerto Rico, Tri-County Community Health Council inNorth Carolina, Salud Integral en la Montaa in Puerto Rico, Rural Medical Services inTennessee, CommuniCare Health Centers in California and Centro de ServiciosPrimarios de Salud de Patillas in Puerto Rico.

MCN offered the partner M/CHC on-site training and technical assistance for one yearto design, implement and evaluate the model. The underlying aim is to sustain effortsand incorporate environmental and occupational health into the centers overallhealthcare plan. MCN did not expect primary care clinicians to become OEM

Specialists. The program focused on primary care services and feasible changes inclinical systems. Key to the success of these partnerships was both administrative andclinical buy-in to the project. At all of the partner health centers, MCN worked directlywith a clinician champion, typically the medical director, who was interested inenvironmental and occupational health and willing to spearhead the clinic-based project.

2National Environmental Education and Training Foundation. National Pesticide Practice Skills

Guidelines for Medical and Nursing Practice. January 2003.


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MCN improved or modified efforts based on each pilot. At the end of the five-yearprogram period, MCN successfully developed a replicable EOH model for primary carethat resulted in:

1. changes in clinical systems including intake, screening, outreach andeducation,

2. demonstration of primary care providers willingness to acknowledge andaddress occupational injury and exposure which leads to improved patientcare;

3. new linkages between health centers and clinicians and the agricultural workplace; and

4. connections between primary care providers and pesticide experts and OEMSpecialists.

A detailed description of the steps involved with these partnerships, an overview of eachcenters project and lessons learned is provided in a separate report entitled FinalReport: MCNs Environmental and Occupational Health Partnerships.

Jose Rodriguez, MD,Medical Director of HospitalGeneral Castaer in PuertoRico, educates workersabout pesticide safety


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Clinician TrainingOver the course of this five-year program, MCN reached a total of 2,512 cliniciansthrough on-site, clinic-based EOH trainings and at local, regional and national EOHconference sessions. Figure 2 shows the geographic distribution of these trainings.

Additionally, MCN provided EOH trainings through 4 national webcasts that reached atotal of 186 individuals. Pesticide conference sessions and trainings were alsopresented internationally to 25 people in Mexico and 15 people in Vietnam.

Figure 2: Geographic Distribution of MCN Trainings

MCN sponsored or organized 47 on-site EOH trainings for clinicians and lay healthworkers. These trainings reached a total of 950 individuals, providing them with anaverage of 1.95 continuing education hours.

Figure 3 shows the breakdown of the type of continuing education received throughMCNs on-site trainings.


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Figure 3: Continuing Education

Training Modules

MCN created several clinician training modules to facilitate this program and assist withimplementation of the EOH model for primary care. The two principal modules aredescribed below:

1. Environmental and Occupational Health for the Primary Care Provider. Thistraining emphasizes the importance of and ways to integrate EOH into primarycare in order to improve health care for migrant patients. It offers participants anoverview of a) recent research and surveillance efforts examining the extent andnature of occupational injuries; b) core environmental and occupational medicineconcepts for the primary care provider; c) best practices, successful strategiesand resources for integrating environmental and occupational medicine intoprimary care; and d) health challenges facing the migrant population. The traininghighlights peer-partnerships between primary care clinicians and OEMSpecialists and flexible clinic-based strategies.

2. Recognition and Management of Pesticide Exposures for the Primary CareProvider. This training helps primary care clinicians integrate the sixcompetencies outlined in National Pesticide Practice Skills Guidelines. Thistraining provides participants an overview of a) pesticides and how they affectpatient health; b) mechanisms of toxicity, indicators of pesticide poisoning, andhistorical implications of pesticides; c) the clinical management of pesticideexposures from treatment to reporting; d) core skills such as environmental and


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occupational history taking; e) information regarding regulations and clinicalreporting requirements; and f) pesticide clinical resources and patient educationmaterials.

