Independent Evaluation of the Arkansas Tobacco Settlement Commission Funded Programs

July - September 2016 Quarterly Report

Indicator Activity

Prepared by

Arkansas Tobacco Settlement Commission Evaluation Team at the University of Central Arkansas

Presented to

Arkansas Tobacco Settlement Commission

Report Prepared February 2017

Arkansas Tobacco Settlement Commission Evaluation Team at the University of Central Arkansas

Emily Lane, MFA Project Manager

Ed Powers, PhD Evaluator: Arkansas Aging Initiative (AAI)

Tucker Staley, PhD Evaluator: Arkansas Biosciences Institute (ABI)

Denise Demers, PhD Evaluator: Arkansas Minority Health Initiative (MHI)

Betty Hubbard, EdD, MCHES Evaluator: UAMS Helena, West Memphis, and Lake Village & College of Public Health (COPH)

Jacquie Rainey, DrPH, MCHES Co-PI Administrator & Evaluator: UAMS Helena, West Memphis, and Lake Village & College of Public Health (COPH)

Joseph Howard, PhD Evaluator: Tobacco Settlement Medicaid Expansion Program (TS-MEP)

Ron Bramlett, PhD Evaluator: Tobacco Prevention and Cessation Program (TPCP)

Rhonda McClellan, EdD Co-PI Qualitative Report

Table of Contents

2 ● Special Thanks 3 ● Arkansas Aging Initiative (AAI) Indicator Activity 4 ○ Claudia Beverly, PhD, RN, FAAN Director of AAI ○ Amy Leigh Overton-McCoy, PhD, GNP-BC, Associate Director of AAI ● Arkansas Biosciences Institute (ABI) Indicator Activity 8 ○ Robert McGehee, Jr., PhD, Director of ABI ○ Leslie Humphries, Program Coordinator ● Minority Health Initiative (MHI) Indicator Activity 12 ○ ShaRhonda Love, MPH, Director of MHI ○ Louise Scott, Senior Grant Coordinator ● Tobacco Settlement Medicaid Expansion Program (TS-MEP) Indicator Activity 16 ○ Mary Franklin, Director, DHS Division of County Operations ● Fay. W. Boozman College of Public Health (COPH) Indicator Activity 20 ○ Jim Raczynski, PhD, FAHA, COPH Dean ○ Liz Gates, JD, MPH, Assistant Dean for Special Projects ● Tobacco Prevention and Cessation Program (TPCP) Indicator Activity 24 ○ Debbie Rushing, Branch Chief ● UAMS Helena, West Memphis, and Lake Village Indicator Activity 30 ○ Becky Hall, EdD, Director ○ Stephanie Loveless, MPH, Associate Director

Special Thanks

3 The evaluation team at the University of Central Arkansas would like to thank all who participated in this evaluation, including commission members, program directors, and coordinators. We appreciate the time and effort each program has made in improving the health of Arkansans. Commissioners

Susan Hanrahan, PhD Allison Hogue Alex Johnston Commission Chair Commission Vice-Chair Director of Rural Services at Dean, Arkansas State Grassroots Director Arkansas Economic Development University, College of Nursing American Heart Association Commission, Arkansas Economic & Health Professions Senate Pro Tempore Appointee Development Governor Appointee Commissioner Designee John Henderson, MD Jerri Clark Mary Franklin Executive Committee Member Director of School Health DCO Director, Division of County Physician, Unity Health Services, Arkansas Department of Operations, Arkansas Department of Speaker of the House Education Human Services Appointee Commissioner Designee Commissioner Designee

Nathaniel Smith, MD, Roddy Smart Lochala, DO Tara Smith MPH Physician, Family Practice Clinic Sr. Associate Director for Institutional Director and State Health Attorney General Appointee Finance, Arkansas Department of Officer, Arkansas Department Higher Education of Health Commissioner Designee Commission Staff

Matt Gilmore Larissa Liddell Executive Director Administrative Specialist III

Arkansas Aging Initiative (AAI) Indicator Activity

Program Description: The purpose of the Arkansas Aging Initiative (AAI) is to address one of the most pressing policy issues facing this country: how to care for the burgeoning number of older adults in rural community settings. The overall goal is to improve the quality of life for older adults and their families through two primary missions: an infrastructure that provides quality interdisciplinary clinical care and innovative education programs.

4 Overall Program Goal: To improve the health of older Arkansans through interdisciplinary geriatric care and innovative education programs and to influence health policy affecting older adults.

Long-term Objective: Improve the health status and decrease death rates of elderly Arkansans as well as obtain federal and philanthropic grant funding.

● Indicator: Provide multiple exercise activities to maximize the number of exercise encounters for older adults throughout the state. ○ Activity: A total of 2,388 exercise encounters with aging Arkansans were facilitated by AAI during this reporting period. ● Indicator: Implement at least two educational offerings (annually) for evidence-based disease management programs. ○ Activity: AAI continues to offer educational offerings such as the Diabetic Empowerment Education Program (DEEP). This quarter, a total of 14,661 education encounters were generated across various communities throughout Arkansas. ● Indicator: Increase the amount of external funding to support AAI programs by the end of FY2015. ○ Activity: AAI and its affiliates continue to be productive in securing external funding. Approximately $910,082 of external grant funding was raised to support AAI programming this reporting period. In addition, AAI estimates the value of its volunteer and in-kind hospital service donations at approximately $70,800 this reporting period. These grants and donations amount to almost three times the $383,736 funding provided by ATSC during this reporting period.

Short-term Objective: Prioritize the list of health problems and planned interventions for elderly Arkansans and increase the number of Arkansans participating in health improvement programs.

● Indicator: Assist partner hospitals in maintaining the maximum number of Senior Health Clinic encounters through a continued positive relationship. ○ Activity: AAI facilitated 6,496 Senior Health Clinic encounters during this reporting period.

