Federation of County Networks “Feeling the Strength of Our Own Spirit…

1. Federation of County Networks “Feeling the Strength of Our Own Spirit… Developing a Plan to Address Comprehensive Approaches to Perinatal and Family Health Taking it to the Streets: Organizing, Planning-ACTION May 20th 2005 Mario Drummonds, MS, LCSW, MBA Board Treasurer, Federation of County Networks, Inc.

2. FCN MISSION: The FCN mission is to reduce fragmentation in the maternal, perinatal and child health systems; to improve outreach and access to care for economically challenged women who may be pregnant and parenting and their families; to enhance and ensure collaboration and coordination among providers; to provide training and technical assistance to maternal and child health providers; and to assist in local health systems planning.

3. Programmatic Activities: • Regional Program Coordination • Local Health System Collaboration and Planning • Technology –Virtual Private Perinatal Network • MCH Management & Clinical Training • Advocacy • Policy Agenda/Direction • Healthy Start Coordination

4. EXTERNAL ENVIRONMENT SCAN: Opportunities: 1. National, state and local focus on reducing racial disparities in health outcomes within the foundation, government and private sectors 2. NYSDOH RFP focusing on chronic disease management by making a six million dollar investment across New York State. States around the country are under increasing fiscal pressure to develop disease management programs that provide quality health care for those most in need, while alleviating some of the cost pressures facing Medicaid

5. EXTERNAL ENVIRONMENT SCAN: 3. National, state and local focus on fighting childhood and adult obesity 4. NYC over the last four years has invested 20 million dollars in community-based solutions to IMR reduction 5. NIH recently released an eleven-year multi-year RFA that focuses on research and practice activities to reduce racial disparitiesin health outcomes

6. EXTERNAL ENVIRONMENT SCAN: 6. National Patient Navigator Program legislation moving fast through Congress that projects to allocate 25 million dollars a year to address structural and cultural barriers to healthcare

7. EXTERNAL ENVIRONMENT SCAN: 7. Renewed focus in Washington on utilizing information technology to computerize medical records. Health experts say that moving to electronic records, which would reduce paper handling and eliminate unnecessary or duplicative tests, could cut 10 percent or more from the nation’s $1.7 trillion a year health care spending. A digital system should sharply reduce medical errors, which are estimated to be responsible for 45,000 to 98,000 deaths a year, more than breast cancer, AIDS or motor vehicle accidents, according to the Institute of Medicine of the National Academy of Sciences

8. EXTERNAL ENVIRONMENT SCAN: 8. Large numbers of immigrant women from Mexico, Dominican Republic, and West Africa have migrated from their home communities and have developed homes in Queens, Central & East Harlem and the South Bronx

9. EXTERNAL ENVIRONMENT SCAN: 9. ACS, NYC Department of Homeless Services, and NYCDOH have begun to collaborate on several projects to improve the care of pregnant and parenting women throughout NYC 10. Former President Clinton joins fight against childhood obesity by launching a public service campaign and funding new program models that show potential for reducing the problem 11. Merck Company Foundation has released a call for proposals to develop a comprehensive campaign against childhood asthma

10. EXTERNAL ENVIRONMENT SCAN: 12. Gov Pataki’s uncertainty about running for a fourth term creates the conditions for a Democratic Governor in Albany that could support many of our MCH policy initiatives 13. On April 21, 2005, Mayor Bloomberg announced the Healthy Women/Healthy Babies Initiative to reduce unintended pregnancies. Over 3 million dollars will be invested in partnership with community-based and health care organizations to increase awareness and access to emergency contraception and family planning and expand the Nurse Family Partnership Program

11. EXTERNAL ENVIRONMENT SCAN: 14. Centers for Medicare & Medicaid Services have been experimenting with pay-for-performance demonstration projects in 270 hospitals around the country concluding financial incentives can improve care. High-performing hospitals receive bonuses totaling $7 million per year. Poorly performing hospitals may face financial penalties in the third year