Michael Rowland, MD, MPH, an OEM Specialist who served as a program advisor and

the clinician champion for the MCN/Maine Migrant Health Program partnership,developed the core training module that overviewed environmental and occupationalhealth. This module was presented extensively to numerous clinicians throughout thefive-year program period. Dr. Rowland facilitated this training nationally through a wellreceived webcast in July 2007, regionally at the East Coast Stream Forum in October2007 and in Spanish at the Puerto Rican Medical Directors Association Meeting in May2008. The webcast was facilitated in conjunction with the Clinical Directors Networkand archived on their website for two years. MCN shared Dr. Rowlands module withother program faculty who tailored it to use at additional trainings at MCHCs as part ofMCNs overall efforts.

Dr. Rowland also developed a one hour training module The Recognition andManagement of Pesticide Exposures. He facilitated this module as a webcast in 2008in conjunction with the Clinical Directors Network. This training is archived on theirwebsite for two years. In addition to Dr. Rowlands module, program advisors, DennisPenzell, DO, MS and Matthew Keifer, MD, MPH, created original versions of pesticidetraining modules and served as expert faculty for MCN trainings at clinics andconferences. Dr. Penzell is based in Florida and served as a medical director in aM/CHC for over 20 years. During his tenure, he oversaw one of the largest reportedpesticide poisoning events in the US. His involvement in that incident and the follow-uphas informed his outstanding work regarding pesticides. He serves as faculty forclinician pesticide training throughout the country. Dr. Keifer is an internationallyrenowned pesticide expert and his module was informed by his extensive research andclinical practice with farmworkers. Dr. Keifer created modules in Spanish and served asfaculty for trainings in Puerto Rico.

MCN also developed a specialized module that focused on womens reproductivehealth and pesticides. Candace Kugel, FNP, CNM developed this module and servedas expert faculty for clinician trainings addressing perinatal care.

In addition to the clinical trainings, MCN developed training resources to assist outreachstaff, health educators or promotores de salud(health promoters) in facilitating patientand community education. MCN has developed targeted training curricula and hasnumerous resources to assist clinics in improving patient education about the risksassociated with pesticide exposure and ways to minimize those risks.


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Technical Assistance and Resource DevelopmentMCN provides technical assistance to clinicians, health centers and other individualsand organizations to improve clinical quality, systems and practices, and access toquality health care for migrants and other underserved populations. Technical

assistance is offered in numerous ways from in-depth, on-site clinic visits to cliniciantraining to helping providers access appropriate clinical tools. Saving Lives by ChangingPracticesenabled MCN to have a pesticide and EOH focus in its technical assistance.In year four of the program, MCN augmented its data base system to improvedocumentation of EOH technical assistance. From 2009-2010, MCN documented atotal of 340 EOH encounters.

The program also allowed MCN to develop EOH specific resources to respond totechnical assistance requests as well as to fill obvious gaps. These resources aredescribed below.

EOH Screening Questions for Primary Care Providers

One of the primary clinical systems change this program promoted involved improvedpatient screening to recognize and manage pesticide and other EOH exposures andinjuries. As MCN began the partnership with health centers it quickly became apparentthat MCN lacked a recommended set of EOH questions to screen patients in primarycare. MCN, in partnership with AOEC and the Pacific Northwest Agricultural Safety andHealth Center (PNASH), initiated a formal process to develop an appropriate tool.MCN, AOEC and PNASH researched existing questions from ten environmental andoccupational history and screening tools and selected pertinent EOH screeningquestions that could easily be inserted into routine patient care. MCN, AOEC and

PNASH used a consensus process and sought input from various experts to finalize thewording and endorse the end product. In 2007 MCN, AOEC and PNASH hosted ameeting with the Occupational and Environmental Medicine Residency Directors toobtain their feedback and endorsement. This group approved the questions. They werethen endorsed by the programs expert advisory committee and AOEC. The finalquestions are:

1. (Occupation) Describe what you do for work?2. (Activities and Cause) Are there any physical activities that you do at work or

away from work that you feel are harmful to you?3. (Substances/Physical Hazards and Cause) Are you exposed to chemicals,

fumes, dusts, noise, and/or high heat at your work or away from work? Do youthink these are harming you?


