Addressing Disparities in Perinatal Addressing Disparities in Perinatal Health Using a Collaborative Approach: Health Using a Collaborative Approach: The PCC Community Wellness Center’s The PCC Community Wellness Center’s

Experience Experience

May 17, 2006May 17, 2006

Mark Loafman, M.D., M.P.H.Mark Loafman, M.D., M.P.H.Andrea McGlynn, C.N.M., M.S.N.Andrea McGlynn, C.N.M., M.S.N.

Chicago, ILChicago, IL

PCC Highest Areas of PCC Highest Areas of Patient PopulationPatient Population

Austin Community Austin Community Selected Demographic/Health Selected Demographic/Health

DataData**

• Chicago Department of Public Health – Chicago Health and Health Systems Project April 20062000 Census Data

0

20

40

60

80

100

Asian Black Hispanic White Multi-race

Other

Austin Chicago

Percent of Population

02468

1012141618

Austin Chicago

0

5

10

15

20

25

Teen Births No PrenatalCare

LowBirthweight

Austin Chicago

Austin vs. Chicago Infant Mortality 2003

Austin vs. Chicago Selected Perinatal

Indicators 2003

Rate/1000 Live Births Percentage

Source: Chicago Department of Public Health – Chicago Health and Health Systems Project April 2006

Overview of PCCOverview of PCC History and missionHistory and mission

Full-service community health center since Full-service community health center since 19931993

330 funding (FQHC) since 2002330 funding (FQHC) since 2002

Model of care Model of care Family MedicineFamily Medicine

9 of 18 Attendings with MCH/OB Fellowship9 of 18 Attendings with MCH/OB Fellowship Peds, OB/GYN, CNMs, FNPs, LCSWs, PsychPeds, OB/GYN, CNMs, FNPs, LCSWs, Psych Health education and outreach Health education and outreach

Hosts MCH Fellowship and FM ResidentsHosts MCH Fellowship and FM Residents

Experience with health disparities Experience with health disparities collaborativescollaboratives

PCC UDS DataPCC UDS Data

YearYear Total Total UsersUsers

Prenatal Prenatal UsersUsers DeliveriesDeliveries % LBW% LBW

% Late % Late Entry to Entry to

CareCare

HIV+ HIV+ Prenatal Prenatal

UsersUsers

20022002 11,35911,359 737737 445445 15%15% 8%8% 00

20032003 20,92820,928 858858 647647 15%15% 20%20% 11

20042004 22,65322,653 17791779 10831083

(836 PN (836 PN users)users)

8%8% 44%44% 22

20052005 25,23525,235 20862086 13951395

(1064 PN (1064 PN users)users)

9.7%9.7% 42%42% 33

Care ModelCare Model

Informed, activated

Patient

Prepared, proactive

practice team

Functional and Clinical Outcomes

Health SystemHealth Care Organization

Self-management

support

Delivery system design

Decision support

Clinical information

systems

CommunityResources and Policies

Productive Productive InteractionsInteractions

Source: Institute for Healthcare Improvement

Impact Analysis of PCC’s Impact Analysis of PCC’s ModelModel

* Austin area, 1999. Source: I-PLAN data system ** RSWH deliveries of PCC and unattached patients, 6-11/2004 Source: Perinatal database.

FAMILY PRACTICE MODEL WITH OBSTETRICS

Low birthweight Low birthweight (140/1,000 live births)*(140/1,000 live births)*

Very low birthweight Very low birthweight (39/1,000 live births)*(39/1,000 live births)*

Low birthweight Low birthweight (101/1,000 live births)**(101/1,000 live births)**

Very low birthweight Very low birthweight (9/1,000 live births)**(9/1,000 live births)**

Family Practice Residency Family Practice Residency MCH Fellowship MCH Fellowship

Case Management Case Management Community Nursing Community Nursing

AmeriCorps Outreach WorkersAmeriCorps Outreach Workers

CLINICAL MODEL

OutcomeCommunity Problem

Opportunities to positively influence MCHPCC and PartnersPCC and Partners

Maternal preconception

health

EnvironmentGenetic/familial

life course

Lifestyle/stressors/stress response

SES conditions & disparities

Prenatal course

Early and individualized

risk assessment

and care

Concurrent & prospective

care management

Networks & collaboration

s

Access to ongoing health

care

Educational & economic opportunities

Environmental

safety

Psychological & spiritual support

services

Social & legal resources

Perinatal Pilot Perinatal Pilot Collaborative Collaborative Seeing wider opportunities Seeing wider opportunities to respond to the problemto respond to the problem

Influences on MCH

Example: Ramp-up of PDSAsExample: Ramp-up of PDSAs

Outreach to patientsOutreach to patients

Refined tracking formRefined tracking form (follow-up needed)(follow-up needed)

Patient given specific contact person for Patient given specific contact person for

appt.appt.

