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The Importance of Pre-And Inter- Conceptional Health

Enterprise Community Healthy Start Inter-Conceptional Care. The Importance of Pre-And Inter- Conceptional Health. ECHS Inter- Conceptional Care Objectives. Identify criteria for client enrollment into ECHS program Cite components of ECHS IC Case Management

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The Importance of Pre-And Inter- Conceptional Health

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  1. Enterprise Community Healthy Start Inter-Conceptional Care The Importance of Pre-And Inter-Conceptional Health Funding for this program was made possible in part by the HHS, HRSA, H59MC12788. The views expressed in written materials or publications and by speakers and moderators at HHS-sponsored conferences do not necessarily reflect the official policies of the Department of Health and Human Services; nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government

  2. ECHSInter-Conceptional CareObjectives • Identify criteria for client enrollment into ECHS program • Cite components of ECHS IC Case Management • Recognize the integration of information gained by case through the use of the Life Skills Progression,(LSP), tool • Identify ways that an ICC message is integrated into client lives • Relate community education opportunities to promoting the importance of an ICC message

  3. HRSA’s Goals for Healthy Start • Improve health care access and outcomes for (high risk) women and infants • Promote healthy behaviors and reduce the causes of infant mortality An Overview of Healthy Start: David S. de la Cruz, PhD, MPH, Captain, US Public Health Serviced Deputy Director Dept. of Health and Human Services Health Resources and Services Administration Division of Healthy Start and Perinatal Services Presentation to SACIM, July 2012

  4. HEALTHY START’S ROLE IN ADDRESSING DISPARITIES • Reduce the rate of Infant Mortality • Eliminate disparities in perinatal health • Implement innovative community-based interventions to support & improve perinatal delivery systems in project communities • Assure that every participating woman & infant gains access to the health delivery system & is followed through the continuum of care • Provide strong linkages with the local & state perinatal system An Overview of Healthy Start: David S. de la Cruz, PhD, MPH, Captain, US Public Health Serviced Deputy Director Dept. of Health and Human Services Health Resources and Services Administration Division of Healthy Start and Perinatal Services Presentation to SACIM, July 2012

  5. Enterprise Community Healthy StartWho We Are The Enterprise Community Healthy Start Initiative, (ECHS) serves Burke and McDuffieCounties • Healthy Start Grantee Since 1999 • One of 4 Healthy Start projects in Georgia • We work together with the counties to: • Improve health care access and outcomes for women, infants and their families • Promote healthy behaviors and reduce causes of infant mortality

  6. ECHS Core Services • Community Outreach and Recruitment • Case Management with Home Visitation • Health Education • Depression Screening

  7. County Profiles Burke County- Population estimate: 23, 504; White-48.3%, Black-47.9% • Per Capita income: $15,901 • 75.1% of persons age 25+, 2006-2010 are high school graduates • 79% of students in the school district are eligible for reduced or free lunch McDuffie County-Population estimate: 21,673; White-57.6%, Black-40.3% • Per Capita income: $18,200 • 70% of persons age 25+, 2006-2010 are high school graduates • 71.6% of students in the school district are eligible for reduced or free lunch

  8. Health FactorsRanking129/156- Burke, 53/156- McDuffie Health factors represent what influences the health of a county Four types of health factors are measured • Health Behaviors: tobacco use, sexual activity, diet and exercise, alcohol use • Clinical Care: quality of care, access to care • Social and Economic Factors: education, community safety, employment, family and social support, income • Physical Environment: environmental quality, built environment 2012 County Health Rankings

  9. Health Outcomes Ranking151/156- Burke, 125/156- McDuffie Health outcomes represent how healthy a county is Two types of health outcomes are measured • How long people live (mortality) Examines mortality (or death) data to find out how long people live. More specifically, premature deaths are measured (deaths before age 75) • How healthy people feel while alive (morbidity) Examines specifically, the measures of their health-related quality of life (their overall health, their physical health, their mental health) and also birth outcomes (in this case, babies born with a low birth-weight) 2012 County Health Rankings

  10. ECHS Birth Overview Oasis Maternal Child Web Query GA Dept of Public Health 2003-2012

  11. ECHS IC Case Management • Implemented IC care CY 2001 • Protocols revised to include 2 years of IC case management • CM services may begin as early as 1st trimester and continue through the child’s 2nd birthday • Case Managers include 3 RN Case Managers and 2 Patient Advocates • Average caseload per CM is 30 mothers • CM visits are monthly at a minimum, with most occurring a client’s home

  12. ECHS IC Case Management • 317 Active Program Participants in 2010 (257 enrolled AP, 60 enrolled PP) • Total Caseload average=200 women • Recruitment/referral sources - physicians, schools, health departments, DFCS, friends, family, self-referral, churches, community agencies