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National Pesticide Practice Skills Guidelines for Medical and Nursing

Practice

The practice skills outlined in the National Pesticide Practice Skills Guidelines forMedical and Nursing Practiceare a core component of this program. MCN made this

resource widely available through its website and via distribution at trainings. Becauseof its importance, MCN translated this document to Spanish. Both the English and theSpanish versions are available from the MCN website.

Migrant Measures

In 2008, the Bureau of Primary Health Care (BPHC) introduced a set of clinical and financialmeasures in an effort to collect data that will allow for the evaluation of individual andcollective performance trends over time. M/CHCs are expected to report on measuressuch as childhood immunization rates, hypertension (controlled vs. uncontrolled),diabetes (adequate control vs. inadequate control) and cost per patient. Health centersthat serve large migrant populations expressed an interest in developing supplementalmeasures that effectively reflect the unique features of both the migrant population itselfand the service delivery modalities of Migrant Health Centers (MHC). The BPHCcontracted with MCN to provide technical assistance and coordinate a work group torespond to this request and develop a set of migrant-specific performance measures.The work group asked to explore three measures, an enabling service measure, anEOH measure and a financial measure. MCN built on the expertise from Saving Livesby Changing Practicesand included Amy Liebman, MPA and Matthew Keifer, MD, MPHin the discussions surrounding the EOH measures. The following EOH performancemeasures were developed and selected:

1. Preferred Environmental and Occupational Health Measure: Percent of

registered farmworker patients who receive pesticide prevention education. Thismeasure would document how many farmworker patients receive educationregarding the prevention of pesticide exposure, such as the use of personalprotective equipment (PPE), proper storage and handling of pesticides, etc.Calculation:Farmworker patients with documented pesticide preventioneducation/Total registered farmworker patients.

2. Additional Environmental and Occupational Health Measures:o Percent of registered farmworker patients screened for EOH risko Percent of registered farmworker patients who receive eye protection

education

Once the EOH measure, along with the other performance measures were agreedupon, MCN promoted and explained these measures through trainings at conferencesand on webcasts, via an article published in Streamline, and the creation of aninformational web page on the clinical grant requirements including the results of thework group. In addition, MCN provided technical assistance to North CarolinaFarmworker Health Program in Raleigh, NC to pilot the three measures. The results


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suggested that implementation across all MHCs would be difficult as it would be hard toachieve consistent EOH training and materials to convey the same message to allfarmworkers.

Clinical Publications

MCNs Streamline is a bimonthly, peer-reviewed, clinical publication. Through SavingLives by Changing Practices, MCN established an EOH section in Streamlinethatfeatured 28 EOH articles, primarily dealing with pesticides. In addition, the sectionhighlighted numerous pesticide resources and partner organizations. Each Streamlineis mailed to approximately 2,300 individuals and 57,500 copies were distributed duringthe five-year program. In addition to Streamline, MCN published a commentary in theJournal of Public Health Management and Practiceto address the importance ofscreening in the recognition of pesticide exposures.3

PartnershipsMCN established regional and national partnerships with various organizations tofacilitate the program and broaden the reach of its scope. A key component of thisprogram involved linking M/CHCs providers to select OEM specialist and clinics. MCNpartnered with the following organizations, listed in alphabetical order, to assist with thisaspect of the program:

1. Agricultural Safety and Health Council of America2. AgriSafe Network3. American College of Occupational and Environmental Medicine4. American Public Health Association, Section on Occupational Health and Safety5. Association for Occupational and Environmental Clinics6. Center for Worker Health, Wake Forest University

