Download Kay Johnson Breakout

K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
1
INTEGRATING SERVICES IN
THE POSTPARTUM PERIOD
Breakout Session
Kay Johnson
DHMIC
April 4, 2017
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Breakout Session Design
• Provide an opportunity to:
• Practice planning in partnership,
• Design approaches for service integration, and
• Identify opportunities for collaboration and coordination of services
to women, infants, and families in the first 60 days following a birth.
• Consider the roles of primary care providers, family
planning staff, home visitors, care coordinators, public
health staff, nutrition programs, and others.
• Emphasize opportunities to deliver interconception care
for women with identified risks.
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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WHY DOES THIS MATTER?
What do we know about women in postpartum period?
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Prevalence of Risk, Medicaid and Total, PRAMS, 26
Reporting Areas, 2004
Source: Centers for Disease Control and Prevention. PRAMS
Preconception
(Pre-pregnancy)
Risks and
Protective
Factors
Interconception/
Postpartum (PP)
Risks and
Protective
Factors
Percent of
Women in
Medicaid
Percent of All
Women
Tobacco use
36.0
23.2
Alcohol use
37.7
50.1
Multi-vitamin use
21.4
35.1
Stress
33.8
18.5
Overweight
14.4
13.1
Obesity
32.7
21.9
Nonuse of Contraceptives
54.9
53.1
Prior LBW
15.6
11.6
Prior Preterm
13.7
11.9
Use of Contraceptives
85.1
85.1
Tobacco use
26.8
17.9
PP Depression
22.5
15.7
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Prevalence of Risk, Medicaid and Total, All
PRAMS and Delaware, 2012
Source: Centers for Disease Control and Prevention. PRAMS
Preconception
Tobacco use
(Pre-pregnancy)
Multi-vitamin use
Risks & Protective
Depression
Factors
Overweight
Obesity
Interconception/ Use of contraceptives
Postpartum Risks
Tobacco use
& Protective
Factors
Depression (self-report)
Percent in
Delaware
Percent of All
in PRAMS
27.2
34.1
9.3
26.9
25.7
21.6
39.8
2.8
24.3
21.6
82.8
80.1
18.6
14.6
13.8
11.7
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Prior Preterm Birth, PRAMS, 2011
16
14
12
Percent
10
8
6
4
2
0
PRAMS
Medicaid
PRAMS Non- DE Medicaid
Medicaid
DE NonMedicaid
MD Medicaid
MD NonMedicaid
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Contraceptive Use at Time of Pregnancy among Women Not
Trying to Become Pregnant, For Medicaid and NonMedicaid, All PRAMS, Delaware, and Maryland, 2011
70
60
All PRAMS
Medicaid
50
All PRAMS NonMedicaid
Percent
DE Medicaid
40
DE Non-Medicaid
30
MD Medicaid
20
MD Non-Medicaid
10
0
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
Contraceptive Use Before and Following
Pregnancy, PRAMS, 2011
Contraceptive use before pregnancy
Contraceptive use postpartum
100
90
80
70
Percent
60
50
40
30
20
10
0
PRAMS
Medicaid
PRAMS Non- DE Medicaid
Medicaid
DE NonMedicaid
MD Medicaid
MD NonMedicaid
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Smoking Use Before and Following Pregnancy,
PRAMS, Total, Delaware, and Maryland, 2011
Smoking before pregnancy
Smoking postpartum
50
45
40
35
Percent
30
25
20
15
10
5
0
PRAMS
Medicaid
PRAMS NonMedicaid
DE Medicaid
DE NonMedicaid
MD Medicaid
MD NonMedicaid
National measures widely used
• HEDIS Measure (Medicaid and Commercial, NCQA, 1994-2009)
• Postpartum Care. The percentage of deliveries that had a
postpartum visit on or between 21 and 56 days after delivery.