  13. ECHS Eligibility Criteria • No/unstable support system • Very unstable living situation • Engages in behavior that puts self or infant’s health at risk • Teen (<= 18 yrs) • Known domestic violence situation • No prenatal care • Mental health issues • Pre-existing medical diagnosis/chronic disease • Significant reproductive history risks • Multiple gestation in current pregnancy • Fragile infant • LBW infant <2000 gms • IUGR and or SGA • Premature birth <37 weeks • Infant with >4 NICU days • Genetic condition • Congenital anamolies • Clients often have more than one risk factor

  14. ECHS Case Managed Clients • 22 % are less than 20 years old • 41.7% have positive depression screens • 82.6% have BMI’s >= 25 • 5% of the enrolled IC clients had infants weighing less than 1500gms • 22% of the enrolled IC clients had infants weighing less than 2500gms

  15. ECHS Case ManagersProfessional Development Extensive ongoing training of the CM staff Establishes a common knowledge base Strengthens CM skills Reinforces best practices for use with case managed clients

  16. ECHS Case Manager Professional Development • Beginnings Pregnancy and Parenting Education Guides • Life Skills Progression Instrument • Ages and Stages Infant Development Questionnaire • NCAST Infant Cues • Promoting Maternal Mental Health • Domestic Violence Technical Assistance • Mental Health First Aid • Cultural Competence • Women and Girls HIV/AIDS Awareness • Preconception Health Concepts • Contraceptive Technology • Membership in professional organizations that promote perinatal care- Georgia Perinatal Association, AWHONN

  17. Goals of IC Case Management • Prepare mother for self-care and parenting • Empower mother and her partner to plan for future pregnancies • Maximize positive relationships • Utilize M & I services appropriately • Promote self-sufficiency • Promote infant-toddler development • Assure health insurance coverage for mother and children Case management services are conceptualized across the continuum of care from the prenatal period through two years of the infant’s life and not as separate programs for prenatal and IC care.

  18. Risk Appraisal • At time of referral to ECHS program • Feedback provided to client’s medical providers • May include referral to resources for client • Re-appraised regularly during IC-CM period • CM review, feedback and integration into plan of care • Preconception assessment and counseling with client

  19. Depression Screening- BDI, EPDS ECHS Antepartum/Postpartum Screening Tool Reproductive history Infant’s history Medical history-chronic disease, BMI Dental history Family health history Family Planning method Psychosocial Assessment Tool Mental health and/or emotional risks Substance use Domestic violence history Risk Appraisal Tools USED

  20. Risk appraisal process is reflective, dynamic, ongoing

  21. Patient Education Components of ECHS IC care

  22. Beginnings Pregnancy and Parenting Guides The Beginnings Guides Curriculum Package: • Presents a strength-based approach to parent education and family support. • Places the mother at the locus of control and values her experience, knowledge and feelings as the foundation for responsive parenting

  23. Patient Education includes: Chronic Disease Management Family Planning Methods Health Maintenance and Prevention maternal-child dental care woman’s health exams SIDS risk reduction maternal- child safety practices, CPR immunizations for mom, child, family Infant and Child Growth and Development Baby Cues, Infant Massage Breastfeeding education and support Nutrition information Life Skills

  24. Tracking of Medical Home and Insurance Status Components of ECHS IC care

  25. Insurance Status • Tracking of client insurance status • 3% of IC clients are on SSI • 12% of IC clients are on LIM • 17% of IC clients are on RSM, not yet 60 days post partum • 69% of IC clients are potentially self-pay • 100% of infants > 1 year old have health insurance • 23% of eligible ECHS IC clients have enrolled in P4HB • Client education regarding maintaining insurance status, insurance/health care coverage options • Empowerment strategies

  26. Client Education and Referral to Planning for Healthy Babies,(P4HB) Eligibility • Residents of Georgia • U.S. citizens, legal immigrants or person with qualified proof of citizenship • Ages 18 through 44 • With family income at or below 200% federal poverty level • Able to have a baby (Have not had a tubal ligation or hysterectomy) • Not already covered by any insurance including private, Medicaid, Medicare, or PeachCareunless • Losing Medicaid coverage, such as after pregnancy • Family planning coverage 2 years • Women having VLBW infant have option for enhanced P4HB coverage • IPC component for 24 months following the delivery of a VLBW baby, • then regular P4HB benefits, 24 months • NOTE: If later have another pregnancy, may re-enroll

