systematic prenatal screening for psychosocial risks: the prenatal risk overview

1. Systematic Prenatal Screening for Psychosocial Risks: the Prenatal Risk Overview Twin Cities Healthy Start Abbey Sidebottom, Evaluator Tasha Montgomery, Case Manager Doriscile Everett-O�Neal, Project Director Pat Harrison, Research Director Today we�re going to talk to you all about the development and use of the Prenatal Risk Overview, a screening interview we developed to examine psychosocial risks. We�ll talk about the development and give a case scenario. We�ve got the perspectives of the director, evaluator, and a case manager. Today we�re going to talk to you all about the development and use of the Prenatal Risk Overview, a screening interview we developed to examine psychosocial risks. We�ll talk about the development and give a case scenario. We�ve got the perspectives of the director, evaluator, and a case manager.

2. First a little background to why this was needed. As we all know�.First a little background to why this was needed. As we all know�.

3. Why a psychosocial risk factor screening tool is needed Evaluation of case management impact on psychosocial risk factors is hampered by lack of clear consistent definitions of risk and lack of universal screening. Use of standardized screening instruments is uncommon. A shared evaluation goal of all HS programs is to to look at impact of case management at addressing risk factors and thus improving birth outcomes. However, we can�t do that research without standardized measurements of these psychosocial risk factors that case management addresses. Standardized measures will also help with studies on the relationship between these risk factors and birth outcomes. On reason for implementing a systematic screening tool is that it will provide universal screening in a way that can provide quantitative measurements of risk. In addition universal screening addresses provider bias in asking questions. From the perspective of a Healthy Start grantee we are also faced with the challenge of the requirement to serve high risk women but the definition of what is high risk and how sites assess for it is left up to us. We previously had used a check list format with problems such as housing, drug and alcohol use, depression, etc on the check list and left it up to the case managers at each site to determine if those risks existed through whatever questions they felt appropriate. However, that made it very hard to document the needs of our population which is another problem all Healthy start grantees face�documenting the need of their community to leverage resources beyond federal healthy start dollars.A shared evaluation goal of all HS programs is to to look at impact of case management at addressing risk factors and thus improving birth outcomes. However, we can�t do that research without standardized measurements of these psychosocial risk factors that case management addresses. Standardized measures will also help with studies on the relationship between these risk factors and birth outcomes. On reason for implementing a systematic screening tool is that it will provide universal screening in a way that can provide quantitative measurements of risk. In addition universal screening addresses provider bias in asking questions. From the perspective of a Healthy Start grantee we are also faced with the challenge of the requirement to serve high risk women but the definition of what is high risk and how sites assess for it is left up to us. We previously had used a check list format with problems such as housing, drug and alcohol use, depression, etc on the check list and left it up to the case managers at each site to determine if those risks existed through whatever questions they felt appropriate. However, that made it very hard to document the needs of our population which is another problem all Healthy start grantees face�documenting the need of their community to leverage resources beyond federal healthy start dollars.

4. 13 Prenatal Risk Overview (PRO) Domains Basic needs: phone, transportation, food, housing. Interpersonal relationships: social support, partner violence, other physical/sexual abuse. Behavioral health: depression; cigarette smoking; alcohol use; other drug use. Legal problems and child protection involvement. So we developed the Prenatal Risk Overview�. The Prenatal Risk Overview was developed to cover 13 risk domains. They fall into these 4 categories. 5 of the PRO risk domains were selected based on screening recommendations from professional organizations such as ACOG and AMA (depression, tobacco use, alcohol use, drug use, and domestic violence). 3 domains were included based on research linked to poor birth outcomes (food security, homelessness, and social support). 4 additional domains were based on local provider input indicating they are critical to prenatal care compliance or care coordination work (phone, transport, legal, CPS) The interview contains approximately 45 (?) questions depending on skip patterns. At takes about 15 minutes to administer. So we developed the Prenatal Risk Overview�. The Prenatal Risk Overview was developed to cover 13 risk domains. They fall into these 4 categories. 5 of the PRO risk domains were selected based on screening recommendations from professional organizations such as ACOG and AMA (depression, tobacco use, alcohol use, drug use, and domestic violence). 3 domains were included based on research linked to poor birth outcomes (food security, homelessness, and social support). 4 additional domains were based on local provider input indicating they are critical to prenatal care compliance or care coordination work (phone, transport, legal, CPS) The interview contains approximately 45 (?) questions depending on skip patterns. At takes about 15 minutes to administer.

5. 8 PPRO (postpartum) domains Basic needs: housing. Interpersonal relationships: social support, partner violence, other physical/sexual abuse. Behavioral health: depression; infant exposure to secondhand smoke; alcohol use; other drug use. We also screen all women postpartum for a subset of those domainsWe also screen all women postpartum for a subset of those domains

6. PRO risk levels Low Risk: no indication of current problem. Moderate Risk: some issues suggest the need for education, emotional support, or other help, but typically do not indicate the need for a referral for specialized professional services. High Risk: reserved for when a referral is needed for specialized professional services or further assessment. If the client is already obtaining the services, an additional referral is not required. Very High Risk: used only for Depression and heightens the urgency of a mental health intervention. Client responses to the PRO are categorized as Low, Moderate, High (and for Depression Very High). These classifications were defined specifically as relates to the activities of the case managers. For risks that are Moderate, the problem may be addressed by some education, emotional support or other need that might be directly handled by the case manager. High risks are�.see slide Client responses to the PRO are categorized as Low, Moderate, High (and for Depression Very High). These classifications were defined specifically as relates to the activities of the case managers. For risks that are Moderate, the problem may be addressed by some education, emotional support or other need that might be directly handled by the case manager. High risks are�.see slide

