Integrating preconception care into primary care: measures and strategies

Transcription

1 Integrating preconception care into primary care: measures and strategies 3 rd European Congress on Preconception Health and Care February 19 th Workshop Sarah Verbiest, DrPH, MSW, MPH Senior Advisor to National PCHHC Clinical Associate Professor, University of North Carolina at Chapel Hill, School of Social Work

2 RECONVENED SELECT PANEL DECEMBER 2014

3 ACHIEVE THE TRIPLE AIM Improve health outcomes Improve the experience of care (quality and satisfaction) Reduce per capita costs 3

4 CROSS CUTTING OPPORTUNITY: THE WELL WOMAN VISIT Education about importance of visit, covered services and quality of care to be expected = activated clients Encourage use of the reproductive life plan and One Key Question TM, establishment of preconception wellness measures, resources for practice integration Developing measures and metrics to hold providers and health systems accountable for delivering care Benchmarking and monitoring to assess national improvements in health and birth outcomes over time. Resource alignment - one of two maternal health National Performance Measures for Title V Block Grant

5 PRECONCEPTION HEALTH CARE Momentum for every woman, every time as a call for providing evidence-based preventive care to all women (and men) of childbearing potential as a gateway to higher levels of wellness, whether or not pregnancy ever occurs Screening around pregnancy intention is essential for both well woman AND acute care, including hospital discharge Increase the capacity of health care providers and systems to integrate and monitor PCC services through routine preventive, primary, and specialty care

6 CURRENT QUALITY MEASURES Focused on chronic disease management and preventive service delivery, e.g. Immunizations (influenza, pneumococcal) BMI assessment and dietary counselling Tobacco screening and counselling HTN, diabetes, CHF evidence based screens, management, and target goals Colon, breast, cervical cancer screening But none focus on reproductive age women as a special group

7 CURRENT QUALITY MEASURES Focused on Electronic Health Record (EHR) meaningful use, e.g. Electronic prescribing Patient registries Patient portal communication Medication reconciliation Focused on patient satisfaction and shared decision making

8 CURRENT QUALITY MEASURES For pregnancy outcomes Prenatal care (access, 17-P, STI screening) Intrapartum management (no elective deliveries <39 weeks, hemorrhage, NTSV rates) Birth outcomes (Apgars, prematurity, BW, neonatal and infant mortality, maternal morbidity and mortality)

9 CURRENT QUALITY MEASURES For preconception care Actually, there are! Just not being addressed in this way. Good PCC starts with good women s health Immunizations, BMI, depression screening, tobacco, STI screening, diabetes management

10 PRECONCEPTION CARE VS. PRECONCEPTION WELLNESS Preconception wellness is the state of a woman s health at the time of conception Preconception care is the care provided to promote and achieve preconception wellness Preconception care is provided in multiple settings across clinical and public health sectors Thus it is difficult to measure and difficult to hold any one group/domain accountable!

11 ACCOUNTABILITY FOR CHANGE An intermediate measure of a woman s preconception wellness upon entering pregnancy would serve as a surrogate marker of the state of preconception care in the community this could drive decisions on processes, programs, and quality improvement Data collected during the first prenatal assessment

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13 PCHHC CLINICAL WORKGROUP CONSENSUS PANEL Broad expert representation MFM, FM, OB-GYN, CNM, Public Health, Nursing Reviewed available evidence based PCC recommendations Current quality measure crosswalk (HEDIS, NCQA, NQF, ACO, CMS, PQRS, etc) Current EHR collection practices and abilities Feasibility and reliability of collecting and reporting data through the EHR Impact for improving perinatal outcomes

14 WHAT WE MEASURE MATTERS: S CLINICAL MEASURES FOR PRECONCEPTION WELLNESS* Intended/planned to become pregnant Entered prenatal care in the 1 st trimester Daily folic acid/multivitamin consumption Tobacco free Not depressed (mentally well / under treatment) Healthy BMI Free of sexually transmitted infections Optimal blood sugar control Medications (if any) are not teratogenic No single measure alone is sufficient to describe preconception wellness But taken in aggregate can be a marker of wellness and receipt of quality preconception care * Manuscript submitted by the PCHHC Clinical Workgroup Current Quality Measure

15 EVERY WOMAN, EVERY TIME: CASE EXAMPLES Patient Visit Routine Care PCC Opportunity Diabetes follow up Adjust meds and assure quality measures (ACE-I, statin, A1C, foot exam, pneumonia vaccine) Family planning, education on risks, MVI with folic acid Asthma follow up from ED after exacerbation, has bipolar controlled on valproic acid Counsel on appropriate inhaler use, asthma action plan, smoking cessation Family planning, education on risks, MVI with folic acid, consider switching valproic acid Recent sex, stopped depo due to side effects, here for pregnancy test (neg) Reassurance, encourage routine appt for birth control, safe sex Emergency contraception, birth control that day, STI screening, MVI with folic acid Acute ankle sprain, college student, no meds Chronic back pain f/u for pain med refill Ankle sprain management Pain management, refill Family planning, MVI with folic acid, STI screening Family planning, MVI with folic acid