• CMS Core Set for Adults covered by Medicaid
• Postpartum Care Rate
• Healthy People 2020: Maternal, Infant, Child Health (MICH)-19
(developmental)
• Increase the proportion of women giving birth who attend a
postpartum visit with a health worker
Sources: http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26
and http://www.ncqa.org/portals/0/Prenatal%20Postpartum%20Care.pdf
Johnson. Preconception & Interconception Care COIIN Strategy Team Meeting, March, 2015
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K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
Percent of Women with Timely
Postpartum Visit, HEDIS, 2001-2010
Commercial Insurance
Medicaid
90
80
70
60
50
40
30
20
10
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Source: Women’s Health USA, 2012. US HHS-HRSA-MCHB. 2013. Data from NCQA.
Postpartum Visit HEDIS Rates, Medicaid,
FFY 2014 (n=34 states)
100
90
80
70
60
50
40
30
20
10
0
25th percentile
50th percentile
75th percentile
Delaware
Johnson. Medicaid & Interconception Care COIIN Strategy Team Meeting, Feb. 21, 2013
ACOG-NCQA-PCPI 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:
1. Breastfeeding evaluation and education, including patientreported breastfeeding
2. Postpartum depression screening
3. Postpartum glucose screening for gestational diabetes
patients
4. 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
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
WHAT IS SPECIAL ABOUT
POSTPARTUM AND
INTERCEPTION?
What are we trying to do?
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Core Components of Preconception Care in Context of
Primary Care, Postpartum, and Well Woman Visits
Health Promotion
& Counseling
Assessment &
Screening
Medical & reproductive history;
Genetic & family history;
Environmental & occupational
exposures; Family planning
and pregnancy spacing;
Nutrition, folic acid intake and
weight management;
Medications; Substance use
(alcohol, tobacco and illegal
drugs); Infectious diseases;
Psycho-social (e.g.,
depression, domestic violence,
housing)
Brief
Interventions
Genetic conditions; Healthy
weight; Nutrition & vitamins;
Preventing STD & HIV
infection; Contraceptive
methods, Abstaining from
tobacco, alcohol, and illicit
drug use; Consuming folic
acid; Risks from prescription
drugs; Controlling preexisting and chronic medical
conditions (e.g., diabetes)
e.g.
Immunization
STIs & other infections
Smoking cessation
Alcohol misuse
Weight management
Family planning
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Characteristics of Challenge
• Need to change systems to enhance women’s health and
•
•
•
•
reproductive outcomes.
Women, particularly low income women, with prior
adverse pregnancy outcomes do not receive risk
appropriate and coordinated care.
Many women miss postpartum visits.
Currently, even for women with identified risks and
continuing coverage, care is not focused on
reproductive health planning, and professional practices
do not emphasize reducing interconception risks.
Like chronic disease management, interconception this
requires intensive, tailored case management (from
medical home, professional support, community health
workers, etc.).
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Concept of Interconception Care (ICC)
• CDC Recommendations for Preconception
Health defined ICC.
• Provide women who had prior adverse pregnancy
outcome with interventions to reduce risks that affect the
woman and any future pregnancy she may choose to
have.
• Using a more intensive, “disease management” approach
that includes medical care and case management to:
• Reduce the impact of chronic disease and other reproductive
health risk factors.
• Promote fulfillment of a women’s reproductive life plan and positive
decision making.
