PUTTING IT ALL TOGETHER: MELDING OUR PASSION & KNOWLEDGE TO ACHIEVE EXCELLENCE Presentation by Kay Johnson For the Maternal and Infant Health Center of Excellence Annual Meeting NYS DOH, Bureau of Women, Infant and Adolescent Health (BWIAH) Provider Day May 10, 2017
Session Objectives - Participants will: Become familiar with the core elements of service systems for women and infants. Review why increased health equity can improve outcomes for women, infants, and families. Reflect on the potential for using data and forging better partnerships. Envision change.
For decades many believed that if we improved access to and use of effective contraception and quality prenatal care, then we could improve outcomes in the health of women and infants. This is true in some ways BUT Now we know much more needs to be done to address cumulative disadvantages and inequities that occur over the life course of many women of childbearing age.
So, what is not happening that should be? Low reproductive health awareness or no reproductive life plan for most men and women. Young adults in working class still uninsured. Primary care discontinuous (no medical home). Majority of women have coverage for well visits with preconception care, but they and their providers are not aware, not benefiting. Many providers not focused on reproductive risks, preconception health, or recurring risks for adverse pregnancy outcomes. Unequal treatment and health inequities drive racial/ethnic and income disparities.
Common system failures Primary care providers not strong on preconception. Prenatal care quality receives too little emphasis. Interconception care devolves into LARC initiatives. Prevention of teen pregnancy but not weathering. Head separated from the body (oral & mental health). Perinatal HIV, opioid use, etc. marginalized. Perinatal QI mainly about hospitals and vital statistics. Home visiting not enough to affect index birth outcome. Developmental screening not done as recommended. SDOH & ACEs assessed but not addressed.
SACIM Strategic Directions: 6 Big Ideas 1 2 3 4 5 6 Improve the health of women before, during, and after pregnancy Ensure access to a continuum of safe and highquality, patient-centered care Redeploy key evidence-based, highly effective preventive interventions to a new generation Increase health equity and reduce disparities by targeting social determinants of health Invest in adequate research and data to measure access, quality, and outcomes Maximize interagency, public-private, and multidisciplinary collaboration
1. Improve the health of women Primary care with preconception components Family planning Community preventive services Primary care Family planning Health promotion and community preventive services Before pregnancy No pregnancy Quality postpartum & ongoing well woman visits Family planning Interconception care for identified risks Beyond pregnancy During pregnancy Quality prenatal care Access to interventions for risk management Effective birth & perinatal systems
Percent of Adults Age 18-64 with No Usual Source of Care, By Insurance Status, US, 1997-98 to 2013-14 Insured continuously all 12 months Uninsured for any period up to 12 months Uninsured more than 12 months 70 60 50 40 30 20 10 0
2. Ensure access to a continuum of safe and high-quality, patientcentered care Equitable Patient centered Six Domains of Health Quality Safe Efficient Timely Effective IOM. Six Domains of Health Quality. Crossing the Quality Chasm. 2001. http://www.nationalacademies.org/hmd/reports/2001/crossing-the-quality-chasm- A-New-Health-System-for-the-21st-Century.aspx https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html http://www.ihi.org/resources/pages/improvementstories/acrossthechasmsixaimsforchangingthehealthcaresystem.aspx
Adopt Systems Integration Strategies Array of services and supports Client Centered Approach What is the process magic in those arrows?
Connections for a continuum of care During pregnancy Before pregnancy Beyond pregnancy Are stand-alone family planning, private OB-GYN, private primary care, and FQHC connected? How are women at-risk connected to home visiting? How does prenatal information reach the birth setting? What connects postpartum/ wellwoman visits, family planning, lactation support, and interconception care?
