A Public Health Story from Washington County – Maine

Washington County in Maine is a very rural and poor county. The population of the biggest city is 4000. It includes the largest tribal community in the NE. Washington County was dubbed the opiate capital in the US by Newsweek Magazine due to the epidemic misuse of prescription drugs. Trauma was the cause of a new generation of children’s issues in the form of toxic stress.

Most of the health and mental health/substance abuse issues come down to trauma as understood by the Adverse Childhood Experiences Survey (ACES). When considering trauma, it is impossible to separate out mental and physical health and you have to talk about social issues such as substance abuse, HIV, poverty and wealth disparity.

In Washington County, the tribe was particularly affected in part because of the legacy of historical trauma and the ongoing trauma of stigma and prejudice. Across Washington County the issues were complicated by rural isolation and hospital care for effected infants being offered 90 miles or more away from home. Long hospitalizations for Neonatal Abstinence Syndrome were complicated by families lacking the means to be present in the NICU because of financial strain and lack of public transportation. Many babies had attachment issues. Once children were released they often missed re-checks babies from Washington County and had a high rate of re-hospitalization. The statistics became alarming. The county included the highest percent of parents with terminated parental rights, children with disabilities in school, children expelled from child care, parents who had opiate addiction issues, and an increasing number of children with parents incarcerated.

It was within this context that a group of 10 people convened to consider the major health issues in their community. They represented different agencies, tribal communities and families and came together, joined by a universal shared concern about the health of the population. Specifically, they were concerned for the infants and young children in the community and realized that without change, the future would be bleak. They saw a growing sense of hopelessness in families, communities in the agencies offering services. Repeatedly people stated that they felt that they were doing too little, too late. They did not define the problem as one thing (health, emotional, etc.) but looked at the intricate overlap of complex issues that were eroding health and changing outcomes for children and their families with negative outcomes and serious consequences.

Public health was identified as the framework by which social change would occur in Washington County. The community recognized that health and wellbeing improvements would only occur through collaboration and a shared vision of health and wellness. A collaborative of 37 entities including tribal, state and county agencies created the Community Caring Collaborative. Mental health, substance abuse and children’s issues were seen as public health issues that required a shared collaborative response that was strength based, community driven and culturally competent. The group also realized that no one would do well unless everyone was healthy. They also felt that changes would be more sustainable if based upon a public health framework.

The group initially spent time articulating what they were worried about and what would make a difference. Out of that came a partnership to look at how to create a seamless system for at risk infants and young children that included a social service to health model.

First the group engaged in grassroots work with families including grandparents as parents and young parents in and out of recovery. They conducted 12 focus groups (at least 2 in tribal communities) and found out what people wanted and needed. They wanted navigators for systems that started in NICU. They dreamed up the Bridging Program which uses both home visitors and nurses (depending on the issues of the infant/family) to offer community based home services to support families so infants could come home and stay home and so families could achieve better outcomes across domains. Ultimately, there were four strands of their program that had one foot in social services and one in health:

  • Bridging
  • Integrating early intervention specialists into primary care. People were more willing to go to doctors and doctors needed to understand trauma and social services in order to be both clinically and cost effective.
  • Child care centers would include mental health consultation by early intervention specialists to avoid expulsions.
  • Training would be available to provide a universal and collaborative foundation in the areas of, poverty, substance, and trauma.

It was at this time that they began to say publicly that this is about public health and to look at how things evolved differently. They are very clear that when they talk about public health they have to stress “public”.

Too often with medical care, it is like separate pearls not strung into a necklace. The strength of the CCC was the emotional buy in. The county was so riddled with substance abuse that no one could save those babies. Now, they are the community’s babies. Our community took ownership. Public health is about ownership of the entire population and the entire system. Everyone sees that their work is important and that they are part of the community response. Health and wellness now means that someone has expertise in the thing the person and the community is facing. This takes away the concept that you treat only at the high end.

The top three things their community did:

  • Look where community is most easily attacked to get where people’s passion lies. Collaboration requires something so compelling that people will share.
  • The one who convenes the collaborative group cannot compete with those they are convening. The group in Washington County is not a non-profit. In rural and tribal areas there are big grants that come and go but money usually only benefits those who get the money. The grant goes and services stops and people feel betrayed. The collaborative cannot belong to anyone. It doesn’t need to continue. Shared data is used to get grants. Data belongs to everyone. Everything is transparent and co-owned. That is where you get pubic health – it is public. Salaries and budget are also public.
  • Celebrate (including families) along the way. This is really important. People feel like there are certain instances when you can’t help families (dead zone) and on a visioning day the group figures out how to fill the gap. The ripple effect of hope impacts those that work in the agencies and those that live in the community. That is worth celebrating.

At this time, the vision of the Community Caring Collaborative is to develop a seamless, family-driven, culturally-competent, strength-based, public-health oriented service system that will help children and their families fulfill their potential and live healthier, happier, more hopeful lives that are substance free. They have worked collaboratively to provide opportunities for families and agencies to meet the needs of infants and young children and to integrate services into primary care and other community resources to insure early intervention and prevention.

For further information, please visit cccmaine.org.