Developing Program Activity
Limited staffing and funding constraints are not strangers to most state government employees working in public health, mental health or aging. But, those with determination and imagination often find ways to influence resources beyond their own budgets. Some may serve as catalysts getting others such as employers or members of the media to give new attention to such issues as depression as a co-morbidity of diabetes. In this section of the resource guide, we will address five areas where additional resources might be brought to the table.
Coalitions can be described as an alliance or partnership of individuals, groups, or organizations with a common purpose or an over-lapping interest. Coalition members retain their own identity but agree to work together towards a common, agreed-upon goal. An attraction to coalition building is that it brings more reach, resource, and impact to achieve an outcome of interest to all members.
Coalitions may be helpful in addressing depression as a co-morbidity of diabetes. Few state health departments have either a mandate or a budget to address this issue. For the most part, each categorical disease is addressed by different sections within the state government. When there is not a visible mandate, and when key programs are operating within their own silos, the ability to move forward in addressing a co-morbid condition is significantly handicapped.
One way several states have overcome this handicap is to form and then participate within coalitions, both internally and externally. There are a number of state-based programs that have benefited by coalitions. In some cases, the state program may take the lead, in other cases it may be more productive for a non-governmental entity to take the lead. Collectively, coalitions bring a level of experience, resource, access, and influence that state programs could not possibly have on their own.
Coalitions for depression and diabetes might include state or local affiliates of national advocacy groups such as the American Diabetes Association, the National Mental Health Association, the National Institutes of Senior Centers and the Black Women’s Health Imperative, all of whom may contribute to an expanded awareness and educational effort. Representatives of physician groups might generate a better understanding of the issue among health care providers. Involvement of legislators could lead to a crucial voice within the policy making arena. Business associations might be recruited which could lead to more employers instituting programs for their employees (addressed in some detail elsewhere in this section).
Fortunately, there exist a number of Web sites that provide detailed guidance on how to develop and maintain coalitions in a way that will bring more resources to the issue you are addressing.
The Community Tool Box (CTB) is one such site providing insight and guidance. Developed by the University of Kansas in Lawrence in cooperation with AHEC (Area Health Education Centers) and Community Partners in Amherst, MA, the site includes practical guidance for various tasks necessary to promote community health and development, including a “Creating and Maintaining a Coalition or Partnership.” This tool box dealing with coalitions can be found at: http://ku.edu/tools/tk/en/tools_tk_l.jsp.
The Prevention Institute provides another source of advice and guidance. It carries a 27-page article entitled “Developing Effective Coalitions: An Eight Step Guide.” Written by Larry Cohen, Nancy Baer, and Pam Satterwhite, it can be found at: http://www.preventioninstitute.org/print/eightstep.html.
Another site—Wisconsin Clearinghouse on Prevention Services—is operated by the University of Wisconsin’s Health Services. A section on Coalition Building that delves into coalition functioning, roles and responsibilities of coalition members, goal setting, and attributes of a good coalition coordinator can be found at: http://wch.uhs.wisc.edu/01-Prevention/01Prev-Coalition.html
The Minnesota Department of Health provides useful information on choosing coalition leadership, brainstorming, and developing a mission statement. The site provides worksheets and checklists to assist in developing coalitions. The site can be found at: http://www.health.state.mn.us/divs/hped/chp/hpkit/text/team_html
The Opportunity for Program Integration
Many in public health have long talked about program integration, but relatively few have done anything about it. But, that may be changing. In March, 2006, a Workshop on Chronic Disease Program Integration was held in Atlanta. Sponsored by the Centers for Disease Control and Prevention (CDC) and the National Association of Chronic Disease Directors (NACDD), the workshop had representation from 23 states. Participants tackled such issues as how to develop effective integration while protecting the integrity of categorical programs and how to meaningfully and respectfully engage key stakeholders. A report on this workshop, along with power point presentations from two states describing model integration efforts can be found on the NACDD Home Page at www.chronicdisease.org. Simply click on “Professional Development” on the left side of the home page, and then click on “Program Integration.”
Whereas coalitions generally include external organizations and entities, program integration usually focuses on internal entities or programs. In addressing depression as a co-morbidity of diabetes within a state government structure , there are a number of program areas with which there could be commonality or over-lapping interest. They could include those concerned with: diabetes, depression, aging issues, and women’s health concerns.
Personnel working in State Health Department’s Diabetes Prevention and Control Programs would be key participants in any program integration effort. Representatives of state mental health departments might also be among those likely to participate in a partnership effort. Since women suffer far more depression than men, program staff concerned with women’s health issues may serve as key participants in an initiative on depression as a co-morbidity of diabetes. Since depression and diabetes disproportionately affect older citizens, those working on aging issues may be interested in being part of a program integration initiative. Perhaps, a first step would be to convene those with an interest in depression, diabetes, women’s health, and aging and map out a strategy for a collaborative program activity which could serve as a forerunner to a broader coalition or partnership.
Drawing on the recommendations of the Program Integration Workshop should be helpful in formulating such a strategy.