Use the power of ONE One key question One medical home One plan One care coordinator lead One stop shopping
3. Redeploy effective, preventive interventions Social marketing, health education, and access to clinical and community preventive services. 1. Immunization 2. Family planning 3. Breastfeeding 4. Safe sleep 5. Smoking cessation What else? Newborn screening Folic acid 17P Developmental screening HIV screening & ARV Source: SACIM (2013) Recommendations for Department of Health and Human Services (HHS) Action and Framework for a National Strategy. Strategic Direction 3. https://www.hrsa.gov/advisorycommittees/mchbadvisory/infantmortality/correspondence/recommendationsjan2013.pdf
Implement Two Gen approaches To learn more, visit: http://ascend.aspeninstitute.org/pages/the-two-generation-approach
4. Increase health equity and reduce disparities by targeting SDOH Not all health differences are health disparities. Health disparities are systematic, plausibly avoidable health differences according to income, race/ethnicity, religion, or socioeconomic position. Disparities in health and its determinants are the metric for assessing health equity. Health equity is the principle underlying a commitment to reducing disparities in health and its determinants. Health equity is social justice in health. Source: Braveman et al. Health Disparities and Health Equity: The Issue Is Justice. Am J Public Health. 2011;101:S149 55.
Achieving health equity by addressing SDOH Economic & Social Opportunities and Resources Living & Working Conditions in Homes and Communities -Reduce poverty & segregation. -Promote economic development in disadvantaged communities. -Promote child & youth development & education, infancy through college. -Job creation & training. Behaviors Medical Care Promote healthier homes, neighborhoods, schools & workplaces. Strengthen safety nets. Interactions between genes and experiences HEALTH Source: P. Braveman et al. University of CA., San Francisco, adapted from version originally created for: Overcoming obstacles to health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. Robert Wood Foundation, 2008.
Social Determinants of Health Exposure to hazards Income/ Poverty Racism Safety/ violence Employment WHO defines SDOH as the circumstances in which people are born, live, and work, and the systems in place to deal with illness. Circumstances shaped by larger forces such as economics, public policies, and politics. Housing/ Neighborhood Social support Stress, trauma, ACE Education
How can we tackle SDOH? Tax policy Family leave ACEs Medical-legal partnerships Housing policy Health in all Policies
Family Tax Credits Improve Outcomes Improved maternal and infant health Better school performance Increased college, work and earnings in next generation
Percentage of US Women on Maternity Leave and Giving Birth by Marital Status, Race-ethnicity, and Education, 1994-2015 Mothers on maternity leave Mothers giving birth 0 10 20 30 40 50 60 70 80 90 100 Married Non-Hispanic White Non-Hispanic Black Hispanic < High school education High-school degree Attended college Source: Zagorsky. Divergent Trends in US Maternity and Paternity Leave, 1994-2015. AJPH Mar; 107(3):460-465. Based on Current Population Survey and US Vital Statistics data. All significant differences <.01.
Select Adverse Childhood Experiences (ACEs) Among Children 0-5 100% 90% ALL CHILDREN AGE 0-5 2 or more ACEs CHILDREN AGE 0-5 IN POVERTY 80% 1 ACE 70% 60% 50% 40% 30% 20% 10% 6.1% 13.3% 18.0% 23.0% 26.0% 23.6% 12.9% 22.2% 32.8% 36.7% 36.9% 31.3% 0% Child less than 2 years of age Child is 2-3 years old Child is 4-5 years old Child less than 2 years of age Child is 2-3 years old Child is 4-5 years old Analysis of National Survey of Children's Health. NSCH 2011/12. Child and Adolescent Health Measurement Initiative (CAHMI), Data Resource Center for Child and Adolescent Health. *Nine adverse experiences include socio-economic hardship, divorce/parental separation, household member with substance/alcohol problem, victim or witness to neighborhood violence, household member with mental illness, domestic violence witness, incarcerated parent, treated unfairly due to race/ethnicity, and death of parent.
5. Invest in adequate research and data to measure access, quality, and outcomes Quality improvement Performance & results Research & evaluation Adapted from IHI: Solberg et al. The three faces of performance measurement: improvement, accountability, and research. The Joint Commission Journal on Quality Improvement. 1997;23(3):135 147.