16 REPRODUCTIVE LIFE PLANNING CONTINUUM Opportunistic Triage of Risk Reproductive Action Plan NOW Reproductive Plan (1-2 years) Life Plan (Includes Reproduction)

17 ONE KEY QUESTION IN PRIMARY CARE A simple screening question to facilitate a conversation with your patient regarding her pregnancy intention Designed to help you identify the preventive reproductive health care needs of your patient s 17

18 OVERCOMING BARRIERS Risky Assumptions by Providers: This person should not become pregnant I won t offer preconception care This patient is getting reproductive health care somewhere else This patient knows how to use their birth control correctly UNDERSTANDING YOUR PATIENTS GOALS WILL HELP YOU Identify THE PREVENTIVE REPRODUCTIVE SERVICES THEY NEED. 18

19 THE WELL CHILD VISIT: AN IDEAL OPPORTUNITY Incorporate maternal assessments into WCV s (An every woman, every time approach) Mothers visit the office regularly even if they do not seek care for themselves 1 Achievable and acceptable to women based on pilot studies 2 Deliverable by primary care providers IMPLICIT Areas of Focus: Family Planning and Birth Spacing Maternal Depression Identification and Care Smoking Cessation Multivitamin and Folic Acid Supplementation 1 Kahn and Wise, Pediatrics, Gjerdingen et al., Ann Fam Med, 2009.

20 THEORY TO ACTION: PRECONCEPTION AND THE MAGNOLIA CLINIC JACKSONVILLE, FLORIDA

21 MISSION & SERVICES Women s Health Services Clinical Care Home Visitation Case Management Reproductive Life Planning Outreach Health Education Mental Wellness Fatherhood Group Education To improve the health and well-being of women during their childbearing years by empowering communities to address medical, behavioral, cultural, and social services needs.

22 MAGNOLIA CLINIC HEALTH ZONE 1 The population is 78.1% African- American There are 21,632 women of childbearing age; nearly onefourth of families live below the federal poverty level. There was an average of 1,938 births annually in the project area during , accounting for about 13 percent of the births in Jacksonville.

23 STEPS Basic assessment of clinic flow, staffing and current services Clinic observation, meetings with staff, training presentation Magnolia team decides what components of preconception health and care they are going to try to implement Implementation technical assistance from PCHHC team Wrap up visit meetings with staff, training presentation, discussion about next steps

24 PRECONCEPTION TRAINING During the pilot phase 31 project and partner primary care provider staff completed Preconception Care Training Training was provided twice to launch the project and to review the project and reinforce learning at the end Case examples from practice were particularly helpful in making the case for integrating PCC into primary care

25 WOMAN-CENTERED EDUCATION The pamphlet Show Your Love! Steps to a Healthier Me! is distributed to all women that came to Magnolia for a clinic visit. During their clinic visit, each participant meets with the health educator and reviews the completed questionnaire on the pamphlet. At her next clinic appointment, each participant reviews or adjusts her previously set goals with the health educator.

26 CLINICAL REPRODUCTIVE LIFE PLAN All women receiving care at the clinic must have a RLP noted in their Electronic Health Record Health Educator begins the conversation with the patient and the health care provider assists with implementation Case Managers support women in achieving larger life goals such as education

27 ACHIEVEMENTS Free multivitamins to all women coming for well woman or family planning care Reproductive life plan established as a vital sign Show Your Love checklist used as part of patient-centered care Comprehensive services and case management available to help a woman implement her plan Women can receive family planning and primary care services in the same visit Exploring ways to provide information to friends and family in the waiting room

28 LESSONS LEARNED Simple quality improvement approach can achieve quick and meaningful results in PCC delivery! Educational buy-in from all members of the staff is key Ingrained process barriers may have simple solutions E.g. Scheduling issues; who can do what and when; billing for primary care visits and family planning at same time The value of patient engagement on interventions Most common patient goals/needs are social Weight management, healthy eating Housing, job, car Relationships, empowerments, stressors

29 CONTACT Sarah Verbiest:

30 CONTACT US Oregon Foundation for Reproductive Health Michele Stranger Hunter- Executive Director Sharon Meieran, MD, JD- Medical Director Hannah Rosenau- Senior Policy & Access Coordinator Follow us on Facebook and Twitter: Oregon RH 4/