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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 2 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 3 WHY DOES THIS MATTER? What do we know about women in postpartum period? K Johnson. Delaware Healthy Mother and Infant Consortium. April 4, 2017 4 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 5 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 6 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 7 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 9 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 11 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? 14 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 16 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 17 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 18 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 22 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 23 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 31 “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 32 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 33 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 34 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.