Three Types of Measurement Quality Improvement - Use of LARC - Unequal treatment of neonates - Key elements of postpartum visits - Developmental screening referrals Performance & Results Accountability Rates for: - Unintended pregnancy - Births in risk appropriate facility - Postpartum visits - Develop-mental screening Evaluation & Research - What is the reproductive experience of women using LARC? - How does NICU environment affect infant? - What motivates postpartum visits? - Validate tools for developmental screening
ACOG-NCQA-PCPI Postpartum QI Measure Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care within 8 weeks of giving birth. Patients receiving all the following at a postpartum visit: Breastfeeding evaluation and education, including patientreported breastfeeding Postpartum depression screening Postpartum glucose screening for gestational diabetes patients Family and contraceptive planning and education American Congress of Obstetricians and Gynecologists (ACOG), National Committee for Quality Assurance (NCQA), Physician Consortium for Performance Improvement (PCPI) Maternity Care Performance Measurement Set (2012) https://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternity.pdf
Monitoring with Focus on Health Equity Monitoring Across Populations Monitoring population health Maternal &/or Infant Overall Population Perinatal data, including vital statistics, clinical data, program evaluations Monitoring Health Equity & Social Determinants of Health for Mothers, Infants, & Families Use PRAMS to monitor stress, housing, hunger, income, etc. Use BRFSS data to monitor ACEs and other life course events Work on data linkages (vital records, housing, Medicaid, welfare, etc.) Build and use data warehouses, etc.
Percentage of Women with Pregnancy Stressors, By Medicaid Status, NY and NYC, PRAMS, 2011 50 45 40 35 30 PRAMS Medicaid PRAMS Non-Medicaid NY Medicaid NY Non-Medicaid NYC Medicaid NYC Non-Medicaid Percent 25 20 15 10 5 0 No stressors 1-2 stressors 3-5 stressors 6-13 stressors Source: Prepared by Johnson. https://nccd.cdc.gov/pramstat/
6. Maximize interagency, public-private, and multi-disciplinary collaboration
What are their roles & what partnerships? Income & Social Support Community Health Workers Primary & OB-GYN Care Woman and her family Family Planning Clinic Housing Early Care & Education Lactation & WIC nutrition Mental Health Provider Home Visiting Employment & Job Training
Maximize Partnership Synergy By combining the perspectives, resources, and skills of partnership, the group creates something new and valuable together a whole that is greater than the sum of its individual parts. Lasker et al. Partnership Synergy. Milbank Quarterly. 2001. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2751192/
Typology of Americans Health Values 16% Equity Advocates HIGH GOVERNMENT ROLE Committed Activists 18% 23% Health Egalitarians LO W HIGH PERSONAL HEALTH IMPORTANCE Privatesector Champions 14% 17% Disinterested Skeptics Self-reliant Individuals 12% NONE Source: Exhibit 1. Bye L, Ghirardelli A, & Fontes A. Promoting health equity and population health: How Americans views differ. Health Affairs, 2016, Nov;35(11):1984. American Health Values Survey. RWJF.
American s Beliefs About Racial-Ethnic-Income Group Health Care Access Disparities, By Population Segments, American Health Values Survey, 2015-16 African Americans have harder access Latinos have harder access Low-income Americans have harder access 96% 94% 97% 80% 67% 46% 42% 36% 53% 54% 4% 7% 7% 9% 15% 17% 17% 17% Health Egalitarians Equity Advocates Committed Activists Self-reliant Individuals Disinterested Skeptics Private-sector Champions Source: Exhibit 3. Bye L, Ghirardelli A, & Fontes A. Promoting health equity and population health: How Americans views differ. Health Affairs, 2016, Nov;35(11):1984. American Health Values Survey. RWJF.
Envisioning the future
Looking ahead, what can New York do? 1 Accelerate improvement in women s health, before and after pregnancy. 2 3 4 5 6 Improve access to a continuum of quality services by strengthening systems of care, reducing gaps. Redeploy effective preventive interventions by implementing coverage of preventive services. Increase health equity through data, training, programs, systems, and policies. Invest in all three types of measurement and use data for change. Maximize partnerships, build bridges and broaden understanding.
A Vision for Improving Preconception Health and Pregnancy Outcomes All women and men of childbearing age have high reproductive awareness. All women have a reproductive life plan. All pregnancies are intended and planned. All women of childbearing age have health coverage. All women of childbearing age are screened prior to pregnancy for risks related to outcomes. Women with a prior adverse pregnancy outcome have access to interconception care to reduce their risks.
A Vision for Maternal and Child Health We envision an America where all children and families are healthy and thriving, and where every child and family have an equitable opportunity to reach their full potential.
because the responsibility is mine and I must, I take a very firm hold on the handles of the baby carriage and I wheel it into the traffic. Grace Abbott 1935 http://ssacentennial.uchicago.edu/features/features-graceabbott.shtml