The Workplace Setting
In the October 9, 2006 issue of the Washington Post an article in the business section underscored the growing investment in on-site clinics by employers as a means of trimming medical costs and boosting preventive care. It cited projections by a leading benefits consulting firm that as many as one-fourth of Fortune 1000 companies would have such clinics by the end of 2007. The article stated that companies are taking these steps in an attempt to manage soaring costs and to increase productivity by cutting down on time away from desks for doctor visits. Freddie Mac, the nation’s second largest financier of home loans, reported a savings of $685,000 the first year their on-site clinic was in operation.
In the same article, a spokesperson for Harrah’s Entertainment, the operator of casinos, said the hope to defray exorbitant costs associated with late-stage disease was one of the motivations for launching on-site clinics at their casinos. Juliet Vestal, Director of the company’s health care management said of the 528 employees given a general health screening at its Lake Tahoe clinic, 80 percent were found to be positive for such conditions as diabetes, high blood pressure, thyroid problems and liver problems.
The Washington Post article reflected an apparent resurgence in employers supporting on-site programs to foster early-detection of a number of conditions, including depression and diabetes, which would be much more amenable to effective intervention when caught in their early stages. Another article in the July, 2006 issue of Managed Care Magazine also highlighted the growing interest of employers to provide more opportunities for preventive care. The article stated: “they (employers) have come to realize that if they pay for health, they’ll pay less for sickness.” The article, written by Martin Sipkoff (which can be accessed at http://managedcaremag.com/archives/0607/0607.wellness.html) quotes several top government health officials, industry leaders, and health benefits experts. The Chief Medical Officer for WellPoint notes the benefits that can be accrued from preventive health services. As an example, he said: “if colorectal cancer screening were offered at recommended intervals to all people 50 and older, 18,000 deaths could be prevented each year.” Nico Pronk, PhD, executive director of the Health Partners Health Behavior Group was quoted as saying: “Disease costs money. Prevention saves. It’s that simple. Evidence exists for the economic benefit experienced by companies with worksite health programs.” Pitney Bowes CEO Michael Critelli says his company saves about $1 million a year in asthma and diabetes costs alone. “We know this (onsite health promotion/disease prevention programs) works.” As in the Washington Post article, the human resource experts agreed they expect to see more on-site medical clinics because if employees have minor health issues dealt with in-house, as well as onsite preventive services and lab tests onsite, companies can save money and reduce absenteeism.
The National Diabetes Education Program (NDEP) has a Business and Managed Care Work Group that produced a report – Making a Difference: The Business Community Takes on Diabetes — which describes how business leaders can become more involved in workplace and community activities to help control diabetes-related complications and reduce the human and economic burden of the disease. A print version can be obtained at the NDEP Web site – www.ndep.nih.gov/resources/business.htm.
The National Business Group on Health in collaboration with the NDEP and America’s Health Insurance Plans sponsors the www.diabetesatwork.org Web site. This site is directed towards business and makes the case that helping to manage their employee’s diabetes is in their business interest. The site includes presentations made at Diabetes At Work Workshops and highlights successful Employer programs, such as those at General Motors, Land’s End, Dallas Federal Reserve Bank, Inland Northwest Health Services, General Electric Energy, Connecticare, and Intracorp/CIGNA.
Although directed at employers, the site provides ammunition to those health professionals interested in persuading business to adopt such programs.
An employer led Community Initiative on Depression was launched in the Kansas City area by the Mid-America Coalition on Health Care. The mission of the coalition is to improve the health of employees and their families and promote employee and community wellness and illness prevention. The initiative on depression had three objectives: 1) destigmatize-stigmatize depression; 2) identify the direct and indirect costs of depression; and, 3) create a community infrastructure to support appropriate and timely diagnosis and treatment. Fifteen employers representing over 140,000 employees and family members provided leadership to the initiative but there was also collaboration with health plans, clinicians, school districts, universities on both sides of the state line, health departments, local and national mental health associations, civic organizations and others. The program is described in three phases and provides a series of lessons learned for those contemplating a similar initiative on depression as a co-morbidity of diabetes. The
URL for the Coalition’s Web site - http://www.machc.org - is not always responsive. An alternative way of accessing the site is to go to the Web Home Page of the “Mid-Atlantic Coalition on Health Care” and then click on “Depression” in the left column.
Another informative Web site is the “Partnership for Workplace Mental Health.” Geared towards employers, it is sponsored by the American Psychiatric Foundation. It provides a toolkit on depression, and highlights such articles as “How Much Does Quality Mental Health Care Profit Employees?” which appeared in the November, 2005 issue of the Journal of Occupational and Environmental Medicine. The article concludes that employers which provide higher quality evaluation and treatment of depression and anxiety will see overall medical costs fall, employees miss fewer days of work, and productivity rises. The Web site can be accessed at www.workplacementalhealth.org.
The aforementioned Web sites should prove to be valuable resources for planning worksite initiatives on depression and diabetes.
Working With The Media
If your objective is to have people with diabetes screened for depression, mass media can be an important ally. Media can help increase awareness about the co-morbidity, enhance knowledge, promote screening and patient visits, and influence attitudes that could lead to more support and priority for a particular health concern.