5 ● Indicator: Partner hospitals will maintain a minimum of three provider Full Time Employees (FTEs) for Senior Health Clinics including a geriatrician, advanced practice nurse, and social worker. ○ Activity: AAI was unable to meet this goal in all but one Center On Aging (TR-Wadley). However, AAI has no direct control over clinic staffing and is seeking to revise this indicator. ● Indicator: Provide education programming to healthcare practitioners and students of the healthcare disciplines to provide specialized training in geriatrics. ○ Activity: AAI produced educational presentations and in-service training opportunities for 2,932 medical professionals and paraprofessionals during this reporting period. AAI also provided educational encounters with 633 healthcare students in the state. ● Indicator: Provide educational opportunities for the community annually. ○ Activity: Through AAI, 14,661 community education encounters were generated across Arkansas during this reporting period.

Challenges: AAI has struggled this quarter with a vacancy in the director’s position in Springdale. There is also some concern about the sustainability of the Schmieding Home Caregiver training program since funds to support this program will expire in a few years. Finally, the end of Broadband Technology Opportunity Program (BTOP) grant funding limits statewide broadcast and has challenged AAI to explore other cost effective training modalities.

Opportunities: During this reporting period, AAI was able to hire additional staff for outreach development to increase coverage in the Delta region. AAI has also been able to increase master trainers for the Diabetic Empowerment Education Program (DEEP) to cover needs in the northern part of the state. Further, AAI has been updating educational offerings and is in the initial development stage of evidence-based continuing education programs for inter-professional teams who will be able to identify food insecurities and make appropriate referrals. Finally, AAI continues to be resourceful in identifying grants, contracts, and donations necessary to support programming.

Testimonials: ● From a resident in South Arkansas and a community program participant: “I would love to

6 ‘testify’ about the SACOA programs HEAT (Healthy Eating and Tasting) and OWLS (Older Wiser Livelier Seniors). For me, a 72 year-old retired woman with no children or grandchildren, your programs are my lifeline. They are informational, entertaining, and a source of socializing for me. I look forward to the programs each month and hate it when I have to miss. The programs provided for the seniors are very interesting, and we also get fed, which for some seniors could be the only meal they have for that day. I am so appreciative and thankful for the SACOA, the programs, and the people who care for us. Thank you.”

● From a resident in south Arkansas and a community program participant: “When my husband was diagnosed with diabetes we started going to HEAT (Healthy Eating and Tasting) to learn more about the disease and how to live with it. We learned quite a lot and got his diabetes under control. We also made new friends, had very good healthy meals, and enjoyed the programs. The programs have covered many problems that come with aging. He has been diagnosed with Parkinson’s disease and we have needed more help as the disease has progressed. We have found that the staff here have been very supportive and have gone above and beyond to get us the help we need. We do appreciate this program and all the advantages offered. Thank you.” ● From a resident from northeast Arkansas and a volunteer at COA-NE: “The Center on Aging- Northeast has given me a positive outlook on aging. I feel that their educational and health- related programs have greatly contributed to my quality of life. This has allowed me to continue working to help others in areas such as the Prostate Cancer Peer Networking group and other community volunteer activities.” ● From a caregiver at an assisted living facility at Kenwood, Texarkana: “I was very skeptical at first, thinking I had all the training I needed for Alzheimer’s and Dementia. The Alzheimer’s Experience was a very good training and I enjoyed it.”

Evaluator Comments: AAI continues to meet its primary goal of improving the health of older Arkansans through direct contact, clinical facilitation, and influencing healthcare providers in the state. While AAI has encountered some challenges with staffing and funding, the leadership of the initiative continues to find ways to positively influence the services and policies related to aging in Arkansas.

7 Arkansas Biosciences Institute Indicator Activity

Program Description: Arkansas Biosciences Institute, the agricultural and biomedical research program of the Tobacco Settlement Proceeds Act, is a partnership of scientists from Arkansas Children’s Hospital Research Institute, Arkansas State University, the University of Arkansas- Division of Agriculture, the University of Arkansas, Fayetteville, and the University of Arkansas for Medical Sciences. ABI supports long-term agricultural and biomedical research at its five member institutions and focuses on fostering collaborative research that connects investigators from various disciplines across institutions. ABI uses this operational approach to directly address the goals as outlined in the Tobacco Settlement Proceeds Act, which is to conduct: ● Agricultural research with medical implications; ● Bioengineering research that expands genetic knowledge and creates new potential applications in the agricultural-medical fields; ● Tobacco-related research that identifies and applies behavioral, diagnostic, and therapeutic knowledge to address the high level of tobacco-related illnesses in Arkansas; ● Nutritional and other research that is aimed at preventing and treating cancer, congenital and hereditary conditions, or other related conditions;

8 ● Other areas of developing research that are related or complementary to primary ABI- supported programs.

Overall Program Goal: To develop new tobacco-related medical and agricultural research initiatives to improve the access to new technologies, to improve the health of Arkansans, and to stabilize the economic security of Arkansas.

Long-term Objective: The institute's research results should translate into commercial, alternate technological, and other applications wherever appropriate in order that the research results may be applied to the planning, implementation, and evaluation of any health-related programs in the state. The institute is also to obtain federal and philanthropic grant funding.

● Indicator: The five member institutions will continue to rely on funding from extramural sources with the goal of increasing leverage funding from a baseline of $3.15 for every $1.00 in ABI funding. ○ For FY2016, ABI leveraged $3.99 in outside funding for each ABI dollar for the year. ● Indicator: ABI-funded research will lead to the development of intellectual property, as measured by the number of patents filed and received. ○ For FY2016, ABI research investigators received five patents and 28 provisional patents. ● Indicator: ABI-funded research will result in new technologies that generate business opportunities, as measured by the number of start-up enterprises and public-private partnerships with ABI and member institutions to conduct research. ○ For FY2016, there was one new start-up enterprise. ● Indicator: ABI will promote its activities through various media outlets to broaden the scope of impact of its research. ○ For FY2015, there were 117 media contacts.

Short-term Objective: The Arkansas Biosciences Institute shall initiate new research programs for the purpose of conducting, as specified in § 19-12-115, agricultural research with medical implications, bioengineering research, tobacco-related research, nutritional research focusing on cancer prevention or treatment, and other research approved by the

9 board.