(barriers to appointment)(barriers to appointment)

Algorithm to prompt care/red foldersAlgorithm to prompt care/red folders

(more comprehensive approach)(more comprehensive approach)

GDM screening at hospital OB triageGDM screening at hospital OB triage

Plan-Do-Study-Act Method of Plan-Do-Study-Act Method of Making ChangesMaking Changes

Identify opportunity, then champion the idea

PDSA changes (> 119 PDSAs in Perinatal Pilot at PCC)

Top 7 ChangesTop 7 Changes

At the Health CenterAt the Health Center Front-loaded careFront-loaded care Prenatal sessions for Prenatal sessions for

all FP providers all FP providers Psychosocial and Psychosocial and

depression screening depression screening (PHQ) (PHQ)

Self-management Self-management goalsgoals

Performance Performance Improvement assistant Improvement assistant (PIA) role(PIA) role

At the HospitalAt the Hospital ““Red folders” Red folders”

algorithm/outreach algorithm/outreach to unattached to unattached patients patients

Joint practice Joint practice committee: pre-committee: pre-M&M quality M&M quality assurance assurance

Perinatal PECS Data at PCCPerinatal PECS Data at PCCJuly 2005 to PresentJuly 2005 to Present

Process (as of 4/06)*Process (as of 4/06)* HIV test (100%)HIV test (100%) Psychosocial risk Psychosocial risk

assessment (83%)assessment (83%) Prenatal depression Prenatal depression

screening (78%)screening (78%) SMG (50%)SMG (50%) Early GDM Early GDM

screening (80%)screening (80%)

Outcome (7/05 to Outcome (7/05 to 3/06)*3/06)*

Preterm labor (13%)Preterm labor (13%) Low birthweight Low birthweight

(13%)(13%) Infant mortality (0)Infant mortality (0)

CHALLENGE

CHALLENGESS* at pilot site only – selected indicators

Performance Improvement Performance Improvement ProgramProgramIdentified NeedsIdentified Needs

Patient Satisfaction

Finance

Grants

Support Services

Clinical & Collaborative

s

Employee/Provider

Satisfaction

P.I..

Team/Task Force

Communication and Systems Communication and Systems Development Development

How do you measure that? Existence of…How do you measure that? Existence of… Processes developed and “institutionalized”Processes developed and “institutionalized” Extend care management model into Extend care management model into

hospitalhospital Evidence-based practice tools – algorithms, Evidence-based practice tools – algorithms,

protocols, drillsprotocols, drills

Excerpt from PCC’s Perinatal Collaborative Aim Statement:Excerpt from PCC’s Perinatal Collaborative Aim Statement:

“… “…implementation of a patient safety system that implementation of a patient safety system that prepares the multidisciplinary PCC and WSMC teams for prepares the multidisciplinary PCC and WSMC teams for high-risk patient care (antepartum, intrapartum, and high-risk patient care (antepartum, intrapartum, and postpartum) and encourages self-reporting and postpartum) and encourages self-reporting and identification of ‘near misses’ by November 2005 at PCC identification of ‘near misses’ by November 2005 at PCC and WSMC Family Birthplace.”and WSMC Family Birthplace.”

PCC Community Wellness Center/West Suburban Medical PCC Community Wellness Center/West Suburban Medical CenterCenter

PCC Community Wellness CenterBoard of DirectorsCEO and President

Chief Medical Officer

Erie CtSite

Lake Site

AustinSite

SaludSite

South OP Site

WSMCSite

Fellowship Training

Integrative referralsystem

Integrative service delivery initiative

Integrative medicaleducation

WSMC Inpatient/outpatient diagnostics

Formal CommunityCollaborations

• Circle Family Care• Interfaith House• Westside Health

Authority• West Side Health

Collaborative Care Coalition

WSMC (PHO)

managed care

WSMC Family

practice residency

Target Population Reach by Risk

Reduction Outreach

• Yellow Brick Road (Women’s Sober Living

• Haymarket House (alcohol/substance abuse

• Infant Jesus Dental• UIC Dental School• Chicago Urban

Ministries (counseling, housing)

• Bethel New Life (social services, housing)

Closing the Gap Programs in Closing the Gap Programs in ChicagoChicago

Health Resources and Services Administration (HRSA)Closing the Health Gap Initiative on Infant Mortality

Maternal and Child Health Bureau (MCHB)Risk Reduction Pilot

Bureau of Primary Health Care (BPHC)Perinatal and Patient Safety

Pilot Health Disparities Collaborative

State MCH agencies and other grantees Perinatal collaborative pilot sites, then all FQHCs

Target population reached by risk reduction outreach Target Population that accesses prenatal care

Still More Needed to Close the Still More Needed to Close the GapGap

…and address social, economic, environmental disparities

Health Resources and Services Administration (HRSA)Closing the Health Gap Initiative on Infant Mortality

Maternal and Child Health Bureau (MCHB)Risk Reduction Pilot

Bureau of Primary Health Care (BPHC)Perinatal and Patient Safety

Pilot Health Disparities Collaborative

State MCH Agencies and Other Grantees FQHCs (perinatal collaborative pilot sites then all FQHCs

State MCH Agencies and Other Grantees Target Population that accesses prenatal care

Unreached target population high-risk for infant mortality,

only accesses emergency services

PCC’s Plans for PCC’s Plans for Collaborative SpreadCollaborative Spread

To other PCC sitesTo other PCC sites Unattached populationUnattached population Assist in spread to other FQHCs Assist in spread to other FQHCs

nationallynationally

More PlansMore Plans

Research to BetterResearch to Better

Understand:Understand: Role of prenatal care in Role of prenatal care in

improving outcomesimproving outcomes Improved psychosocial Improved psychosocial

screening and healthscreening and health Workforce Workforce

developmentdevelopment Model replicationModel replication

Integration of ServicesIntegration of Services WIC/Case management WIC/Case management

together with CHC together with CHC servicesservices

Behavioral healthBehavioral health Community-based Community-based

agenciesagencies