12. EXTERNAL ENVIRONMENT SCAN: 15. A coalition of politicians and health providers over the last year have pushed for the passage of Timothy’s Law that calls for the expansion of mental health services. The law would eliminate discriminatory and unequal mental health and substance abuse coverage by insurance companies. The NYS Assembly has passed the legislation. More work has to be done in the Senate to pass the bill

13. Threats: 1. MCH community has not made any strides in reducing low birth weight rates in high-risk communities 2. Congress and the NYS governor has attempted to cut the Medicaid budget 3. NYC IMR rate increased from 6.0 to 6.5between 2002 and 2003 4. NYC LBW rate remained constant between 2002 and 2003

14. Threats: 5. Depressed pregnant women throughout NYC have to wait over six weeks for an appointment with a therapist 6. Fort Greene, Jamaica East and Tremont have the highest IMR in NYC in 2003 7. One in four New Yorkers do not exercise, one in six is obese, and one in 13 has diabetes 8. Black and Latina women in NYC have a life expectancy almost 5 years shorter than white woman.

15. Threats: 9. Black and Latina women in NYC are more than twice as likely as white women to die from pregnancy-related complications 10. Data suggests that women are more obese than men. An estimated 30% of black women, 26% of Latina women, 15% of white women and 10% of Asian women are obese. 11. Midwives and OB’s are unable to practice due to increases in malpractice insurance that is closing freestanding birthing centers

16. Threats: 12. NYS legislature has developed a commission to examine the closing of hospitals throughout NYS. Closing the wrong hospital could increase barriers to care for poor and working women we serve 13. The number of teens in foster care who become pregnant is on the rise as well as the quality of health and social services delivered to teens in the foster care system is poor (NYC Public Advocates Report May 2005)

17. Threats: 14. Reductions in affordable housing and the development of a citywide gentrification movement has forced poor and working class women and their families to move from their traditional neighborhoods to more affordable communities in the South Bronx and Brownsville that will become flashpoints for poverty and family dislocation over the next five years

18. Threats: 15. African American women who report experiences of discrimination based on their race or skin color appear to have an increased risk of poor pregnancy outcomes according Dr. Sarah Mustillo, of Duke University School of Medicine, Durham North Carolina. Black women are more likely than white women to experience premature delivery and to have low birth-weight babies, but the discrepancy is not fully explained by factors such as prenatal care, genetics and socioeconomic factors. The study above reveals evidence that chronic stress from racial discrimination may play a role in poor birth outcomes

19. Threats: 16. HIV infection and abusive relationships are especially difficult for women based on the finding of a new study showing increased risks for depression and suicide attempts in women afflicted with both of these problems according to Andrea C. Gielen, deputy director of the Center for Injury Research and Policy at Johns Hopkins Bloomberg School of Public Health who conducted the study and authored the report

20. Threats: 17. In 2003, more than 1 in 4 babies were born by Cesarean section. The Cesarean section rate of 26.1% is the highest ever reported in the United States. The World Health Organization states that the Cesarean rate should be no more than 10-15%. Studies have indicated that a woman is 4-7 times more likely to die as a result of Cesarean surgery than vaginal birth. Studies also show that babies born by Cesarean surgery are 5 times more likely to be admitted to an intermediate or intensive care nursery. The increasing Cesarean section rate is a major public health concern for maternal and infant health

21. Threats: 18.Research conducted by clinicians from Columbia University’s Mailman School of Public Health and the Mount Sinai School of Medicine found that pollutants in the air in Upper Manhattan, the South Bronx and neighborhoods surrounding the World Trade Center area have been linked to lower birth weight babies and smaller skulls in African American babies. High rates of child asthma have been found in these same communities as well as an increased risk of cancer