● Indicator: ABI will allocate funding to its five member institutions to support research, while also monitoring that funded research activities are conducted on time, within scope, and with no overruns. ○ For FY2016, ABI is engaged in 174 new and ongoing research projects covering all five research areas. ● Indicator: ABI and its member institutions will systematically disseminate research results, and ensure that at least 290 publications and 370 presentations are delivered each year. These include presentations and publications of results, curricula, and interventions developed using the grant funding, symposia held by investigators, and the creation of new research tools and methodologies that will advance science in the future. ○ Final data on the number of publications are still being compiled. ● Indicator: Employment supported by ABI and extramural funding will increase from a baseline of 300 full-time equivalent (FTE). ○ For FY2016, ABI supported 309 FTE jobs through direct and leveraged funds. ● Indicator: ABI will facilitate and increase research collaboration among member institutions, as measured by both ABI and extramural funding of research projects that involve researchers at more than one member institution. ○ Data on collaborative activities are still being compiled.

Challenges: The biggest challenge faced by ABI includes continued federal funding cuts, which reduce the possible leveraged support for Arkansas research. This includes a reduction in technical support personnel as well.

Opportunities: ABI-supported research investigators continue to leverage their ABI funding to apply for outside funding from agencies such as the National Institutes of Health, the National Science Foundation, and the US Department of Agriculture. Additionally, ABI plans to continue support (partial) for conferences and symposia, which foster collaboration among researchers, scientists, faculty, and students from various disciplines, institutions, and organizations. ABI's continued work toward collaboration is a key asset to the state of Arkansas. Before the creation

10 of ABI, very little communications existed among researchers at the five partner institutions. These collaborative activities promote research production, funding opportunities, public-private partnerships, and opportunities for patent filings.

Testimonials: Ralph Henry, PhD, Distinguished Professor of Biological Sciences at the University of Arkansas, Fayetteville, collaborates with Michael Owens, PhD, Professor of Pharmacology and Toxicology in the UAMS College of Medicine, to make proteins, specifically antibodies, which can be used as treatments for drugs of abuse. The antibody that binds to (and therefore inhibits the efficacy of) methamphetamine, the abuse of which is an acute public health problem in Arkansas and throughout the US, has moved closer to FDA approval by completing a Phase 1 clinical trial in healthy volunteers. This progress was in turn rewarded with a substantial infusion of federal funding in 2015 (a total of $14.5 million), enabling plans to move forward with testing on a much larger scale for this promising new medication. Dr. Henry says it has helped foster these endeavors as well, particularly through help with the acquisition and maintenance of instrumentation like the Fast Protein Liquid Chromatography (FPLC) device that enables his current protein purification work. Not a lot of federal grants provide funds for instrumentation, he points out. “Some, but it’s not that common. And so instrumentation funds are critical. It creates a research infrastructure,” Henry concludes, “That helps us recruit technology to the state, helps us recruit technology-based businesses to the state, and helps us recruit the next crop of scientists to the state, because they see people here being successful. And ABI has had a huge impact on that picture.”

Evaluator Comments: ABI continues to perform above benchmarks for all key indicators. Given the decline in available government money, increasing collaborative activities (including public-private partnerships) is crucial in aiding in the ability of ABI and partner institutions to leverage their resources and market their research capabilities. Despite the funding challenges, ABI has been very successful in attracting outside money to the state of Arkansas and supporting a large number of high-quality jobs.

11 Minority Health Initiative Indicator Activity

Program Description: The Arkansas Minority Health Initiative (MHI) was established in 2001 through Initiated Act I to administer the Targeted State Needs for screening, monitoring, and treating hypertension, strokes, and other disorders disproportionately critical to minority groups in Arkansas by 1) increasing awareness, 2) providing screening or access to screening, 3) developing intervention strategies (including educational programs) and developing/maintaining a database. To achieve this goal, the MHI’s focus is on addressing existing disparities in minority communities, educating these communities on diseases that disproportionately impact them, encouraging healthier lifestyles, promoting awareness of services and accessibility within our current healthcare system, and collaborating with community partners.

Overall Program Goal: To improve healthcare systems in Arkansas and access to healthcare delivery systems, thereby resolving critical deficiencies that negatively impact the health of the citizens of the state.

Long-term Objective: Reduce death/disability due to tobacco, chronic, and other lifestyle- related illnesses of Arkansans.

When reviewing the indicator activity for MHI, please refer to the following table of health screening numbers.

12 Table 1 Screening Number Provided Blood Pressure 2,124 Ht/Wt 871 BMI 912 Cholesterol 124 Glucose 502 (increased level readings = 38) Heart Rate/Pulse 435 HIV/STDs 463 Clinical Breast Exam/Mammogram 24 Prostate 86

● Indicator: To increase stroke awareness by one percent annually among minority Arkansans as measured by previous comparison beginning in FY2015. ○ Activity: During July to September 2016, MHI provided a total of 6,871 screenings to community members in 14 counties. The number of Blood Pressure screenings was 2,124. Additionally, MHI partnered with 15 grassroots, nonprofit government and faith-based organizations to provide screenings and educational programming to increase stroke awareness among minority Arkansans. Data from the Behavioral Risk Factor Surveillance System (BRFSS) will be available annually, and reported in 2019. ● Indicator: To increase hypertension awareness by one percent annually among minority Arkansans as measured by previous comparison beginning in FY2015. ○ Activity: Of the 6,871 total screenings provided by MHI this quarter, 2,124 were screened for blood pressure. In addition to blood pressure screenings, MHI provided other screenings relative to hypertension like Height/Weight, Body Mass Index (BMI), Cholesterol, and Glucose, all of which raise awareness about hypertension and its contributing factors. The screening numbers provided by MHI this quarter are shown in Table 1. Additionally, as shown in the previous indicator, 19 events included educational packets with hypertension awareness materials. ● Indicator: To increase heart disease awareness by one percent annually among minority Arkansans as measured by previous comparison beginning in FY2015. ○ Activity: MHI continues to work with community partners to provide screenings, educational packets, and information regarding healthy living. Concerning heart disease, Table 1 lists the screenings that were provided. Moreover, 2,240 individuals received educational packets including heart disease and healthy lifestyle information. Again, further data will be provided by

13 Behavioral Risk Factor Surveillance System (BRFSS) annually. ● Indicator: To increase diabetes awareness by one percent annually among minority Arkansans as measured by previous comparison beginning in FY2015. ○ Activity: Table 1 indicates the number of screenings MHI provided as they partnered with multiple community organizations. Furthermore, 2,240 individuals received educational materials including information regarding healthy lifestyles, specifically heart disease and smoking cessation, which are both risk factors for diabetes.