• Improve the outcome of any subsequent pregnancies
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Pregnancy Outcomes Associated with Future
Adverse Pregnancy Outcomes
• Mortality fetal (stillbirth) and infant
• Preterm birth (<37 weeks gestation)
• Low birthweight and very low birthweight
• Prior short birth interval
• Maternal complications (prevalence and predictive
value for future health)
• Diabetes (gestational diabetes and/or Type II
diabetes)
• Hypertension (essential and/or pregnancy induced
hypertension)
• Postpartum depression/mood disorders
Why interconception care should be easy
• Almost all the women in need of interconception care are
already known to the health system
• Over 95% had some prenatal care and gave birth at hospital
• All live births and still births identified by certificates
• Most births, miscarriages, and elective abortions were cared for
in the medical care system
• Most take infant to pediatric care provider
• Majority seek family planning services postpartum
Why interconception care is hard
• Consumer demand and provider supply are low
Source: Lorraine Klerman, 1st National Summit on Preconception Care, June 2005
POSTPARTUM AND
INTERCONCEPTION
PROJECTS
General findings on postpartum visits
• Use of prenatal care a strong indicator of whether a woman
obtains postpartum visit.*
• LAMB study** found women significantly less likely to use
postpartum if they had/were:
Less than high
school education
Received late or
no prenatal care
Younger than 26
No or
inadequate
insurance
Low income
Preterm or low
birthweight
Immigration
status concerns
Unmarried
Unintended
pregnancy
Hispanic
Feelings and
beliefs against it
Multiparous
* Kogan et al. 1990. † York et al, 2000. ** DiBari et al. 2014.
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Postpartum Visit Utilization
• National data indicate that 85% of women had received
outpatient care within 6 months postpartum.
• Significant risk factors for no postpartum visit:
• having no prenatal care,
• less than high school education,
• household income of less than $20,000, and
• no preterm labor interventions
• Also suggest current postpartum visits may not be
sufficient to address the array of psycho-social factors
that influence maternal health and behavior.
Source: Lu and Prentice, 2002.
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Primary Drivers of Postpartum Care Quality
Engage
women
• CLAS for education
• Reminders & incentives
• More patient-centered approaches
Delivery
system
• QI & provider education
• Appointments scheduled early
• Outreach & case management
Community
supports
• Home visits
• Transportation
• Referrals to WIC, etc.
Payment &
policies
• Provider/plan incentives
• Require documentation
• Guidance on billing codes
Adapted from: Centers for Medicare and Medicaid Services.
https://www.medicaid.gov/medicaid/quality-of-care/downloads/strategies-to-improve-postpartum-care.pdf
Interconception Care Project of California
Postpartum visit redesign to address pregnancy
outcomes, prepare for future pregnancies, and
optimize women’s health.
• A project of California ACOG, supported by March of Dimes and
guided by Jeanne Conry, past President ACOG
• To provide tools to support improvement in postpartum visits as a
gateway to interconception care
• Review of 26 topics to identify recommended interventions and clinical
approaches
• Creation of algorithms and clinical tools based on evidence and best
practice review
• Development of new patient education materials
http://www.everywomancalifornia.org/
Interconception – One state’s vision
Target: High Risk Women
n=?
Case
Management
High-Risk
Women
Medical
Management
• What criteria for high risk?
• Disease Management approach
• What risk assessment to identify
• Primary care / medical home
women?
• Family planning
• Who provides case management?
• Specialty care
• 12 or 24 months intensive case
• Behavioral health
management for pregnancy spacing?
• Reproductive life planning
• Health promotion and education
• Coordination/integration of
delivery system
ICC Research Project: Atlanta
• Population: 21 high risk African American women with prior
adverse outcomes
• Method: Mixed prospective-retrospective cohort
• Intervention:
• Primary care and social support for 24 months following delivery of
VLBW infant
• Results: Compared to intervention group, women in control
cohort had:
• 2.6 times as many pregnancies in 18 months of index birth
• 3.5 times as many adverse pregnancy outcomes
Sources: Biermann et al. MCHJ, 2006; 10(5Suppl):S21-8;
Dunlop et al. MCHJ, 2008;12(4):461-8.
ICC Research Projects: Chicago
• Population: 220 African American women with prior
adverse pregnancy outcomes
• Longitudinal, multi-method, intervention:
• Team approach with medical care and case
management
• Focused on integration of family planning, social
services, and medical care
• Results:
• Socioeconomic needs overshadowed health needs
• Medical care not top priority for ICC participants
• Women’s perceptions of contraceptive effectiveness not
in synch with clinical knowledge
Source: Handler et al. Am J Health Promot. 2013;27(3 supple):eS21-31.
