A Safe Place to Sleep: Developing a National/Local Partnership

State: NY Type: Neither Year: 2015

The Nassau County Department of Health (NCDOH) was created in 1938 by the Nassau County Charter. The mission of the Nassau County Department of Health is to promote and protect the health of all who live, work, and play in Nassau County. The mission of the DOH is accomplished through direct services and community partnerships in the following areas: development and maintenance of individual and community preparedness for public health hazards and events; investigation, prevention, and control of communicable diseases; prevention of environmental health hazards through assessment, regulation, and remediation; promotion of healthy lifestyles through outreach and education; provision for evaluation and services to individuals, children, and families that have developmental delays and concerns. Nassau County, New York has a population of 1.3 million making it the 27th largest county in the nation.  Out of a population of 1.3 million, Nassau County consists of 76.7% white, 12.4% black/African American, 15.7% Hispanic/Latino, 8.7% Asian, 0.5% American Indian, 0.1% Pacific Islander/Hawaiian, 1.6% two or more races (United States Census Bureau, 2013).  The County is undergoing a rapid demographic shift; it is aging and it is becoming far more ethnically, racially, and economically diverse.  Although there are pockets of great prosperity in Nassau County, areas of extreme poverty abound, and subsequent health disparities are a major concern.  Infant deaths resulting from unsafe sleep environments is a preventable public health issue. According to the CDC (2014), there are 4000 deaths each year in the United States due to unexplained sudden infant death.  Unexplained sudden infant death can be due to suffocation or entrapment of an infant while sleeping in an adult bed, on couches, in a crib filled with blankets and pillows, or in a defective product (Cribs for Kids, n.d.).  These deaths are preventable through education and the access and use of safe sleep environments. The goal of this project is to reduce the number of infant deaths resulting from unsafe sleep environments. The objectives include: §  Secure and manage funding to purchase cribs. §  Identify local partners to identify, refer, and educate families at risk. §  Evaluate changes in family safe sleep practices following partner intervention.  §  Continue to monitor county level infant deaths due to unsafe sleep. The Nassau County, NY- Cribs for Kids chapter was established through a Trademark License Agreement between Nassau County and National Cribs for Kids.  Funding for the program will be through grants and donations. Milestones, Objectives and outcomes are as follows:  1a. Milestone: Have all agreements in place to establish a local chapter. 1b. Objective: Memorandum of Understandings (MOU) 1c. Outcomes: ·         Establishment of local Cribs for Kids Chapter ·         Activation of a 501(c)3 account through the national chapter.   2a. Milestone: Funding 2b. Objective: Secure and manage funding to purchase cribs. 2c. Outcomes: ·         $2000 from the Ronald McDonald House Charities. ·         $300 Private donations ·         Local Business Donations* 3a. Milestone: Partnerships 3b. Objective:  Identify local partners to identify all local partners who 3c. Outcomes: Local Partners: ·         Identify ·         *Engage ·         *Sign MOU ·         *Train * Indicates ongoing activity To date we have been successful in becoming a local Cribs for Kids chapter as well as activating a 501(c)3 account though the national Cribs for Kids program. We have also been successful in obtaining some initial funding to start the program and are continuing to apply for other grants.  Community outreach for donations will expand as we move forward. Our next steps will be to engage community partners and securing Memorandum of Understandings to secure the partnerships.  One completed, we will train the partners who will then act as safe sleep ambassadors in the community.  They will be able to identify families in need of a crib, refer them to the program and once approved, they will be able to go into the home and educate the family as well as supply the infant with a safe place to sleep. The public health impact of Crib for Kids is a reduction in infant deaths due to unsafe sleep environment.  Our website is located at:  and  
Sudden infant death (SIDS) has been a public health concern for over 2 decades. After the implementation of the American Academy of Pediatrics (AAP) recommendation of back sleep position for infants, the number of SIDS deaths in the United States decreased by 53% between 1992 and 2001 (Kochanek, 2004). Prone sleep positioning declined from 70% in 1992 to 11.3% in 2002 and then increased slightly to 13.0% in 2004. Some studies indicate that the prevalence of prone sleep position is contributing to the continued disparity in SIDS rates between African American and Caucasian infants. (Hauck et al., 2002). The prevalence of prone sleeping position in 2001 among Caucasian infants was 11% compared with 21% among African American infants. Research conducted in California that examined data from 1997 – 2000 revealed that there was an exceptionally high incidence of SIDS for infants placed on the side and found on the stomach or for infants who were placed in the prone position who were accustomed to sleeping on their backs, reinforcing the importance of a consistent, clear, continuing message to parents about safe sleep for infants (Li, DK, et al., 2003). Clearly, sleep position and sleep environment represents a crucial modifiable risk factor in combating infant deaths. In October 2005, the AAP published “The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk”. This policy statement presents updated recommendations to reduce SIDS deaths and describes a safe sleep environment for an infant as being “separate but proximate”, that is, a baby should sleep in the same room as the parent(s) but in its own separate sleep space of a safety-approved crib, bassinet, pack and play, or cradle (American Academy of Pediatrics, 2005). In October 2011, the AAP published “SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment”, reinforcing the above policy statement and adding some new recommendations.  