Short-term Objective: Prioritize the list of health problems and planned interventions for minority populations and increase the number of Arkansans screened and treated for tobacco, chronic, and lifestyle related illnesses.

● Indicator: MHI will conduct ongoing needs assessments to determine the most critical minority health needs to target, including implementation of a comprehensive survey of racial and ethnic minority disparities in health and healthcare every five years. ○ Activity: The Arkansas Minority Health Commission continues to commission the Economic Cost of Health Inequalities in Arkansas report to better understand and estimate the economic impact of racial and ethnic disparities in Arkansas. They found that eliminating health disparities for Arkansas minorities would result in a reduction of direct medical care expenditures of $518.6 million. This survey is completed every five years. The next survey will be completed in FY2019. ● Indicator: MHI will increase awareness and provide access to screenings for disorders disproportionately critical to minorities as well as to any citizen within the state regardless of racial/ethnic group. ○ Activity: MHI collaborated with over 15 grassroots, nonprofit, government and faith-based organizations to provide health education information and screenings targeting individuals in 14 counties. Total number of attendees was 9,165 and total number of screenings was 6,871. Refer to Table 1 for a complete list of screenings related to increasing awareness and providing access to screenings. ● Indicator: MHI will develop and implement at least one pilot project every five years to identify effective strategies to reduce health disparities among Arkansans.

14 ○ Activity: Camp iRock was and annual residential fitness and nutrition camp for girls with a BMI at least in the 85th percentile. The camp was held for five years, and the final camp was in 2015, with the last follow up in 2016. Plans are on the way for a Camp iRock reunion for the girls as well as a Camp iRock male version.

Challenges: Heart Disease remains the number one cause of death in Arkansas. The cardiovascular disease rate is the 5th highest in the U.S.

Opportunities: MHI will continue partnerships to increase awareness and screenings to reduce death/disability due to tobacco, chronic, and other lifestyle related illnesses of Arkansans.

Testimonials: ● Six of the 24 women who obtained a mammogram received abnormal results. ○ One of the women indicated that this was her first time to be screened due to lack of resources and a language barrier. All of the women who received abnormal results were referred to the BreastCare program for follow-up services.

Evaluator Comments: MHI continues to work toward their goals of spreading awareness to the entire state, but also specifically to minority populations. They continue to work with community organizations to provide screenings, educational literature, and programs that provide information regarding heart disease, stroke, smoking cessation, and healthy lifestyles.

Tobacco Settlement Medicaid Expansion Program Indicator Activity

Program Description: The Tobacco Settlement Medicaid Expansion Program (TS-MEP) is a separate component of the Arkansas Medicaid Program that improves the health of Arkansans by

15 expanding healthcare coverage and benefits to targeted populations. The program works to expand Medicaid coverage and benefits in four populations:

● Population one expands Medicaid coverage and benefits to pregnant women with incomes ranging from 138–200% of the Federal Poverty Level (FPL); ● Population two expands inpatient and outpatient hospital reimbursements and benefits to adults age 19-64; ● Population three expands non-institutional coverage and benefits to seniors age 65 and over; ● Population four provides a limited benefits package to low-income employed adults age 19-64. The Tobacco Settlement funds are also used to pay the state share required to leverage federal Medicaid matching funds.

Overall Program Goal: To expand access to healthcare through targeted Medicaid expansions, thereby improving the health of eligible Arkansans.

Long-term Objective: Demonstrate improved health and reduce long-term health costs of Medicaid eligible persons participating in the expanded programs.

● Indicator: Demonstrate improved health and reduced long-term health costs of Medicaid eligible persons participating in the expanded programs. ○ Activity: With the implementation of the Arkansas Works program, more individuals will have health coverage beyond the TS-MEP initiatives. Therefore, the TS-MEP long-term impact will be limited compared to the influences outside of the TS-MEP. During this quarter, TS-MEP initiatives provided expanded access to health benefits and services for 6,075 eligible pregnant women, seniors, and adults. Total claims paid for the TS-MEP populations this reporting period were $4.23 million. Additionally, TS-MEP funds are also used to pay the state share required to leverage approximately 70% federal Medicaid matching funds. This amounted to nearly $2.2 million in federal matching Medicaid funds during this quarter.

Short-term Objective: The Arkansas Department of Human Services will demonstrate an increase in the number of new Medicaid eligible persons participating in the expanded programs.

16 ● Indicator: Increase the number of pregnant women with incomes ranging from 138-200% of the FPL enrolled in the Pregnant Women Expansion. ○ Activity: During this quarter, there were 174 participants in the TS-MEP initiative Pregnant Women Expansion program. This was an increase from the previous quarter with 125 participants. This program provides prenatal health services for pregnant women with incomes ranging from 138–200% FPL. With the implementation of Arkansas Works and other healthcare options provided through the federally-facilitated marketplace for this population, a decline in the number of participants in the TS-MEP Pregnant Women Expansion program was anticipated. The TS-MEP funds for the Pregnant Expansion program totaled $241,183 in this quarter. ● Indicator: Increase the average number of adults aged 19-64 years receiving inpatient and outpatient hospital reimbursements and benefits through the Hospital Benefit Coverage. ○ Activity: During this quarter, the TS-MEP initiative Hospital Benefit Coverage provided inpatient and outpatient hospital reimbursements and benefits to 4,116 adults aged 19-64 by increasing the number of benefit days from 20 to 24 and decreasing the co-pay on the first day of hospitalization from 22% to 10%. This is the same number of adults as the previous quarter. TS- MEP funds for the Hospital Benefit Coverage totaled $1,015,591. ● Indicator: Increase the average number of persons enrolled in the ARSeniors program, which expands non-institutional coverage and benefits for seniors age 65 and over. ○ Activity: The ARSeniors program expanded Medicaid coverage to 1,785 seniors during this quarter. There is an increase from 1,759 participants in the previous quarter. Qualified Medicare Beneficiary recipients below 80% FPL automatically qualify for ARSeniors coverage. Medicaid benefits that are not covered by Medicare are available to ARSeniors. An example of this is non- emergency medical transportation and personal care services. TS-MEP funds for the ARSeniors program totaled $2,973,895 during this quarter. ● Indicator: Increase the average number of persons enrolled in the ARHealthNetworks program, which provides a limited benefit package to low-income employed adults in the age range of 19- 64 years. ○ Activity: The ARHealthNetworks program was discontinued on December 31, 2013, due to implementation of Arkansas Works, previously known as the Arkansas Health Care Independence Program/Private Option. This population is now offered more comprehensive

17 healthcare coverage options through the Arkansas Works program. Individuals with incomes equal to or less than 138% of the FPL are eligible for Arkansas Works program, and those with incomes above 138% FPL can access the federally-facilitated marketplace to determine their eligibility for federally-subsidized private insurance plans. Arkansas Works eligible individuals with exceptional healthcare needs and determined medically frail are enrolled in the traditional Medicaid program.