•.
Postpartum/Interconception & Home Visits
Screen & Assess Risks
Educate
Intervene Refer for
in Home health care
Family planning, reproductive plan
●
●
Prior adverse pregnancy outcome
●
●
Smoking
●
●
●
Other substance misuse
●
Alcohol
●
Mental health/depression
●
●
●
Chronic disease
●
Obesity, nutrition
●
●
Domestic violence / IPA
●
?
Education and employment
●
Social support / stress
●
Marriage / partnerships
Refer to
other
●
●
●
●
●
●
?
●
DESIGNING A BETTER WAY
Group Challenge
• Pick a focus
1. Increase use of postpartum visit
2. Increase use of interconception care
• Address elements such as:
• Effective contraceptive methods
• Breastfeeding
• Smoking cessation
• Psychosocial risk factors
• Healthy weight and nutrition
• Managing diabetes & other chronic conditions
• Social determinants of health (SDOH)
Adapted from: Preconception Health and Health Care Initiative tools for clinicians https://beforeandbeyond.org/
Lu MC et al. The Content of Internatal Care. Matern Child Health J. 2006; 10(5 Suppl):S107-S122.
Johnson & Gee. Interpregnancy Care. 2015.
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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“Almost shovel ready” projects
• QI & performance measurement
• Postpartum visit incentives
• Provider education and tools
• Interconception care enhanced case
management in Medicaid
• Screening/assessment pilot
• Communication, EHR, IT upgrades
• Integrated care models (e.g., ACO)
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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What are their roles & partnerships?
Primary
Care
Social
support
Community
Health
Team
Housing
Family
Planning
Clinic
Woman
and her
family
Early
Care &
Education
Home
Visiting
Lactation &
nutrition
Mental
Health
Providers
Employment
& Job
Training
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Adopt Systems Integration Strategies
Array of services
and supports
What is the
process magic
in those arrows?
Client
Centered
Approach
K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017
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Additional References
• AHRQ. Measure Summary: Postpartum care.
https://www.qualitymeasures.ahrq.gov/summaries/summary/49780/postpartum-carepercentage-of-deliveries-that-had-a-postpartum-visit-on-or-between-21-and-56-days-afterdelivery
• CMS. Resources on Strategies to Improve Postpartum Care Among Medicaid and CHIP
Populations. https://www.medicaid.gov/medicaid/quality-of-care/downloads/strategies-toimprove-postpartum-care.pdf
• NCQA. Approaches to Improving Unintended Pregnancy Rates in the United States
http://www.ncqa.org/hedis-quality-measurement/research/women-s-health
• DiBari JN, Yu SM, Chao SM, & Lu MC. Use of Postpartum Care: Predictors and Barriers.
Journal of Pregnancy, 2014.
• Johnson KA, Gee RE. Interpregnancy care. Seminars in Perinatology. 2015 Jun;39(4):310-5.
• Thiel De Bocanegra H, Braughton M, Bradsberry M, Howell M, Logan J, & Schwarz EB. Racial
and ethnic disparities in postpartum care and contraception in California's Medicaid program.
American Journal of Obstetrics & Gynecoly. 2017 Mar 3. pii: S0002-9378(17)30368-X. 0
• Verbiest S. Postpartum Thinktank. http://www.amchp.org/programsandtopics/womens-
health/Focus%20Areas/Documents/Postpartum%20Think%20Tank%20Slides.pdf
• Weir S, Posner HE, Zhang J, Willis G, Baxter JD, & Clark RE. Predictors of prenatal
and postpartum care adequacy in a Medicaid managed care population. Women’s Health
Issues. 2011 Jul-Aug;21(4):277-85.