22. Threats: 19. New Yorkers with diabetes are twice as likely to experience depression, anxiety, schizophrenia, and other disorders causing serious psychological distress than those without diabetes according to a NYCDOH/MH study published late last year in the Center for Disease Control’s Morbidity and Mortality Weekly Report. The study also found that individuals with co-occurring diabetes and serious psychological distress are more likely than those with diabetes only to experience poor physical and mental health, live in poverty, and lack access to health care and social support. Diabetes is now the fourth leading cause of death in New York City

23. INTERNAL MCH SYSTEM REVIEW: STRENGTHS: PEOPLE-CULTURE-PROCESS-STRUCTURE 1. NYC has some of the best and largest health care facilities in the world 2. NYC has 3 Healthy Start grantees, 9 lay model home visiting programs, 3 nurse family partnership programs and 5 CHWP operating in NYC 3. Two yearsagoNYCDOH/MH built local public health offices in Central Brooklyn, Central Harlem and the South Bronx

24. STRENGTHS: PEOPLE-CULTURE-PROCESS-STRUCTURE 4. Through mandatory testing of newborns, care management and counseling of high-risk mothers, the HIV mother-to-child transmission rate has decreased from 10% 1993 to less than 2% in 2003. In NYC, 321 newborns were infected with H.I.V. in 1990, the year the virus peaked among newborns in the city. In 2003, five babies were born with the virus

25. STRENGTHS: PEOPLE-CULTURE-PROCESS-STRUCTURE 5. More than half of the hospitals in NYS have joined an effort to save 7,000 lives over the next year or so by applying best practices to improve quality of care (Daily News 5/16/05) Healthcare Association of New York State 6. As the general population ages, more women over 35 are deciding to have a child

26. STRENGTHS: PEOPLE-CULTURE-PROCESS-STRUCTURE 7. The Citywide Coalition to End Infant Morality has over sixty community-based agencies delivering various maternal and child health services throughout NYC. This network of providers is maturing and delivering better results 8. Across New York State the regionalization of perinatal care has started. In NYC, the Citywide Regional Perinatal Forum and local borough forums of hospitals and community-based organizations have begun to determine the MCH needs in their areas and develop borough-specific action plans to address identified needs. 9. The NYCDOH/MH has developed plans to screen patients at all HHC hospitals for depression and make it a routine part of primary care, much like a blood pressure test or a cholesterol reading.

27. WEAKNESSES: PEOPLE-CULTURE-PROCESS-STRUCTURE 1. MCH care system fragmented 2. Uninsured population in downstate region over 2 million 3. 40% of NYC hospitals are operating in the red 4. More New Yorkers die from medical mistakes each year than from highway accidents, breast cancer, or AIDS

28. WEAKNESSES: PEOPLE-CULTURE-PROCESS-STRUCTURE 5. Recently, Jacobi Hospital in the Bronx failed to tell 307 women that they had abnormal cancer-test results. These women did not receive follow-up care 6. Racial disparities in care and outcomes is prevalent even at some of the best medical centers 7. Constant movement from one provider to another characterizes the patient base within the MCH system in NYC where a woman might secure her prenatal care at one facility and deliver at another. Continuity of care suffers and patients move to the providers that respect them and deliver quality care- HAVE MEDICAID CARD WILL TRAVEL!

29. WEAKNESSES: PEOPLE-CULTURE-PROCESS-STRUCTURE 8. The maternal mental health provider network is weak across NYC. There are not enough clinicians who are trained to screen, diagnose or treat various perinatal mood disorders 9. Nursing shortage in NYC can be described as a health care state of emergency that has negative consequences to patient safety, the quality of patient care and morale issues among existing nursing staff 10. Medicaid poorly reimburses mental health providers who manage the care of pregnant, emotionally depressed women

30. WEAKNESSES: PEOPLE-CULTURE-PROCESS-STRUCTURE 11. The health and mental health care systems are poorly integrated to meet the growing needs of pregnant and parenting women