Challenges: As a result of the implementation of the Arkansas Works program, one of the TS- MEP initiatives was discontinued (ARHealthNetworks) and another one has experienced an overall decline in participation (Pregnant Women Expansion). Some of the TS-MEP’s indicators may need to be updated to reflect the change in programs covered by TS-MEP. As of now, successful performance has been measured by growth in the number of participants in the TS- MEP initiatives. Arkansas Department of Human Services (DHS) will need to continue to explore new performance measurements for the TS-MEP initiatives as individuals are transitioning into new coverage groups. Opportunities: The discontinuation of the TS-MEP initiative, ARHealthNetworks, provides the opportunity to support both the other three TS-MEP populations and the state’s overall Medicaid efforts. DHS has had the legislative authority for over ten years to use any savings in the TS- MEP programs to provide funding for the traditional Medicaid program with the approval of the State’s Chief Fiscal Officer. These savings are not used to provide any funding for the Arkansas Works program. As the state of Arkansas continues to explore opportunities for Medicaid reform, new possibilities for using TS-MEP funds may emerge. DHS has proposed to add the Division of Developmental Disabilities Alternative Community Services Waiver Waiting list new group. If the legislation passes, this will allow these services to be extended to 500-900 individuals currently waiting for these services.

Evaluator Comments: TS-MEP has been impacted by the significant changes in the healthcare system. During this quarter, the Pregnant Women Expansion program and the ARSeniors program have experienced an increase in the number of participants. The Hospital Benefit Coverage has remained relatively stable in the number of people being provided service while one of the covered populations (ARHealthNewtorks) has been eliminated. There are no

18 immediate plans to change the Pregnant Women Expansion, Hospital Benefit Coverage, and ARSeniors programs. However, as noted, there is a legislative proposal to establish a new population (persons with developmental disabilities) to reduce the waiting list and provide community and home services for these individuals.

Fay W. Boozman College of Public Health Indicator Activity

Program Description: The Fay W. Boozman College of Public Health (COPH) educates a public health workforce and advances the health of the public by investigating the causes, treatments, and prevention of human health problems. Preventing chronic disease and promoting positive health behavior is the most effective way to improve the health of all people. The College’s mission of improving the health of all Arkansans is realized through teaching and research as well as service to elected officials, agencies, organizations, and communities. Examples of the complex health issues addressed include: improving the multiple dimensions of access to healthcare; reducing the preventable causes of chronic disease; controlling infectious diseases; reducing environmental hazards, violence, substance abuse, and injury; and promoting preparedness for health issues resulting from terrorist acts, natural disasters, and newly emerging infectious diseases.

Overall Program Goal: To improve the health and promote the well-being of individuals, families, and communities in Arkansas through education, research, and service.

19 Long-term Objective: Elevate the overall ranking of the health status of Arkansans.

● Indicator: Through consultations, partnerships and dissemination of knowledge, the COPH serves as an educational resource for Arkansans (e.g., general public, public health practitioners and researchers, and policymakers) with the potential to affect public health practice and policy – and population health. ○ Activity: Thirty-one activities were conducted by COPH faculty who served as members, partners, representatives, volunteers, co-chairs, and consultants for groups and institutions with a focus on public health. Twenty-seven of these activities were ongoing, two were quarterly, and two met monthly. The majority of these activities (22) were statewide in scope; five had a central Arkansas emphasis and four had a national focus. ● Indicator: Faculty productivity is maintained at a level of 2 publications in peer-reviewed journals to 1 FTE for primary research faculty. ○ Activity: Data for this indicator is provided in the October - December report. ● Indicator: Research conducted by COPH faculty and students contributes to public health practice, public health research, and the health and well-being of Arkansans. ○ Activity: Data for this indicator is provided in the October - December, January - March, and April - June reports. ● Indicator: COPH faculty, staff and students are engaged in research that is based in Arkansas. ○ Activity: Data for this indicator is provided in the October - December, January - March, and April - June reports. ● Indicator: The COPH makes courses and presentations available statewide. ○ Activity: Data for this indicator is provided in the October - December, January - March, and April - June reports. ● Indicator: Twenty percent of enrolled students come from rural areas of Arkansas. ○ Activity: Data for this indicator is provided in the October - December, January - March, and April - June reports. ● Indicator: Graduates’ race/ethnicity demographics for whites, African American and Hispanic/Latinos are reflective of Arkansas race/ethnicity demographics. ○ Activity: One PhD degree was awarded to a White (non-Hispanic) student during the summer of

20 2016. ● Indicator: The majority of alumni stay in Arkansas and work in public health. ○ Activity: The student who received a PhD plans to work in public health in Arkansas. ○ Short-term Objective: Obtain federal and philanthropic grant funding.

● Indicator: The COPH maintains a level of leveraged (extramural) funding in relation to unrestricted funding that exceeds that of comparable accredited schools of public health. ○ Activity: The fiscal data for July 1, 2015 through June 30, 2016 that is necessary to evaluate this indicator was unavailable. Therefore, no conclusions can be drawn regarding progress toward the achievement of this short-term objective. The program directors report that the indicator, as currently written, is difficult to quantify due to the amount of data required to show the comparison between the COPH and comparable schools of public health. The financial information that was provided by COPH indicated a 2.32:1 ratio of external funds to tobacco funds, a slight decrease between FY15 and FY16. This decrease was attributed to the completion of several contracts.