  27. P4HB General Information • Three Levels of service with varying benefits: • Family planning • Inter-pregnancy care • Resource mothers Costs • No premium • No deductible • Possible minimal co-pays Benefits • An annual exam • pelvic exam • Pap smear to screen for cervical cancer • breast examination • screening for sexually transmitted infections including HIV testing • A pregnancy test if indicated • A birth control method • Follow-up of abnormal Pap smear • Follow up family planning visits (up to 4 per year) • Select immunizations for participants 19 and 20

  28. P4HB Benefits Prescription Birth Control Methods Covered • Oral Birth Control (pills) • Injectable Birth Control (shots) • Intrauterine Devices (IUDs) • Diaphragms Sterilization (Permanent Birth Control) Procedures Covered • Tubal ligation, postpartum & interval Testing & Treatment Services Covered • Sexually Transmitted Infection (STI) Test • Sexually Transmitted Infection Treatment • HIV Test • Pap Smear for cervical cancer screening • Colposcopy (a procedure for a magnified view of cervical cells) Special Coverage for Women Having a Very Low Birth Weight Baby On or After Jan 1, 2011 • VLBW = less than 1500 grams or about 3 pounds, 5 ounces • interpregnancy care • limited primary care- up to 5 visits • dental services • medications to treat chronic illnesses • substance abuse services • case management, including Resource Mothers outreach. • non emergency transportation

  29. P4HB Information Sources • Website:http://www.planning4healthybabies.org • Phone:1-877-P4H-B101 or 1-877-744-2101

  30. Medical Home • The medical provider a client identifies as provider for well visits, disease specific care and GYN/FP- non-ER visit 95% of IC clients identify having a medical home • Medical home as indicated by outpatient visit • 79% of IC year 1 clients • 70% of IC year 2 clients • 33% of teen clients

  31. Infant’s Medical Home 97% of infants over 2 months old have medical home listed • Infants/toddlers >= 6 months old who have 2 or more health checks between 0-7mos- 100%: • Infants/toddlers>=12 months old who have 3 or more health checks between 0-13 mos- 96% • Infants/toddlers>=19 month old who have 2 or more health checks between 12-19 mos- 67% • Infants/toddlers between 12-25 mos. who have 3 or more health checks- 62%

  32. Reproductive Health Plan Components of ECHS IC care

  33. Why the Use of aReproductive Health Plan? • Challenges • % of clients completing FP visit in 1st year postpartum • 2007 Deliveries – 55.8% (58/104) • 2008 Deliveries – 45.4% (59/130) • 2009 Deliveries – 54.8% (68/124) • 2010 Deliveries (thru 4/24/10) – 46.7% (21/45) • % of clients completing FP visit in 2nd year postpartum • 2006 Deliveries – 25.0% (32/128) • 2007 Deliveries – 19.2% (20/104) • 2008 Deliveries – 23.1% (30/130) • 2009 Deliveries (thru 4/24/09) – 40.7% (11/27)

  34. Reproductive Health Plan-a key component to ECHS IC care A Reproductive Health Planis a plan that reflects a person’s intentions regarding the number and timing of pregnancies that meets their personal values and life goals

  35. Reproductive Health Plan Objectives of Reproductive Health Plan • To engage the client in discussion about preconception health, pregnancy planning and life plans • To facilitate an opportunity for a woman to consider and plan her reproductive health before she is pregnant and reduce pregnancy associated risks • To serve as a starting point for ongoing education about reproductive health, family planning and related topics

  36. ECHS CM Reproductive Health Plan Policy- • introduced early in the case management relationship • it is important to recognize a client’s social, religious, ethnic, cultural beliefs and values when discussing their personal RHP’s • recognize client’s health literacy when planning and discussing related concepts and education.

  37. Reproductive Health Plan as a part of IC Case Management • Self Completed, provide guidance as needed • Encourage client to discuss with partner • Have client sign RHP • Give original to client, keep copy in client file • Provide education materials that may assist client in making decisions regarding her reproductive health • Consider referrals to resources to enhance client’s RHP

  38. Reproductive Health Plan as a part of IC Case Management • Provide preconception care counseling to include: • healthy weight, physical activity • the benefit of folic acid supplementation • adequate interpregnancy interval • contraceptive methods • medical conditions requiring ongoing management • immunizations (Rubella, Hepatitis, Pertussis) • STIs (HIV, Chlamydia) • substance use • medication use • environmental exposures • dental care