7. Screening protocol TCHS sites screen all prenatal clients at first prenatal appointment Screening is one element used to determine eligibility for case management services Screening results outline a case management plan Sites screen all clients postpartum with smaller version (8 domains)

8. Case Study We�ve selected a sample client to show how this screening system works. The PRO is part of a web-based system so typically a nurse sits town with a client in her office as part of a larger prenatal intake appointment where she is getting a lot of OB health history information. She indicates this is an interview that is done with all clients to determine any other services that might be useful during her pregnancy. The nurse logs into the system and enters a new clients name and date of birth and begins the interview. Rather than show you the questions for each domain we�ve selected a few. First from the Basic Needs area we have the questions for food insecurity and Housing insecurity.We�ve selected a sample client to show how this screening system works. The PRO is part of a web-based system so typically a nurse sits town with a client in her office as part of a larger prenatal intake appointment where she is getting a lot of OB health history information. She indicates this is an interview that is done with all clients to determine any other services that might be useful during her pregnancy. The nurse logs into the system and enters a new clients name and date of birth and begins the interview. Rather than show you the questions for each domain we�ve selected a few. First from the Basic Needs area we have the questions for food insecurity and Housing insecurity.

9. These questions are taken from the Short form of the 12 month food Security Scale of the US Census Population survey. Here the client indicated that sometimes she experiences all of these problems�..These questions are taken from the Short form of the 12 month food Security Scale of the US Census Population survey. Here the client indicated that sometimes she experiences all of these problems�..

10. She reports that she didn�t stay w/friends/ relatives or in a shelter in the last year and she considers her current housing somewhat stable and is somewhat concerned she won�t have a place to live when the baby is born.She reports that she didn�t stay w/friends/ relatives or in a shelter in the last year and she considers her current housing somewhat stable and is somewhat concerned she won�t have a place to live when the baby is born.

11. From our category of interpersonal relationships we�ve selected the social support and abuse measures to show you On lack of social support she�s very satisfied with her relationships and has 3 people she can count on in a time of need generally and 2 she could count on to care for her kidsFrom our category of interpersonal relationships we�ve selected the social support and abuse measures to show you On lack of social support she�s very satisfied with her relationships and has 3 people she can count on in a time of need generally and 2 she could count on to care for her kids

12. She has not experienced abuse by an intimate partner but has experienced abuse prior to pregnancy by someone other than an intimate partner. Some questions here are blank because they were added recently to the system (after this client was interviewed).She has not experienced abuse by an intimate partner but has experienced abuse prior to pregnancy by someone other than an intimate partner. Some questions here are blank because they were added recently to the system (after this client was interviewed).

13. From the behavioral categories we�ve selected part of the depression, alcohol, and drug use measures to show you. For depression we use the PHA-9. This is just the first page. This client indicated that on several days out of the past two weeks she�d experienced these symptoms of depression. From the behavioral categories we�ve selected part of the depression, alcohol, and drug use measures to show you. For depression we use the PHA-9. This is just the first page. This client indicated that on several days out of the past two weeks she�d experienced these symptoms of depression.

14. For alcohol use we�ve got a combination of questions that look at frequency and quantity of use before the client found out they were pregnant as well as after finding out they were pregnant (those questions are on another page). We also use the Rapid Alcohol Problems Screen questions. This client reported rarely drinking prior to pregnancy and no alcohol use since finding out she was pregnant. For alcohol use we�ve got a combination of questions that look at frequency and quantity of use before the client found out they were pregnant as well as after finding out they were pregnant (those questions are on another page). We also use the Rapid Alcohol Problems Screen questions. This client reported rarely drinking prior to pregnancy and no alcohol use since finding out she was pregnant.

15. The client reported daily drug use prior to pregnancy and rare use since finding out she was pregnant.The client reported daily drug use prior to pregnancy and rare use since finding out she was pregnant.

16. PRO Results This page shows the final scoring results indicating she is at high risk for physical abuse and drug use and moderate risk for alcohol use (this is because of the quantity of drinks she would have), social support, housing, food insecurity. This page shows the final scoring results indicating she is at high risk for physical abuse and drug use and moderate risk for alcohol use (this is because of the quantity of drinks she would have), social support, housing, food insecurity.

17. Use of the PRO to date In use at 4 clinics and 1 social service agency since November 2005. Administered to 1,594 pregnant patients, as of June 29 (20 months).

18. Age and race of women screened Also, approximately 1/3 of the pregnant women screened are foreign born primarily Somali, Hmong and Hispanic women.Also, approximately 1/3 of the pregnant women screened are foreign born primarily Somali, Hmong and Hispanic women.

19. Healthy Start ResultsBasic needs domains Usually we would provide some information about how these risk categories were defined based on their responses to our actual questions. However, due to time constraints that isn�t possible. If you are interested in understanding how we define the cut points for High and Moderate risk I have a document that describes that. Usually we would provide some information about how these risk categories were defined based on their responses to our actual questions. However, due to time constraints that isn�t possible. If you are interested in understanding how we define the cut points for High and Moderate risk I have a document that describes that.

20. Healthy Start ResultsInterpersonal relationship domains

21. Healthy Start ResultsBehavioral health domains

22. Healthy Start ResultsLegal problems & child protection involvement

23. Next steps New 4 year research grant through HRSA to: Validate violence, drug, alcohol, and depression components of the screening tool Examine benefit of re-screening clients during pregnancy Examine use of Community Health Workers vs. Nurses to do the screening Evaluation of whether case management activities are conducted to address identified risk factors

24. For more information contact Doriscile Everett-O�neal Twin Cities Healthy Start Project Director 612 673-2622 doris.o�neal@ci.minneapolis.mn.us Abbey Sidebottom Epidemiologist 612 673-3931 Abbey.sidebottom@ci.minneapolis.mn.us Or check out our exhibit