Challenges: The search for a faculty member to be the Director for the Center for Obesity Prevention and Governor Sydney S. McMath Endowed Chair for Obesity Prevention slowed during this time period due to staff being on leave and summer schedules not aligning for meetings of the search committee. The end of September saw increased progress in this faculty candidate search, though finding qualified candidates has proved somewhat challenging.

Opportunities: Several faculty and administrative positions were filled between July - September, 2016. The Associate Dean for Academic Affairs, and faculty in the departments of Environmental and Occupational Health and the Department of Health Policy and Management, all started in August. The Assistant Dean for Special Projects, the Director of the Center for Tobacco Study, and faculty in the departments of Epidemiology and Biostatistics started in September. The Director of Communications position was established and interviews for that position were conducted in September with the expectation that the search would be completed before the end of the calendar year.

21 Testimonials: “I recently graduated with a doctorate (PhD) in Health Promotion and Prevention Research from the UAMS Fay W. Boozman College of Public Health and am now working on the CDC-funded Arkansas Prevention Research Center as a Postdoctoral Fellow. My main responsibilities include training and overseeing our Community Health Workers (CHWs) who work on the project in the Arkansas Delta. This research project is designed to determine if CHWs are cost effective in helping people with uncontrolled hypertension learn to gain greater control of their blood pressure. Of course, they are not treating people but are trying to help people be compliant with their doctor’s recommendations. Hypertension is extremely common in Arkansas, and just under one-third of adult Arkansans are walking around with their blood pressure not under good control, which is the main reason that our state has the highest rate of stroke deaths in most years. Our CHWs are working in Desha County, screening community members to enroll 600 people with uncontrolled hypertension. Every participant then receives basic educational materials about hypertension and referral to doctors in the area if they don’t have one, as well as referral to prescription assistance if they have difficulty paying for their medications. Half of the participants then receive regular visits by a CHW to help them deal with barriers to regularly taking their medicine or being compliant with other recommendations made by their doctor. I am continually amazed by the feedback our CHWs receive from people they screen who did not know they have high blood pressure. They consistently say how grateful they are to know that their blood pressure is a problem, and that there is a way to manage it so they can avoid the health problems they have seen develop among friends and family who have high blood pressure. The CHWs also receive a lot of positive feedback about the number of people who have been screened and about the information provided on resources in their community to help people improve their health. Utilizing the knowledge and skills I gained during my doctoral training allows me to contribute to the project, evaluate the cost effectiveness of a CHW model program and learn what works in Arkansas to help people lead healthier lives.”

Evaluator Comments: The Fay W. Boozman College of Public Health continues activities that work toward its long-term objective, elevate the overall ranking of the health status of Arkansans. Data for each indicator was not collected this quarter because some of the data are collected during different quarters or on an annual basis. From the beginning of July through

22 September, faculty served as educational resources for Arkansans and graduated one PhD student who plans to work in public health within the state. Data for the short-term objective, obtain federal philanthropic grant funding, were unavailable to the evaluation team this year. Due to the difficulty in gathering the amount of data required to effectively show the comparison between the COPH and comparable schools, the COPH will propose an updated indicator specifying a ratio of extramural funding to tobacco settlement dollars for each fiscal year.

Tobacco Prevention and Cessation Program Indicator Activity

Program Description: The Arkansas Department of Health (ADH) Tobacco Prevention and Cessation Program (TPCP) includes community and school education prevention programs, enforcement of youth tobacco control laws, tobacco cessation programs, health communications, and awareness campaigns. The TPCP also sponsors statewide tobacco control programs that involve youth to increase local coalition activities, tobacco-related disease prevention programs, minority initiatives and monitoring, and evaluation. TPCP follows the Centers for Disease Control and Prevention (CDC) Best Practices for Tobacco Control 2014 as a guide for program development. Outcomes achieved by Arkansas’s TPCP include a reduction in disease, disability, and death related to tobacco use by preventing initial use of tobacco by young people, promoting quitting, eliminating exposure to secondhand smoke, and educating Arkansans about the deleterious health effects of tobacco use.

Overall Program Goal: To reduce the initiation of tobacco use and the resulting negative health and economic impact.

Long-term Objective: Survey data will demonstrate a reduction in numbers of Arkansans who smoke and/or use tobacco.

● Indicator: By March 2020, decrease the tobacco use prevalence (cigarette, smokeless, and cigar) in youth by 23% (a decrease from 32% to 24.5%) and tobacco use prevalence (cigarette and

23 smokeless) in young adults (18-24) by 10 % (a decrease from 27.7% to 25%). [Data Source: Youth Risk Behavior Surveillance System (YRBSS) 2015 & Behavioral Risk Factor Surveillance System (BRFSS) 2013]. ○ Activity: 2014 data have been released and are currently being analyzed ● Indicator: By March 2020, decrease tobacco use among disparate populations (LGBT, Hispanics, African American, and Pregnant Women) by 2 percentage point change (Data Source: LGBT Survey, BRFSS, Vital Statistics Data). ○ Activity: Nothing to report this quarter. ● Indicator: By March 2020, decrease smoking prevalence among youth by 10.5% (a decrease from 19.1% to 17.1%) and among adults (18 to 24 year olds) by 3% (a decrease from 24.7% to 23.9%) (Data Source: 2015 YRBSS, 2014 BRFSS). ○ Activity: Youth portion of the indicator has been met and previously reported. The 2014 Behavioral Risk Factor Surveillance System (BRFSS) data have been released and are currently being analyzed to determine 18-24 year old prevalence.

Short-term Objective: Communities shall establish local tobacco prevention initiatives.