7. National Childrens Center for Rural Agricultural Health and Safety, MarshfieldResearch Foundation

8. National Farm Medicine Center, Marshfield Research Foundation9. National Pesticide Information Center10. Northeast Center for Agricultural and Occupational Health11. Pacific Northwest Agricultural Safety and Health Center, University of

Washington12. Southwest Center for Agricultural Health, Injury Prevention, and Education,

University of Texas Tyler13. Western Center for Agricultural Health and Safety, University of California - Davis

Additionally, MCN leveraged important existing partnerships to assist with programimplementation. These partners, listed in alphabetical order, include:

3Liebman & Rowland. (2009). To ask or not ask: The critical role of the primary care provider inscreening for occupational injuries and exposures. Journal of Public Health Management andPractice, 15(2).


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1. Clinical Directors Network - Facilitates MCNs national webcasts2. Farmworker Justice - Provides farmworker specific research and policy updates

and resources3. National Association of Community Health Centers Organizes the National

Farmworker Health Conference4. National Center for Farmworker Health - Organizes the Midwest Migrant StreamForum

5. National Center for Primary Care, Morehouse School of Medicine - Co-Organizeswith MCN the biannual National Summit of Clinicians for Healthcare Justice

6. National Environmental Education Foundation Publishes the National PesticidePractice Skills Guidelines for Medical and Nursing Practice

7. Northwest Regional Primary Care Association - Organizes of the WesternStream Migrant Forum

8. North Carolina Community Health Center Association - Organizes of the EastCoast Migrant Stream Forum

MCN also collaborated with regional groups and organizations to assist with programimplementation. These organizations, listed in alphabetical order, include:

1. East Tennessee State University Partnered with MCN and Rural MedicalServices to strengthen program evaluation

2. Farmworker Association of Florida Facilitated regional pesticide training inFlorida that MCN co-sponsored

3. PathStone Provided community and worker pesticide safety training in PuertoRico

4. Puerto Rican Medical Directors Association Assisted MCN with establishingpartnerships with Puerto Rican M/CHCs

5. Puerto Rican Primary Care Association - Assisted MCN with establishingpartnerships with Puerto Rican M/CHCs

MCN also worked closely with state and federal agencies for to leverage our efforts andto assist clinicians in better recognizing and managing pesticide exposures.

1. Agency for Toxic Substance and Disease Registry2. Bureau of Primary Health Care / Health Resources Services Administration3. California Department of Public Health4. North Carolina Department of Health and Human Services5. National Institute for Occupational Health and Safety6. Occupational Health and Safety Administration


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Resources Distributed

Clinical Resources

A major component of MCNs efforts in the five-year EPA program was to distribute high

quality, relevant EOH materials to clinicians working on the front lines of primary care.Through the course of this program MCN was able to distribute a total of 63,070 clinicalresources. While these materials are available to download on the MCN website, thequantities described in Table 2 were largely printed copies directly provided toindividuals.

Table 2: Clinical Resources Distributed, 2006-2010

Medical and

NursingPesticideGuidelines

EPAsRecognition

andManagementof PesticidePoisonings

Streamline,MCNs

bimonthly

clinicalpublication

with an EOHsection

A MigrantFarmworker

OccupationalHealthReference

Manual

Eye onFarmworkerHealth, anelectronic

publicationwith pesticide

policy/researchupdates

MCNs

PesticideClinicGuidelines

499 624 57,500 43 5,355 131


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Patient Education Materials

In order to assist clinics and healthcare providers in incorporating educationalinformation about pesticides into their EOH program, MCN offered numerous resourcesto assist them. Table 3 describes these resources and Figure 4 shows the breakdown

of the 35,822 resources distributed. While these materials are all available on the MCNwebsite, the quantities described here reflect the printed copies distributed to ourconstituents.