New recommendations included avoiding sitting devices for sleep, avoiding co-sleepers, avoiding commercial devices marketed to reduce SIDS and avoiding the use of bumpers pads (American Academy of Pediatrics, 2011) Although SIDS and suffocation are not the same thing, the measures used to reduce the risk for each of them are the same: placing the baby on a firm surface, in a safety-approved crib, cradle, bassinet or Pack and Play, with no soft bedding in the crib or near the infant. The recommendation is to always place an infant in its own sleep environment separate but proximate to the parent(s), and to never share a sleep surface with the infant. Research consistently shows that bed-sharing with an infant in an adult bed or nontraditional surface is hazardous to the infant due to inherent risks of entrapment, wedging of the infant’s body and head between the mattress or another object such as bed railings, possible overlaying by the parent, sibling or other adult sharing the bed, and dangerous soft bedding (Nakamura, Wind, Danello, 1999) According to the US Census Bureau (2012), Nassau County has the 13th highest income in the nation, however, there are still deep pockets of poverty and health disparity within the County.  The racial disparities in child fatality are distinct with an infant mortality rate of African American children being four times that of Caucasian children—a trend that has remained persistent (New York Department of Health, 2009-2011).  The Nassau County Child Fatality Review Team releases Independent Reports based on case reviews it conducts. Since January 2009, the Nassau County Child Fatality Review Team (NCCFRT) reviewed twenty seven (27) infant deaths occurring since 2009, where unsafe sleeping could not be eliminated as a risk factor in the death. Of the 27 cases reviewed: 56% are Black/African American, 24% White and 20% Hispanic/Latino.  This illustrates a significant disparity as out of the 1.3 million residents in Nassau County only 12.4% are Black/African American, 15.7% are Hispanic/Latino and 76.7% are White. The age range of cases reviewed spanned from 9 days to 5 months and occurred during warm and cold seasons.  All 27 cases revealed at least one of the following risk factors: bed sharing, prone (belly) sleep position, positional supports/sleep positioner and/or soft bedding. Some or all of these factors may have contributed to the death of the child, resulting in the team's classifications of the deaths as either "preventable" or "undetermined." estimates that in 2009, 7.6% of Nassau County children birth – 17 years live in poverty. Based on approximately 14,000 births per year in Nassau County, we anticipate there could be up to 1,000 infants in need of a safe place to sleep. The Cribs for Kids program began in Allegheny, Pennsylvania and has evidenced the reduction of sleep-related death rates from 17 in 1998 to 6 in 2004 in Allegheny County. Since the creation of the Cribs for Kids in 1998, all babies in Allegheny County whose parents or caregivers have received and properly used the Graco Pack n' Play portable crib from Cribs for Kids have lived to celebrate their first birthdays. Due to the success of the Cribs for Kids® program it has become a National Infant Safe Sleep program in 320 locations nationwide. Prior activities to educate families on appropriate safe sleep practices have traditionally been done by birthing hospitals and pediatricians.  Currently, there are no state guidelines that outline what a birthing hospital must do to educate newborn parents regarding safe sleep.  Therefore, the intensity of the education as well as the information relayed varies. Prior to the Cribs for Kids- Nassau County chapter there was no formal program in Nassau County with the ability to provide both education and a crib free of charge.  The Cribs for Kids- Nassau county chapter has identified potential partners that service pregnant and/or parenting families. Our next step will be to engage and train these partners according to guidelines in our partnership agreements. The individual partners will follow a curriculum developed for the safe sleep education and distribution of cribs. For the cost of $100 we can purchase a Crib for Kids Graco Pack n' Play, Halo sleep sack, 1 crib sheets with a safe-sleep message, 1 soothie pacifier and safe sleep educational material. Each unit will be drop shipped to the recipient. The home will be the site of where the education piece of the program occurs, which will afford the partner the opportunity of a visual as to what is the status of the home. Since unsafe sleep deaths disproportionately affects low income and minority families who cannot afford to purchase a crib, our chapter will target underserved communities via our community partners through a comprehensive communication plan and educational campaign that promotes healthy sleep conditions for infants. Every family deserves to receive clear, consistent, repetitive, and culturally appropriate information regarding a safe-sleep environment for their baby, as well as the tool with which to implement this safe environment: a safety-approved crib. The provision of the portable crib is a crucial educational component to the safe sleep campaign, because once the community is enlightened about infant safe sleep, the means with which to implement the safe environment must be part of the intervention. Otherwise, the message is an empty admonition that the family is unable to achieve. The provision of the crib empowers the mother to fulfill her biological nesting instinct to prepare a safe place for her infant. Funding to support the purchase of cribs is through grant writing and fundraising. The National Cribs for Kids chapter has designated an account within their 501(c)3 for use by our local chapter.  There are no overhead fees associated with the use of this account allowing all funds secured to be used to benefit families in need.  