● Indicator: By June 2017, 100 new smoke-free/tobacco-free policies will be implemented across Arkansas (Data Source: TPCP Policy Tracker). ○ Activity: Total policies this reporting period: 19 ● Six workplace, two park/festival, one farmers' market, two faith-based, two comprehensive school--protecting 7,297 students, zero college campus, zero private schools, six multi-unit housing complexes covering 275 units and up to 407 residents. ● Indicator: By June 2017, decrease sales to minor violations from 11% to 9% (Data Source: FY2014 Arkansas Tobacco Control). ○ Activity: 1157 sales to minor compliance checks, 66 sales to minor violations equating to a 5% non-compliance rate, 27 educational sessions with 423 total attendees ● Indicator: By June 2017, increase by 25% the proportion of youth and young adults up to age 24 who engage in tobacco control activities to include point of sale, counter marketing efforts, and other advocacy activities to increase tobacco free social norms (Data Source: Youth Prevention

24 Program Participation FY2014). ○ Activity: The Project Prevent Youth Coalition recruited 101 new members during the reporting period. There were 621 youth who attended and participated in conferences/teen summits or Peer to Peer Education activities. A total of 722 youth engaged in tobacco control activities. ● Indicator: By June 2017, increase Arkansas’ quit rates for the Arkansas Tobacco Quitline from 27.7% to 29.7% (Data Source: ATQ FY2014 Evaluation Report, 7-month follow-up of multiple calls with NRT quit rate). ○ Activity: FY16 Quit Rate is 28%. ● Indicator: By June 2017, increase the number of callers to the Arkansas Tobacco Quitline from 245 to 294 for Hispanics; 2,596 to 3,115 for African-American; 476 to 571 for LGBT (Data Source: ATQ Yearly Demographic Report, 2014). ○ Activity: This quarter, there were 36 Hispanic, 332 African-Americans, 84 LGBT, and 23 pregnant women who called the quitline. ● Indicator: By June 2017, decrease the overall rate of pregnant women reporting tobacco use during pregnancy from 14.9% to 13.9% (Data Source: 2013 Vital Statistics Data). ○ Activity: No data this quarter. ● Indicator: By June 2017, increase number of healthcare providers, traditional and nontraditional, from 3,116 to 3,500 who have been reached by the STOP program (Data Source: FY2014 End of Year Summary Report for STOP from Alere). ○ Activity: There were no healthcare provider trainings conducted during this reporting period.

Challenges: ● Arkansas Legislative Council (ALC) voted against renewing the state’s contract for the ATQ in June 2016. TPCP was given two months to gather and present evidence to the Public Health, Welfare and Labor Committee to secure support for the contract, and send back to ALC for final approval. TPCP reached out to CDC and other national partners for support and resources, which proved invaluable to the success of securing the final approval of the ATQ contract. ● While TPCP was successful in maintaining the ATQ contract, call volume to the quitline is down. ● A hiring freeze has been in effect since January of 2015, this change affected program continuity. At the end of the reporting period (September 2016), there were ten vacancies, and of

25 those, three were federal positions. The TPCP Branch Chief was vacated June of 2016. TPCP team members have taken on additional duties to aid in achieving goals and objectives. In July, four positions were released and those positions have been or are in the process of being filled. Although the positions were released, Arkansas has a limited candidate pool in tobacco control experience, resulting in challenges in hiring qualified personnel. Tobacco control requires on- the-job training to successfully develop and implement innovative strategies and tactics to create a culture of health. ● TPCP epidemiologist functions have been curtailed to work on the Zika virus and a Mumps outbreak.

Opportunities: ● Earned Media: The Arkansas Community Foundation published a magazine called “Engage” in August of 2016. The magazine contained information regarding tobacco control from cover to cover. The articles in the magazine demonstrated the support and need for comprehensive smoke-free, clean indoor air. ● Project Prevent Youth Coalition started a recruitment campaign in August 2016. As of this reporting period, 101 members have joined. ● Following the analysis of the Arkansas Adult Tobacco Survey, it was determined that a significant proportion of tobacco users in Arkansas quit “cold turkey”--without public services or professional aids. This has prompted TPCP to review research and begin to design other viable avenues for quitting tobacco. ● TPCP has engaged the regional HUD office along with Local Public Housing Authorities (PHAs) to assist in the adoption of smoke-free, multi-unit housing policies (SFMUH) in support of the pending federal rule. ● With assistance from partners, the TPCP illustrated how beneficial the ATQ is to the ALC. After a two-month review, the ALC voted to approve the contract with a legislative mandate to secure cost sharing from insurance companies to support the quitline. TPCP, partnering organizations, and healthcare officials in Arkansas and surrounding states are committed to ensuring the life span and success of the ATQ. ● TPCP conducted an evaluation of the tobacco cessation campaign “No Judgments.” The campaign promoted the new services offered by the ATQ, including text messaging support and

26 web-based services. After determining a baseline, TPCP placed the campaign on local television throughout the state. Call volume from the ATQ significantly increased during the campaign. Other tobacco cessation campaigns ran simultaneously, however after “No Judgments” campaign ended, call volume dropped. TPCP was able to conclude there was a significant correlation between increased call volumes and the “No Judgments” campaign.

Testimonials: ● Brenda Benton stated that her experience with the ATQ was "helpful, the patches helped." The advice she would give to smokers wanting to quit was "Be aware that other side effects will happen like weight gain, but none of it is more important than quitting." She stated that her favorite part about being smoke-free is smelling good and getting rid of the coughing and sinus problems. ● Robert Johnson stated that the ATQ made it easier to quit by offering the products and services. The advice he would give smokers wanting to quit was "Use the products that the quitline offers. Just put down the bad habits and get away from triggers." He noted that the best part about being tobacco-free is being able to save money. ● ATQ Happy Quitter Quotes ○ Sharon Berger mentioned that the ATQ, the gum, and the patches helped her take her first step toward living tobacco-free and she had reached her one-year mark. She stated that she'd advise any smoker to "definitely call the quitline. Anyone who wants to quit can't do it alone." The best part of quitting is "feeling better and living healthy." ○ Christine Desalvio affirms the effectiveness of the quitline: "It works." Reaching the 10-month mark of living tobacco-free, she advises smokers who are trying to quit to "Be patient, keep trying, and be determined to do it." ○ Charles Hime stated that he has gotten over the temptations. He mentioned that he tried quitting by himself several times before and it never worked. When asked what did it for him this time, he stated, "You have to take the first step, and the quitline is the first step."

Evaluator Comments: TPCP is implementing specific activities to address their indicators. Data for each indicator were not collected this quarter because some of the data are collected on an annual or biennial basis. Some of the methodology has changed, which has affected the baseline

27 numbers particularly for tobacco use by youth and for women during pregnancy. The University of Arkansas at Pine Bluff’s Minority Initiative Sub-Recipient Grant Office (MISRGO) receives 15% of TPCP’s funding to prevent and reduce tobacco use in minority communities. Some of their data are included in this report; however, their entire evaluation has been conducted by Fetterman and Associates.