31. Perinatal Depression Campaign Performance Objectives: • By December 31, 2006, FCN’s perinatal mood disorder social marketing poster campaign will have motivated at least 1,000 pregnant and parenting women to seek mental health care in NYC and every year until 2009 • By December 31, 2006, FCN’s maternal mental health training program will have organized at least 50 grand round trainings of doctors, nurses, midwives, and social workers that will begin to standardize the expectations of practice to screen, diagnose, and treat various perinatal mood disorders

32. Perinatal Depression Campaign Performance Objectives: • By December 31, 2007, FCN will develop a citywide network of trained individual and group therapists that are willing and have the skills to screen, diagnose and treat various perinatal mood disorders • By December 31, 2006, a statewide movement to address the funding, slot capacity, and practice development issues regarding perinatal mood disorders will be built mobilizing contacts throughout NYC and upstate New York where the Mayor of NYC and the Governor of New York State will support new funding and systems change proposals to strengthen the system of care to address this problem

33. Perinatal Depression Campaign Performance Objectives: • By May 31, 2009, two NYC schools of social work, one medical school and one psychology department will develop specialty programs to produce students trained to appropriately screen, diagnose and treat various perinatal mood disorders.

34. Perinatal Depression Campaign Action Areas: Legislative Actions: 1. Develop a brief narrative that summarizes the clinical, waiting list/slot capacity, provider training, and stigma-marketing issues related to treating various perinatal mood disorders in the down state region by 8/18/05. The narrative should describe the problem and point to solutions for each problem identified 2. Use the narrative to develop a legislative fact sheet, legislative action letters and other communication vehicles that will be used to bring about reforms by 8/30/05

35. Perinatal Depression Campaign Action Areas: 3. Form Perinatal Depression Legislative Action Team that is representative of all the networks, Healthy Start and home visiting programs within the downstate region that will be charged with implementing this plan by 9/8/05 4. Action Team should study Timothy’s Law and Assemblyman JamesBrennan’s proposed bill (A. 2016) that would force OMH to repealthe regulation enforcing Medicaid Neutrality

36. Perinatal Depression Campaign Action Areas: 5. Begin setting up meetings in Albany with targeted republican and democratic legislators in the Senate and Assembly to persuade them to support the above legislation 6. Set up a meeting with the Commissioner of State OMH to understand OMH’s position on Timothy’s Law and Medicaid Neutrality 7. Contact Speaker Silver & Senator Bruno to present our case concerning the perinatal mood disorder problems and solutions and win their support

37. Perinatal Depression Campaign Action Areas: 8. Set up meetings with Governor Pataki’s health and social service representatives in Albany, Ms. Renee Rider, Director of Human Services Programs, State Capital, Room 253 and Mark Kissinger, Executive Chamber, State Capital to make our case and position our narrative as a campaign issue that the governor must address. Show how the issue relates to key constituencies that any republican candidate for governor must develop an informed response

38. Perinatal Depression Campaign Action Areas: 9. Meet with the democratic candidate for governor, Attorney General Eliot Spitzer and transform our case statement into a campaign issue for him 10. Make contact with our friends at 1199 Hospital Worker’s Union and see if they can transmit our legislative narrative into a print and electronic media campaign during the election period and right before the budget debate begins in December 2005

39. Perinatal Depression Campaign Action Areas: 11. Begin letter writing and phone bank activities to targeted legislators starting on November 20, 2005 12. Action Team should have at least three operatives completing media work (letters to editor, story development, press conference planning, phone follow up work with health reporters, etc.) to achieve the passage of the two laws

40. Perinatal Depression Campaign Action Areas: 13. Attend September 2005 APN meeting to communicate FCN’s overall action plan and secure commitments from the networks in other parts of NYS to our political narrative 14. Set up a meeting with State Senator Jeff Klein and his staff who sponsored Timothy’s Law to target the coalition of mental health parity activists who support the legislation and join their movement

41. Perinatal Depression Campaign Action Areas: 15. Organize clergy across NYC and secure their support for our PPD legislative objectives by organizing “Clergy Day to Treat Perinatal Mood Disorders.” Get major clergy leaders and coalitions in NYC to attend a press conference focused on our core message/narrative