The goal of Cribs for Kids, Nassau County N.Y. chapter is to to reduce the number of infant deaths resulting from unsafe sleep environments. The objectives include: §  Secure and manage funding to purchase cribs. §  Identify local partners to identify, refer, and educate families at risk. §  Evaluate changes in family safe sleep practices following partner intervention.  §  Continue to monitor county level infant deaths due to unsafe sleep. The steps taken to implement the Crib for Kids-Nassau County chapter include: 1.      Identification of the public health issue 2.      Evaluation of evidence based strategies 3.      Developing a partnership between a local health department and a national organization 4.      Developing partnerships within and external to the county health department for crib distribution 5.      Developing capital to support the purchase of cribs for distribution   1. Identification of the public health issue: The identification of unsafe sleep as a public health issue was accomplished by the Nassau County Child Fatality Review Team.  The Nassau County Child Fatality Review Team (NCCFRT) is a multidisciplinary team established pursuant to NY Social Services Law (SSL) § 422-b. The NCCFRT has functioned since December 2008.   The team was created to review fatalities of Nassau County residents ages 0-17 years who die in Nassau County and whose death is otherwise unexpected or unexplained (“Child Fatalities”). Cases reviewed include, but are not limited to cases: Ø  whose care and custody or custody and guardianship has been transferred to an authorized agency. Ø  any child for who Child Protective Services (CPS) has an open case. Ø  any child for whom Social Services has an open preventive services case. Ø  any case for which a report has been made to the State Central Registry (SCR). Ø  any case for which a report has been made to the State Central Registry (SCR). Child Fatality Review Teams were first developed in the U.S. more than 20 years ago in response to the underreporting of child abuse deaths and the lack of communication between child welfare agencies.  The multidisciplinary approach allows for collaboration among agencies and thereby enhances the ability to accurately determine the cause and circumstances of death, making it less likely for maltreatment to be missed.  As of July 2013 in NYS, there are 16 CFRTS, of which 2 function out of the local Department of Health (Broome County and Nassau County). Since January 2009, the NCCFRT has met monthly to review child fatalities.  The team approaches each case in a systematic manner allowing for a complete review of each case identified.  Cases are reviewed after completion of any investigations and completion and filing of death certificates.  Therefore, not all deaths are able to be reviewed in the same year of occurrence.  Membership in the NCCFRT is defined by SSL §422-b(3).  This statute requires the participation of certain agencies and also allows for the appointment of associate members from various fields of practice.  Statutorily required team members include Nassau County Child Protective Services, Office of Children and Family Services (OCFS), Nassau County Department of Health, Nassau County Office of the Medical Examiner, Nassau County District Attorney’s Office, Office of the Nassau County Attorney, Nassau County Police Department, Emergency Medical Services, New York State Law Enforcement and a pediatrician or comparable medical professional, preferably with expertise in child abuse. The team has added additional members with expertise relevant to child fatality prevention and/or review (see Appendix A).  The mission of the NCCFRT is to review child fatalities to better understand the causes of these deaths and to make recommendations based on the team’s findings in order to reduce future child fatalities.  The NCCFRT meetings by statute are confidential and closed to the public.  Further, NCCFRT requires that a confidentiality statement be signed by each member, at the start of each team meeting.  The team’s protocol and procedure manual is in accordance with New York State Social Service Law §§ 20(5), 422-b, and the rules and regulations of OCFS.   2. Evaluation of evidence based strategies: Based on reviews conducted by the NCCFRT, unsafe sleep was identified as an ongoing public health concerns, consistent with finding across the country. The next step was to evaluate evidences based strategies to address this issue. Based on well recognized publications, such as the American Academy of Pediatrics 2011 described earlier, “SIDS and Other Sleep-Related Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment”, it is well established that the safest place for an infant to sleep is alone in a crib, in his/her back, with nothing else in the crib. The national Cribs for Kids program is unique in its ability to not only provide education to families at risk, but also can supply the tool (a pack n’ play) to act.   3.      Developing a partnership between a local health department and a national organization Our next step was to develop a partnership with the national Cribs for Kids program via a Trademark License Agreement. This step involved partnering a Not for Profit organization with a local municipality. Obtaining a signed Trademark License Agreement required intensive coordination between multiple agencies including the county attorney’s office, national Cribs for Kids and the Nassau County Department of Health.   