UAMS Helena, West Memphis, and Lake Village

28 Indicator Activity

Program Description: University of Arkansas Medical Sciences Helena, West Memphis, and Lake Village provide healthcare outreach services to seven counties including St. Francis, Lee, Phillips, Chicot, Desha, Monroe, and Crittenden counties. UAMS Helena, West Memphis, and Lake Village, formerly known as the Delta Area Health Education Center (AHEC) and UAMS East, was established in 1990 with the purpose of providing health education to underserved populations in the Arkansas Delta region. The counties and populations served by UAMS Helena, West Memphis, and Lake Village are some of the unhealthiest in the state with limited access to healthcare services being one of the challenges. As a result of limited access and health challenges, UAMS Helena, West Memphis, and Lake Village has become a full service health education center with a focus on wellness and prevention for this region. The program has shown a steady increase in encounters with the resident population and produced a positive impact on the health and wellness of the region. Programs to address local health needs of residents are being implemented in partnership with more than 100 different agencies. The overall mission of UAMS Helena, West Memphis, and Lake Village is to improve the health of the Delta’s population. Goals include increasing the number of communities and clients served and increasing access to a primary care provider in underserved counties.

Overall Program Goal: To recruit and retain health care professionals and to provide community-based healthcare and education to improve the health of the people residing in the Delta region.

Long-term Objective: Increase the number of health professionals practicing in the UAMS Helena, West Memphis, and Lake Village service areas.

● Indicator: Increase the number of students participating in UAMS Helena, West Memphis and Lake Village pre-health professions recruitment activities, ○ Activity: UAMS Helena and UAMS Lake Village held M*A*S*H camps for 20 high school students. The UAMS Helena, West Memphis, and Lake Village recruiter attended eight career fairs and spoke with 1,486 students. She also provided health career presentations to 176 students

29 and taught club scrub programs to 80 middle school participants. ● Indicator: Continue to provide assistance to health professions students and residents, including RN to BSN and BSN to MSN students, medical students and other interns. ○ Activity: UAMS Helena supported ten BSN students this quarter. Dr. Jackson, UAMS Helena, an advanced practice nurse assisted as an adjunct instructor for five MSN students as well as support for two UAMS BSN students.

Short-term Objective: Increase the number of communities and clients served through UAMS Helena, West Memphis, and Lake Village programs.

● Indicator: Increase or maintain the number of clients receiving health screenings, referrals to primary care physicians, and education on chronic disease prevention and management. ○ Activity: Twenty-six health screening events were held for 650 adults in five different cities. ● Indicator: Maintain a robust health education promotion and prevention program for area youth and adults. ○ Activity: UAMS Helena, West Memphis, and Lake Village provided health education promotion and prevention activities for a total of 8,583 youth and 1,069 adults. ● Indicator: Increase the number of clients participating in exercise programs offered by UAMS Helena, West Memphis, and Lake Village. ○ Activity: This quarter the UAMS Helena Fitness Center encounters totaled 8,419. Additionally, a total of 12,205 adults and children participated in various exercise programs throughout the service area. ● Indicator: Provide crisis assistance to rape victims as needed. ○ Activity: The Delta Crisis Center received 56 hotline calls and seven text messages from clients, potential partnerships, and possible referrals. Delta Crisis Center serviced five clients in St. Francis, Lee, and Crittenden Counties. Delta Crisis Center Staff provided over 25 hours per week of client services via personal/mobile/electronic contact. ● Indicator: Increase or maintain the number of clients in Chicot and Phillips counties receiving prescription assistance. ○ Activity: This quarter UAMS Helena provided prescription assistance to 223 participants with 277 total prescriptions. The amount saved totaled $159,100.51.

30 ● Indicator: Provide medical library services to consumers, students, and health professionals. ○ Activity: UAMS Helena Medical Resource Library provided support to healthcare professionals and students through literature searches and teaching materials. This quarter, 64 nursing students and 145 healthcare professionals utilized the library. UAMS Helena Library provided support to 2,772 consumers. ● Indicator: Plan and implement a Rural Residency Training Track for Family Medicine in Helena, in partnership with UAMS South Central's residency program. ○ Activity: UAMS Helena is working to begin a clinic in Helena, which will serve as the foundation for the future rural residency training track. ● Indicator: Provide targeted clinical care in Helena. ○ Activity: No report at this time. ● Indicator: Provide diabetes education to community members and increase the proportion of patients in the diabetes clinic who maintain an A1C below seven. ○ Activity: UAMS Helena provided 13 HbA1c test to patients. There were six elevated HbA1c tests, above the goal of an HbA1c score of less than seven. Diabetes education classes have resumed at UAMS Helena on a regular basis. There are 77 participants in Diabetes Self- Management.

Challenges: Challenges include maintaining a robust program with continuing budgets cuts and changes in administration.

Opportunities: UAMS Helena, East Arkansas Family Health Center, Helena Health Foundation, and Phillips County Rotary received funding for the "Healthy Smiles" dental hygiene project. The joint project will offer all kids kindergarten through sixth grade dental hygiene education as well as dental hygiene supplies. The project will reach over 2,500 youth in both public and private schools in Phillips County. UAMS Helena was a sub-grantee recipient from the Greater Delta Alliance for Health, a nonprofit organization of hospitals in Southeast Arkansas. This healthy community initiative is funded through a HRSA grant. The three year, $92,000 grant will help fund additional diabetes education, cooking matters classes, and a Registered Dietician position to work in the counties of Chicot, Desha, St. Francis, and Phillips.

31 Testimonials: Silver Sneaker Participant self-reported that she is able to walk without a cane after coming to class two months. A Group Lifestyle Weight Loss member wrote: Stephanie, "Thank you for always being so encouraging in our Group Lifestyle Class. Thank You for showing me what discipline looks like! I enjoyed the class."

Evaluator Comments: UAMS Helena, West Memphis, and Lake Village are making progress in exposing students in the Delta to health education programs and the health professions. Disease management, health promotion, and exercise programs are being offered to promote optimal health and prevent disease in the region. Efforts are still underway to provide targeted clinical services in Helena.