Steps: An Innovative National Model to
Reduce the Cost and Health Complications of Chronic Diseases. The Steps model gives communities the tools to attack the root causes of the chronic disease epidemic: poor nutrition, physical inactivity, and tobacco use. Administered by Area Health Education Centers (AHECs) & funded by the Pennsylvania Department of Health through a grant from the Center for Disease Control and Prevention (CDC). Steps works with community groups, health care providers, schools and worksites in Tioga, Fayette and Luzerne Counties to change communities in ways that can help residents adopt healthy lifestyle behaviors that will reduce the risk factors of poor nutrition, physical inactivity, and tobacco. Pennsylvania is home to four of the CDC’s Steps regions that serve over 167 separate communities and neighborhoods representing more than 507,000 Pennsylvania residents. The Steps model could be adapted and set up in other communities in Pennsylvania. The City of Philadelphia has a separately funded Steps grant. Read more...

Although chronic disease care accounts for more than 75 percent of the $1.4 trillion spent in the U.S. annually  on medical care, less than four percent of health care dollars are spent to prevent the negative health consequences of chronic diseases. Governor Rendell’s Prescription for PA recognizes the impact of chronic diseases on Pennsylvanians and their health care system.

As one of his first actions under the Prescription for Pennsylvania, Governor Edward G. Rendell signed an executive order creating the Pennsylvania Chronic Care Management, Reimbursement and Cost Reduction Commission. “About 78 percent of all health care costs can be traced to 20 percent of all patients -- those with chronic diseases,” Governor Rendell said in May 2007 when he announced the new commission. “We cannot reduce the occurrence and cost of chronic diseases without aggressively addressing prevention, detection and treatment in a comprehensive, proactive way….”

The CDC estimates that eliminating three risk factors: poor diet, physical inactivity and smoking, would prevent 80% of heart disease and stroke, 80% of Type 2 diabetes, and 40% of cancers. Information from the Behavioral Risk Surveillance Survey (BRFSS), PA School Health statistics and the PA Health Care Cost Containment Council (PHC4), illustrates the scope and cost of the problem in Pennsylvania:

• Between 1995 and 2005, the percent of Pennsylvania residents who reported having a diagnosis of diabetes rose from 6% to 8.1 % of the population. 
• Black and Hispanic individuals, persons with lower incomes and persons with less education are all more likely to be diagnosed with diabetes and to suffer its related health consequences.
• Over $673 million was spent on hospital care for persons with diabetes between 2000 and 2004
• Between 2000 and 2004, the number of hospitalizations where diabetes was the principal diagnosis rose by 8.6%, to 23,725 (this number is 17.5% of all hospital admissions).
• Almost ten percent of students enrolled in Pennsylvania schools during the 2003/2004 school year (201,088 students) report having physician-diagnosed asthma. 
• In 2006, almost 62% of Pennsylvania adults reported being overweight; and 25% reported being obese. Since 1995, the rate of obesity has increased from 51% to 62%. 
• In 2006, a significantly higher percentage of black (non-Hispanic) adults reported that they were obese (32%) compared to white (non-hispanic) adults (25%).

Since December 2004, Steps programs have been working successfully with community groups, health care providers, worksites and schools to help communities create systems and policy changes that will help residents of all ages make healthier lifestyle choices, eat more nutritious food, maintain healthy weights, learn how to better manage asthma and diabetes, and take steps to lower the health risks associated with chronic diseases.

During 2007-2008, the three Steps to a Healthier PA counties will be working to reduce the costs and risks of chronic diseases in their communities, through:

1. Providing training and technical assistance to 154 schools serving over 73,000 students to implement their local school wellness policy.
2. Providing technical assistance to 20 school districts to establish county-wide School Health Advisory Councils (SHACs).  
3. Establishing partnerships with more than 71 worksites to promote sustainable policy changes to improve nutrition, increase physical activity and prevent tobacco exposure.
4. Providing technical assistance and training to over 35 health care provider sites and 150 health care providers to link clients to community referral sources.   