Table 3: Patient Educational Material DistributedAunque Cerca...Sano Pesticide Comic Book: Targets migrantand seasonal farmworker families to educate parents aboutchildren's risks to pesticide exposure and ways to minimizethese risks. English and Spanish.http://www.migrantclinician.org/mcn/patient-

education/pesticides/index.html

LO QUE BIEN EMPIEZA...BIEN ACABA: Consejos para lasmujeres para prevenir daos a la salud y a sus bebscausados por pesticidas - Pesticide Prevention DuringPregnancy Comic Book:Spanish educational comic book thataddresses pesticide exposure in women of reproductive age.http://www.migrantclinician.org/mcn/patient-education/pesticides/index.html Poco Veneno...No Mata? - Pesticide Comic Book:Offerseducational story and messages to about risks from pesticide

exposure and ways to minimize these risks in the home setting.English and Spanishhttp://www.migrantclinician.org/mcn/patient-education/pesticides/index.html


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Figure 4: Patient Education Materials

EOH Web Pages and Resources

MCNs award winning website offers a very important mechanism for distribution ofEOH resources. Over the course of the five-year program, there were a total of 537,766unique visits to environmental/occupational health pages on MCNs website, includingMCNs pesticide specific pages. Figure 5 shows the total number of pesticide specificresources downloaded from MCNs website by quarter.


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Figure 5: Pesticide Resources Downloaded from MCNs Website

LESSONS LEARNED

Saving Lives by Changing Practicesoverwhelmingly succeeded in carrying out its

original objectives. The program also allowed MCN to leverage numerous activities,enabling the program to far exceed its original plans. MCN achieved important resultswhile learning from the program to improve future efforts. Outlined below are insightsfrom MCNs experience with this important program.

1. Clinicians and health centers demonstrated a strong interest and desire toaddress environmental and occupational injury and exposure. Key to helpingfrontline clinicians integrate EOH into their daily efforts is a simple modelcomplemented by clinical tools to support system changes.

2. The program fostered new interest among clinicians and health centers regardingthe agricultural workplace. An unexpected program result involved new

opportunities and improved relationships that strengthened the linkages betweenhealthcare providers and the workplace.

3. Saving Lives by Changing Practicesdemonstrates clinical systems can bechanged to improve the recognition and management of pesticide exposures.MCN learned that bringing EOH into primary care is feasible. Screening andhaving a policy to document environmental and work-related exposures,encourages clinicians to consider occupational and environmental injuries,illnesses and exposures as part of their patient workup. However, identification


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and reporting of pesticide exposures will remain challenging without accessibleclinical diagnostic tools to assist healthcare providers in accurately determiningexposures.

4. Saving Lives by Changing Practicesbrought MCN to the front lines of primarycare for underserved populations, placing MCN in a unique position to offer EPA

relevant information from the field regarding the use of pesticides and the clinicalpractices. As a result of observing clinicians integrate EOH into primary care,MCN strongly recommended EPA establish a robust pesticide reporting andsurveillance system and launch policies to make clinical diagnostic toolsaccessible to clinicians. Additionally, M/CHCs turned to MCN for help inrequesting changes to existing policies. M/CHCs noted their patients challengesin reading pesticide labels provided only English. MCN formally asked EPA toconsider requiring labels in Spanish.

5. Solely focusing on pesticides in primary care presents challenges in achievingclinician support. Focusing on EOH more generally, with a focus on pesticides,is more appropriate for primary care settings.

6. MCN achieved the breath and scope of this effort through leveraging its otherprograms and through an important network of partners.7. An expert advisory committee furthered MCNs ability to achieve clinical

excellence in this program.8. Saving Lives by Changing Practicespositioned MCN to strengthen and further its

organizational capacity to provide EOH training and technical assistance toclinicians and health centers.

9. Clinician retention in M/CHCs is an overarching concern. MCN must considerways to feasibly sustain program efforts in light of position changes within clinics.

- Earldotter.com

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