  39. What is Your Reproductive Health Plan? (Between Pregnancies) 1. Would you (your partner) like to have any more kids? _____ Yes _____ No 2. How old would you like to be when you have your next baby? __________________________________________ 3. How far apart do you (your partner) want your kids to be? ____________________________________________ 4. How many children do you (your partner) want? ______ 5. What would you (your partner) do if you end up getting pregnant again? 6. What is your (your partner’s) plan to prevent another pregnancy? 7. Are you currently taking any birth control? _____ Yes _____ No If so, what are you taking? _______________________ 8. Are you (your partner) currently using condoms when you have sex? ____________ Why or why not?   . Are you comfortable talking to your partner(s) about STDS and birth control? __________ Why or why not? ________________________________________________ 10. Is there someone you can talk to about birth control, sex, STD’s? _____ Yes _____ No If yes, who? _____________________________________ 11. What you (your partner) will be doing in 5 years? 12. What do you (your partner) need to do to meet these goals? Goals ~Take folic acid ______ ~Refill of multi-vitamins (every 3 months) ______ ~Get STD/STI screening (date of screening) _____ ~Get HIV/AIDS test (date of test) ______ ~Get HIV retest (6 months) _______ ~Get GYN annual physical and check up (date of visit) ____________________ ~Make sure your immunizations and H1N1 flu shot are up to date _____ ~Get HPV/Gardasil vaccine (date of vaccine) _______ ~Quit smoking if you are a smoker Name: _________________________________________ Signature: ______________________________________ • Case Manager Signature: __________________________ • Date: ______________

  40. Community Messages Are You Planning for a Healthy Family? • Every woman should be thinking about her health whether or not she is planning a pregnancy. • Did you know that over 50% of pregnancies are unplanned? Unplanned pregnancies are at greater risk of preterm birth and low birth-weightbabies. • Experts agree that women need to be healthier before becoming pregnant. By taking action on health issues and risks before pregnancy, you can prevent problems that might affect you or your baby later. • If you are not ready, physically, emotionally or financially, to be pregnant, see your health care provider about a birth control method

  41. Your Partner's Role in Preparing for Pregnancy Your partner can do a lot to support and encourage you in every aspect of preparing for pregnancy. Here are some ways: • Screening for and treating sexually transmitted infections(STIs) can help make sure infections are not passed to female partners. • Male partners can improve their own reproductive health and overall health by limiting alcohol, quitting smoking or illegal drug use, eating healthy, and reducing stress. • Your partner should also talk to his doctor about his own health, his family health history, and any medicines he uses. • People who work with chemicals or other toxins can be careful not to expose women to them. For example, people who work with fertilizers or pesticides should change out of dirty clothes before coming near women. They should handle and wash soiled clothes separately.

  42. Personal Habits Related to Having a Health Baby These behaviors could harm you and your future babies and it is best if you avoid them • Smoking • Underage drinking (younger than 21) or binge drinking when • you’re 21 or older (drinking 5 or more drinks with alcohol in one • sitting) • Using illegal drugs (marijuana or hash, cocaine, crack, etc.) • Unhealthy dieting or overeating These behaviors are healthy habits and help you prepare your body to have healthy babies when you’re ready • Eating plenty of fruits, vegetables and whole grains • Exercising regularly • Taking a multivitamin that contains folic acid everyday (folic acid is a nutrient that helps to prevent certain birth defects, but it needs to be taken before a woman gets pregnant and during pregnancy because timing is very important. Most multivitamins have this nutrient). • Getting regular checkups with your doctor and dentist • Getting enough sleep

  43. Life Skills Progression Component of ECHS IC care

  44. ECHS Use of the LSP in IC Care • LSP defines a life skill as a behavior, ability, attitude, or characteristic used to achieve and maintain a satisfying and healthy life, free from the negative affects of poverty. • A summary that the CM team uses to sort and organize information gathered from visits, screening tools, and observation of the family. Reflective Functioning • Used to help CM gain a clear understanding of family needs, strengths and issues.

  45. The Life Skills Progression is used to: • To profile an individual parent, child, or both. • Document baseline characteristics and quantify change by comparing baseline profiles with ongoing and closeout data. • Identifies parent and child strengths, needs, and goals for collaborative planning within ECHS and county-based resources. • It includes the ability to: have nurturing relationships, provide for health care and healthy life styles, utilize available resources and information, complete basic education, have regular gainful employment, provide for basic needs, and raise children who have optimal health and development.

  46. Nuts and Bolts of the LSP • Complete initial LSP within the first two visits of enrollment/intake for ECHS case management. • Update LSP every 6 months and at closure. • In the context of home visiting, we use this working definition: Reflective functioning is the capacity to think about and see the links between events, a person’s behavior, feelings and knowledge, and to respond appropriately. Wolleson

  47. RNCMs advocate women’s development of personal skills and autonomy in their home environments, teaching reflective function skills (Think-Link-Respond ) to address problems and create acceptable solutions. • The CM approach incorporates a life course perspective as women are guided to Think-Link-Respond relative to their life goals at this particular time and with thought toward the future. (Olds, David;Wollesen, Linda)

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