Here are a few recent examples of the successful work that is being done in Steps communities.

• Steps to a Healthier Tioga Partners with Neighboring YMCA to Provide Community Education Classes: Although Tioga County residents do not have access to a local YMCA, a collaborative effort between Steps to a Healthier Tioga and the Bradford County YMCA has provided opportunities for local Tioga County residents to participate in classes in the areas of goal setting, nutrition and physical activity at multiple locations across Tioga County.
  
  
• Tioga County Steps partners with the Tioga County Development Corporation to Promote Local Farmer’s Markets: Tioga County Development Corporation (TCDC) has always had a focus on buying local Tioga County items. Through a partnership with the Tioga County Steps Program, that focus has been expanded to include local Farmer’s Markets. Steps and TCDC worked together this summer to provide advertising and signage for several Farmer’s Markets with the intent of increasing consumption of locally grown fruits and vegetables.

• Steps Fayette Empowers Community Group to be Leaders in Health
  
  The Hopwood Village Group’s ‘Healthier Hopwood’ project has helped to spread the Steps to a Healthier Fayette County message by partnering with Steps to implement the Neighborhood Health Leadership Program (NHLP.) NHLP is a Centers for Disease Control and Prevention (CDC) evidence-based program using the PATCH (Planned Approach to Community Health) model. The goal of the program is to enable a sustainable community group to address health interventions in their community.
  
  In addition to the PATCH program’s five phases: mobilizing the community, collecting and organizing data, choosing a health priority, developing a comprehensive intervention plan, and evaluation; Steps included instruction on board management, communication, project development, grant writing, marketing, and fundraising.
  
  To encourage the community to be more physically active, The ‘Healthier Hopwood’ project has developed a walking/historical map of the community and signage for the walking area. Steps to a Healthier Fayette County partnered with the group to assist in signage placement and walking map printing. 
  
  After completing the NHLP, Healthier Hopwood will continue to identify needs and apply for funding to plan and implement needed community health interventions.

“We want to help the community get more active and also learn about the history of the community. A marked path along Route 40 will showcase the stone historical buildings, while allowing community members to walk the one-mile length …in an easy, well lighted, community friendly walking path.”
-Pat Tobal, Healthier Hopwood, Fayette County.  

• Fayette County Schools Multiply the Impact of Steps Interventions: As a result of standardized school staff trainings, schools in Fayette County’s six school districts have implemented numerous sustainable changes to increase the number of physical activity opportunities for students and staff. The changes include daily walking programs in eight schools, other fitness programs including after-school yoga, integrated physical activity lesson-plans, Dance Dance Revolution Programs in seventeen schools, and staff physical activity options available to teachers in nineteen schools.
  
  
• Steps Community Partner Adopts After School Activity: Steps to a Healthier Fayette partnered with faculty and students at Penn State University, Eberly Campus and the East End United Community Center (EEUCC) in Uniontown that resulted in the EEUCC receiving a $22,000 grant to expand the Take 10! physical activity program for students enrolled in an after school program in one of Uniontown’s most highly concentrated minority population areas.

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• Workplaces Challenged To Make Wellness Changes Using New Toolkit: “Steps has asked me to challenge you to refute the myth that we have no control over our healthcare costs, and to empower your employees to accept personal responsibility for their health!” Carl Witkowski, Executive Vice President of Information Systems and CAO for the Guard Financial Group, issued this challenge to more than 30 Luzerne County employers at a breakfast launch of the new Steps To A HealthierPA Workplace Wellness Toolkit. “Today, Steps is challenging you to use your toolkit to implement one sustainable worksite wellness change within the next six months then return on April 16, 2008 to share your successes, challenges and lessons learned.” 

The nutritious breakfast, hosted by Steps Luzerne County and co-sponsored by the Greater Wilkes-Barre Chamber of Business and Industry’s Human Resources Task Force, included a fitness break and speakers including Janet Boyer, Food Service Director at Wyoming Area School District, who discussed the district’s new employee wellness initiative.