4.      Developing partnerships within and external to the county health department for crib distribution Following the implemantation of the Trademark License Agreement, we identified potential partners that service pregnant and/or parenting families. Partners have been identified as either within the county or external to the county.  In partnership with the County attorney’s office a Memorandum of Understanding (MOU) has been developed for potential partner agencies.  Once partners are recruited, representatives from each agency will be trained.  A training curriculum has been developed which includes all necessary information and forms for the partners.   5.      Developing capital to support the purchase of cribs for distribution A simultaneous activity that is ongoing is the process of securing funds to support the purchase of cribs.  We have been successful in securing a $2,000 Ronald McDonalds House Charities grant.  We will be continuing to apply for grants to support the program as well as as reach out to local community based organizations. The Nassau County Cribs for Kids Program will target low-income families. Eligibility Requirements must meet one of the following criteria: They receive some type of public health benefit (such as TANF, WIC, food stamps, child care subsidy, disability, SSI, Section 8 housing)Nobody in the home is workingThey can demonstrate that they are otherwise unable to afford a crib**If you feel that a special circumstance exists that would qualify family for a crib, please indicate on the form.  The case will be reviewed on an individual basis.·         Infant should be less than 9 months of age, or mother is within 8 weeks of due date.    All recipients should: Be a Nassau County residentNot already have a safe crib or pack n’ play for the referred infantEither be pregnant within 8 weeks of delivery or already have an infant under 9 months of age.   The program is intended to be ongoing, supported by grants and private donations
In developing this partnership we have discovered that a successful public-private partnership can be achieved in order to address unsafe sleep in Nassau County. The national Cribs for Kids program has been supportive at every juncture to ensure our success. Other local health departments can benefit from the ability to obtain a 501(c)3 account within the national cribs for Kids program We have been successful in securing a partnership with the National Cribs for Kids program. We now have a viable partnership to obtain cribs for distribution to families in need.  The objectives, as described earlier include: -Secure and manage funding to purchase cribs.-Identify local partners to identify, refer, and educate families at risk. -Evaluate changes in family safe sleep practices following partner intervention.  -Continue to monitor county level infant deaths due to unsafe sleep.   Our first objective, to secure and manage funds to purchase cribs has been successful and is an ongoing process.  We now have several other grant applications completed and will launch a community wide campaign for donations in the near future. Our second objective, to identify local partners has been met. As a municipality, Memorandums of Understandings (MOU) gave been drafted for both inter-departmental and community based organizations. We anticipate a first partners meeting and signing of MOU’s in the next few months. For our third and fourth objective above, we will be using both the partners that join and the Nassau County Child Fatality Review Team as our primary data sources. Three questionnaires have been developed which will serve as our performance measures. Our partners will be administering questionnaire to the families receiving the cribs prior to education and six weeks later. All results will be reported to us. We will be able to compare knowledge and behavior regarding safe sleep before and after the intervention.  The third questionnaire will be a follow-up at one year to determine if the behaviors were sustained. Based on what the results of the questionnaires reveal, the program will be adapted. It is the routine practice of the Nassau County Child Fatality Review Team to review all death certificates to identify appropriate cases for review and release reports which will be used as necessary.  
Stakeholder commitment at both the national and local level is strong. The national Cribs for Program began in 1998 and has expanded to over 320 locations.  It is committed to supporting safe sleep for babies. The Nassau County Department of Health is also committed to making this local chapter sustainable. This project has shown us the tenacity and persistence needed to coordinate multiple agencies including a national organization and county attorney office and a local health department.  We realize that these efforts will need to be continued as we partner with other agencies on this project. It is our experience that support for this program has been strong and the need for safe sleep environments is clear.  The programs sustainability will be a direct result of the department’s ability to raise funds for this project.  We expect to be successful in securing both grants and in developing a base of organizations willing to contribute.  
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