For media personnel to be interested, they have to be convinced that your cause deserves its attention amidst an array of competing causes that are brought to them. While that may seem to be a huge barrier, there are elements of this particular co-morbidity that will help you get the attention of your media gatekeepers. It is a serious condition that is largely ignored by health providers and the public alike. Unaddressed, the co-morbidity can result in dire, life-threatening consequences. But these consequences can be prevented with early detection and treatment. And, the media can help make that happen. Convincing media people that their actions can help alleviate suffering and avert premature death can be very effective in gaining their support or even partnership.
Showing media that a sizable portion of its viewers, listeners, or readers is afflicted is also helpful in getting their support. Whereas local data are often hard to come by, estimates based on national data with appropriate caveats are desirable. Although national data may be impressive, local data are persuasive.
The fact that women with diabetes are about twice as likely to have depression as those who don’t have diabetes may serve as an “angle” of interest to media. Women’s health is a popular topic and broadcast stations, newspaper and magazines frequently devote programs, columns, or articles to the topic.
Knowing whether or not a station or newspaper, TV or radio station does devote time or space to women’s issues is one of the things you need to know before approaching media. Does a TV or radio station in your area feature talk shows that frequently focus on women’s health? Do the stations run public service announcements? Do the newspapers have a health column or guest editorials or “op eds” that often deal with health issues? Knowing the answer to these questions will help you tailor your “pitch” for support when you approach media.
Knowing whom to approach is important as well. Large TV and radio stations may have a medical editor or a medical reporter who might serve as a helpful initial contact. At smaller stations, it would likely be the station manager or public affairs director. The same would hold true with newspapers. The larger ones are more likely to have a medical editor or reporter than the smaller ones where the editor may be your prime target.
It is also helpful to bring some ideas with you to illustrate how media might help. You might suggest a partnership effort such as a special depression screening day, perhaps in conjunction with the day-long event that is carried out in many sites throughout the country in October. You might suggest an articulate and authoritative individual who would make for a good interview on one of the talk shows, or suggest a call-in show with the expert.
There exist a number of guides and tips on how to work with the media. The following represent some that you may find helpful. One can be found in another resource guide (mentioned elsewhere in this guide) that was prepared for those working at the state level. Go to www.chronicdisease.org and go to the “Information About” window and scroll down to “Osteoporosis” and click on “Go.” That will take you to the Osteoporosis Council home page. Then, click on “Resource Guide for State Programs.” On page 25 of that guide, is the section “Working With The Media.” It will provide guidance and insights into how to approach media, what special projects you may want to propose, how to work with TV and radio talk shows, examples of some public service announcements and “op eds.”
The W.K. Kellogg Foundation has a Web-based toolkit which includes a comprehensive section on the media. Among topics in the toolkit are: Building Media Relationships; Pitching a Story; The On-Line Connection; Writing a Press Release That Works; Letters to the Editor; Op-Ed Pieces; Spokesperson Training, and Crisis Communication. Go to the W.K. Kellogg web site and click on the “Knowledgebase” bar at the top and scroll down to Toolkits.
Another source of guidance is the Center for Medicare Education which produces a series of issue briefs, one of which is called “Mastering the Key Elements of Working With the Media.” The brief describes effective strategies for building a relationship with the media and advises how to conduct media interviews and get a story published on the editorial page. Go to www.MedicareEd.org and click on “CME issue briefs” at the bottom of the opening page. The brief on media is at the top of the list—Issue Brief, Vol. 5, No. 9, 2005.
Thirdly, there are a number of media tips published by the National Diabetes Education Program which can be found at: http://ndep.nih.gov/campaigns/media.htm.
Sources of Support
There are a number of pharmaceutical companies and foundations that may be open to applications for program support. Companies that
manufacture (or have in the pipeline) drugs for the treatment of depression and/or diabetes would be likely targets. Foundations that focus largely on improving the health status of our most vulnerable citizens would be another potential source.
In the pharmaceutical industry, there is a trend to set up separate foundations within individual companies which award non-profit organizations grants to carry out health initiatives. The company foundations generally operate independently of the marketing side of the business but the awards often focus on diseases or populations of interest to that particular company. Many company foundations accept applications that are submitted via their Web sites. While that represents the growing trend at corporate headquarters, there are field staff in regional or state areas for many companies that still provide direct, albeit modest, assistance to non-profit and governmental groups.
There are foundations that focus heavily on vulnerable populations and the improvement of their health status. The Hartford Foundation is most concerned with the health status of the elderly. The Robert Wood Johnson foundation has often supported health initiatives by states directed at lower-income or uninsured individuals. The MacArthur Foundation fosters team approaches among primary care providers and mental health counselors in addressing depression. The American Psychiatric Foundation supports efforts to reduce mental illness stigma, and initiatives that create understanding about mental health and early identification of diseases like depression. The foundations can be found at the following Web sites.
Robert Wood Johnson Foundation (http://www.rwjf.org)
John D. and Catherine MacArthur Foundation (http://www.macfound.org)
John A. Hartford Foundation (http://www.jhartfound.org)
American Psychiatric Foundation (http://www.psychfoundation.org)