The toolkit, compiled by the community’s Steps Workplace Action Team, is modeled after the Worksite Resource Kit developed by the Colorado Department of Public Health. Workplaces of any size can use the resource guide to bring wellness programs to their employees.                  

Steps will act as an “e-coach” to employers by providing ongoing resource information,  support, and a web-based evaluation. Any company that institutes at least one sustainable policy will be awarded $200 to put toward future health promotion efforts.  

The Steps Worksite Wellness Toolkit is housed and sustained by the Employment Law Information Network (ELIN).  You can access it through the Luzerne County Steps’ website, www.stepspalc.org or by visiting the ELIN website. 

• Penn State Cooperative Extension And Steps Partner To Create Lasting Change In Luzerne County

Since 2005, the Luzerne County office of the Penn State Cooperative Extension has partnered with Steps to a Healthier Luzerne County by: providing the local site and coordinating PANA satellite trainings and meetings; assisting with program development and delivery with multiple partners on workplace wellness, healthy restaurant efforts and Fruits & Veggies: More Matters™; assisting with food service training; and helping 11 school districts develop their wellness policies.  In the spring of 2007, this partnership was expanded when the local extension office created a permanent position: Community Nutrition Educator (CNE). The CNE will support Steps’ workplace wellness efforts by providing follow-up and technical assistance to 30 workplaces using the Steps Worksite Wellness Toolkit.  

This position, the first in the Penn State extension system, is jointly funded by Steps and the extension office, and will become part of the extension’s annual budget . “This has been a wonderful partnership” said Chris Orrson, M.S., and Extension Director. “This permanent position will not only advance the mission of Steps, it will also enhance our ability to continue to bring the best national and Penn State research and evidence-based resources to the schools, workplaces and communities in Luzerne County.”

Community Partnership: Steps operates as a partnership between the Department of Health, Area Health Education Centers, Community Consortia, and State Health  Improvement Partnerships (SHIPs). Community consortia draw from a variety of  statewide and regional advocacy  organizations involved in chronic disease prevention and intervention.

Evaluation:  With the assistance of East Stroudsburg University, Steps to a HealthierPA is conducting a five-year evaluation using existing data sources, such as the Behavioral Risk Factor Surveillance System (BRFSS), the Steps Youth Survey, and locally collected data identify and measure program outcomes and assess progress toward program goals.  The baseline year of 2005 will be used to measure Steps outcomes through the BRFSS. The following types of indicators are examples of data that will be tracked during the course of the Steps program: 

• The percentage for eating five or more fruits and vegetables per day as compared to the rest of PA non-Steps counties: In 2005, Fayette County adults had a significantly lower percentage as compared to the rest of PA.  
  
  
• The percentage of adults who are overweight: In 2005, Fayette and Tioga Counties had a significantly higher percentage compared to the rest of PA (Source: 2005 BRFSS.) 
  
  
• The percentage of current smokers compared to the rest of PA: In 2005, Luzerne County adults had a significantly higher percentage compared to the rest of PA.

The Future of Steps to a HealthierPA: The Pennsylvania Department of Health is currently in the fourth year of a five-year cooperative agreement grant with the CDC. The Department has entered into five-year grant agreements with the North Central, Southwest and Northeast Area Health Education Centers (AHECs) to serve as the fiscal and grant agents for Steps to a Healthier Tioga, Fayette and Luzerne Counties, respectively. We are exploring opportunities to sustain the funding, infrastructure and partnerships to ensure continuation of the promising chronic disease prevention efforts already realized through the Steps program. 

How Can I Get more Information about Steps?
For further information on Steps to a Healthier Pennsylvania, contact the Steps community websites listed at beginning of this newsletter. If you would like to add your name to the mailing list to receive this newsletter, click on the following link, and you will be included on the listserve to receive future copies. http://www.health.state.pa.us/subscribe