42. Perinatal Depression Campaign Action Areas: Social Marketing Anti-Stigma Actions: 1. Work with NMPP and the NYCDOH/MH to review their recent perinatal depression anti-stigma campaign and obtain some of the unused proofs to develop a citywide perinatal mood disorder poster campaign by November 30th 2005 2. Secure NMPP’s Social Health Marketing Group to retouch some of the photo’s, headlines and poster copy to produce drafts for a FCN PPD citywide campaign 3. Develop a mini proposal to the foundation community to secure resources to mass produce the campaign poster and secure 250,000 for citywide dissemination

43. Perinatal Depression Campaign Action Areas: 4. Develop radio and television public service announcements and work to get them placed as well as secure free time within mainstream, local print and electronic media throughout NYC 5. Work the radio talk show circuit communicating our core messages concerning the PPD problem and fiscal, legislative and network development solutions

44. Perinatal Depression Campaign Action Areas: Provider Network Development Actions: 1. Study the network development work of MHRA, NMPP and the Black Psychiatrists of Greater New York who are developing a network of clinicians in Harlem who treat maternal mental health problems 2. Each Citywide Coalition to End Infant Mortality Borough Coordinating Body will take responsibility for organizing maternal mental health networks throughout their borough beginning on December 1, 2005 3. The FCN executive director will computerize each borough network database and distribute the list to all perinatal networks, community health worker programs, Healthy Start sites, etc

45. Perinatal Depression Campaign Action Areas: 4. Borough networks should meet quarterly to determine the need for maternal mental health services in the area, the status of the service network (strengths & weaknesses), network training needs and develop an action plan for network development by January 30th 2006 5. Each borough network should develop clinical and referral protocols and MOU’s to formalize network communications and to ensure each patient obtains the best level of care to meet her needs 6. Integrate grand rounds trainings with network development activities to ensure that all clinicians develop their knowledge base to screen, diagnose, and treat various perinatal psychiatric disorders

46. Perinatal Depression Campaign Action Areas: 7. By May 20, 2006, each borough network will present a status report at the FCN annual conference

47. Perinatal Depression Campaign Action Areas: Workforce Training Actions: 1. Set up meetings with two medical school deans and one school of social work dean to persuade the decision makers to develop core curriculum and a training practice area focused on producing students with core skills to screen, diagnose and treating perinatal mood disorders starting on January 22, 2006 2. Connect media, legislative and research work plan activities to create the right conditions to positively influence university leadership to adopt our workforce training objectives

48. Perinatal Depression Campaign Action Areas: 3. Secure three of the top national maternal mental health clinicians to practice in NYC and complete the administrative and fund development tasks to create a fellowship that will attract medical and psychiatry students to enroll and graduate with special knowledge of treating perinatal psychiatric disorders 4. Attend all of the schools of social work in NYC and Long Island to educate their deans and curriculum committee chairs about the need to train and deploy more social workers who have special skills screening for, diagnosing and treating perinatal mood disorders

49. Perinatal Depression Campaign Action Areas: • 5. Develop concept paper on Centers of • Excellence on Maternal Mental Health and • develop a funding proposal that one or two of the universities would manage to make New York City or New York State the national intellectual center for policy, research and practice for treating • various perinatal mood disorders

50. Perinatal Depression Campaign Action Areas: Organization Mobilization Actions: To achieve the objectives and tasks outlined above, FCN must partner with the following entities and persuade them to join our campaign: MHRA, Black Psychiatrists of Greater New York and Associates (BPGNY), New York City Home Visiting Council, COFFCA, New YorkState Mental Health Association, Mailman School of Public Health, APN, New York State March of Dimes, New York State Perinatal Association, National Association of Social Workers, National Association of Black Social Workers, New York State Midwife Association, New York State Nurses Association, NYC Health & Hospitals Corporation,